Thursday, August 23, 2007

Where to Begin?

When I got to work on Sunday night, I saw that they had SIX patients for me.  SIX!!!!  I know they were short-staffed, but come on!  Not only was it six, but they were all accuchecks and three of them were total cares.  This is just way too much.  As much as I wanted to scream "I refuse to take six patients", I quietly kept in those screams & took it in stride...because I know I can't stand when others flip out & complain.  And I knew that the clinical leader was trying her best to get some of the patients downgraded to med-surg.  So I patiently waited & sure enough, she ended up transferring one patient to another unit before I even got report on that patient.  So I was back down to our maximum patient load of 5. 

I always hate the evening shift change.  It is so chaotic compared to the morning shift change.  I feel like night shift gets dumped on, yet in the morning we return the patients all calm & cool.  I guess that's just the way it is everywhere.  It took forever to get report on my patients.  I get there early on purpose (6:30) so that I'm not in report until 8 pm.  Sometimes that works out, but most of the time I have to track the day nurse down, get her/him to sit down & give me report so I can start my shift.  If I sound frustrated, it's because I am....partly for the reason above & partly cause I only got a couple of hours of sleep today.

Sunday night I was on my feet until about 1 am.  The only good thing about being that busy is that the time flies by.  It took that long to stabilize my patients & get them some sleep.  One patient that I got report on...his blood pressure was 179/62 at 1600 (4 pm).  I said "What did you do for it?"  Because anything over 170 is generally a concern for any nurse.  Her reply..."Well, you're giving him Clonidine tonight."  Huh?  His Clonidine is for 10 pm - you expect him to go 6 hours with a blood pressure that high?  Responses like that irritate me.  I'd rather hear the generic "I paged the doctor, but he never called back" line then something dumb like she said to me. 

My total cares took a lot of my time, but I didn't mind.  They were post surgical patients that ended up in PCU.  One had an abdominal mass & the surgeon biopsied it & did a Whipple procedure at the same time.  This patient had been in ICU, then downgraded to med-surg - while he was there his heart rate went up & he was sent to my floor.  The cardiologist had downgraded him to med-surg again, but the surgeon wouldn't agree because he was afraid the heart rate would go up again.  What?  I swear life would be easier if these doctors could put their egos aside & work together.  I didn't see why the patient couldn't be moved back to med-surg.  If his heart rate went up again, then he could come back to PCU - but the surgeon wouldn't give in.  Also, for some reason, the surgeon discontinued the JP drain & I was told that the dressing over the site where the drain was needed to be changed a few times during the shift. 

I went in to assess the patient & he was soaked in drainage...gross!  So I cleaned him up, changed the dressing, put a lot of 4x4's over it, taped it very well - only to come in an hour later & he was soaked again. I repeated what I did above & I taped a wash cloth below the dressing so it could absorb anything that might leak out.  That didn't work as he was soaked again about an hour later.  Next I tried ABD pads & a towel instead of a washcloth.  That lasted a little longer, but eventually soaked through.  It made me wonder why in the world was the drain discontinued when he obviously still had a lot of drainage.  The next morning I discussed this with the day nurse & she came up with the idea to put a colostomy bag over the site.....and it worked!  Beautifully!!!  She's my

My other total care patient was a woman in her 50's that came in with adhesions and a fistula.  She had an exploratory lap and a colostomy done by a certain pair of surgeons that I don't have a lot of faith in.  The last time I had a patient from these two with the same type surgery (minus the colostomy), the patient went downhill quickly and died.  In fact, when a surgical patient goes bad - it's usually a given that at least one of these two were the surgeon.  Anyways...this patient had VRE (vanco resistant enterococci)....basically a very bad infection that was resistant to one of the most powerful antibiotics ever made.  It was in her surgical wound.  One would think that with an infection like that, the surgeons might want to consult with our infectious disease doctors...but nope.  In fact, they rarely ever want the infectious disease doctors around their patients.  Again, if they'd find a way to put their egos aside & do what is best for the patient, we'd probably have better outcomes.  On Sunday, it was determined that this patient also had a yeast infection.  Again, another sign that infectious disease should be playing a role in helping to heal this patient, but no...the surgeon ordered monistat vaginal suppositories instead.  Oh - those are such fun to insert...grrrr.  This patient was getting morphine around the clock over the few days I had her, I was beginning to wonder if she really needed it.  She seems like she is hooked on it to me, but we aren't to judge that...we are supposed to take the patient's word that they are in pain.  So I continued to give it every 4 hours as ordered.

My other patients were easy to care for - one was awaiting a transfer to another hospital so he could have a pacemaker inserted.  The patient with the high blood pressure has got to be the nicest patient I've ever encountered.  Usually patients tend to complain or be needy.  This one was so happy go lucky & always had a smile & was so appreciative of anything done for him.  I told him he needed to go around & talk to the other patients to get them to be like this.  He laughed.  He told me I was the best nurse & of course I couldn't argue with that!! 

My fifth patient was pretty self-sufficient also.  She had a spanish accent & I could barely understand the english she was speaking, but she was stable.

Monday night we ended up having 4 nurses instead of 3, so I didn't have the patient with the VRE infection.  My other patients remained the same.  I transferred the one needing the pacemaker that evening and never did get a new admit.  I stayed at 3 patients the rest of the night & I was happy.  It's reasons like that which kept me from freaking out when the day before I almost started with 6 patients.  There will be good nights & there will be bad's just part of the job.  Monday night was one of those good nights.

Tuesday night it was back to 3 nurses, so I got both surgical patients back as well as a couple of new ones as my spanish speaking patient had been discharged at shift change.  She came up to me & gave me a hug & a kiss.  She was sweet, but I wasn't expecting that.  My only pet peeve that night was the order for blood I had on my surgical patient that had the JP drain which was now covered with a colostomy bag.  He had orders from the morning for a unit of blood, but of course it wasn't even started when I got there.  I guess I should be lucky he at least was typed & crossmatched...but still...that blood should have been started.  I had the unit up & running within 15 min of getting out of report.  It's not a difficult task. 

It was a pretty simple night even with 5 patients.  I was trying to figure out what was going on with my super nice patient as his blood sugars had been all over the place...high, low, high, low.  I looked over his medications & saw that he was getting huge amounts of both novolin and regular insulin morning and night.  His blood sugar for me that night was 74 - which is ok...the low side of normal, but I knew he had received something like 30 units of Novolin & that it would be peaking later that night.  I gave him a snack & rechecked his blood sugar around 2 am.  Sure enough, it was 71.  I had him drink some juice as he was on a clear liquid diet now because he had a stress test later that day.  I gave up telling the day nurses my concerns because nothing seems to be addressed anyways, so I typed up a note to the doctor & attached it to the front of the chart in hopes that maybe if he was aware of the patient's blood sugars, he would adjust the medications.  I came back the next night & he had indeed listened to me and decreased the patient's insulin and his blood sugars were perfect last night.....ahhhhh!

I picked up an extra shift last night for the overtime.  My credit card bills are high this month, although I have no idea why.  I make a real effort to pay them off completely each month & needed to work this extra shift to cover it so I didn't have to worry.  Technically, I should work again tonight - but I'm tired & don't have it in me.  Not to mention I don't think they needed me as our census was starting to drop. 

Anyways...last surgical patient with VRE...well, she now had a yeast infection in her blood.  Who knew that was even possible?  I didn't.  So after having a long discussion with the surgeon, they finally talked him into getting a consult with the infectious disease doctor.  He was in at the change of shift & had written a whole page of orders....lucky me.  They weren't too difficult, just timely.  She needed her foley catheter changed.  I delegated this task to our PCT who of course didn't do it.  She was afraid to do it.  Since she helped me out with my other surgical patient (I'll get to that later), I gave her a break & did the foley myself.  I got a urine specimen, a wound culture specimen, started 3 new antibiotics...pretty much completed everything he had ordered.  I was quite proud of  The patient was pretty much indifferent to anything I was doing as she was so drugged up it wasn't even funny.  I ended up holding her pain med for 6 hours rather than 4 because she was just too out of it...even though every chance she got, she was asking for it.  I can generally tell that if a patient were in extreme pain, they would be ranting & raving.  They wouldn't simply say "ok, I'll just wait until it's time."  She had been in the hospital nearly a month & on morphine the entire time.  No wonder she is getting addicted to it.  Her room reaked of the smell of infection.  It wasn't a gross smell, but definitely the smell of sickness.  I wish I could open the window & air it out...but we can't.  And being that she is on precautions, we have to keep the hospital room door closed that smell will never get out of there as long as she's in there.  I don't know why they were doing wet to dry dressings rather than a wound vac either.  I never see the doctors during the night to ask them these questions & I get no info out of the day nurses - probably cause the doctors aren't quite the type to explain anything they are doing.  She was pretty much content the rest of the night.

My super friendly patient was still there, but I knew it wouldn't be long before he'd be discharged.  I had another patient that came in the night before with COPD.  He had a tracheostomy that was constantly getting clogged with flem.  Luckily, the respiratory therapist was on the ball & took care of this patient's needs the entire night.  I could never be a respiratory therapist - the sound of suctioning really grosses me out...a lot.  I had to close the door, that's how much it turns my stomach.  I can't stand the sound, much less the sight of what is being suctioned out.  Probably a reason I couldn't be an ICU nurse at this point either.  They are always having to suction their patients.  I don't know why it grosses me out, but it does.  Other than needing that, he was fine.

My problem patient was my other surgical patient.  He had been improving & getting close to being discharged - until yesterday - he developed a temperature of 102.  One would think that the doctor would do something about it...but no.  I was told by the day nurse that the doctor didn't want to do anything & I read the notes - the doctor hadn't even been in to see the patient...his physician's assistant was & she didn't address the temperature.  Looking back, I probably should have called him as soon as I found out the patient had a temp that high...because he probably wasn't even aware of it.  It was probably an oversight by his physician's assistant & therefore went untreated.  The day nurse had been giving him tylenol, but it was taking the fever away.  It dropped it a 101, but by 4 am it was back up to 102.4.  I gave more tylenol & rechecked it at 6 am only to find it was now 103.7.  Not good.  I called the surgeon & got a long list of orders at 6:15.  I could have easily just passed it onto the dayshift like they do to us at night, but I had grown to care about this patient & didn't like seeing him get worse instead ofbetter.  So I did as much as I could on that list of orders that I could possibly do.  I discontinued his TPN, hung the new IV bag that was ordered, did a wound culture of the drainage, ordered the stat labs & followed up with the lab when after 30 min...the blood still had not been drawn.  So much for STAT.  I had the IV antibiotics ready to be go...just waiting on lab to do the blood cultures.  The surgeon had requested some special kind of drain...which it turns out hasn't been used in yearssssssss.  The OR nurse gave me every other type of drain they had because she didn't know what he would use since the one he ordered no longer exists.  I had all of those drains waiting outside the patient's room.  I didn't know if he was going to insert it at bedside or in the OR, but I was glad to see he was finally addressing the issue of the patient still needing something for all that drainage besides a colostomy bag.  I guess he was suspecting that the infection was starting in that location.  Anyways, I did everything I could possibly do including staying an hour later to make sure I was the one that started the antibiotics that were ordered.  I just know how much I hate being handed off a patient with a ton of orders that just came in right at shift change, so I did what I could to make it easier for the day nurse as well as what was best for the patient.  I'm patting myself on the back.  :)

I hope he's ok and that he's not becoming septic.  I looked at his AM labs - that were drawn prior to realizing his temp went up.  His white blood cell count was actually low...3.3, which I didn't understand.  How could he have a high-grade temp, but a low white blood cell count?  WBC's usually are the indicator for infection.  Anyone know the answer?

I had a staff meeting on Tuesday before work.  The big announcement is that our director of nurses (I think that's what she is) is resigning.  She came in a year ago & made a lot of changes & now is leaving.  I've been at this hospital for just under 3 years & this is the third director we've had that has come & gone.  It has to be a stressful position - which is why I never want to go into administration.  Way too much stress & drama.  It will be interesting to see who they get to replace her & what kind of changes they'll come in & make.  That's the one thing I don't like though - they bring in a new person & allow them to do pretty much whatever they want as far as changes...and then the person leaves.  There has been so many altercations between nursing & administration in the last year.  We have lost sooooooooo many good nurses & for what?  No good reason.  It's kinda scary that she'll be leaving at the end of September & we'll be going into our busy time of the year shortly after that with staffing issues.  Right now we have hardly any agency nurses and no travelers...which is fine...because it allows me to get overtime, but when the census climbs & our nursing director is no longer there...what is going to happen with staffing?  Are they going to overload us with travelers & agency like they've done in the past?  Are they going to offer staff some incentives for doing overtime - like we had when I first started?  Only time will tell.

Our chief of staff doctor was also at the meeting.  I'm not sure what I think of him.  I do respect him as a doctor - he's a cardiologist & seems to do a good job with his patients (most of the time), but the things he was saying to us...were a little off the wall.  I am trying to give him the benefit of the doubt as I'm sure he meant well.  He is making a real effort to improve communication between the doctors and the nurses.  He did emphasize that we as nurses do not work for the doctors, that we shouldn't be afraid of any of them or allow them to intimidate us.  He advised us to round with the doctors (if possible) as they see our patients - because we are a team working together.  Of course since he isn't a nurse, he doesn't realize we have 9023803049830948903243 other things to do during our shift as opposed to following the doctors around, but I know he meant well. 

He also advised us to make an effort to get to know the doctors - that every doctor should know our name.  I don't see that happening...especially on the night shift.  Those doctors are in & out of there as quickly as possible & I don't blame them - it's nighttime & they've been working all day.  On top of that, he advised us on what to do if a doctor yells at us for some reason.  This was off the wall as I don't think it's ever appropriate for a doctor or anyone to be yelling at one another - unless perhaps it's said in an effort to save a patient's life - like for example "DON'T PUSH THAT MEDICATION, THE PATIENT IS ALLERGIC TO IT!"  I can see that being appropriate, but for someone to flip out to the point of yelling - does yelling ever really work?  He advised us to pull the doctor into the nurses lounge & speak to him/her in a calm manner.  Yeah, right...just what I'd be capable of doing after being yelled at in front of everyone.  He said that it is probably best to wait a few days so that everyone has cooled off.  What???  I am trying to picture this scenario in my head & for the life of me, I can't.  He went on to say that when he gets mad at his employees in the office...he doesn't speak to them for 3 to 5 days.  It was funny to hear him say that, but at the same first thought unprofessional!  Are we adults or are we 12 yr olds?  Anyways...I know he means well & it is nice that he has an interest in improving communication.  He is very open to suggestions & that's a good thing.  We never heard a peep out of our last chief of staff & although he is currently my primary doctor & a good one - very kind, he just never went to this level of going to the nurses directly to improve patient care.  Hopefully things will improve in that area.  It's about time someone is focusing on it & he has the power to make changes.

That is my week in a nutshell.  My brother watched Shay all week.  I have her now & I think she misses my brother.  She is growing up...sigh.  She definitely does not look like the adorable little puppy I got 7 weeks ago.  She is sleeping at my feet right now.  She has surgery to get fixed next Friday & then shortly after that I'll be getting her into some obedience classes.  I saw that there is a 2-week bootcamp I could send her to.  It's expensive...$795, they keep her for the entire 2-weeks & train her...supposedly to the point that I won't even need a leash on her.  I'll see how she does with the basic obedience classes & decide from there.  If I can work it out to where those 2 weeks she's in bootcamp I can work the entire time - then I might do it.  Because that would allow me to do the overtime without worrying about who is watching her & she'll be learning some valuable training lessons. So we'll see...I can't bring her there until she's 6 months old anyways.  I've been watching The Dog Whisperer a lot & try to follow what he says...but it's not always easy. 

School started for my niece & nephew...I'm glad!  I finally have my house back to myself & some peace & quiet.  I have BLS/CPR class in 2 weeks & ACLS in about a month.  Why can't they combine BLS with ACLS so you can do it all in one shot?  Makes no sense to me. 

I joined - it's a great deal.  I know have 7 movies to watch between now &  I think I'll get started on that now. 

Have a good weekend everyone!


tendernoggle said...

Bless your have been BUSY!!!!
I so wish all nurses had your patience and caring .... that is why your patients love you so....I think you would be a good Director of Nurses yourself!!!
You know..being a nurse was my big dream as a young girl...but when I saw my brother-in-law have to get his trach suctioned out...I gagged so bad! lol He was comatose, bless his heart...(had a cerebreal brain hemmorage and was comatose for two years before he finally died...) but anyway....I can stomach most anything but I can not take phlem.....nope....Blood, bodily functions...that doesn't faze me...but the other...OH NO WAY HOSEA!!!! lol
PLease make sure on that doggy boot camp...make sure they do not punish your little pup...
love ya,

am4039 said...

nurses are the best. You do such a great job and know so much. I have had the most wonderful nurses when I have been sick.