COS v.1 #12

Change of Shift is up again over at Fat Doctor. She did a good one....check it out!

Patient advocated

Patient X:
A middle aged man comes with back pain. "Back Pain?" I thought "What middle aged person doesn't have Back pain?"
As it turns out this one broke his back a couple of years ago at work. Fixed by surgery, rods were put in. He became addicted to pain killers... and then other things.
Now he's in the hospital with an abscess in the soft tissues of his lumbar spine that won't heal. Because of his past and present addictions (he came in positive for 2 different types of drugs, nonRx) The doctors are serving up the pain relievers very sparingly.
So every 2 hours...on the dot...I went in with his meager 1/2 mg pain shot.
Every 2 hours, I called the MD and reminded him about how much pain our patient was in.How he yelled out for help, writhed in bed, had a constant sqinty eyed look, never watched TV, ate, or slept. (If my patient and I were going to suffer so was he)
The really sucky thing is his drug use became known to his family (By him) just recently. He won't be getting the emotional support he needs from them.

Patient Y:
I stopped a seizure dead in it's tracks today.(I used a vagal stimulator magnet thingy, which was so cool.) A seizure that causes a Post-Ictal Violent phase. So Violent that the seizures this patient has had since admission usually takes 6 staff members to restrain him after he throws several punches, kicks, bites. He'd been in restraints off and on since admission. He was as nice as the Pope himself when not seizing.

But no restraints from me. After this 4 minute Tonic Clonic seizure, I gave him the PRN Zyprexa. It worked! No violence, a bit lethargic but nobody got hurt. He was cooperative even. I passed the word on to his MDs and the night RN. Zyprexa, Zyprexa, Zyprexa. Miracle drug for this one. For some reason the nurses before me hadn't thought to give it. I was the first, even though it was ordered. He awaits placement in a home soon...his family can't handle his violence.

Change of Shift v.1 #11

Change of Shift is up again!
Julie over across the pond at Life in the NHS did a fantastic job.
Yeah, I'm in it again.

a Special kind of hell

I'm assigned 5 patients in one shift.....here they are.

1 Elderly gentlemen showing new neurological deficits....weakness on the right side, pupils dilating sluggishly, Nystagmus, sometimes he could answer you sometimes he couldn't. Total care. Doctors think it was all side effects from a med he WAS on. Doctors were notified of changes...I was worried all day.

1 middle aged women who happened to be a prostitute who was also thrown from a moving car with a broken patella and road rash...You'd think she would be on the trauma floor but God Forbid should they take anyone who might be in withdrawal from CRACK. The whole morning she cussed and yelled at us, refused everything (except pain meds) until finally I talked the doctor into some Ativan. (took me three calls and stopping the MD in the hallway but I did it). She was a new person after the Ativan.

1 middle aged man with severe asthma exacerbation. Enough so that he would De-Sat into the 70s with the oxygen off. He was my only compliant and somewhat pleasant patient.

1 middle aged man with End stage renal disease....seemed nice enough until I wheeled him to dialysis and THEN he decided to refuse it. It took me, the dialysis RN and the Nephrologist to talk him back into it. The Doctor got tough....Literally said "OK...then go home and die then" when suddenly the patient had a change of heart. This patient was incarcerated....had 2 deputies at the bedside.

Last but not least....1 middle aged man ALSO with end stage renal disease ....this one confused (Kept calling to ask for the "OhnoPogo Man" After trying to reorient him several times I finally told him the Ohnopogo man had the day off....and he stopped asking) ,
incontinent (the world's largest code Brown on record....I guarantee),
forgetful (he would call to be turned.....every 5-10 minutes, forgetting that we just did it) Never mind that there was absolutely nothing wrong with his arms and legs and on admission he could walk fine.
The man had a history of "faking paralysis" according to his doc. He drove me the most insane.

I've never had to be so assertive, stern, and patient ever in one shift since my career started in Nursing. It was a special kinda hell....seriously.

Creature of Habit

I thought it would be interesting to see how my Med/surg unit routine would compare with nurses who work on other type units. Feel free to comment on the differences.

I work 8 hour shifts...from 0700-1500. I know most RNs work 7-7 12 hour shifts. I'm fortunate to have a boss who can be open minded and family friendly and allow some of us slackers to work ONLY 8 hours.

My Routine:

0430-0550~ Wake up, get coffee, shower. Pack lunch and Ari's things and leave carrying a sleeping 5 yr old to the car.

0550-0600~ Drop Ari at best friend's house (she's so awesome for making sure Ari gets on the bus in the AMs)

0600-0645~ Commute to work while drinking my breakfast, coffee and a slimfast shake

0645-0715~ Clock in, put my stuff in my locker, grab a phone (a cordless type that's run within the hospital only) and listen to the voicemail report on my patients. I pull them up on my computer. The computers are on rolling stands and you have to snag one quick and put your name on it.

0715-0800~ If the nightshift nurse is a decent one, he/she waits to see if you have any questions before leaving. Start assessing my five patients beginning with the most critical sounding ones. (Granted....most of the patients on my unit should all be stable and not critical or they have no business being there. I go by the "what's the worst that can happen " when determining which patients I see first) For example, those on telemetry monitoring with cardiac history come before those with diabetic foot wounds.

0800-0830~ Our unit should change it's name from Internal medicine to the Diabetic floor. Usually 3 to 4 out of my 5 patients have diabetes and need to have blood sugar checks and insulin coverage before breakfast comes up at 0830. I don't head for the med room to get the insulin until I see the trays coming down the hall.....you never know when the trays will be late and diabetic patient's glucose can crash if they don't get something to eat with their insulin. Blood draws NOT done on the night shift and any frequents (Like cardiac enzymes and Vancomycin levels) are done about this time.

0830-1000~ Morning meds. Everyone's got them. We only pray you weren't assigned with more then 1 or 2 elderly or dialysis patients. They tend to have at least 10 daily meds a piece. Also, any ER admissions you might be getting we hope and pray wait until 1000 to come up or your whole routine and schedule is totally blown. Happens all the time, though. Also, help aides give out lunch trays, call Dietary dept. about any missing or wrong trays. Order missing meds....everyday the pharmacy has forgotten at least 1-5 meds.....everyday.

1000-1130~ Help aides give bed baths, daily care, get my walkie-talkies in the shower. If things run smoothly with meds and baths I might have started charting my assessments at this point. Any meds that were not where they were supposed to be have been ordered by me and brought up by now...Administer those. Chart , chart, chart

11:30- 1200~ Eat my lunch while my aides are checking blood glucoses. Lunch comes between 1200 and 1230. Insulin will need to be administered.

1200-1300~ Insulin, help aides give out lunch trays, call Dietary dept. about any missing or wrong trays. Chart

1300-1415~ This is the time to finish any charting undone, do any non-routine things like dressing changes, IV tubing changes, new IV starts (they expire in 96 hours) and start any discharge paperwork for those patients going home.

1415-1430~ Leave voicemail report for new shift coming on at 1500. Finish last minute charting

1430- 1530~ Send any ambulatory discharging patients on their way after any appropriate teaching, applying dressings, and discontinuing any IVs they may have. Walk down or get the aide to walk down via wheelchair any patients who aren't so ambulatory. Ask replacing nurse if they have any questions and clock out.

1530-1630~ One hour (usually) commute home in rush hour traffic. Rush hour starts at 3 pm in this city. The price I pay for a safe community.

1630-2100~ After getting out of the parking garage, fighting traffic, & picking up Ari from her afterschool program I'm finally home by 1700. Time to make Ari dinner while checking my email. Eat dinner, get Ari in the Bath, story time and a little TV then bed by 2100....if I'm lucky.

Holidays can suck

Daphne from Scooby doo

















Ari designed this Jack o' Lantern

With Halloween and everything I've been busy. I had a visit from Daphne from Scooby doo. I was Velma. It was fun.

Work has had me busier then ever. I'm running from the moment I get my patient assignments to the moment I report off and then some.

In the past 2 weeks I discharged 7 patients total. We have a new protocol that requires us to give Flu and Pneumococcal vaccines before D/C to any patient with a chronic disease or over a certain age. (That's all of them)

I gave about 14 vaccinations in 2 weeks. I say "about" because I gave some of them to my nursing students. Before these past 2 weeks I had only given one intramuscular injection...morphine...in school.

Talk about breaking in a new skill.

I'm an expert at Deltoid (Arm) and vastus lateralis (thigh) injection sites now.

Prevention, Prevention, Prevention

What would be really nice is if my hospital with get off it's derriere and get it's employees the flu shot.

"There's not enough right now" they say. And I'm feeling a little flu-ish today.

I'm loyal to my charity hospital system because I think it's better then the other money grubbing hospital system here. However, their health benefits really suck.....and they get suckier every year.

Their holiday pay sucks. I will have to work Thanksgiving this year and I won't even get time and a half for it. (Only Christmas day, Easter Sunday, New Year's Day and Labor Day (!) ) are holidays.

It's bad enough I have to find sitters for the school holidays surrounding the holidays but I won't even get to offset that cost with time and 1/2. I'm still looking at possible clinic jobs.....for when my residency is over.

Change of Shift v1/10

Change of Shift v1, number 10 is up again at Disappearing John RN.

He's done a really great job. Not only good reading but great links.