It was my second day in a row taking care of him and I was physically and mentally worn out. It’s a lot of work to reposition someone in the bed every 20 minutes because they are about to fall out of the bed or laying so crooked that their head is hitting the railings. One of the phlebotomists walked in the room to get a blood sample (the nurses were usually drawing blood samples from his central line, but our policy is for one set of blood cultures to be drawn directly by venipuncture by the lab staff). She gets ready to check his veins and he starts flailing, just as I warned her he would do. I was holding his arm down to the best of my ability, but it still shook a little. Then, she says “isn’t there something you can do about this? It’s making it really hard for me to do my job.” Wow. Really, lady? It’s making it really hard for ME to do my job too. I was about 18 hours deep with this patient… and she only had to be there for about 10 minutes. I wanted to tell her how hard it was to just do an assessment – listen to his lung sounds, check his pupils, assess pulses in his feet, or give medication down his feeding tube, or heck, even irrigate his rectal tube. Every single thing I’ve done over the last 18 hours has been difficult.

I know that she’s not used to being around these patients as much as we, as ICU staff, are but I would think there would be a little bit of understanding for the situation. If I could give the patient a magic medication that would make him calm, while allowing him to continue breathing and allow us to continue monitoring his mental status, I would give it in a heartbeat.

Uhhh… exhausting.

Lately, I’ve been working in our hospital’s PACU (post anesthesia care unit) where patients come immediately after surgery to wake up before they head home or to their room at the hospital.  It is so much quicker to access alcohol swabs as they are consistently within 2 steps of where we’re standing, as opposed to standard medication treatments which are about 50 feet away in a room where I need to swipe my ID card to enter, then enter my username and fingerprint to obtain access to drugs. I don’t have any information on the cost to the hospital or the patient for these anti-nausea medications, but I can only assume that they cost more than the penny or so that an alcohol swab costs.

I started searching for research that talks about this topic and found a journal article in Nursing Research from 2002 that explains the theory well. It talks about mechanisms of vomiting, what makes us puke after anesthesia and how the traditional medication treatments work to affect nausea. They also did a research study in a hospital using a control group of traditional medication treatments and rubbing alcohol as a treatment and their results came out to show no significant difference in nausea reduction between the treatments.

Just some food for thought. I thought this was an interesting topic since I work in a unit that seems to primarily see surgical patients.

But, I do it. And do does everyone else in healthcare. The difference is how the attitude changes when we walk into the hospital. I try my best to put on a smile as I walk into the break room to get my patient assignment- I say hi to my coworkers (which is better than the dreary, early morning silence), and I go out to get report from the night shift nurse. I then walk into my patient’s room and great them with a “Good morning, my name is Amy and I’m going to be your nurse today. How are you feeling? Are you ready for some breakfast?” All with a positive outlook. I really think that our patients can sense our moods within the first 30 seconds of the day. If you come in with a less than positive attitude, they’re going to feed off of that for the next 12 hours. Not good.

We often have patients after open heart surgery who complain about having to get out of bed, or having to use their incentive spirometer (breathing exerciser which reduces risk of pneumonia post-op), etc. These patients can drain the heck out of you- it’s hard to be a cheerleader for a cranky patient, especially when you’re not in the best mood yourself. I have gotten into the habit of making it into a joke for myself, while using the humor to (hopefully) encourage the patient. As we’re getting the cranky patient out of the bed, I joke around by asking him if he can describe the truck that hit him. If I can get even a little bit of a smile, the patients seem to cheer up and it makes my day a little less #fail.

Bottom line: Put on a happy face. It will help you be in a better mood yourself, and your patients will thank you for it (even if they’re too crankpants to actually say it out loud).

I went through triage, and with my abdominal pain, I was very low priority. So, I sat in the waiting room for about 2 hours before ever being put in a gown and being seen by a physician. The doc came in and did an assessment, ordered some IV fluids, a GI cocktail, and an abdominal ultrasound. The nurse came through for the IV and the delicious elixir, and transport later came through to to take me to ultrasound. After my ultrasound, my gurney was placed in the hallway as there were no curtained beds available (my least favorite part of being a patient in the ER).

I never felt like I was being rushed through the process or that people weren’t listening to me, but I did feel like it would be easy to get lost in the shuffle. As one health care employee came to speak to me, they had no contact with the other health care workers nor did they acknowledge each other. Every person had their own job and they each did their job right on queue. As a patient though, it felt very automated; I never talked to one person for more than 60 seconds at a time and since the nurse was writing her notes on a crumpled piece of paper from her pocket and the doc walked away without writing a single thing, I didn’t really feel like everything I was telling them was being taken in.

But, now from the other side of the coin, I can understand not writing down pieces of information. I’ll often take a history from a family member without writing things down or having the computer open if they have a minimal amount of previous medical problems. I’m not an ER nurse and I never have had that experience, but I assume that they have several patients at the same time, especially in the sub-acute section of the ER (like where I was located) and aren’t able to take the time and sit and talk.

This does make me look at my practice a little differently. As I admit a patient into the ICU, I take a couple extra minutes to explain the plan and ask them if they have any questions. If I can, I will tell them that I need to call the physician to get some orders, but I expect to go for a CT scan that afternoon and have some blood drawn in the next hour. Knowing what the plan is and who might be coming to see them takes away a lot of the automation of health care and gives them a constant person (me) to talk to if they have concerns or questions.

“Mrs. Smith, when your husband collapsed at work, his heart had stopped beating. We know that his brain went without oxygen for at least 10 minutes, the length of time it took the paramedics to get to him, in addition to the amount of time it took his coworker to find him. While they were able to get his heart restarted, there is no way to repair the damage done to his brain. After 48 hours, he has not woken up or shown any signs of responsiveness. All of the tests we have done to his brain have shown that it is not functioning – he is brain dead.”

After a member of the healthcare team gives grave news like this, the response sometimes goes like this:
“Oh look at that! *points outside at the helicopter pad* When Mr Smith was little, he used to live near a small airport where all of these planes and helicopters used to fly in and out. I’m sure this is a very peaceful sleep for him. He’s always been such a fighter.”

A response like this makes you wonder if they were actually listening to what you were saying, or if they’re just using avoidance as a defense mechanism. I have compassion for people who are dealing with one of the hardest events in their lifetime like this, I really do, but I wish it was easier for people to open up their eyes to reality.

How do you handle these situations?

We had one particular nursing school come through our unit in rotation this fall and I was disheartened by each and every student I met from this school. I had one student who was assigned to my patient. She came in that morning (and was late and we were already halfway through shift report), she did not know what CHF, congestive heart failure, was nor how it is treated… and this was the patient’s diagnosis. We had morning medications to give and the student said “I dont know” when asked about each of the 3 medications we were giving. I asked her to look up the medications and come back to me with the pertinent information and she stood there for a moment, then came over to me and said “I dont have a book”, I told her that there were online resources as well as several books in our medication room. Next, we had to take this intubated patient down for a CT scan and upon our arrival to the unit, I hooked the patient’s cardiac leads to the monitor and I asked the student to hook up the blood pressure cuff and pulse oximeter (finger probe). After taking a phone call, I came back into the room and the student was holding the blood pressure cuff in her hand and said “I can’t figure out how this goes on”. That’s it. I was mentally checked-out as a teacher.

This woman (and I say woman because she was about 35 years old) was going to graduate, potentially, from nursing school in just a few months. Upon probing her to get a better idea of her clinical experience, she told me that she has been an LPN for years, but has never actually worked. She got divorced, gets a large alimony sum, and just needed something to do to get out of the house while her kids were at school, which is why she went to nursing school. Students just don’t seem to care. They went into nursing school because they heard it was an easy road to a good salary. But, now after being on a waiting list to get into nursing school for a year, and being about ready to graduate, the market has turned around and hospitals are not hiring new graduate nurses (things will change, and they can easily get experience in LTC for a year and then apply for whatever their “dream job” is).

Throughout my posts, I keep going back to the topic of professionalism. I think that is huge for nursing. If we as a group show that we deserve to be treated with respect, then we will be. This is a big topic that seems to be missing in nursing education. What could we do as hospital-based preceptors to get this message across to students that we only see during a one-day shift?

Every once in awhile an article comes along that I love. Heck, I’ve even been known to rip out an article and put it in the nurses’ lounge at the hospital a time or two. In September 2009, they published an article titled “Patients’ Perceptions of Nurses’ Skill” which I read and loved. The article discusses the factors that our patients use to assess our skill level. How do the factors that they use differ from the factors you use to look at your own nursing skill, or the skill of your coworkers?

Nursing practice has three domains that make up skill: interpersonal, critical thinking, and technical. Which of these can our patients most easily pick up on? Interpersonal, of course. Our patients have very little insight into our critical thinking skills. As they lay in bed trying to breathe post-extubation with stridor, they don’t know that you’re the one calling the doctor for racemic epi, IV steroids, and heliox because you know the cause of the stridor. The same is true with our technical skills. Sure, they see us removing their central line, but they don’t know correct steps to tell if you’re performing the procedure in conjunction with best practice standards. All that our patients can see is our attitude about these things. When you call the physician on your patient with respiratory stridor, they see that you are doing this quickly and with confidence. You are in the room reassuring them that things will be okay and educating them on what is happening. When you are pulling the central line, you are explaining each step to the patient to reduce their stress level about the procedure and possibly chatting about another topic to get their mind off of it and show interest in them as a person.

I highly suggest reading the article (I’ve attached the PDF below), but the big take-aways for me were:

• Patients describe the attributes of skilled nurses as: friendly, caring, compassionate, kind, good listener, confident, enjoyed his/her job, well-organized, and followed through with tasks he/she said they would do
• Patients describe the attributes of a non-skilled nurse as: Lack of confidence, timidity, rudeness, abrupt answers to questions, indecisiveness, frustration, and a negative attitude

So, I look at these terms that our patients use to decipher our nursing skill and I can see the affect on our unit. There are a certain group of nurses who often get thank you cards or small tokens of appreciation from patients and family members and they display off of the attributes of skilled nurses – seems that this article is telling the truth :)

This article helps me remind myself when my day is going horribly, to take a breath. You’re getting paid to be at work and these patients/families are going through a hard time right now. Relax and do your job, they don’t need to know that you just got chewed out by a jerk physician or that the patient next door is confused, crawling out of bed, and on your last nerve. When you go in the room to do something, do it with a smile and take the extra time to try and make a connection with each one of your patients. You will stand out as they remember their hospital stay and you will personally feel better for having a relaxed attitude.

Patients’ Perceptions of Nurses’ Skill – Critical Care Nurse

We had an extreme example of this happen to us awhile back. We received a patient who went emergently to the cath lab with an acute MI (heart attack). He came to us in the ICU with his femoral sheaths still in place and was unable to urinate while laying flat in the bed. So, the nurse was in the room getting ready to place a foley catheter in his bladder which left the patient without any covering over his lower half as she was prepping his with iodine to sterilize and prevent infection. Little did the nurse know, the patient’s physician was in the next room speaking to another patient’s family members about the Steelers (which happened to be both of their favorite football team). The physician then decided to take these family members to meet his patient next door, who was also a Steelers fan. The physician pulled the curtain wide open, exposing the half naked patient and without a second thought started talking about football. The nurse, who had sterile gloves on, started saying something along the lines of “You need to get out. We’re in the middle of a procedure” and the physician kept talking over her. She then took off her gloves and pulled the curtain closed again in front of his face and the physician started screaming for the charge nurse because of the nurse’s “attitude”.

If I were that nurse, I think I would have had a hard time keeping my cool in front of the vulnerable patient, the idiot physician, and the family members who got pulled into this awkward situation. And, even after speaking to the charge nurse and the nurse involved, the physician still insisted that he did nothing wrong and the nurse needed an “attitude adjustment”.

Whew.

For those of you who may not be familiar, “snowbird” is our loving term for those in the elderly population who live in a warm climate for the winter and return to their northern/midwest home when the temperature is more tolerable there (and less tolerable during Phoenix summers). The exact times that the snowbirds arrive in Phoenix varies each year… sometimes we get busy in December if the snows are intense in other parts of the continent and other times we don’t start getting busy until after they have celebrated the new year with their children and grandchildren. Then, the snowbirds usually start to head back home in April or May, again depending on the weather where ever “home” is for them.

So, we’ve officially been hit with snowbird fever. I don’t know what it is, but it seems that people get out here every year and get hit with unplanned illness. Maybe it’s the stress of the holiday season or the stress of packing up and moving across the country? I’m honestly not sure. But, this year, I’ve noticed an especially large number of unexpected admissions- ruptured AAAs (abdominal aortic anneurisms, where the aorta ruptures and the patient is bleeding out into their belly), ruptures esophagus (esophagus ruptures, leaving the patient unable to breathe and emptying stomach contents into the chest cavity), and massive heart attacks leaving the body systems nearly useless. We have a high percentage of patients on dialysis (meaning they have kidney failure), which attests to the overall acuity of our unit right now.

I’m wondering if this is a downward trend in the health of our country, or perhaps a sign of the times with less people getting preventative health care. Hmmmm?

Stay healthy, Phoenix.

I was team leading (same as a relief charge nurse) & helping another nurse admit a patient to the ICU from the cath lab. He was in his 50s, had a heart attack, and the lesion was successfully opened and stented by the cardiologist. This patient was spanish-speaking (surprisingly, something we don’t see in my area of Phoenix as often as you’d think) and he was waking up from sedation very wildly – thrashing all over the bed and trying to sit up. I was holding one of his arms down, and the other nurse was on his other side, because he still had a sheath (big IV access) in his groin and if he sat up, he would run the risk of severe bleeding. We were attempting to get him to calm down, when he pulled his arm (the one I was holding) up to his face and bit my arm. I pulled away quickly and used my other hand on his forehead to keep it on the pillow.

Two more male staff members came into the room to help us physically restrain the patient (now for our safety as well as his own). We then called for security and the house supervisors to come to the room and the patient was placed in restraints and his sedation from the procedure kicked back in.

I know that there were many variables that act as excuses for this patient to act how he did (language barriers, confusion from sedatives), but there was a spanish-speaking staff member in the room while the patient was acting out and the patient was fully aware of what was going on. He knew that he was in the hospital and remembered coming to the emergency room with chest pain. If a person is awake enough to realize these things, I think there is no real excuse for actions like that. I’m sure it’s hard being in that situation – not knowing what exactly is going on and having people trying to restrain you, but to lash out and bite someone when you willingly came into the hospital for help is inexcusable.

Situations like these make me weary of getting as close to patients as we often have to. But, my two options as a nurse are to 1) attempt to restrain him and put myself in danger, or 2) let him do what he wants, which would cause a life-threatening bleed from his artery onto the bed or into his abdomen.

What’s a nurse to do?