10/31 What I learned this week: Walking Dead anatomy lesson, herpes EVERYWHERE

[ixchel]

I'm having my annual struggle to decide what I want to be when I grow up. Thankfully, things are feeling a bit narrowed down this year. At the very least, I think it's time to start the typical core NP classes.

Every level of care provider at my facility is frustrated by our current lack of psychiatric specialty care, psychiatric consulting provider, and poor staffing for acute psychiatric needs, but no one knows what to do about it. Why aren't we diverting some of these patients?

Huh. Perhaps becoming a PMHNP would knock out both those birds with one stone. (Honestly, though, I'd burn out faster than The Donald's political dreams should have. Hey, Dogen, come to the mid Atlantic when you graduate. We have crab cakes and they are amazing.)

A terminal DNR patient will become full code if they are admitted from an incomplete suicide attempt. I have a serious problem with this.

If you only see one piece stitched in on a central line (IJ, SC, or femoral), you should get in touch with the MD to get the second piece stitched in. That is a lot easier than having to pull a line and reinsert a whole new line. If you only see one piece capable of being stitched in, the other piece wasn't put on, and it needs to be. You'll have someone irritatedly inform you that that will require wasting an entire central line kit just for that little thing, but again, this is better than requiring a whole new line insertion. If you notice this is a trend, consider incident reports. Seriously, it's not okay to increase infection risks and invasive procedures to patients just because the ED doc or intensivist just didn't feel like sewing in a couple more stitches. (See picture) [/rant]

The Fitbit charge HR is my favorite toy right now.

Every time I open the AN app on my iPad, I want to get the eye booger off the right eye of the nurse in the front.

Herpes can literally get in and on every part of the body. I'm glad my innocence was already shattered by sidepockets because for real, people. EVERYWHERE.

My fellow Walking Dead community - blood does not pour like that from the second intercostal space lateral to the midclavicular line, and there are no intestines at approximately the fifth or sixth intercostal space, even if that was somewhat midline. I'm just saying.

I hate to admit this (because I'm in love with, and rather loyal to my hospital), but lately, some ED shifts have been a little scary. I really hope they get their act together quickly.

One of my floor's charge nurses has advanced so highly on my "you are an amazing nurse and charge nurse" scale, that I think she broke the meter. During some of the hardest shifts I have ever had, she has put herself right at my side, battling through the thick of it with me. She has truly made me realize the value of a charge nurse you can TRUST.

That does, unfortunately, make it suck to realize how much harder a shift can be with a charge you can't trust. My understanding is that a previous manager made it a habit of promoting the slower, lazier nurses to charge. Look, if you are a manager and you think it's easier to promote them than it is to fire them when it is obvious the bedside isn't a good fit, you're doing it WRONG.

I have heard that in the last two years, my unit has gone from "fend for yourself" to a cooperative team that has each other's back. It's sad to hear that it was that way, but I'm proud to be part of the change.

This makes me laugh every time I see it:

Apparently my screenname is a planet name in A Wrinkle In Time where Aunt Beast lives. How did I not remember this?! Charles Wallace knows!

After the last two fresh off residency new hires we got (who are absolutely terrible to work with), I never expected to feel the massive amount of relief I felt when we just got a new hire who has a decent background and enough experience to realize nurses are a valuable resource, not competitors in an ego pissing match.

What have you learned this week?

As a friendly reminder, it is important to keep our WILTW threads mostly related to nursing. It's okay to throw in personal life observations, as long as the main focus of discussion remains nursing. Be safe on this All Hallows' Eve, my friends. :) And all you ED peeps - I'm hoping for some really good lessons from you on Sunday!

[WKShadowNP, DNP, APRN]

Blessed Samhain!

I learned that Johns Hopkins really does a bang up job in teaching PICC line care to their patients. Had a fellow today who was kind in his gentle reminders on asking us to remember to wear makes when we did the dressing change, and even though he didn't remember the name, he new he didn't have and needed the antimicrobial patch under the transparent dressing. He thought the cap was clotted because of dependent pooling of a nominal amount of serous liquid in it, and because the infusion center hadn't been able to remove the cap in their attempt at troubleshooting the pt came to me.

BUT!! I educated him on the least invasive approach first and impressed him with my ability to declot it with alteplase in a matter of minutes. He was impressed and we did the whole dressing and cap change appropriately and to his satisfaction. Go team.

I learned that my next quarter is finally registered and none of my core classmates are with me. This kind of bummed me out. I've been traveling along this grad student road with a built in support group for about 18 months. So I'll get new acquaintances, but it won't be the same.

I learned that a little pain medication goes a long way when taken before pain is so miserable that I whimper with any turn in bed. My desire to not take the stronger stuff led to a delay in relief. As a nurse, I'm pretty darn smart, but I'm an idiot when advocating for myself to myself.

[margin261]

Ixchel- I think you would be an awesome NP!! Are you at the 'considering it' stage or the 'yeah, I'm going to do it stage'? You know you will get all kinds of encouragement here!!

And can you elaborate a little about the terminal DNR/unsuccessful suicide attempt... I have kind of an idea what you mean---I'm just hoping I'm misunderstanding

[ixchel]

Ixchel- I think you would be an awesome NP!! Are you at the 'considering it' stage or the 'yeah, I'm going to do it stage'? You know you will get all kinds of encouragement here!!

And can you elaborate a little about the terminal DNR/unsuccessful suicide attempt... I have kind of an idea what you mean---I'm just hoping I'm misunderstanding

Thank you! I think I've reached the "I'm doing this now" stage.

The terminal DNR.... Had a guy with a terminal diagnosis and very poor quality of life due to poverty, lack of mobility, and access to care issues. He chose to attempt suicide, was resuscitated, and was placed on 1:1 and kept admitted until a facility for transfer for psych intervention could be found. Attempting suicide makes him incompetent for decision making, and therefore, full code.

If a truly suffering terminal person without family decides to opt out, does that really prove inability to make medical decisions? This was a fully alert, oriented person, completely capable of complex thought, rationalization and reason.

[margin261]

Thank you! I think I've reached the "I'm doing this now" stage.

The terminal DNR.... Had a guy with a terminal diagnosis and very poor quality of life due to poverty, lack of mobility, and access to care issues. He chose to attempt suicide, was resuscitated, and was placed on 1:1 and kept admitted until a facility for transfer for psych intervention could be found. Attempting suicide makes him incompetent for decision making, and therefore, full code.

If a truly suffering terminal person without family decides to opt out, does that really prove inability to make medical decisions? This was a fully alert, oriented person, completely capable of complex thought, rationalization and reason.

That's basically what I thought it meant, but was so hoping I was wrong. Poor patient. Thanks for elaborating.

And I'll be sending you all the good luck in school vibes I can round up!

I'm about ready to go back to work. Only intended to take off 1-2 months to get married & moved into a new home. Just after those were accomplished, my father had a CVA. Quite a scare, but he's doing well. At home & doing outpt therapy 3x/wk. the CVA seems to have sped up the dementia he was just starting to display prior. He'll be 89 next month.

What I've learned this week is that it's a difficult balance between being nurse & daughter. There's been some role reversal that bothers us both, but I am doing everything I possibly can to maintain his dignity & as much independence as possible.

I'm proud & humbled that I have the knowledge & ability to go through this with him and to help my Mother with it as well.

But it's hard, and more often than not, I shed a few tears on my way home.

[Rose_Queen, BSN, MSN, RN]

I've learned how uncomfortable it can be to tell a patient we've just brought into the OR and given Vitamin V (Versed) to that we now have to cancel surgery due to an emergency. Patient was not happy, I was not happy, and the surgeon was a bear to work with during the emergency.

But, I've also learned that one of my coworkers is really good at defusing situations like that. And that other departments can work together to get the patient somewhere they could be more comfortable until they could find a new room on one of the floors.

That the more students I see rotate through the OR and see on the floors when dropping off patients solidifies my decision to move into staff development in the future instead of academic education. Just seems to fit my personality better.

[cracklingkraken, ASN, RN]

I've learned that there are a lot of things that can go wrong in a pregnancy. Also learned VEAL, CHOP, MINE.

I learned that children are little monsters (just kidding, sort of). Terminally ill children break my heart.

I've learned that some children need a good spanking. Dear goodness, some of these older children's behaviors...

I've learned that trying to look for reviews on hospitals while narrowing down my choices of nurse residency programs is very discouraging. Then again, who really leaves their workplace if they enjoy it?

[Spidey's mom, ADN, BSN, RN]

I learned from a friend who was involved in The American Nurse Project that their new project will feature end-of-life issues and a look at hospice. This is something that needs more of the limelight for the public. Hospice still has to fight the myth that we sign people up and then go into their homes and kill them with morphine.

The American Nurse Project

[Dogen]

I learned that sometimes the things I know fall out of my head. I recently had to be prompted to remember Wellbutrin XL exists (versus IR and SR, which my patient was on)... I blame the 60+ hour work weeks since September.

I've developed a more in-depth understanding of Prader-Willi syndrome, thanks in part to having a patient with it and also surprisingly a classmate who's a bit of an expert. Convenient!

I can talk to patients about their suicidal ideation all day, but when someone says, "Sometimes I think my eye just shouldn't be there," I have to pause and think about how to respond.

I'm the Most Expensive Sitter today in the ED and I just heard an MD say to my SI patient, "I need you to tell me what the risk is that you're going to harm yourself. Do you want to go home?" ... That's a technique I've never seen before.

An internship that I was interested in but which ended MAY be starting up again. I'm keeping my fingers crossed until January. Paid internship. Mmmm.

If you take enough Artane you will hallucinate. I kind of want to try it? But I don't want to damage my brains. So.

[Lauraingalls, BSN, RN]

I learned VEAL CHOP this week too! I cried when I was at my first lady partsl birth this week. I was so happy for the couple.

[ixchel]

Dogen, I had a Prader Willi patient in my outpatient psych rotation. What a wild thing to have. This guy had had very intense inpatient management recently and had lost well over 100 lbs. I can't imagine how torturous that was to experience. We had a day when we went on an outing with the group we were working with. His intellectual deficits were quite noteworthy and obvious to the random people who were where we were. His social awareness was decreased enough that he didn't notice. It didn't help that his family lived in poverty and his brother, a huge influence in his life, was in and out of jail for drug selling. It's the stories like this that make me know I'm not strong enough for psych. It's hard enough having the little bit of psych I do see on my unit.

[Jensmom7, BSN, RN]

I learned VEAL CHOP this week too! I cried when I was at my first lady partsl birth this week. I was so happy for the couple.

This makes me so glad that there are myriad opportunities for nurses, and myriad nurses to fill those roles.

I learned many many decades ago that L&D was NOT on my short list of interests. Frankly, if I had to palpate One. More. Fundus I was going to throw up lol.

I'm glad you enjoy it.