11/7: what I learned this week: Trey Anastasio wants to weigh your head; Cerner is stupid

[ixchel]

I have an absolute passion for discharge teaching, especially with new meds and diagnoses.

Sometimes compliance really does depend on convenience.

Cerner is stupid. A one-time stat dose of a med IV will cancel itself and mark itself as complete when that dose isn't given within an hour. The problem with this is if the dose is ordered in the ED and isn't immediately given because the patient needs fluid boluses, dopamine and atropine first, they come up to the floor and it looks like either someone discontinued the med, or administered the med. If anyone less neurotic than me got this med, they wouldn't have spent the half hour I spent going between ED nurse, hospitalist and pharmacy trying to figure out what happened.

Had a patient who is fairly new to alcoholism. New enough that no real damage has been done yet. He came in HR in 30s, SBP in 60s, after falling out in the kitchen. He is the first alcoholic patient I've had that I genuinely believe may be quitting. He's been scared sober.

After sitting on it for nearly two years, I have finally decided on grad school, which one and how to approach it. What I learned from this decision is that I'm probably really going to miss my unit. It's the most chaotic, busy unit in the hospital, and some days are soul crushing, and yet, I just love the people (usually).

If you have an LPN doing an admission assessment, first, make sure it got signed by an RN, but also, actually make sure what was charted is accurate.

If a cardiologist blows off intervention on a patient who has had a ridiculous number of 4-9 second pauses over several days, that patient may become brady and hypotension to a dangerous degree, right before shift change, causing her to need a temporary pacer before she gets the permanent one she was scheduled to get the next day.

AND, if that same cardiologist blows off an intermittent heart rate in the 200s for two days before deciding cardizem might be nice, probably an incident report would be a good idea.

AND, my favorite, most helpful cardiologist has left my favorites list and gotten onto my ess list.

When the generally lazy CN actually tries to "help", she may actually make things SO MUCH WORSE.

When upper management is entirely made of nurses, I genuinely believe this contributes to a wonderful work environment.

Did I mention I love patient teaching?

Four discharges going in simultaneously for four impatient patients makes for a horrible day. HORRIBLE. And of course, discharging 4 means more terribleness. Brace yourselves. Admissions are coming.

When your patient has been saying literally the entire day that she will sign out AMA if she is not discharged, expect her to pull a bait and switch while her husband talks to you at the nurses' station. Also, expect to get security involved when you can't actually find her anywhere. Expect her to be hiding around the corner of the building chain smoking, literally leaning on the "no smoking sign". Expect her to flip out when she thinks security is approaching to force her to go back inside. And then expect your coworkers to be confused when you tell them you had to find her to get her IV out. Dude, I'm not giving her free access to a vein.

(Also expect that to happen at shift change as well.)

Benzos and opiates can metabolize so quickly that ED doses may not pop a UDS positive that evening. I didn't even want to send the UDS to lab because the most likely meds to pop positive on, she'd just gotten in the ED. Unless, of course, grandma is doing coke, meth and ecstasy.

I'm really lacking patience for a couple of posters in the controversy vaccination thread.

Some patients have no problem whatsoever being really nasty to everyone EXCEPT their nurse when they feel the nurse should have done something that that nurse chose not to do. For instance, patient complained of headache and noted there was a nitro patch on, with no order to continue nitro patches. Removed it, waited a little while to see if that worked. The tech goes in and the patient tore him a new one over not getting pain medication. Every time I went into this room, the patient was sound asleep. She got medication and tea with her 2200 meds, and hers were given last because she stayed asleep. When I woke her up, not one single complaint. It's just weird.

I'm incredibly disappointed when floor nurses identify a need, and case management blows it off.

Got a song stuck in my head. It's not all instrumental, I promise. And the lyrics are.... Well, you'll hear. Enjoy.

Phish - "Weigh" (HD) - YouTube

[ixchel]

I forgot to ask! What have you learned this week?

[WKShadowNP, DNP, APRN]

I have learned that my squeals of excitement at a high decibel worthy of Sarah Brightman's ears do not, in fact, break glass even though it was for a good reason (first NP job interview).

I have learned that it is a good thing I put in my satisfaction survey at the beginning of my day on Monday instead of the end because that was possibly one of the worst shifts I've had. And, while I'm not proud of my behavior, that saying a few f-bombs did make me feel better. It also amuses my peers to see the very typically sweet and demure, but not shy, Shadow swearing like a sailor and aggressively looking for an effin' pack of crackers so the g.d. drug addict with the suspicion of osteomyelitis in her thumb will go get her forsaken xrays taken. But then to sign out AMA before getting an IV started and two IV antibiotics when she returns. But here. Here's all the crackers I could find *throws box at the wall* because there were none in my department so I had to go find your damn snack and I had higher acuity patients and lots of em...eat you mother lovin' CRACKERS!

Not cool, cupcake, not cool.

[Alisonisayoshi, LVN]

If a pt is yelling at me to go f myself about his meds, on my re approach I should stand kinda far back, especially if he's been combative in the past. Getting hit for trying to help isn't fun or conducive to me having a good shift.

To remember it's a disease process and not a personal attack no matter how upset it makes me.

That management doesn't always want to hear you when you say someone needs psych care not SNF care.

[Alisonisayoshi, LVN]

Oh and that a good nursing tote bag is invaluable to me. Finally broke down and bought one and I see why everyone I work with has one.

[Purple_roses]

I learned that my hands heavily shake when I'm nervous about performing a procedure, like wound care, for the first time. I'm hoping this stops by the time I have to start working with IVs.

I learned that I love clinicals, and that clincials have somehow made lecture even more boring than it was before. Who would have thought that was even possible!

I learned what a heart murmur sounds like first hand, and I'm happy to say I was the one that caught it (not happy for the patient though). A month ago, I was still unsure about where exactly to place my stethoscope. Now, I'm feeling more competent and confident.

I learned that some patients can be on 40+ meds, and that this makes for one hell of a care plan. I'll have to print off some extra medication sheets.

I learned that one of my best friends has feelings for me. This knowledge is more confusing than the electrolytes.

[Purple_roses]

I have learned that my squeals of excitement at a high decibel worthy of Sarah Brightman's ears do not, in fact, break glass even though it was for a good reason (first NP job interview).

I have learned that it is a good thing I put in my satisfaction survey at the beginning of my day on Monday instead of the end because that was possibly one of the worst shifts I've had. And, while I'm not proud of my behavior, that saying a few f-bombs did make me feel better. It also amuses my peers to see the very typically sweet and demure, but not shy, Shadow swearing like a sailor and aggressively looking for an effin' pack of crackers so the g.d. drug addict with the suspicion of osteomyelitis in her thumb will go get her forsaken xrays taken. But then to sign out AMA before getting an IV started and two IV antibiotics when she returns. But here. Here's all the crackers I could find *throws box at the wall* because there were none in my department so I had to go find your damn snack and I had higher acuity patients and lots of em...eat you mother lovin' CRACKERS!

Not cool, cupcake, not cool.

I would suggest a glass or five of wine.

[canigraduate]

I learned that I am the nutjob whisperer and they punish me with nutjobs because of it.

I learned that meth is a helluva drug. At least this one remembered his name.

Spice is killing our young and stupid population too fast. There is going to be a shortage of people in following generations if they keep doing dumb stuff.

I learned that it I like Med-Surg obs better than tele obs. I'm nervous around a bad ticker.

I learned that I can still cry for my patients. Had a super sweet little old guy who is slowly drowning due to persistent pleural effusions secondary to ESRD and EF of 20-25%. He's a walking balloon. He brady'ed down to 20-25 BPM and refused atropine. He was alert and oriented the whole time. I think he's tired and ready to go, but he hates being a burden to his overburdened son. The poor son is helping take care of him while his taking care of his own wife, who was placed on hospice for cancer. That was a super sad situation and I had to take five on that one. Had a nice little cry when I got home.

I learned that I love precepting, even when my assignment is crazy stupid.

I learned that my worst days at work are all coinciding with the days a certain manager is on shift. I swear she either hates me or is using me as a tool. Either way, she isn't my favorite person.

I also learned that I am not a fan of one of the night shift managers. I asked for help so I could get a lunch, and she said no. Yup. She SAID NO. The next time they whine to me about overtime and productivity, they're getting an earful.

[canigraduate]

I learned that my hands heavily shake when I'm nervous about performing a procedure, like wound care, for the first time. I'm hoping this stops by the time I have to start working with IVs.

I learned that I love clinicals, and that clincials have somehow made lecture even more boring than it was before. Who would have thought that was even possible!

I learned what a heart murmur sounds like first hand, and I'm happy to say I was the one that caught it (not happy for the patient though). A month ago, I was still unsure about where exactly to place my stethoscope. Now, I'm feeling more competent and confident.

I learned that some patients can be on 40+ meds, and that this makes for one hell of a care plan. I'll have to print off some extra medication sheets.

I learned that one of my best friends has feelings for me. This knowledge is more confusing than the electrolytes.

Eventful week!

I'm glad you like clinical. That was my favorite part, too.

As for the IV starts, if you have a SIM lab, practice on the dummies until your hands stop shaking. Or, you can make a fake vein with grape juice, an empty fluid bag, and some tubing placed under a chuck. I had a veteran IV starter with a 90% rate teach me using that and went from 25% to 75%. Good stuff.

At the risk of sounding like an advice columnist, I would advise you to go for it. The best relationships come from solid friendships. My husband is my BFF. Unless there's no chemistry. You gotta have good chemistry, too. It makes up for a lot of other aggravation.

[WKShadowNP, DNP, APRN]

I also learned to get more information from the patient who medics bring in saying that all he wants is a shot of dilaudid.

Back story: guy falls and breaks his sternum two weeks ago. He is in so much pain despite prescriptions that he is unable to bear it and comes back to the ED at 3 am yesterday. He is seen, written different meds and sent home by cab (can't drive with the sternal frx d/t pain.) During my shift he comes in by ambulance around lunch time or so. At first I'm asking him what happened between 7 am and now. (biased from medic report). In the 5 hours that I had him it turned out that he is so shaky because he hasn't slept, he could not get the meds filled (which I did not know about until after getting him) and he can't fix himself food. He is so unsteady that he needs help transferring from the exam table to the w/c and then the toilet and back. I had no turkey sandwiches and only had crackers for him. I felt so sorry for him. He was certainly overlooked.

[Purple_roses]

I also learned to get more information from the patient who medics bring in saying that all he wants is a shot of dilaudid.

Back story: guy falls and breaks his sternum two weeks ago. He is in so much pain despite prescriptions that he is unable to bear it and comes back to the ED at 3 am yesterday. He is seen, written different meds and sent home by cab (can't drive with the sternal frx d/t pain.) During my shift he comes in by ambulance around lunch time or so. At first I'm asking him what happened between 7 am and now. (biased from medic report). In the 5 hours that I had him it turned out that he is so shaky because he hasn't slept, he could not get the meds filled (which I did not know about until after getting him) and he can't fix himself food. He is so unsteady that he needs help transferring from the exam table to the w/c and then the toilet and back. I had no turkey sandwiches and only had crackers for him. I felt so sorry for him. He was certainly overlooked.

That poor man.

[Jensmom7, BSN, RN]

I learned that even when I'm on the phone at the Nurses station, it's a good idea to actually pay attention and look when one of the Memory Care residents comes up and hands me something that turns out to be wet and sticky.

Fortunately it was just a bottle of pop wrapped in a wet napkin, but even so...eew.

This is the same little grandma who totally cops a feel when she rolls up in her wheelchair and gives you a hug.