Latest Comments by Anna Flaxis

Latest Comments by Anna Flaxis

Anna Flaxis, ASN 19,500 Views

Joined Oct 15, '10. Posts: 2,787 (67% Liked) Likes: 8,067

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  • 2
    Here.I.Stand and Altra like this.

    All4NursingRN, what do you hope to accomplish?

    His behavior was definitely rude, but did it impact patient care in any way?

    What do you think a union rep or HR might do about a co-worker butting in on a conversation that had nothing to do with patient care?

    You could try to talk to the physician in question, but I'm not certain how constructive that would be.

    I would suggest letting it go. The best time to deal with things like this is in the moment, and the moment has passed.

    I must say it sounds like he has the world's crappiest schedule. That doesn't excuse him acting like a horse's behind, but taking call every day for a month? I. Just. Can't. Even.

  • 4
    ShaneTeam, SmilingBluEyes, Cola89, and 1 other like this.

    Quote from Cola89
    Once in awhile this ER doc calls the nurses monkeys. Being as I'm new, I haven't heard it for my self yet. The subject just came up when I was telling another nurse that this doc had just explained to another doc on behalf of our new ER Physician Assistant that 'PA school is like nursing school, but for smarter people.'

    How would you interact with someone who such an apparent disdain for nurses and other health care personnel?
    So you haven't actually heard this doc referring to nurses as monkeys?

    The PA school comment certainly sounds inappropriate, but if you weren't involved in the conversation, I say MYOB.

    How I would interact with someone like you describe would be to keep my interactions professional and appropriately respectful and centered around patient care.

    Since you are a newbie, don't go into this expecting this doctor to treat you badly based on hearsay/gossip. Go in expecting to be treated in a professional manner, and behave accordingly.

    If and only if this physician treats you in an unprofessional and derogatory manner, address it in the moment and let him or her know you will not tolerate it. If it continues, then file an incident report on his or her disruptive behavior.

  • 1
    emtb2rn likes this.

    We do this quite often, as we are a small hospital and specialties are frequently unavailable. How we handle it depends. For instance, if it's an interfacility transport, we handle it like an EMTALA transfer except they go POV. If the specialist wants the person to come to their clinic, or meet them at the ED of the other facility, then we discharge them. We only ask them to sign AMA if the physician does not agree with their wish to go POV. If the physician thinks it is safe to go POV, then we do not ask them to sign AMA.

  • 1
    Pixie.RN likes this.

    I helped start our unit practice council. Processes, since they relate to nursing practice, are very much within the scope of a unit based council. Is there a specific process you'd like to start with? I suggest attending the next unit based council meeting and getting it on the agenda.

  • 7

    ^^ Ugh, Ambien comes to mind...

  • 44
    estellebb, bindikwan, Hollybobs, and 41 others like this.

    I was just curious how others handled this type of situation.
    I am rarely caught by surprise when an otherwise sweet LOL suddenly turns into a raving lunatic. I actually kind of expect it.

    Some potential causes are UTI, constipation, hypoglycemia, sundowners syndrome, a pulmonary embolus, worsening illness, or even just being afraid and feeling helpless. A change in mental status should trigger inquiry into what could be causing it.

    UTI would be one of the more common causes, and constipation can be a contributing factor to UTI due to compression of the urethra by bowel contents, leading to incomplete bladder emptying and thus, urinary stasis. So maybe, your LOL's complaint about being constipated might not be too far off the mark. One of the more common symptoms of UTI in the elderly is altered mentation/delirium.

    Also consider the reason this person was admitted-for pneumonia. Her change in mentation could be related to a worsening of her condition.

    Another consideration is that often, elderly folks with milder forms of dementia compensate well at home in their normal, predictable environment, but once they are in an unfamiliar environment with different routines, the altered mentation is more noticeable. Family members may tell you that "Grandma has all her marbles" or is "as sharp as a tack", but that's in the home environment where she is able to compensate. The hospital environment interferes with this ability to compensate, and so you will see behavioral changes that would go otherwise unnoticed.

    So, to answer your question, how I handle this type of situation is first, I do what I need to do in order to keep the patient safe. Make sure the room is free of clutter, the patient is wearing nonskid slippers, and offer to toilet her. I will offer warm blankets, another pillow, PO fluids or a snack. I will offer a distraction, such as TV, or ask her about her life- her children, pets, where she grew up, etc etc. Once the patient is calmed down and safe, I will take a complete set of vitals, including a temperature; if diabetic, check a CBG; and I will then notify the physician of this change in condition. The physician may want to order a UA, or a repeat chest xray, as her change in mentation may be related to worsening pneumonia.

    I would then document the patient's behavior, the actions I took to ensure her safety, my assessment data, that I notified the physician, and whether any new orders were received.

  • 1
    vicy likes this.

    Selemat datang allnurses! :-)

  • 1
    Lucy1798 likes this.

    I'm going to preface my comments with the disclaimer that you may not like what I have to say-but I'm going to be candid and share my impression of what I see here.

    For example, I was preparing an IM injection of Haldol Dec, which is very thick and syrup-like and she told me that I was using the wrong gauge needle. I was using a 20 gauge and she told me I needed to use a 25 gauge. I would be there for days drawing it up if I used a 25 gauge. She also told me that I could give 2.5 ml in the deltoid per patient request and that she does it all the time. I refused....
    There are no absolute contraindications to injecting 2.5mL in the deltoid. It is best practice? Maybe not, but is it flat out wrong? No. As far as needle size, while it's true that more viscous medications take longer to draw up in a smaller needle, the injection will be more painful with the larger needle. Unless there was a compelling reason to draw up this medication rapidly, other than for your own convenience, your charge nurse is right that the smaller needle is appropriate. In the absence of contraindications, honoring the patient's request and injecting into the deltoid and using the smallest gauge needle possible for patient comfort is more patient centered care, and I think your charge nurse is correct here.

    she told me I needed to brush up on my nursing skills and told me that I was, "being stupid and insubordinate."
    While I don't advocate this response and I think it was inappropriate and unprofessional, what I am seeing is that she was very frustrated by your refusal to receive her input.

    As a Charge Nurse, she has the authority to supervise you and give you feedback on your practice. That is part of her job. The line between "micromanaging" and "managing" can be a fine one, and it's easy, when given feedback about improving your performance, to feel defensive and to view that feedback as micromanaging, especially when the supervisor is not skilled in giving constructive feedback. But, this doesn't make her wrong, and it doesn't erase the fact that she has the authority to give you this feedback.

    From what I can gather from your post, she appears to have an 'Authoritarian" or autocratic leadership style. This is the "do as I say, not as I do" type, who will sit in front of a desk and bark out orders. There is a time and a place for this style of leadership, but in the day to day running of the unit, most people will chafe against it, particularly when the autocratic leader is not very skilled at communication.

    Does anyone have any tips in dealing with this?
    Short of finding a new job (not because that would let her "win", but because you will have to work with all kids of different people for your entire career, and leaving a workplace because of interpersonal difficulties is not a pattern that I see as particularly healthy), my suggestion would be that when she gives you feedback, try to rise above the manner in which she is delivering it that makes you feel so defensive, and ask yourself if maybe she has a point? Give her the benefit of the doubt that maybe she knows something. Treat these interactions like a conversation in which you might learn something.

    In the end, she is the Charge Nurse, and management is aware of her behaviors, and if you love your job as much as you do, you have got to figure out how to make this work. If you just can't, then I think looking for work elsewhere is probably your best option, although as I stated above, it would be a last resort. You're going to work with difficult people everywhere you go.

    Good luck! :-)

  • 3
    NewbieEDRN, Momma1RN, and amzyRN like this.

    My experience is that physicians, no matter what specialty, are just like everyone else and put their pants on one leg at a time just like everyone else. You will have physicians in the ED that you only speak to when you have to, some that you enjoy a collegial relationship with, and some that are just downright wonderful human beings that you feel proud to work elbow to elbow with, and everything else in-between. Just like on the inpatient unit.

  • 2
    Toastedpeanut and Kitiger like this.

    Agree with above ^^^

    Also, I'd like to add that complaints about food or other things speak to the patient's mood, which is a part of a behavioral health assessment. If behavioral health is called in to see the patient, it's really helpful to have some information on the patient's mood and behaviors. Quoting the patient in their own words is good practice.

    As a House Supervisor, I get called when patients are threatening to leave AMA. It's really helpful when there is documentation of behavior leading up to that point, ie what the patient said or did, what the staff said or did, whether we attempted to make reasonable accommodations, etc. When the patient is found dead from an acute GI bleed under a freeway overpass, it's really important that we be able to show that we did our due diligence to meet the patient's needs. It's really frustrating when there is not a single note in the chart for an entire shift or two leading up to that moment when the patient walked out the door.

    Or if Grandma falls while trying to get back into bed from the chair, where is the documentation that somebody spoke to her about safety, made sure she was wearing nonskid socks, made sure the room was free of clutter, and made sure the call button was within reach? What was her mental status at that time? Was she known to be impulsive, or was she completely A&O and able to make her needs known?

    So again, observations about behaviors are not necessarily irrelevant, and the person making the observation (RN, CNA, Tech) is qualified to enter it into the record in accordance with institutional policy.

  • 4

    I can't answer "yes" or "no" in your poll, because I don't think this is a black or white issue.

    If your institution has an hourly rounding policy, and documentation requirements include an observation note, then I don't think it's necessarily inappropriate for the tech to follow institutional policy by entering a note. If the entries are truly riddled with errors, I don't think it would be unreasonable to gently coach the tech to use the spell-check function.

    As far as the content, this information *could* be relevant. If the patient's behaviors are disruptive to the unit, if the patient's mentation is in question, if the patient is a fall risk, if the patient's dietary preferences have not been addressed in the plan of care, etc etc etc, then this is all relevant information.

    I think that in this day and age of click-boxes in the EHR, that the narrative note serves an essential function. The narrative note paints a picture of the patient and their situation that all the click-boxes don't. I think hourly observations should be charted, even if it's just a brief "resting quietly, denies needs at this time". It only takes a few seconds to do, it is helpful for charge nurses, physicians, house supervisors, and other folks who might be needing to know what's going on with any given patient and don't have time to go digging through the chart to look at all the click boxes and decipher what they could mean about the patient's condition, and it could really save your bacon in the event that a patient or a family member claims that you were never in the room or that you didn't address certain issues, etc.

    Some people argue that it is double charting; ie if my neuro assessment says they were A&Ox4, my musculoskeletal assessment was WNL, then why should I document a narrative to that effect? Or, the record shows I was in the room giving a medication, why should I also document that I was in the room in a narrative note?

    The reason is that notes paint a picture of the patient's course of illness and the notable events during their stay in a way that click-boxes do not. The chart might show that you did an assessment or that you were in the room giving meds, but it does not give an impression of what the patient looked like at that moment in time. No, you don't have to chart every time they fart sideways or have an itch on their backside. The narratives should be relevant to the patient's specific situation.

    So, in a nutshell, if the tech's notes do not contain relevant information, then they need a little coaching on what should and should not be a part of the hospital chart. But if the notes are relevant to the patient's situation, then your narrative notes need to contain relevant observations too, and show that you followed up on anything the tech might have noted.

    Something that drives me nuts when people chart, is when they chart subjective feelings, like "patient is angry". Don't do that. Chart behaviors, like "patient pacing back and forth with fists clenched, states loudly "This place is horrible! I can't get any rest!" (and document what you did about it). Another one is when nurses chart "patient aware" or "doctor aware". How do you know what the patient or doctor is aware of? Instead, chart "plan of care explained to patient, patient verbalizes understanding", or "doctor notified, new orders received (or no new orders received, whichever is the case)".

    Anyway, I support the tech entering a brief observational note, if hourly rounding documentation is required at your facility, and I support you coaching the tech in using spell check and making sure the content of their notes is relevant and appropriate. For hourly rounding, typically you just want to show that the "Five Ps" (or whatever criteria your institution has laid out) were addressed.

  • 1
    SurgicalTechCST likes this.

    Put in your vacation request and don't pay for your vacation until your time off is approved.

    Quote from bunnynurse
    Hi everyone,

    I've been currently working at a LTC facility since mid-January 2016. We are quite short-staffed. My boyfriend and I are wanting to go to Cancun in July. I plan on putting in my vacation request this week. My facility has been known to be stingy on accepting time-off requests... and I'm kind of worried. What if I've already paid for my vacation, and they decline my request?

    Has anyone have any experience on this? Thanks!

  • 0

    Quote from cphillipslpn
    Okay, so I'm a nursing student about to start externship in a physicians office. I recently was a patient at my gynecologist's office, my doctor was female, and they are required to have a chaperon. This particular nurse likes to stand between my legs right next to the doctor and watch the whole procedure. The second time I was there a different nurse stood opposite the doctor to where she could not see what was going on. So my question is; do you have to watch what is going on during a pelvic exam as the nurse? Because it made me very uncomfortable to have so many people down there and I don't want to have to make my patients feel uncomfortable. Where do you all stand during an exam?
    I work in the ER. I do the pelvic set-up, which means I set up all the necessary equipment, i.e. speculum, lube, specimen swabs, get the stirrups ready, have the patient remove underwear, etc. Once the pelvic exam is underway, I stand at the patient's side, facing the physician, so that I may offer emotional support to the patient and hand and receive the specimen swabs to and from the physician.

    Since I am not an advanced practice RN and have no desire to become a SANE nurse, I have no need to observe the physician's pelvic exam technique, and as an RN, it is not necessary to document a pelvic assessment - there are some assessments that are perfectly acceptable to defer to the physician.

  • 0

    Quote from Altra
    This thread is about treatment of suicidal patients in the ED. Not the woulda-coulda-shoulda that may or may not have occurred prior to the patient arriving in the ED, or the various modalities of mental health treatment across the entire spectrum of care ... just what happens once a patient presents to the ED expressing suicidality or at risk.

    The baseline expectation is safety of the patient. Procedures are designed to maintain the physical safety of the patient, to allow for evaluation of what the best next steps are.
    Agreed. I agree with some of the ideals expressed, but ideals are often not congruent with reality, as is the case here. I would love it if we treated mental health crises differently, but we don't.

  • 5

    Quote from Dany102
    Anna Flaxis,

    Thank you. Your post has done much to explain some misconceptions I had. Are you familiar with a training program called "Living Works?" Also known as "ASSIST." It is, in essence a suicide prevention and intervention training program open for anyone willing to pay to get it. I do not know if it is available in the United States, but I am sure there must be something equivalent. I have received this training and have used it in a few occasions. I will not claim I deal with many suicidal persons (I don't think I would be able to handle it), but I have. Most of my comments, especially with risks assessment are, derived from this training.

    Part of that training taught me how to assess those risks (in order to make a decision as to how to best help a suicidal person). It's not that hard, really. You just have to be committed to ask the right questions. The issue is that I don't think that every suicidal person is best treated at the hospital. The more severe cases, with high risks? Sure. But low risks? No. I wouldn't and I haven't, except in one occasion.

    Dany
    I agree with the bolded sentiment above.

    But please keep in mind, that it is not the role of the ER RN to determine this. The role of the ER RN is to provide for patient safety while they are under our care. It is the qualified mental health professional who interviews the patient, and based upon their professional assessment, makes recommendations for further intervention, whether it is discharging the patient home with a safety plan in place or inpatient admission to a behavioral health facility. This is not the role of the ER Nurse. Again, the ER nurse's role is to keep the person - a person that we do not know, who has expressed a desire to take their own life -safe while they are in the Emergency Department.

    Also keep in mind that the ED did not go to the patient. The patient came to the ED. Contextually, this is much different from intervening as a private citizen out in the community. You are attempting to apply this to the ED context, and it just doesn't work. It's apples and oranges.

    And, we cannot turn anyone away if we receive any federal money, due to EMTALA. We take all comers. And if we do discharge someone who ends up going out and killing themselves, then we can be held liable. I personally know of situations like this, where the family is now suing the hospital.

    That's great that you're trained and have provided assistance to individuals in your community. But it's important to understand that this is not the function of the ED in this situation. We do not provide intervention and treatment beyond immediate, acute needs. We are only the conduit to the next phase as determined by the qualified mental health professional.

    Do I think this is the way it should be? Absolutely not. We have a mental health crisis in the USA. Behavioral health services are terribly underfunded so as to be nonexistent for all intents and purposes in some locales, and people come to the ED because there is no other way for them to get help. Inpatient behavioral health beds are at such a premium that people who really need this service spend days, weeks, and even months in the Emergency Department - not receiving therapeutic treatment, but just being housed. You may think I am exaggerating, but I'm not.

    It is messed up. Nobody is more aware of this than the ED RNs who are on the front lines. You are trying to apply your own experiences and ideals to a context where it just doesn't work. We are just as frustrated by the situation as anyone, if not more so because we see it day in and day out. It's frustrating as hell, because we know we're not providing for the patient therapeutically, we're just meeting basic needs.

    The solution, in my opinion, is to undo what Ronald Reagan did in the 1980s, and federally fund mental health services, taking away the block grants and imposing rules and structure for what the states have to do, and, most importantly, to fund those things appropriately.


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