Content That P B and J Likes

Content That P B and J Likes

P B and J 2,448 Views

Joined Nov 30, '10. Posts: 113 (33% Liked) Likes: 124

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  • Apr 26 '14

    Old-school RN here. Studied for Boards (before they were called NCLEX) while traveling West in a wagon train, fighting dinosaurs along the way. Cut my teeth in several ICUs, when Swan-Ganz catheters were becoming all the rage. Have seen trends and treatments come and go, the pendulum of nursing practice swing first one way then the other way.

    Background: I worked in IR (Interventional Radiology, which included staffing the Cardiac Cath Lab) for 21 years. Most recently (past 10 years) I work exclusively in Cardiology: Cath Lab, Stress Lab and Cardiology Case Management.

    Current Issue: Two recent encounters blew dust off a few dendrites, and got me wondering about the practice of transporting cardiac patients from either the ICU or tele unit to various procedure areas.

    Encounter One:

    Patient with NSTEMI (non-ST-elevated MI, the "less" dangerous form of MI) and +chest pain in the past 24 hours arrived via bed to our Cath Lab. He is not on a cardiac monitor. Say what???

    Repeat: He is not on a cardiac monitor. His accompanying nurse reported "the doctor said he could go unmonitored."

    EncounterTwo:

    Waiting for my next patient to enter the Stress Lab, I heard a familiar beep-beep-beep and turned toward the door expecting to see a gurney roll through, patient attached to the monitor, RN in attendance.

    What rolled through the door: Nuclear Med tech pushing a wheelchair, on which sits a patient with the transport monitor in his lap. Beep-beep-beep. No RN.

    My question: WHO is monitoring the patient???

    And now I ask you, gentle readers:

    1. Do you know your OFFICIAL hospital policy regarding transporting cardiac patients (or any ICU or telemetry patient, for that matter) off the unit for procedures?
    2. How old is the policy?
    3. Is it reasonable, sensible and sustainable (i.e., is there sufficient trained staff to accompany a monitored patient off the unit for two hours, while other nurses cover the transport nurse's patients)?
    4. Do ALL tele patients and ICU patients require RN attendance and monitoring for transport for procedures?
    5. Is it time for re-evaluation of said policy?

    I offer food for thought in the form of four articles my newly-dusted dendrites found when I did an online search for "monitoring patients going off the unit."

    First is a short thread from our own allnurses.com, in which members describe a wide range of policies and how they are implemented: Transporting Telemetry Patients off the unit - page 2

    Next I found a 2004 article - a statement of practice guidelines! - from the American Heart Association: Practice Standards for Electrocardiographic Monitoring in Hospital Settings

    (make some popcorn and settle down for serious reading with this one)

    Patients are divided into three classifications according to diagnosis and condition, to determine the need for monitoring. Lots to consider and ponder.

    I was pleased the website search revealed a wonderful small article outlining how one facility empowered nurses to formulate an algorithm to use that "enables safe patient transport without an RN or monitoring."

    The article is written by Nancy J. Mayer, MBA, BSN, RN, and published in the AJN Nov 2009. The algorithm is simple to use, takes a lot of guesswork out of the decision-making and requires a second nurse's (usually the charge nurse) approval for the transport plan.

    Look up Transporting Telemetry Patients -Aligning Forces for Quality (pdf)

    And finally, a short article about, well, exactly what the title says:
    Telemetry monitoring during transport of low-risk chest pain patients from the emergency department: is it necessary?

    Targeted mainly for patients being transported from the ED to a tele or ICU unit, this is a thoughtful study. Lots of ideas here.

    Oh, and the encounters I described earlier?

    Encounter One:

    I respectfully requested the nurse re-evaluate each transport situation. Patient with NSTEMI and chest pain within 24 hours who is going to the Cath Lab (which means, we don't yet know for sure the extent of coronary disease but he just had an MI, so it is quite possible he has cardiac disease!), no matter what the MD writes --- I will transport him on a cardiac monitor!

    Encounter Two:

    Think about it: Yes the patient was sent on a monitor. However, is sending the patient on a monitor, without an RN in attendance to watch the monitor, really carrying through with the intent of the policy of monitoring a patient during transport? IMO,either send him on a monitor with an RN or obtain an MD order to transport without monitoring.

    Ah, my old dendrites are tired now. Hopefully your patients who need watching (to paraphrase the Bard, [mis-]quoted in the article title) "must not unwatch'd go."

    Thank you for your attention, and I wish your patients EXCELLENT care!

  • Feb 16 '14

    One of my fellow nurses- let's call her Jane- was overheard complaining loudly this morning. She had received feedback from a physician that one of her chart notes was "unacceptable." She went on to say that she didn't understand why her note was unacceptable. I asked Jane to read aloud the note in question:

    "Patient was inappropriate."

    "What's wrong with that?" she asked, explaining that this particular patient had been rude the day before, yelling that it took too long for Jane to retrieve her narcotic prescription. The patient had, apparently, shouted a few choice words at this nurse while exhibiting some threatening behaviors.

    Jane's documentation, however, did not reflect that.

    As nurses, we need to chart specifics, and we also need to be objective. This is straightforward when we are describing, say, a wound that can be measured with a ruler, or a patient's report of pain as "burning in nature rated at a '6' on a 1-10 scale." But when it comes to behaviors, things get a little more difficult. A patient's wrath can evoke a negative response within the nurse that makes it difficult for him or her to remain impartial. Also, nurses may lack the precise vocabulary to explain the event.

    Jane told me that she had felt threatened by this patient, describing her as angry and inappropriate.

    "Okay, Jane," I said, "what specifically did the patient do or say that made you think she was angry?"

    "She started yelling. She was talking loud and fast."

    "So you could chart that the patient's speech became louder and faster. What did she yell at you?"

    Jane repeated some choice four-letter words that had been addressed to her.

    "Great, I would have charted those verbatim. Use quotes. What about her stance? Did she get closer to you, point, stiffen up? What gestures did she use? Did she threaten you?"

    Remember that the chart is a legal document and, as such, can be considered evidence. An accurate, unambiguous description of behavior, statements, stance, and gestures will stand on its own in a chart review. If you ever need to testify in court, the specific words will speak for themselves.

    The same goes for what patients say over the phone if you are a telephonic nurse: chart specific words in quotes, tone of voice, or change in tone if that occurs. If words are slurred, chart that.

    Don't use subjective words such as agitated, upset, verbally abusive, aggressive, angry, or, as Jane did, inappropriate. These are ill-chosen because they are interpretations of behavior, not precise narrative; being subjective interpretations, they mean different things to different people. Instead, chart specific behavior, actions, and appearance. Some examples are:

    • Pacing
    • Clenching fists or jaw
    • Reddening of the face
    • Trembling of face or body
    • Stiffening of body
    • Sudden movements
    • Changes in vocalizations such as voice becoming louder or faster
    • Approaching or touching the writer or other staff

    Use exact quotes whenever possible, including any obscene or threatening language that was used. One of our allnurses members, Meriwhen- an experienced psych nurse- is clear and unapologetic about this: "I've written out, in unedited and exquisite detail, the most profane things that patients have said...if they're addressing me and/or I hear them being verbally aggressive to others, they will get quoted verbatim. And I never asterisk/ampersand anything out, not even the really bad words.... As they were making threatening statements to us, I documented it all word for word" (Meriwhen, 2013).

    After our discussion, Jane was able to compose the following thorough, specific, professional late entry note about the encounter:
    "Patient stated 'It took you too darn long to bring me this prescription.' Patients voice became louder and faster. Patient stepped within 12 inches of this writer and pointed finger in face. 'Tell Dr. Smith that he's a terrible doctor! I'm never waiting this long again!' Patient declined offer to speak with clinic manager and left building without further incident."
    May your documentation, likewise, always be descriptive, specific, and accurate, and may your patients always be cooperative.

    References

    Buppert, C (2012). Nurses: What Is the Most Important Documentation Advice? Medscape Nurses. Retrieved from http://www.medscape.com/viewarticle/769148
    Meriwhen (2013). Retrieved from http://allnurses.com/general-nursing...246-page3.html
    (no author). Chart Smart: Documenting a patient's violent behavior. Retrieved from www.Nursing2010.com.

  • Feb 16 '14

    When I first started in our emergency department night shift, I noticed that the 2-3 students were largely ignored for the first half hour or so during shift change. They stood nervously by the desks, repeatedly adjusting their coats and book bags with a look of "please tell me what to do!" on their faces.

    I looked around at the day shift staff, busily getting report on the sick, critical, violent, or the repeat pts that they will be taking over on, so busy that having to explain things to students was just not possible at that moment.

    So I took over and made a whole structure for them which was heartily accepted by my coworkers. On student days, I try to wrap things up early and give a quick orientation. I give a few tips on NCLEX, on how to stay cool in crazy situations, and what to expect for the day, and what to do when an ambulance arrives with a pt. Then I pair people up with the most patient, coolest and toughest 20+ year vets and go home. I usually get told how the students did when I get back to work that night. It's almost always great news. The evening students are always paired with me.

    When it hits the fan at the wrong moment, I still have been able to get them in on mega-codes, help ortho MDs reset bones, start CPR, explain the critical nature of XYZ patient, and why that walking/talking pt will be sent to the ICU. Even with varying degrees of receptiveness, students have almost always been amazingly well mannered and willing to dig in. Except once.

    One day last semester, a pair of students came down and I noticed increasing amounts of boredom/irritation as I went through my (now well practiced and tailored) orientation when I was interrupted in my talk about megacodes.

    "I don't want to see that, and I definitely don't want to DO that. Just tell me where to stand while they do whatever they have to do and I'll wait until it's all over," she said dismissively.

    I was floored. I asked her if she had intention to work as a nurse. She answered that she did, but not in any situation where she would have to do anything dirty or see blood. In fact, she planned to get her NP as soon as possible so she could just write orders and walk away. Her friend agreed.

    When I asked her why she was in the E.R. rotation, she said that it was only because she had been assigned to it. I could only think about the other students who would have loved to be there and what a waste of everyone's time it was for her to have even been there at all. I couldn't help but think of what a waste of time it was for me to have just spent the last 20 minutes telling them anything at all since it had clearly been thrown away before I even spoke.

    To tell you the truth, I was completely upset. I remained upset for almost a week. I spoke to my coworkers who said that many times they will avoid having a student because of that very attitude. I ended up going home and thinking that I didn't know if all students secretly felt that way. If so, why was I putting so much effort into them?

    Just before the winter break, I spoke to an instructor and asked her opinion. She gave me great news. It was this, "Just send them back to their instructors and pop an email to the school."

    Huh. So with the semester ending, I dug back into work and stopped thinking about it.

    This semester the students started to arrive again. I watched them stand a fidget for a moment before my instincts took over and I started to cautiously orient them. My fears were immediately dissolved when one asked "Do you think we might get to do CPR?"

    Thank God for the kind of students I look forward to seeing in my department.

  • Feb 16 '14

    Quote from Jackson County EMS to GWER
    We are inbound to your facility with two patients involved in a MVC with multiple injuries...
    The nurses took report on both patients and prepared the trauma bays for a couple in their 80's who had been T-boned when the husband pulled into an intersection. No current life threatening emergencies were reported. Each patient was assessed and stabilized. A recurring theme was each spouse asking about the other spouse.

    After the hustle and bustled settled down we reassured each patient that their spouse was fine. We opened the curtain separating their rooms and informed them that they were right beside each other and they could talk to one another. They could not see one another because they were secured to backboards and unable to turn their heads to the side but they could hear one another. The wife wanted me to know her husband had a blood pressure problem......oh dear she couldn't remember the name of the medicine he was on. The husband told me how they had been married for 60 years and I could see the sparkle of love in his eyes.

    As time went on and test results returned it was decided that the wife had an injury that required her to be shipped to a Level 1 trauma center. The doctor informed the couple of the care decisions he felt were necessary. I began to see fear and worry in the husband's eyes. That is when I jumped into gear of getting the portable heart monitor. I connected the husband to the monitor and moved his IV pole and bed right beside his wife's bed. I put his left bed rail down and her right bed rail down. I told them that if they just reached out they would be able to feel each other's hands. They reached out and found each other's hands and held on tight.

    They talked and reassured each other it would all be okay. They told each other they loved them. The husband told her as soon as he could find someone to drive him to the other hospital he would be there. The doctor told the wife it would be best if her husband stayed all night for just one night to be observed and make sure he was okay. The husband didn't want to but the wife encouraged him that he could see her tomorrow.

    The helicopter crew came and the beds had to be separated after a final hand squeeze and I love you. The Mrs. was loaded and transported to the other hospital while the husband was admitted for overnight observation.

    The next day I came to work I found out the wife had died that night from her injuries. I was heartbroken for this lovely couple. As I reflected, I was so thankful that I had taken the time to connect the portable equipment and rearrange the beds and allow them to hold hands.

    Many times we are too rushed in the ER to make time for the important things in life. And what was more important at this point in time? To hold hands for the very last time...

  • Feb 16 '14

    If the faculty knows who they are they can check their answer sheets to see if they all match, too. I like the "There's a lot of whispering and page rattling in the back row-- it's so distracting. Could you please ask them to stop?" approach.

  • Jan 4 '14

    Also, why when I hand them a cup of meds that they could easily tip up into their mouth without losing a single one, will instead pour them into their hand and try to aim, instead dropping half of them all over the bed and sometimes floor.

  • Dec 12 '13

    Quote from LL143KnB
    The tactful way is to ask if they have any religious or cultural preferences that could impact the quality of their care. Like others have pointed out, Jehovah's Witnesses are not the only ones who object to blood products.
    As one of JW, i assure you that this is quite sufficient and appreciated. This will not necessarily impact the quality of care but rather influence the care that is offered or that is accepted. There are many, many preferences/requirements of a religious or cultural nature that may come up in the delivery of patient care. As nurses, we should be cognizant of this fact and therefore always make an effort to assess this to some degree with each patient encounter as appropriate.

    For those who would like additional information, perhaps in order to be more informed regarding JW beliefs when you take care of them as patients, i invite you read the article found at the following link. Speaking for the organization of JWs, we sincerely thank you for your consideration of our beliefs.

    Questions From Readers โ€” Watchtower ONLINE LIBRARY

  • Nov 7 '13

    If you give a patient a cookie, they'll want a glass of milk.

    If you give them a glass of milk, they'll probably need to go to the bathroom.

    They'll be too weak to get out of bed so you'll have them use the bedpan, but they won't be able to go in that.

    So you'll bladder scan them and see they have 900ml's of urine in their bladder, which you will promptly proceed to straight cath.

    When you stick the catheter in, you'll probably meet resistance, but with a little elbow grease, you'll soon strike gold. However, it will only be later when the patient has a temp of 38.5 that you realize you accidentally contaminated the catheter and caused a UTI.

    For this you'll certainly hang some antibiotics. Unfortunately this will probably cause the patient to have some major diarrhea. By the third complete bed change you'll realize that this patient would benefit from a rectal tube for which you'll get an order and go to place. However, the patient will probably vasovagal when your padded finger penetrates his rectum a little too forcefully, which you'll then report to the doctor.

    The doctor will then consult neurology, cardiology, endocrinology, PT, OT, ST, and a chaplain for good measure. They'll likely all take turns calling your mobile phone while you're elbows deep in doodoo. You'll answer their every wild question from memory, phone sandwiched between cheek and shoulder.

    By now though, the patient will be in pain, which the doctor will kindly order acetaminophen 81 mg Q Day for. You'll be forced to try to remember those non-pharmacological interventions for pain that they taught you in nursing school. You'll try showing the patient the beautiful landscapes on the screensaver to your portable computer, attempting to sooth him with guided imagery. His pain will probably rise to a 10 out of 10 with this intervention, so you'll have him close his eyes for some progressive muscle relaxation.

    When you tell him to open his eyes again, he won't. The bedside monitor will then start dinging that his O2 sat is 82% and rapidly declining. You'll sternal rub him and shout "Mr. Velasquez! Emilio!!! Abre los ojos!!!!!" to which he will not respond. You'll call a staff assist which will bring 60 people to the room. The patient will be intubated, sedated, and paralyzed. His new diagnosis will be urosepsis and he'll need a central line and an art line placed.

    However, when the intern overconfidently attempts the central line, he'll accidentally puncture the lung and cause a pneumothorax, adding a needle decompression and chest tube insertion to the impressive roster of procedures he's done now that he's finally a doctor.

    While turning your patient every 2 hours in attempt to prevent him from getting bedsores, the shift in intrathoracic pressures will probably compress his vena cava to the point of cardiac arrest. You will promptly begin high quality chest compressions, advise someone nearby to activate the emergency response system, and apply an AED, but to no avail. The code will be called and the patient will be dead.

    After finishing his post mortem care, you'll sit down to mount the heart rhythm strips to his chart. Another nurse will proceed from your other room to say, "I answered Mr. Jones' call light while you were in that code. Can he have a cookie?" You'll look up at the clock and realize that the next shift comes in in 10 minutes. "Yeah, sure," you'll reply, "but he'll probably want a glass of milk with it too..."

  • Sep 16 '13

    Several years ago I started working w a lovely teen girl who has a disease in the MD spectrum who uses a wheelchair. She's smart, pretty, funny, and we established a fantastic rapport within days of my start w her. After a year of being her primary home health nurse, she went off to college several states away. For the last several years, I've only worked w her a night or two at a time when she comes home for holidays, and more during the summers. This past summer she stayed at college for classes, so I didn't see her for months. Well, she came home for three days this weekend and ... {sob}.... she's all grown up! Not only is she sporting a shorter hair style and business-like glasses, she's more poised in her speech and behavior, has less "silly" college stories of fun nights out, and speaks more of her classes and her future career path (grad school soon), and lost some of her juvenile ways, such as some good-natured teasing and playing pranks. While I'm incredibly proud of her achievements and her mature character, and overcoming the odds she faces with her physical challenges, I'm starting to feel for her the same wistful feeling I get from seeing my own kids grow! Work hazard or special blessing, it's hard to keep feelings strictly professional when you work in PDN. These kids become your own.

  • Sep 16 '13

    I would just put it out there for people. I tell everyone I work with and most of my patients about my hearing impairment and we make a joke about it. I remind people about it all the time "Hey remember I am half deaf!" (I have very little hearing in one ear).

    It is absolutely normal to be nervous to the point of vomiting on your first day of clinicals- you have something to focus on as your "handicap." It probably makes you even more nervous- but use it to your advantage. Tell people hey I stutter and it takes me some time to get my thoughts out but that has made me an excellent listener. I would work with you and precept you in a heartbeat because I bet that your issue has made you more empathetic and caring of others. I bet you listen when others talk- really truly listen. Remember your strengths- but don't be afraid to admit to your areas of concern.

    Also, introduce yourself to EVERYONE (including the housekeeper and dietary- everyone thinks they are invisible)- especially ALL the docs. that way when you do need something (where are the urinals kept?) you have already spoken to them before and they already have a sense that you are kind.

    One thing that you may need to prove- that you will ask for help. I would be looking- if I was your instructor- to see if you are willing to face the stutter issue by advocating for your patient and to clarify issues (questioning the doc for a strange order). Are you willing to be embarrassed to take care of your patient? I think this is what every student BTW has to prove, not just you but you may find it harder.

    I do hope you keep us posted! I look forward to hearing about you bonding with your patients and coworkers- I bet you will be awesome.

  • Sep 16 '13

    Have you ever heard that people are "born to be nurses"? I don't believe that. I think that the skills of nursing can be learned, just as any other career field. I don't think that every nurse has woken up at the age of 5 and said, I want to be a nurse. The difference is the type of person you are, and if you believe you can be caring and empathetic, that you can take care of a human being when they may be at the worst point in their life, possibly dying; that you will be able to handle the stress of those things and do all of those without becoming bitter as some nurses I have seen are, then you can be a nurse. I never wanted to be a nurse, not until my first year of college when I figured out how much I enjoyed helping people and that I loved science. For me, I learned how to want to be a nurse, and now I love it and I get told by many patients that I am the best nurse assistant that they have ever had (I'm still in my RN program). This is the first job I have actually enjoyed, even when I'm wiping people's butts because that feeling of helping people really is what its about, and those people are grateful. I know I sound dramatic, but I'm saying all of it so that you can see that nursing isn't all about knowing how to chart or what meds to give, you can learn all of those things and you will in nursing school. So don't give up because your afraid you can't learn those things, because you can. Quit because you don't think you can be all of things I stated above and more.

  • Feb 22 '13

    Please, keep an open mind. I know the advice you’ve received seems harsh. I received similar advice several months ago, however, and I sincerely regret that I did not follow it. I am currently a senior in my Baccalaureate program. Throughout my program, I have been an A/B student. During my junior year, I befriended a fellow nursing student. We became very close, and when she began to struggle with the coursework, I was eager to help her succeed. I devoted countless hours of my time assisting her with her studies. But, it hurt both of us in the long run.

    When we progressed to senior year, our work load more than doubled. I tried my hardest to maintain my GPA while continuing to help my friend. Eventually, I began to experience panic attacks. I was spending so much time helping her grasp the material and complete her projects that I scarcely had time for myself. I ended up turning in projects and papers late, and which did not adequately reflect the quality of work that I am capable of producing. My exam grades began to slip. I tried to distance myself from my friend so that I could bring up my grades. But, her requests for help were relentless and I felt obligated to support her.
    I did manage to maintain my GPA that semester, but I had to bust my ass near the end in order to make up for lost time. I am now in my final semester. The work load is as intense as it’s ever been. I had to cut my friend off completely because I could not help her with her studies and keep my head above water at the same time. I referred her to the school’s tutoring program. But, she is now performing worse than ever on our exams. Why? Because she relied so heavily on my assistance that she never developed the critical thinking skills necessary to succeed. Nursing isn’t about rote memorization. You have to develop a knowledge base and be able to apply it to clinical situations. Your friend has to develop her own knowledge base. You won’t be there to hold her hand during N.C.L.E.X. And, you certainly won’t be around to help her make clinical judgments when she starts practicing as an RN.

    It is natural for you to be concerned for your friend. Many people are drawn to nursing because of their caring natures. Not everyone, however, will make it through nursing school. It isn’t your job to be responsible for anyone else’s success – ensuring your own success as you proceed through the program will be difficult enough.

  • Jan 6 '13

    And next time, email this kind of thing to your manager so she'll know whose work it is!

  • Dec 11 '12

    Besides, I think your biggest problem is that you can't discuss your health with your spouse.

  • Dec 7 '12

    Recently I was traveling in Florida with my family to Disney World and a cement truck traveling in the opposite direction, on I 10, had a catastrophic blow out of a front steer tire. He started flipping and went through the median and hit us head on. The impact threw our car 88ft and we landed in a drainage ditch pointing the opposite direction we were traveling.

    To make a long story shorter, I had to be extricated with jaws of life, I went in to shock and while paramedics were medicating me for pain. I had an anaphylactic reaction to Fentanyl and lost my airway.I was airlifted to a trauma center and my kids were taken to ALABAMA to another trauma center because we overloaded the Panama City hospital with our wreck. I didn't know how my kids were doing for over 8 hours.

    The worst part was hearing the screams from my kids asking them not to let their mommy die. I am an RN in the MICU and I it was so hard knowing everything going on and having absolutely no control. I was the one that gave paramedics report when they arrived on scene and I told them when I was loosing my airway.

    Once I lost consciousness and they cut my clothes off and stuck things in every orifice I had, I became scared and realized I was no longer a nurse, I was a patient. I am used to doing this to my patients and I have never stopped to think how I make them feel. I rarely ever was told what was going on or that they were getting ready to do a procedure to me. I just wonder if any of you have experienced being a trauma patient and how did it make you feel.

    This experience has taught me to ALWAYS, whether they are conscious or not, tell my patient what I'm doing. They may not understand but when you are having a rectal probe used on you and they just flop you over and use it..WARN ME that its coming! I never knew how much Lovenox burns when going in, I never realized how hard it is to "cough and deep breathe" with broken ribs, or how it feels to ambulate with a broken foot and busted knees. Also, DVT's HURT like heck! Yeah, I got one.

    Needless to say I have learned so much from being a patient and if I can help one nurse realize that patients are scared and just to have a friendly voice or a hand to hold, MAKES a HUGE difference. Once I have recovered and get back on the unit my patient care will be quite different and I think my patients will be better for it.


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