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libran1984 6,023 Views

Joined Aug 3, '11 - from 'Disco Hogwarts'. libran1984 is a Registered Nurse. He has '4' year(s) of experience and specializes in 'Emergency Nursing'. Posts: 590 (37% Liked) Likes: 663

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  • Mar 13

    That's the problem tho... we all want to and strive to provide quality care, Lb321. However, in so many places it is just not possible, ie see above libran1984 posts!

  • Mar 13

    The best way to avoid the worst nursing homes is to get your RN.

    otherwise you can try asking these...

    Ask what sort of acuity levels you will be working with.

    Ask what the nurse to patient ratio is? (don't worry tho, you'll have TONS of help the management will say. Also add 2 more patietns minimum on to what ever number they give you) I truly feel anything over 10 patients per nurse is ludicrous unless the patients are TRUE assisted living classes- however, most assisted living facilities i'm familiar with still hold residents who need complete and total assistance and no way should they be in assisted living.

    Its all about the money, man. That's why LPNs work in these places because they know we are the "low paid nurses" and they can get away with paying less than they would for an RN.

    ugh....

    just steer clear. Otherwise next thing you know you'll be forced to put an NG tube down a guy with esophageal verices and you'll cause excessive bleeding and he'll expire. Then the DoN will blame it all on you because you should have known he had the esophageal verices, but the patient was non-verbal so how were you to have known? His chart is all paper and its not even mentioned on his Dx's except for 300 pages into the chart where it was inexplicably left out in more recet Dx's....

    Then the medicare charting is terribad. Computerized charting, you say.... no no no... ugh.

    I honestly don't know what to tell you Jasmine other than I can imagine no worse job than being in LTC.

    One guy I dealt with had a terrible MRSA infection in his leg and was at the rehab center to help heal it up. I asked my supervisor why the pt was unable to move his upper extremities and why is Level of consciousness was down the toilet. The nurse responded, "I think he had a stroke sometime". Upon further investigation, the hospital discharge assessment made him out to be A/Ox3 with full RoM except for his affected lower extremity. Because there was no charting EVER in regards to the computer and all the MAR assessments had been put into a storage box no one was able to tell when the pt became the way he is now. So what happened to him? It obviously happened while in rehab!

    My first nursing job was ~$14/hr. That's like 2-3 dollars more than most CNA's and in many cases less.... if these LTC centers could just pay all the LPNs $14/hr and staff extra nurses, then patient safety and satisfaction would go up, and nursing retention would increase (as long as year raises of up to 4% were provided to allow financial growth) because it would offer valuable skills in a safe environment because let's face it, most of us got into nursing to help people.

    I'd always heard how terrible the nursing pay was and then I became an LPN so I wasn't overly surprised when I began making $14/hr.

    /sigh....


    Jasmine, I'll be coming back to this post to see if anyone else has better advice to offer you. I'm sure I'm just scaring you. I apologize, but I've been scarred by the LTC experience as well as most other LPN jobs I've ever had. I love being an ER nurse but I'm not often referred to as a nurse by my co-workers but rather a "non-RN" and that just grates me. At the LTC centers where I am considered a nurse, I feel that I actually harm the patients through neglect since I can't assess them or offer them the emotional support they frequently need.

    Find a clinic job, girl! Find a clinic job!!!!

  • Mar 13

    Oh and vintagemother had another point.... The call lights never EVER stopped. NEVER!!!!

    I worked in fast food during my teens and early twenties and heard less beeping at the drive thru than I did with the incessant call lights.

    I'm getting so worked up and angry over all of this..... Phew.... Just breathe....

    I hate LTC

    Edit:: heaven forbid someone uses their call light for resp distress, choking, or CP... They might not survive the 20-40 minutes it takes to respond!!

  • Mar 13

    I hate LTC. I hate it with an undying passion. I truly feel if it were my only resort I'd just leave nursing altogether.

    In my experience, my patients were not "stable".

    I never had proper supplies let alone hand sanitizers.

    Orientation was pointless ( 2 eight hour shifts and ur on ur own)

    The charting was redundant to the point of sheer ludicrous.

    Everything was on paper and then expected to be transcribed to the computer.

    Hours were watched like a hawk for fear u go over.

    You never left the med cart.

    The MARs are illegible.

    The meds are disorganized and u are encouraged to steal from other resident's supply to fill an empty med slot for another resident.

    Med pass should be but a medium chunk of the day, not all of it. If I were actually at my computer and not in my iPhone I would write very precisely every thing, in detail, that is wrong with many LTC settings.

    The environment is toxic and leads to... No, encourages poor nursing care.

    On a side note, this has only been my overall impression of LTC from observation and experience.

    I look at LTC centers where LPNs are few to none and the staffing seems much better. Get this.... In a pediatric LTC center for rehab (and some hospice) there were no LPNs, but instead an all RN staff and QMA's who passed meds. The RN approved PRN meds for the QMA, she did all the charting, VS's, assessments, and treatments. The RN never had more than 8 patients at a time.

    Now why are the RNs making more and doing less? Why are her patient ratios so much smaller? Why does she have someone dedicated to med pass so she can do the appropriate work required of her position.

    I, an LPN, had to deal with brand new strokes straight from the hospital who were total care pts. Ppl in recovery for post op open heart, ppl who would regularly be placed on bipap (srsly), and ppl with god awful infections of varying kinds and at least half are on IV vanc and merripenem (!!!) thru their PICC lines. How am I supposed to deal with meds, new admits, treatments, ADLs, blood draws, daily weights, accuchecks, more meds, and spontaneous colostomy seepage when I, an LPN am responsible for 16 patients and btw, WHERE is the foresaken handwashing station!!!!!????

    That's not even that bad. My friend went to a diff LTC center for her LPN to RN critical care clinicals and some dude was on Levophed- and he was awake!!! Seriously, the same "levophed leave 'em dead" stuff. This is the kind of stuff LPNs have to deal with in LTC.

    Yes yes- someone is going to say that isn't the typical LTC experience. That is correct. Many LTC facilities hold are not SNF's, or rehab, etc. it's just an elderly, frail, person who needs a little guidance and reminder to take all their meds- but that has not been my experience.

    And working in the ER, when I get report from a LTC nurse, it generally results in a lot of eye rolling. Seriously who continues to give Norco's for a fever to a dialysis pt and then wonder why she's become lethargic. /facepalm


    I hate LTC. I feel very strongly on this subject and believe "hate" is sufficient to convey the amount of contempt I have for LTC.

    God bless all the nurses who work there because I cannot.

    Sorry this tangent kept going on and on

  • Jan 20

    HA! I was working fast track and read some of the fast track patient assessments by one of the RNs.....

    Pt 1:

    A/Ox3. Hx of Cdiff. Recent blood noted in stool x8 hours.


    Pt 2:

    Fell yesterday in ED. Presents today with hip and knee pain bilaterally.


    Pt 3:

    Believes she may be pregnant due to multiple positive UPT's


    Those were examples of our RN assessments today in Fast Track.



    Our hospital also makes all RN assessments simple check boxes for different body systems. Click Click Click Assessment complete.

    When you're running around like a chicken with your head cut off, you could write out a very detailed assessment in the flow-sheet, or you could get to doing orders and use the check boxes. /sigh.... somedays, i feel assessment skills fly out the window

    ---------

    I get mad props on my assessment skills in my ED and I moved into my second year of ER nursing. A good generalized written flow sheet assessment could even go like this.....

    "Pt presents to ED with c/o..... (why pt is here) x (how long s/s persisted).
    Pt ranks discomfort / pain a (#/10).

    (Insert focused assessment- ie: use your head to toe assessment skills learned in school but focus only on that one system)

    Pt Hx includes....

    Bowel and bladder question
    Pregnancy question


    Call light in reach. Pt voices understanding of current plan of care. Family at bedside.


    -----------


    So to make one up off the top of my head....

    Pt presents to ED with c/o worsening RUQ abominal pain x 3 days. Pt state pain is "consistent & sharp, like it never goes away" pain ranking 9/10. Pt denies previous Hx of current c/o.

    Bowel sounds are normo-active x4. Abdomen is soft and non-distended. Tenderness upon palpation per pt in RUQ.

    Medic line 20G LAC. 150 mL NS successfully infused by medics. Infusion discontinued upon arrival to ED. Pt seen at St. Jane Doe ED last night for similar s/s. Pt Dx'd with bladder infection.

    Pt denies dysuria, urinary frequency, hesitancy, anuria, or pain upon urination. Pt denies fever, chills. Pt professes to outstanding hx of ovarian cysts, commonly treated with Norco Rx. Last menstruation stated to be approximately 1 week ago and WNL per pt.

    Pt states BMs are WNL and denies dark tarry stools or bright red blood.
    Denies chance of pregnancy.

    Call light in reach. Family at bedside. Pt voices understanding of current plan of care.


    ------

    The assessment included

    1. primary complaint (HOW LONG and complete with a SUBJECTIVE DESCRIPTION as well as if this c/o is something NEW or OLD.)
    2. Nursing assessment (notice its similar to your GI assessment in your head-to-toe assessment)
    3. Hx leading directly up to current ED visit.
    4. Previous medical Hx for pt
    5. always ask about urinary and BM outputs because they factor into almost every system in one way or another.
    6. Pregnancy does F-ed up things to the body, so might as well ask, particularly if u suspect a CT or Xray.
    7 Call light in reach. Family at bedside. Pt voices understanding of current plan of care

    --------


    Good luck.

  • Jan 18

    I hate LTC

    I recently commented... excessively commented on a post last night. This post was titled "What's wrong with working in a nursing home?" This topic lit a fire under my dear rear. I couldn't contain the animosity I had about LTC and my experiences with it. I have so many problems with LTC and so many other things. So I want to attempt and compile a list of rants and possible solutions to solve my rants ranging from staffing issues to regulation of scope of practice.

    Some time ago I picked up PRN work at a rehab/LTC facility that ended quite poorly. I will first list my problems with the experience and then go in depth on the issue. I will draw comparisons and make stark contrasts.

    Let's first start with my list of LTC issues:

    1. Pt to nurse ratios were completely unacceptable

    2. Call lights were nonstop

    3. Med pass consumed 6 hours of my 8 hour shift

    4.The MARs are illegible

    5. The redundancy of the charting was asinine

    6. The organization was in a utter disheveled state.

    7. Orientation is expected to end after two days of following a preceptor.

    8. Supplies were scarce and next to non-existent.

    9. Strong lack of communication between disciplines.

    10. Strong lack of hand sanitizing stations.

    11. Strong knowledge deficit of patient diagnosis and risk factors.

    12. Strong lack of post rehab education.

    13. Illegal behavior was often promoted.

    This Rehab facility had won many state and national recognition awards and boasted incessantly about their achievements. It was expected to be a wonderful new job to supplement my hours at the hospital while I wait to start my LPN-RN bridge. How wrong I turned out to be.

    1. This particular unit had a very high acuity level. These were patients post open heart surgery and fresh strokes with complete left or right sided deficits. These were patients with MRSA and VRE infections worse than I'd ever seen come through my ER and here we were trying to treat these poor souls. Several patients were recovering from untreatable hip fractures and needed max assist when transferring. Six of my sixteen patients had PICC lines and regularly scheduled antibiotic or TPN infusions. Every patient had a secondary diagnosis and tertiary diagnosis being simultaneously treated as well.

    2. There was 1.5 CNAs per 16 patients (1 CNA/16 residents and 1 extra CNA per 32 residents) and that 1.5 CNAs was , understandably, always busy. The call lights went off non-stop. They never ceased to halt their infuriating chiming. During my teens and early twenties I worked in several fast food drive-thru's and heard less chiming and alarms than in this facility. Heavens forbid someone use their call light for respiratory distress, chest pain, or choking. They might not survive the 15-30 minutes it takes to answer the light. I would run room to room and attempt to assist the resident with their request but ultimately fell incredibly behind on med pass. One morning, a resident's son became very irate with our unit manager. He declared the call lights a momentous interruption during what should be a peaceful morning breakfast. The unit manager said to him there is nothing we can do about it and that everyone is already busy and working to their highest capacity to meet every residents' needs. The resident's son huffed off and eventually left the dining area muttering obscenities while his poor father heaved a drawn out sigh.

    3. Med pass consumed 6 of my 8 hour shift. If it wasn't regularly scheduled meds I was administering, it was all the PRN meds I have to continually give out. For our stroke patients, it was not uncommon to have one or two that hadn't accepted the need for rehabilitation and they lived in a fit of anger and denial over their condition. It was 10-15 minutes minimum crushing each pill and spoon feeding it in apple sauce or yogurt. The more compassion I showed the further behind med pass I became. Compassion is not time efficient. Eventually you just give up and say you'll call the family and the doctor to notify them of the patient's non-compliance. Med pass also includes blood pressures on every single patient because every single patient is on blood pressure medication. There are no known documented ranges upon which to hold the blood pressure medication except for nursing knowledge of course. Don't forget the accuchecks for blood glucose. That accucheck machine was the most finicky piece of work I've handled to date. I cannot even describe the frustration it caused me over the course of 4 shifts. Daily weights were never before breakfast and I was lucky to get them at all. Then there were the antibiotic and TPN infusions. You had to just hope you saw it in the MAR as you skimmed through during the AM meds. Where do I wash my hands between patients and administrations?

    4. The MARs were very much of the time illegible. Pt identifiers were lacking. Every MAR was carbon copied and at this point I realized nurses have worse handwriting than physicians. Having only been familiar with fifty or so emergency medications, I frequently found my knowledge base coming up short when I saw a new medication. What is namenda? I've never heard of it, but half of my patient load is on it! Every three to four medications there was a new medication. I was constantly shouting to the other nurse down the hall, "What is Elavil?!" Usually I could identify the first few letters of the medication and associate the medication with what was in the medication drawer under the patient's name.

    At one point there had been two new admissions both by the name of Jane Doe and Jane Doey. Neither MAR had the birthday on it, Allergies were different, and both lived next door to the other. At one point I'm explaining the meds to Jane Doe and she says, "I don't have any memory problems? Why would I be taking that?" I eventually grab the MAR to list her medications to her and explain them as best as I could in my limited knowledge and she straight up said "I've never taken that before. I don't know what any of those meds are!" I eventually saw that someone had taken Jane Doe and Jane Doey's MARs and shuffled them together and their meds were no better off either. Talk about a potentially terrible medication error! I spent an unacceptably large portion of the day trying to sort through everything particularly since the doctor had made a visit and rattled off orders about one of the Jane Doe... or was it Jane Doey? I was terribly confused and eventually it was looking at the allergies it became clear who the doctor was talking about.

    5. The charting was asenine. The amount of redundancies found in the charting was infuriating. The accucheck book and PT/INR book needed to be documented in for each accucheck / coagulation check. Then that same documentation needed to into the main MAR. In addition, every day of the week required an specialized assessment on all residents (ie: skin check Mondays; cardio-pulmonary Tuesdays; neuro Wednesdays, etc). Then there were also the residents who needed medicare charting for their specific admission condition. So the nurse was to document in MAR yes or no to weight gain in excess of 5 lbs or presence of cough for those with CHF exacerbation admissions or post op heart surgery. After charting 3 pages of "aguessments" the nurse is to go into the computer and free text every one of her assessments for focused day of the week and medicare charting. This never happened. It was left to remain in the MAR, for who really has time to double chart all that. You were lucky, as the nurse to just put in your daily accuchecks into the computer in combination with morning BPs. If, by chance something did happen and you had to make a progress note, there was a character limit in the computer. I could not exceed 980 characters. That's no more than one or two paragraphs! How do you chart an admission assessment with a 980 character limit? Hell, how do you even have time to write a 980 character assessment, many of you are probably asking right now.

    6. To go along with the redundant charting, there was the poor organization. There was a book for doctor appointments, a book for accuchecks and coagulations, there was the MAR, there was book for pharmacy transcriptions, the book for doctor orders and 3 different bins to put the carbon copies of the doctor orders in. There was the treatment book. Then there was the Narc book and finally the patient hard chart. How many books am I supposed to look through at the beginning of my shift? Is there any book that will simply tell me why these patients are here and what their rehabilitation goals are?

    A poor woman was scheduled for a paracentesis but missed two of her scheduled sessions due to lack of organization. She was in terrible shape when she finally left- she was also supposed to be NPO, but no one told me and I didn't figure it out until transport came to pick her up. I came back 3 days after her departure and what should have been a procedure that only took a few hours she was still gone away at the hospital. I keep thinking about how we all let it get by us. It was so easy to ignore her quiet demeanor, her constant replies of "no, I'm okay" and to cater to the needy more vocal residents.

    One resident I dealt with during orientation had a terrible MRSA infection in his leg and was at the rehab center to help heal it up. I asked my preceptor why the patient was unable to move his upper extremities and why his Level of consciousness was down the toilet. The nurse responded, "I think he had a stroke sometime". Upon further investigation, the hospital discharge assessment made him out to be A/Ox3 with full RoM except for his affected lower extremity. Because there was no charting EVER in regards to the computer and all the MAR assessments had been put into a storage box no one was able to tell when the pt became the way he is now. So what happened to him? It obviously happened while in rehab! Whatever verbal communication had been passed down had long since been left in the dry desert of despair. This was now the way the patient is and may very well remain. Just 6 months ago he was at his grandson's baseball game, completely healthy and now the compartmentalized warehouse we store this man in is cold, heartless, and neglectful.

    7. Finally, after two days of orientation it is time for the new nurse to become self-sufficient! Here you go, Nurse Mary! 16 patients all for you! You will love them and they will love you. Don't forget the dressing changes in room 2,4,6,8. Room 10 and 12 have colostomy bags that keep leaking, so you'll probably have to replace them before the end of your shift. Oh, where is that forsaken hand washing station? I have just been cleaning colostomy sites for the last half hour!

    8. Supplies were so scarce. Perhaps, Like my imaginary Nurse Mary, I was too new to know where to look or we were just short in stock. It was just that simple. So little to work with.

    9. There was a strong lack of communication between disciplines. I never knew the PT / OT therapy schedule of my residents. Even if there was a sheet, where would it have been located? I already have six or seven binders I need to look at each morning and thus transcribe all of it on to my brain sheet. Things could go so much better if I was allowed to just premedicate my patients prior to the Physical and occupational therapies. Finally, we should find a way to communicate the patient's goals during therapy. Perhaps, as a nurse, if I ever break away from the med cart, I can encourage the patient to stay on track with their recommended exercises. We can help each other and benefit the patient. Instead, I'm always thrown under the bus for giving poor nursing care and glared at by the PTs and OTs. These looks of frustration and anger make me feel dirty...

    10. Seriously, now! Where is that freaking hand washing station!? For a hall with 16 residents there is one hand sanitizing station. There are no other hand sanitizer dispensers. The only sinks are in the resident's rooms and those are frequently cluttered with all their personal hygiene materials and the sink itself just doesn't look the best with all their flaking skin and hair oh forget it... I'm going to wash my hands. I can't deal with this. I go to reach the faucet with a paper towel covering my hand so I don't touch the faucet. In using the paper towel the extra length of the towel clips a perfume container and it falls to the ground shattering. The resident is unimaginably angry... wait, I'm trying to wash my hands in the personal sink of someone who has... C-diff? Really? This is so messed up on so many levels.

    11. There is a strong knowledge deficit on patient diagnoses and their associated risk factors. Most of the staff has no idea why their patients are here or what their co morbidities are. If you are a nurse who is new to the unit, you may be requested to perform any number of treatments or procedures and next thing you know you'll be forced to put an NG tube down a guy with esophageal vertices. You'll cause excessive bleeding and he'll expire. Then the DoN will blame it all on you because you should have known he had the esophageal verices, but the patient was non-verbal so how were you to have known? His chart is all on paper, the admission assessment that should have had a list of diagnoses and pt admission statuses is limited to a 980 character limit!! It's not until you look back over 40 pages of physician progress notes you finally find a Dx of esophageal vertices that was inexplicably left out in more recent Dx's. Oh the excitement you are in for, Nurse Mary!

    12. In the middle of your day you have a discharge for room 3. Your discharge instructions must be manually typed with a list of all medications the patient is currently taking. The patient must be made aware through these discharge instructions what the medication is for, how much to take, and when to take it. There is no further education regarding the patient's original rehab diagnosis for who really knows why the patient was really here anyways, rt?

    13. While taking meds from another resident to supply your current resident with the same or equivalent prescription is common, it is still illegal and should not be encouraged. Yet, here we are. State regulations prohibit administering medications during meal times, yet we do it all the time. This isn't a feasible system.

    NOW LET'S TRY TO SOLVE THIS PROBLEM....

    When I entered nursing school, I heard repeatedly how we should not be in nursing for the money because there is not a lot of money in nursing. I expected that. I even expected less because I was going to become an LPN ( "Low Paid Nurse" ) but I was going to take much pride in my work and I was going to make a difference!

    My first job at a correctional facility paid me $14.96 / hr. My first job within a hospital setting paid me $13.69 / hr. This was significantly less than I ever anticipated as an LPN, however, I was still making a difference and I was having fun doing it, knowing I made a difference today.

    If LTC reduced their LPN wages to match that of the non-LTC facilities to about $14/hr and hired more LPNs at that rate then there would be a much higher nurse to patient ratio. I know CNAs that make more than $14/hr in LTC. That is crazy! I'm a nurse and they're making more than myself!

    So if I had only 8 patients and another LPN took my other 8 patients we wouldn't have to do "aguessments" but rather real "assessments". Perhaps accurate documentation could be performed and we would know what happened to that gentleman with MRSA infection in his leg. With an extra nurse, I could keep on top of my patient's pain. I could potentially, look through all those books and figure out who needs what and when they need it. Perhaps skin break down wouldn't be such a huge issue. Maybe I develop that rapport with my patients that I always wanted. Maybe I could actually learn about all these meds I'm unwittingly administering!

    Maybe the patient in room 11 wouldn't have to keep reminding staff that she's supposed to be receiving an IV vanc infusion but for the last 3 days no one has remembered to order it and now she's screaming at the top of her lungs to speak with management. How do we explain this? Heck, I just walked in. Maybe we should ask why it wasn't written in the MAR but only in the treatment book?

    Maybe I'll find the time to finally speak with management about the lack of hand sanitation stations!! How glorious that would be. Have you heard about that new CRE out there? The Carbapenem-resistant enterobacteriaceae? Yeah, kinda scary. I think hand washing is very important.

    Yes, I think that would help out immensely. We are nurses to help people. We are not in nursing for the money. It was instilled in us from day one that nurses don't make any money. I know this and you know this. Let's make a difference. As long as I love my job and get a raise every year, say around 4%, then my pay check will grow every year with my experience. Retention of nursing staff will increase as well as patient satisfaction. Rapports and relationships will be made and state regulations will be adhered on a more strict basis, although I still see us administering meds every now and then when we fall behind to a resident during his/her meal.

    Yes, let's fix this! I believe there are enough new grads out there that want a job bad enough and want to learn about a wide array of procedures like bipap, EKG's, blood draws, NG tube insertion, etc and will take a lower paying job for job satisfaction and reap financial rewards for their job well-done. (More) Accurate charting will be performed and MDS can capture more costs to gain more money!

    Yet, I don't see this where LPNs are concerned.

    My friend went to a LTC facility for pediatric hospice and rehab patients as an RN student nurse. It was an all RN staff. There were no LPNs. Each RN was assigned to eight patients similarly to my own idea, but there was a Qualified Medications Aide working under the RN to pass prescribed medications to the RNs patients. The RN was to assess the patient, take vitals, weights, and work with the interdisciplinary team to create appropriate goals, and authorize PRN meds. This is how it should be!

    Why do the RNs have this all figured out? And how much are they making? Not $14/hr. I constantly feel like areas of nursing where LPNs dominate are the areas of nursing no one wants to ever be at.

    I feel like the LPN role is to fill in the niche of nursing the majority of nurses have no interest in. Yes, this may be an overly broad generalization but my primary job rarely refers to me as an LPN, but rather tells me daily what I'm not, and that is a "non-RN". So there will always be a rivalry when my official designation on the schedule is "non-RN" and when an all RN staff in LTC get to make use of QMAs and get to focus on their 8 patients and discuss goals, education, and perform assessments. I am jealous and angry that RNs in an all RN setting are so frequently set up for success while areas dominated by LPNs are set up for failure. Bah, weak argument here but the point I'm trying to make, is I feel LPNs get the short end of the stick when it comes to nursing.

    Okay, enough about that, back on track. (and yes, for those who are going to say, "why don't you just become an RN then" I will reply back with, "I'm already in the process, thank you!")

    Another idea for LTC would be to have one nurse be a "med nurse" and pass all scheduled and prn meds while the other nurse assesses, educates, and performs treatments. I heard one of my coworkers discussing at the hospital how before there was the Pyxis, there would be a med nurse for the unit, a treatment nurse, and a nurse to do just assessments and charting of assessments. I think that plan sounds rather feasible as well.

    Next thing, I think there should be a standardized scope of practice across the USA for all RNs and LPNs. I was constantly feeling conflicted with my hospital training vs what the LTC facility wanted of me. At the hospital I draw blood from PICC lines all the time while the LTC facility was very adamant that it be an RN. At the hospital I'm not allowed to hang any kind of cardiac drug, at the LTC facility there was someone on Levophed- and he was awake! This was part of the critical care unit at the facility. I've always heard "Levophed, leave 'em dead". Like are you serious? At the hospital I can hang blood under my own license. At the LTC facility I'm not supposed to. It gets so conflicting. At the LTC facility it said I'm not allowed to start IVs without an IV certification. My state doesn't require an IV certification for an LPN to perform IV therapy. So, the LTC facility would just blatantly ignore its own rule. The hospital says an LPN cannot assess, while the LTC facility demands I assess! Assess! ASSESS!! I already made a post that received almost no replies on the difference between data collection and assessments. I suppose it was just so ludicrous to think an LPN can't assess that it wasn't worthy of any replies as I'm sure this post will be so long no one will read and thus replies will be limited. HAHAHA. I've been typing for 3 hours. I still feel like I have so much more to say but I'm starting to ramble.

    Someone is going to say that my experience isn't the typical LTC experience. That is correct. Many LTC facilities are not SNF's, or rehab, etc. The resident is just an elderly, frail, person who needs a little guidance and reminder to take all their meds- but that has not been my experience.

    And working in the ER, when I get report from a LTC nurse, it generally results in a lot of eye rolling. Seriously who continues to give Norco's for a fever to a dialysis pt and then wonder why she's become lethargic.

    I hate LTC

    Please tell me of a LTC facility where things run smoothly, nurse's understand their patient's needs, and make a difference; where the resident is not just thrown away to a corner while you move onwards. I want to hear of a place where real life is reflected on the billboard I pass every day on the interstate with the smiling nurse and the resident is laughing at some cosmic joke I'm only just beginning to understand.

  • Oct 16 '15

    Body Glide.


    In my ER we call this problem the "chub rub"

  • Sep 15 '15

    I feel RNs make quite a fair chunk of change. I def need to stop eating out tho.

  • Jul 26 '15

    Quote from ANNIENURSEANGEL
    I work at a rural hospital in nevada. 2 er beds, and 11 acute beds. I have 6 years of experience there. I want to go to a bigger hospital, in order to get more experience, in surgery and wound care. Does anyone think it is a stigma to work in a rural hospital? Is it going against me, when i apply at bigger hospitals? What can i do or say, when the nurse recruiter talks to me about my rural hospital experience.
    Annie, I think u got it backwards, girl!!!

    "Hi my name is Annie and I'm interviewing for this amazing opening at your Trauma 1 inner city hospital.

    My experience in my rural hospital has provided me with a vast array of knowledge and independance. Often I was the only RN working the floor and delt with our entire ER. Because the larger hospitals were so far away, I often single handedly provided nursing care to our most tramatic patients in an effort to stabilize them before forwarding them to one of the larger hospitals.

    Sometimes at night it was only myself and a Nurse Practitioner and due to our limited supplies for certain occassions we were forced to rely on our ingenuity like when our supply of finger splints was exhausted and I combined two halfs of a tongue depressor to make a splint. It was always a wild ride with just a skeleton staff. I think my 6 years of independant experience would an invaluable asset if were able serve your hospital. "

    Ta da!!! You're gonna kick butt, Annienurse!

  • Jul 20 '15

    I think most people are just wanting the paycheck. It is, perhaps, one of the highest paying entry level associate degrees available. However, many of those people will never become a nurse. Nursing schools know how to weed out the wannabes versus the truly dedicated.

  • Jul 16 '15

    I am an LPN and worked in a level 2 correctional facility for 11
    months. The Prison's doctor was a wonderfully smart man and lived by a few simple rules, Never trust the offender regarding pain level. There are too many substance abusers who cry out in pain for attention and medication. You can only trust your objective assessment data.

    Chest pain was a daily complaint and between 1600 offenders,
    it was always something. Thankfully, all that drama and my insistence
    to pursue more nursing knowledge, nursing interventions, and perform
    proper assessment skills it landed me a highly coveted LPN position at
    a local Emergency Room where I see and even act as a primary nurse for
    varying levels of acuity. I wish to share with you my success in a
    correctional setting and tell you what I learned.

    1. Perform Immediate Visual assessment
    ---- Look for pallor (think deathly pale) clutching at chest, gasping
    for air, and extremely diaphoretic.
    ---- How did the offender get to the Health Services Unit?

    2. Take control of the situation, this is an offender who may need
    health care but simultaneously poses a safety risk to you.\
    --- Tell the the Custody officer to calm down (if in a panic), to
    release the offender, and not to leave you alone. If necassary ask
    unneeded personal or extra officers to leave to provide you room to
    work.
    ---Tell the offender to stand up.
    ---Tell the offender to get on the gurney.
    ---Tell the offender to take off his shirt in preparation for EKG.
    --- Above all, you must be persistent. Encourage the offender's goal
    of obtaining treatment only should he comply with your stipulations.
    You are in charge.


    Don't help or touch the offender until you have seen and noted what
    the offender is capable of. Measure his physical limitations. They may
    groan and complain the entire time about how it hurts to get their arm
    out from under their shirt but too bad too sad. If they can do it then
    thats a check mark in the "they'll survive category". If the offender
    refuses or honestly cannot, in your opinion, perform any of the above
    tasks then help him and continue to the next steps.

    3. Place on 2L Nasal Cannula ( if readily available- my correctional
    clinic rarely had easy access to supplies due to everything being
    locked up)

    4. Obtain Vitals.

    5. Obtain an EKG
    --- Familiarize yourself with a ST - elevation (STEMI) as would be
    seen on a 12-lead (often the machine will tell you too)
    --- Is the rhythm a regular? (If they have a pacemaker it will usually
    look a mess, but you should see very small notches at regular
    intervals that indicate the pacemaker is firing.)
    --- Is the EKG different than past EKGs? (This usually was info that
    required a bit of chart searching in the EMR, and even at times,
    required me to pull the hard chart.)


    6. Perform Hx with the following or similar questions:
    --- Do you have any other associated symptoms? (do not offer
    suggestions, but look for nausea, pain in L arm, Shortness of Breath,
    etc)
    --- Where is the pain?
    --- When did the pain begin?
    --- What does the pain feel like?
    --- What were you doing when the pain started?
    --- Have you ever had a heart attack previously?
    --- Are you on any Medications?
    --- Do you have any allergies?
    --- Have you ever taken Sublingual Nitro?


    7. Perform head to toe assessment.
    --- a/ox3 ?
    --- PERRL ?
    --- Skin warm, dry, intact?
    --- Respirations even and unlabored?
    --- Breath sounds clear to auscultation anterior / posterior
    --- S1&S2 auscultated?
    --- apical pulse correlates to radial pulse?
    --- bilateral extremities (lower and upper) overcome resistance?
    --- grips strong?
    --- capillary refill brisk?


    8. Give ASA 325 mg or 2-4 BABY ASA of 81 mg / tab - make sure he chews
    --- hold if allergy is present

    9. Give sublingual nitro if offender has on hand and has not already taken.
    --- Sublingual nitro is contraindicated for offenders who...
    ------ do not have their own SL nitro on hand and do not have IV access
    ------ have an SBP < 100, or DBP < 50 for fear of bottoming their
    blood pressure out.
    --- repeat up to 3 total doses 5 minutes apart and assess offender's
    supposed comfort level.


    Now allow me to describe a scenario for you. The exact one that
    happened to me a few months ago.


    The officers call HSU (Health services unit) while I'm working the clinic
    alone. There are other nurses in the infirmary and one nurse in the
    med room. It is a scorching, hot, weekend. The doctor is not on site nor is
    management. An offender is complaining of chest pain and an CO (Correctional Officer) radios in that he'll be bringing an offender up to the clinic.

    Its 1625. The peak of my insulin line. I already have 20+ offenders standing in a single file line outside of my open door waiting for their insulin. I have 30+ more offenders I am expecting to come before 1700. This is just not the time to deal with this CP (chest pain) crap. I yell back to my CO in the clinic, "How's he getting up here?" as I continue shooting my offenders with their insulin.

    Officer Wise shouts back, "They're bringing him up in a wheel chair." I roll my eyes and stab another offender with his Humulin R as she continues, "I'll meet them at the entrance". Little does the officer realize she's now leaving me alone with these 20 offenders. My concerns have been voiced repeatedly for this safety issue but have always landed on deaf ears. The considerations for the nurse's safety by the CO's is atrocious.

    "Hey." says an offender in front me, "While I'm here can you look up what my last A1C was?" he pleads as he towers over me as I sit at my station.

    "No. I've got to get as many people done before this chest pain arrives and we're not supposed to hold up insulin line for requests." I plainly state.

    "Awe, it'll not even a minute." the offender reckons.

    "I'm sorry. I have to get everyone else done. You'll have to put in a health care request where we'll write you back with the information or either you'll need to wait for your next chronic care appointment."

    "I don't see what the big deal is. The computer is right in front of you."

    "I said no. If you do not leave so I can get the next person I will call the CO". I state in my most authoritative voice.

    "Man, you used to be cool." the offender storms off muttering audible, derogatory curses under his breath.

    The next offender steps in and pricks himself with a lancet. He throws it away in front of me to a sharps container. We wait a moment for his accucheck to register when I hear Officer Wise yelling, "Get out! Get out of the way!" Her high pitched voice is chilling and filled with panic. "He's having a heart attack!"

    Not one, not two, not even three officers.... but FOUR officers were around this heart attack guy all trying to talk at once and explain what was going on to me, where they found him, his Hx, etc.

    "Hold on! Hold on!" Their panic is very contagious. I'm feeling overwhelmed already and haven't even made contact with the patient yet. Miss Wise can you move the offenders out of the hall?" She looks at me and eagerly nods.

    "OOHH! My chest. I can't breathe. I can't breathe. OH MY GOD. OH GOD. Its hurting!" The offender in the wheelchair moans. I look at the offender. He's white, in his 50's, and slim. No visible injury or trauma noted.

    ********* NURSING CHECK 1:

    OFFENDER CAN BREATHE
    as evidenced by his ability to coherently express his pain

    OFFENDER IS PROFUSELY SWEATING,
    is that from the awful heat outside or is he truly diaphoretic?

    OFFENDER IS BADLY SUNBURNT
    pallor cannot be noted at this time.

    OFFENDER ARRIVED BY W/C -
    gait not visualized at this time.


    ***********


    I take a deep breath and I hate this next part. I begin to take control of the situation by issuing orders to everyone.

    "Who has this guy's ID?" I ask the three remaining officers. One of them hands it to me with the offender's DOC #. With the officer's own out of breath pants informed me, "He was in the chow line when he collapsed and began screaming for help".

    "Sir," I address the offender, "I need you on this bed. We need vitals and an EKG." I state while simultaneously picking up my insulin sharps and throwing them into a random drawer. Officer Wise only cleared the offenders out of the doorway but did not take them out of the hall. My sharps are still at risk and need to be far out of the offender's reach.

    The offender momentarily just sits there, hyperventilating, moaning, and grabbing his L shoulder. The officers don't bother to wait for him to move but instead grab under his arms and begin to lift him from the wheel chair.

    "Wait! Wait!" I rush forward flaring my hands up to the officers. "No. I need him to do it. This is a nursing assessment." Test? Assessment? Its all the same right? Assessment just sounds better. "I have this. Just watch him..." I purposefully fail to verbalize "In case he falls" for fear of putting ideas into the offender's head. Hopefully the overeager officers will take the hint, but I doubt it.

    I look back to the offender and provide him with instruction. "Now, I need you to move to the gurney. The longer we put this off, the longer we delay treatment" I decide to tack on an enthusiastic, "and you look like you might need it, so let's get started."

    With much complaining, but absolutely no difficulty, the offender leaves his wheel chair and hops onto the gurney.

    "Okay, officers. Thank you so much for your help. Can you have Miss Wise come back in here and help me. You guys can go now, I'm good." The Officers grudgingly comply and are probably thinking about why I'm not calling 911 this very moment. I turn back to the offender and reach for my vital sign equipment. "This will probably be uncomfortable for you but I need you take off your shirt" The offender complies, slowly. His hyperventilation increases and the groans are still persistent.


    ***** NURSING CHECK 2:

    OFFENDER IS AMBULATORY

    OFFENDER'S GAIT IS STEADY

    OFFENDER APPROPRIATELY AND READILY OBEYS COMMANDS

    *********



    Now that this XXL T-shirt and jumpsuit are off of him, I notice he has a small baggy with a familiar dark glass bottle of SL nitro on him, attached by a safety pin to his pant's waistline. I inwardly groan and my level of anxiety jumps a notch. I'm starting to lean to the side that this may be real. I think it might be time for oxygen, at the very least to help his hyperventilating. I also think how odd it is that the offender is allowed a safety pin- I'd have thought such an item would be contraband. Pushing that thought aside, I reach to the cabinet, praying we have even one nasal cannula available. I open it and not to my surprise it was completely empty. I longed to be at my second job this instant in the hospital where supplies were abundant and I always had something I could use.

    Turning my attention to the Offender and getting a set of Vitals on him, I request Officer Wise to retrieve the Emergency Cart from an adjacent room. The gaggle of offenders in the hall are watching with enthusiasm. Others are yelling to get my attention telling me they need their insulin or they're blood sugars would drop, which of course made no sense. An odd few even left, cursed my name, and went to eat without taking insulin.

    Vitals read:

    BP: 132 / 84
    HR: 124 BPM
    O2: 88%
    Resp: 32 / min



    Officer Wise returned with the Emergency Cart. Thankfully, it was stocked with one NC. I put the offender on 2L O2, informed he must take deeper and slower breaths by inhaling through his nose and exhaling through his mouth, and immediately began to proceed with obtaining an EKG. Oxygenation levels out at 94% on 2L NC. As I hook the offender up to the machine I try to get a Hx and quick vibe for what he's going through at this time.

    ************ Nursing Check 3 & 4

    OFFENDER IS ON 2L OXYGEN
    putting someone on Oxygen, even if they don't need it often helps the patient / offender feel more at ease, trusting, and more secure with the nurse. This is something we do in the ER to allay fears and make people "think" we're actually doing something for them

    BLOOD PRESSURE IS SHOWING MILD HTN,
    a BP does not provide much information when experiencing an MI, but it is good to know none-the-less.

    HR IS SLIGHTLY TACHYCARDIC,
    this would indicate a compensatory mechanism for lack of O2 being perfused and/or possible stress.

    OXYGEN IS VERY LOW,
    is this due to the heart perfusing poorly or is the offender hyperventilating so much he's just getting very little oxygen period?

    RESPIRATIONS INDICATE HYPERVENTILATION,
    is this due to the lungs attempting to compensate for the heart perfusing poorly or is the offender just anxious and doing this to himself?


    ******************


    I ask him, as I place the electrodes on his bare chest, "What does the pain feel like?"

    "Its like someone is sitting on my chest. Its a horrible pressure and I can't get my breath, " he gasps. "It just keeps shooting down my arm. I don't think I can move it much."

    I respond back, "Well, have you tried taking your Nitro. You're supposed to take a tab when you begin feeling this way."

    "I've never taken it before. They just gave it to me over at RDC" states the offender. RDC is our sister prison that receives all new inmates and sends them to an appropriate facility for their sentencing.

    "When did the pain begin?" I'm having difficulty getting the electrodes to stick to his sweaty chest. The heat outside has been absolutely horrid lately and even HSU has been without air conditioning for the better part of the summer.

    "I was just standing in line for Chow when it just overtook me."

    "Did you have anything to eat prior to standing in line?"

    "No."

    "Have you ever had a heart attack before?"

    "Yeah. My first one was in September of 2009. I've had about 12 heart attacks since then."

    "How long have you been in prison?" My interest is peaked

    "Since Februrary of 2010."

    "Are you taking any medication?"

    "I'm on Coreg for my blood pressure." he says. I notice his respirations are slowing and becoming more regular. "I missed my morning dose because I slept in today".

    The EKG is ready. I hit the interpret / print button.

    "Do you have any allergies?" I ask.

    He responds, "I'm allergic to aspirin."

    The rhythm appears at even intervals. All components of the the rhythm, PQRST, are present. EKG reads, "NORMAL SINUS RHYTHM. ABNORMAL EKG." Heart rate, per EKG is now at 101 BPM.

    "Are you ready to give me my insulin?" I hear a shout from the hallway, reminding me my insulin line is still waiting.

    "Give me a few more minutes. I need to get this guy an IV. " Hoping those words would strike a profound sense of gravity to the waiting offenders outside. It didn't.


    ********** NURSING CHECK 5 & 6

    OFFENDER'S PAIN IS DESCRIBED AS SOMEONE SITTING ON CHEST
    as is typical with angina

    OFFENDER'S ASSOCIATED S/S INCLUDE SOB AND RADIATING PAIN TO LEFT ARM
    as is typical with classic male MI's

    OFFENDER IS NOT DIAPHORETIC AND COLOR IS INTACT,
    after seeing offender shirtless I conclude he is wet due to the raging summer heat and pigment is of normal color.

    OFFENDER HAS AN EMPTY STOMACH
    so this is not merely an episode of GERD

    OFFENDER STATES HE HAS HAD 12 PAST MI's,
    I find this highly unlikely that he's had 12 MI's and still standing here. Even more so, I wish to point out he is only on one medication, Coreg, a beta blocker for HTN. Most patients, after an MI, are put on an ACE Inhibitor and should take it every day for the rest of their life and the mortician should probably put one in their mouth after death just to be safe.

    OFFENDER'S EKG READS "NORMAL SINUS RHYTHM, ABNORMAL EKG".
    I really don't see what is abnormal about it, and I don't put too much investment in the computerized interpretation being that I'm 26 years old at this point and myself have an abnormal EKG with normal sinus rhythm.

    OFFENDER'S HEART RATE IS SLOWING DOWN AND RESPIRATIONS ARE DECREASING TO A MORE APPROPRIATE RATE WHILE OXYGENATION HAS INCREASED TO 94%.
    this is a good sign with the offender's vitals stabilizing.

    OFFENDER HAS NEVER TAKEN SL NITRO BEFORE AND UNAWARE OF ITS USE
    sublingual nitro can be very potent and the general population have varying sensitivities to it. Some people are so sensitive just coming in contact with it can cause a sudden and dangerous decrease in blood pressure. It is a nursing consideration and intervention to establish IV access before allowing someone to take Nitro without prior experience. Should things go badly and EMS be called, it will save valuable minutes having already established an IV.

    OFFENDER IS ALLERGIC TO ASA
    obviously we are not going to give it. Although, it would have been appropriate should it not have been contraindicated.

    ********************************


    I begin a necessary head to toe assessment to establish a baseline. As I proceed the offender is talking and talking. He is asking me questions about my choice in jobs at the prison. How much experience I have. What he used to do on the streets. What his past cardiac history has been like and what Correctional Doctors and Nurse Practitioners he has seen while in prison and so on. He's talking so much I'm beginning to think he's going to be just fine. I ask him to grab my two fingers and squeeze. He lifts his arms and squeezes well. I put my hands over both of his arms and tell him to raise his arms. His L arm is not overcoming resistance. I lighten my touch to just only the mildest of contact and tell him to lift his L arm again. He is still unable to perform saying it hurts too much. He begins moaning in pain. He says its starting to hit him so hard again. An important observation has now been made. Refer to Nursing check #7 below.

    "Calm down. Remember, just breathe through your nose and exhale through your mouth. That oxygen is going to help you." I calmly say to him, nodding my head.

    "So are you just going to deny us our insulin. This is some ********!" I hear a familiar voice yell. A regular insulin dependent offender has stepped into the doorway. There's another, older offender behind the accuser who speaks up also. "C'mon I need to go eat. I got commissary today and I already know my blood sugar is sky high. I didn't know I was given a death sentence."

    I ignore them. My temper is getting very short. I speak to Officer Wise. "Will you please escort everyone to the cage so I can open up a couple of locked drawers and start this IV without people yelling at me."

    "Alright you guys," Officer Wise begins as she swings her 250 lbs around in commanding five foot two inch height. "You need to give us some room. Get back there behind the cage and wait while we get this finished."

    "But Miss Wise, we need our insulin. This is some serious ****. If we leave and eat, you know the walk officers will tell us to turn around." a new diabetic to our camp says.

    I can't help but chime in, "That's never stopped anyone before. You guys come up here whenever you want like those walk officers dont even exist. I'm almost finished. After I'm finished with the IV I'll start the insulin line again. Its only been 15 minutes."

    Officer Wise successfully herds up the offenders into caged area, allowing me to go from room to room in search of an IV start kit, since the Emergency Cart was fresh out.


    ********** Nursing Check #7:

    -- a/ox3
    shows no difficulty answering or asking his own questions

    --- PERRL
    +3mm

    --- Skin warm, moist, and intact. Color is normal.
    nursing notes / later documentation explain cause of adjective "moist"

    --- Respirations even and unlabored anterior/posterior

    --- Breath sounds clear to auscultation anterior / posterior

    --- Abdomen is soft, nontender, nondistended, and bowel sounds are normoactive.

    --- S1&S2 auscultated

    --- apical pulse correlates to radial pulse
    Rhythm is regular.

    --- The offender was able to raise his hands and arms without difficulty to reach up and grab my fingers to squeeze, but can no longer lift his L arm when specifically assigned that task. This tells me the offender is lying about something

    --- grips strong are strong +2

    -- Capillary refill is < 3 seconds.
    If you are having difficulty judging perfusion on an African American, pull down their lower eyelid. If they're suffering hypoxia the inside of the eye lid will be white instead of red or bright pink.


    *************

    I establish a 20 gauge in the offender's LAC. First attempt. Offender tolerated. I'm beginning to lean toward the offender suffering from anxiety rather than actual chest pain. My notes describe the offender as tolerating the IV attempt, not tolerating well. He was whooping and hollering about how much he hated IVs and how much they hurt while I was I was sticking him, more than he was about his latest recourse of chest pain.

    I think to myself, this guy is faking. He's gotta be having anxiety or faking. He's talking too much and is terrified of one measly needle.

    Now that I've established IV access I administer one tablet of SL Nitro to the offender. "We're going to recheck your vitals in five minutes and I'm going to resume the insulin line. I'll be right here. Just tell me if you start feeling any worse than you currently do." I raise the gurney's side rail for safety.

    I restart the insulin line for five minutes. The offender suffering the chest pains is making conversation with diabetics as they enter the room. Its keeping me calm knowing that he's not bottoming out, but also irritating me because he was acting like he was dying 20 minutes ago.

    I repeat the VS and NITRO two more times with minimal drop in BP and no reduced chest pain per offender, but he has since significantly calmed down. I also recheck his O2 levels without oxygen. It immediately drops to 90% or 91%. I put the offender back on 2L.

    I finish insulin line before I start looking at my scattered sheets of paper with vitals on them and times. While the offender is stable, its to look through his EMR (Electronic Medical Record). I find several EKGs over the last few years that all say "Normal Sinus Rhythm. Normal EKG" in the EMR. I think that is unusual that the offender suddenly has an abnormal EKG. I look to the offender's paper chart in the Medical Records room and find the original EKGs and a few that were not entered in the EMR. Same results as the EMR. The EMR also states no further cardiac Hx beyond HTN.

    I silently curse at myself. I should probably call the doctor to report the abnormal EKG and chest pain.

    I page the doctor to call me back. I receive a call back within 15 minutes. I explain the situation to the Doctor; hi-lighting these things.


    ******* SBAR:

    Situation: I have an offender complaining of chest pain starting at 1620. He has allergies to aspirin. He has his own Nitro. He has taken three supervised doses without relief.

    Background: Only medical Hx includes HTN. He has no meds other than Coreg which he states he missed his AM dose today. Has several EKGs in the EMR, all of which show Normal Sinus Rhythm, Normal EKG.

    Assessment: Today's EKG, in tandem with chest pain show Normal Sinus Rhythm. Abnormal EKG." Oxygen levels started out upon arrival by wheel chair at 88%. Increased to 94% with 2L. When O2 is removed they drop to 91%. Pain radiates to L arm. Describes chest pain as if someone were sitting on his chest. No physical impairment is noted at this time.

    Recommendation: I'd like to send him out for further evaluation.


    ************************



    The doctor agreed with me and Officer called 911. I gathered as much of the offender's paperwork as I tried the best i could to gather pertinent information.


    Two days later I see the offender return to the prison. He had been diagnosed with severe anxiety. He was prescribed Xanax which our doctor took away due to its ability to be sold and abused within the prison. I later went to the doctor to ask if I did the right thing. My gut had been telling me this guy was faking and this was not a heart attack. The doctor said that because of the odd oxygen level and the new abnormal EKG my choices were sound.

    In the end, you must go by vital signs and lab results. Those are the things that will hold up in court. An offender has already proven themselves to be untrustworthy just by being in prison. As the doctor believes, trust only your objective data.

  • Jul 6 '15

    I am an LPN and worked in a level 2 correctional facility for 11
    months. The Prison's doctor was a wonderfully smart man and lived by a few simple rules, Never trust the offender regarding pain level. There are too many substance abusers who cry out in pain for attention and medication. You can only trust your objective assessment data.

    Chest pain was a daily complaint and between 1600 offenders,
    it was always something. Thankfully, all that drama and my insistence
    to pursue more nursing knowledge, nursing interventions, and perform
    proper assessment skills it landed me a highly coveted LPN position at
    a local Emergency Room where I see and even act as a primary nurse for
    varying levels of acuity. I wish to share with you my success in a
    correctional setting and tell you what I learned.

    1. Perform Immediate Visual assessment
    ---- Look for pallor (think deathly pale) clutching at chest, gasping
    for air, and extremely diaphoretic.
    ---- How did the offender get to the Health Services Unit?

    2. Take control of the situation, this is an offender who may need
    health care but simultaneously poses a safety risk to you.\
    --- Tell the the Custody officer to calm down (if in a panic), to
    release the offender, and not to leave you alone. If necassary ask
    unneeded personal or extra officers to leave to provide you room to
    work.
    ---Tell the offender to stand up.
    ---Tell the offender to get on the gurney.
    ---Tell the offender to take off his shirt in preparation for EKG.
    --- Above all, you must be persistent. Encourage the offender's goal
    of obtaining treatment only should he comply with your stipulations.
    You are in charge.


    Don't help or touch the offender until you have seen and noted what
    the offender is capable of. Measure his physical limitations. They may
    groan and complain the entire time about how it hurts to get their arm
    out from under their shirt but too bad too sad. If they can do it then
    thats a check mark in the "they'll survive category". If the offender
    refuses or honestly cannot, in your opinion, perform any of the above
    tasks then help him and continue to the next steps.

    3. Place on 2L Nasal Cannula ( if readily available- my correctional
    clinic rarely had easy access to supplies due to everything being
    locked up)

    4. Obtain Vitals.

    5. Obtain an EKG
    --- Familiarize yourself with a ST - elevation (STEMI) as would be
    seen on a 12-lead (often the machine will tell you too)
    --- Is the rhythm a regular? (If they have a pacemaker it will usually
    look a mess, but you should see very small notches at regular
    intervals that indicate the pacemaker is firing.)
    --- Is the EKG different than past EKGs? (This usually was info that
    required a bit of chart searching in the EMR, and even at times,
    required me to pull the hard chart.)


    6. Perform Hx with the following or similar questions:
    --- Do you have any other associated symptoms? (do not offer
    suggestions, but look for nausea, pain in L arm, Shortness of Breath,
    etc)
    --- Where is the pain?
    --- When did the pain begin?
    --- What does the pain feel like?
    --- What were you doing when the pain started?
    --- Have you ever had a heart attack previously?
    --- Are you on any Medications?
    --- Do you have any allergies?
    --- Have you ever taken Sublingual Nitro?


    7. Perform head to toe assessment.
    --- a/ox3 ?
    --- PERRL ?
    --- Skin warm, dry, intact?
    --- Respirations even and unlabored?
    --- Breath sounds clear to auscultation anterior / posterior
    --- S1&S2 auscultated?
    --- apical pulse correlates to radial pulse?
    --- bilateral extremities (lower and upper) overcome resistance?
    --- grips strong?
    --- capillary refill brisk?


    8. Give ASA 325 mg or 2-4 BABY ASA of 81 mg / tab - make sure he chews
    --- hold if allergy is present

    9. Give sublingual nitro if offender has on hand and has not already taken.
    --- Sublingual nitro is contraindicated for offenders who...
    ------ do not have their own SL nitro on hand and do not have IV access
    ------ have an SBP < 100, or DBP < 50 for fear of bottoming their
    blood pressure out.
    --- repeat up to 3 total doses 5 minutes apart and assess offender's
    supposed comfort level.


    Now allow me to describe a scenario for you. The exact one that
    happened to me a few months ago.


    The officers call HSU (Health services unit) while I'm working the clinic
    alone. There are other nurses in the infirmary and one nurse in the
    med room. It is a scorching, hot, weekend. The doctor is not on site nor is
    management. An offender is complaining of chest pain and an CO (Correctional Officer) radios in that he'll be bringing an offender up to the clinic.

    Its 1625. The peak of my insulin line. I already have 20+ offenders standing in a single file line outside of my open door waiting for their insulin. I have 30+ more offenders I am expecting to come before 1700. This is just not the time to deal with this CP (chest pain) crap. I yell back to my CO in the clinic, "How's he getting up here?" as I continue shooting my offenders with their insulin.

    Officer Wise shouts back, "They're bringing him up in a wheel chair." I roll my eyes and stab another offender with his Humulin R as she continues, "I'll meet them at the entrance". Little does the officer realize she's now leaving me alone with these 20 offenders. My concerns have been voiced repeatedly for this safety issue but have always landed on deaf ears. The considerations for the nurse's safety by the CO's is atrocious.

    "Hey." says an offender in front me, "While I'm here can you look up what my last A1C was?" he pleads as he towers over me as I sit at my station.

    "No. I've got to get as many people done before this chest pain arrives and we're not supposed to hold up insulin line for requests." I plainly state.

    "Awe, it'll not even a minute." the offender reckons.

    "I'm sorry. I have to get everyone else done. You'll have to put in a health care request where we'll write you back with the information or either you'll need to wait for your next chronic care appointment."

    "I don't see what the big deal is. The computer is right in front of you."

    "I said no. If you do not leave so I can get the next person I will call the CO". I state in my most authoritative voice.

    "Man, you used to be cool." the offender storms off muttering audible, derogatory curses under his breath.

    The next offender steps in and pricks himself with a lancet. He throws it away in front of me to a sharps container. We wait a moment for his accucheck to register when I hear Officer Wise yelling, "Get out! Get out of the way!" Her high pitched voice is chilling and filled with panic. "He's having a heart attack!"

    Not one, not two, not even three officers.... but FOUR officers were around this heart attack guy all trying to talk at once and explain what was going on to me, where they found him, his Hx, etc.

    "Hold on! Hold on!" Their panic is very contagious. I'm feeling overwhelmed already and haven't even made contact with the patient yet. Miss Wise can you move the offenders out of the hall?" She looks at me and eagerly nods.

    "OOHH! My chest. I can't breathe. I can't breathe. OH MY GOD. OH GOD. Its hurting!" The offender in the wheelchair moans. I look at the offender. He's white, in his 50's, and slim. No visible injury or trauma noted.

    ********* NURSING CHECK 1:

    OFFENDER CAN BREATHE
    as evidenced by his ability to coherently express his pain

    OFFENDER IS PROFUSELY SWEATING,
    is that from the awful heat outside or is he truly diaphoretic?

    OFFENDER IS BADLY SUNBURNT
    pallor cannot be noted at this time.

    OFFENDER ARRIVED BY W/C -
    gait not visualized at this time.


    ***********


    I take a deep breath and I hate this next part. I begin to take control of the situation by issuing orders to everyone.

    "Who has this guy's ID?" I ask the three remaining officers. One of them hands it to me with the offender's DOC #. With the officer's own out of breath pants informed me, "He was in the chow line when he collapsed and began screaming for help".

    "Sir," I address the offender, "I need you on this bed. We need vitals and an EKG." I state while simultaneously picking up my insulin sharps and throwing them into a random drawer. Officer Wise only cleared the offenders out of the doorway but did not take them out of the hall. My sharps are still at risk and need to be far out of the offender's reach.

    The offender momentarily just sits there, hyperventilating, moaning, and grabbing his L shoulder. The officers don't bother to wait for him to move but instead grab under his arms and begin to lift him from the wheel chair.

    "Wait! Wait!" I rush forward flaring my hands up to the officers. "No. I need him to do it. This is a nursing assessment." Test? Assessment? Its all the same right? Assessment just sounds better. "I have this. Just watch him..." I purposefully fail to verbalize "In case he falls" for fear of putting ideas into the offender's head. Hopefully the overeager officers will take the hint, but I doubt it.

    I look back to the offender and provide him with instruction. "Now, I need you to move to the gurney. The longer we put this off, the longer we delay treatment" I decide to tack on an enthusiastic, "and you look like you might need it, so let's get started."

    With much complaining, but absolutely no difficulty, the offender leaves his wheel chair and hops onto the gurney.

    "Okay, officers. Thank you so much for your help. Can you have Miss Wise come back in here and help me. You guys can go now, I'm good." The Officers grudgingly comply and are probably thinking about why I'm not calling 911 this very moment. I turn back to the offender and reach for my vital sign equipment. "This will probably be uncomfortable for you but I need you take off your shirt" The offender complies, slowly. His hyperventilation increases and the groans are still persistent.


    ***** NURSING CHECK 2:

    OFFENDER IS AMBULATORY

    OFFENDER'S GAIT IS STEADY

    OFFENDER APPROPRIATELY AND READILY OBEYS COMMANDS

    *********



    Now that this XXL T-shirt and jumpsuit are off of him, I notice he has a small baggy with a familiar dark glass bottle of SL nitro on him, attached by a safety pin to his pant's waistline. I inwardly groan and my level of anxiety jumps a notch. I'm starting to lean to the side that this may be real. I think it might be time for oxygen, at the very least to help his hyperventilating. I also think how odd it is that the offender is allowed a safety pin- I'd have thought such an item would be contraband. Pushing that thought aside, I reach to the cabinet, praying we have even one nasal cannula available. I open it and not to my surprise it was completely empty. I longed to be at my second job this instant in the hospital where supplies were abundant and I always had something I could use.

    Turning my attention to the Offender and getting a set of Vitals on him, I request Officer Wise to retrieve the Emergency Cart from an adjacent room. The gaggle of offenders in the hall are watching with enthusiasm. Others are yelling to get my attention telling me they need their insulin or they're blood sugars would drop, which of course made no sense. An odd few even left, cursed my name, and went to eat without taking insulin.

    Vitals read:

    BP: 132 / 84
    HR: 124 BPM
    O2: 88%
    Resp: 32 / min



    Officer Wise returned with the Emergency Cart. Thankfully, it was stocked with one NC. I put the offender on 2L O2, informed he must take deeper and slower breaths by inhaling through his nose and exhaling through his mouth, and immediately began to proceed with obtaining an EKG. Oxygenation levels out at 94% on 2L NC. As I hook the offender up to the machine I try to get a Hx and quick vibe for what he's going through at this time.

    ************ Nursing Check 3 & 4

    OFFENDER IS ON 2L OXYGEN
    putting someone on Oxygen, even if they don't need it often helps the patient / offender feel more at ease, trusting, and more secure with the nurse. This is something we do in the ER to allay fears and make people "think" we're actually doing something for them

    BLOOD PRESSURE IS SHOWING MILD HTN,
    a BP does not provide much information when experiencing an MI, but it is good to know none-the-less.

    HR IS SLIGHTLY TACHYCARDIC,
    this would indicate a compensatory mechanism for lack of O2 being perfused and/or possible stress.

    OXYGEN IS VERY LOW,
    is this due to the heart perfusing poorly or is the offender hyperventilating so much he's just getting very little oxygen period?

    RESPIRATIONS INDICATE HYPERVENTILATION,
    is this due to the lungs attempting to compensate for the heart perfusing poorly or is the offender just anxious and doing this to himself?


    ******************


    I ask him, as I place the electrodes on his bare chest, "What does the pain feel like?"

    "Its like someone is sitting on my chest. Its a horrible pressure and I can't get my breath, " he gasps. "It just keeps shooting down my arm. I don't think I can move it much."

    I respond back, "Well, have you tried taking your Nitro. You're supposed to take a tab when you begin feeling this way."

    "I've never taken it before. They just gave it to me over at RDC" states the offender. RDC is our sister prison that receives all new inmates and sends them to an appropriate facility for their sentencing.

    "When did the pain begin?" I'm having difficulty getting the electrodes to stick to his sweaty chest. The heat outside has been absolutely horrid lately and even HSU has been without air conditioning for the better part of the summer.

    "I was just standing in line for Chow when it just overtook me."

    "Did you have anything to eat prior to standing in line?"

    "No."

    "Have you ever had a heart attack before?"

    "Yeah. My first one was in September of 2009. I've had about 12 heart attacks since then."

    "How long have you been in prison?" My interest is peaked

    "Since Februrary of 2010."

    "Are you taking any medication?"

    "I'm on Coreg for my blood pressure." he says. I notice his respirations are slowing and becoming more regular. "I missed my morning dose because I slept in today".

    The EKG is ready. I hit the interpret / print button.

    "Do you have any allergies?" I ask.

    He responds, "I'm allergic to aspirin."

    The rhythm appears at even intervals. All components of the the rhythm, PQRST, are present. EKG reads, "NORMAL SINUS RHYTHM. ABNORMAL EKG." Heart rate, per EKG is now at 101 BPM.

    "Are you ready to give me my insulin?" I hear a shout from the hallway, reminding me my insulin line is still waiting.

    "Give me a few more minutes. I need to get this guy an IV. " Hoping those words would strike a profound sense of gravity to the waiting offenders outside. It didn't.


    ********** NURSING CHECK 5 & 6

    OFFENDER'S PAIN IS DESCRIBED AS SOMEONE SITTING ON CHEST
    as is typical with angina

    OFFENDER'S ASSOCIATED S/S INCLUDE SOB AND RADIATING PAIN TO LEFT ARM
    as is typical with classic male MI's

    OFFENDER IS NOT DIAPHORETIC AND COLOR IS INTACT,
    after seeing offender shirtless I conclude he is wet due to the raging summer heat and pigment is of normal color.

    OFFENDER HAS AN EMPTY STOMACH
    so this is not merely an episode of GERD

    OFFENDER STATES HE HAS HAD 12 PAST MI's,
    I find this highly unlikely that he's had 12 MI's and still standing here. Even more so, I wish to point out he is only on one medication, Coreg, a beta blocker for HTN. Most patients, after an MI, are put on an ACE Inhibitor and should take it every day for the rest of their life and the mortician should probably put one in their mouth after death just to be safe.

    OFFENDER'S EKG READS "NORMAL SINUS RHYTHM, ABNORMAL EKG".
    I really don't see what is abnormal about it, and I don't put too much investment in the computerized interpretation being that I'm 26 years old at this point and myself have an abnormal EKG with normal sinus rhythm.

    OFFENDER'S HEART RATE IS SLOWING DOWN AND RESPIRATIONS ARE DECREASING TO A MORE APPROPRIATE RATE WHILE OXYGENATION HAS INCREASED TO 94%.
    this is a good sign with the offender's vitals stabilizing.

    OFFENDER HAS NEVER TAKEN SL NITRO BEFORE AND UNAWARE OF ITS USE
    sublingual nitro can be very potent and the general population have varying sensitivities to it. Some people are so sensitive just coming in contact with it can cause a sudden and dangerous decrease in blood pressure. It is a nursing consideration and intervention to establish IV access before allowing someone to take Nitro without prior experience. Should things go badly and EMS be called, it will save valuable minutes having already established an IV.

    OFFENDER IS ALLERGIC TO ASA
    obviously we are not going to give it. Although, it would have been appropriate should it not have been contraindicated.

    ********************************


    I begin a necessary head to toe assessment to establish a baseline. As I proceed the offender is talking and talking. He is asking me questions about my choice in jobs at the prison. How much experience I have. What he used to do on the streets. What his past cardiac history has been like and what Correctional Doctors and Nurse Practitioners he has seen while in prison and so on. He's talking so much I'm beginning to think he's going to be just fine. I ask him to grab my two fingers and squeeze. He lifts his arms and squeezes well. I put my hands over both of his arms and tell him to raise his arms. His L arm is not overcoming resistance. I lighten my touch to just only the mildest of contact and tell him to lift his L arm again. He is still unable to perform saying it hurts too much. He begins moaning in pain. He says its starting to hit him so hard again. An important observation has now been made. Refer to Nursing check #7 below.

    "Calm down. Remember, just breathe through your nose and exhale through your mouth. That oxygen is going to help you." I calmly say to him, nodding my head.

    "So are you just going to deny us our insulin. This is some ********!" I hear a familiar voice yell. A regular insulin dependent offender has stepped into the doorway. There's another, older offender behind the accuser who speaks up also. "C'mon I need to go eat. I got commissary today and I already know my blood sugar is sky high. I didn't know I was given a death sentence."

    I ignore them. My temper is getting very short. I speak to Officer Wise. "Will you please escort everyone to the cage so I can open up a couple of locked drawers and start this IV without people yelling at me."

    "Alright you guys," Officer Wise begins as she swings her 250 lbs around in commanding five foot two inch height. "You need to give us some room. Get back there behind the cage and wait while we get this finished."

    "But Miss Wise, we need our insulin. This is some serious ****. If we leave and eat, you know the walk officers will tell us to turn around." a new diabetic to our camp says.

    I can't help but chime in, "That's never stopped anyone before. You guys come up here whenever you want like those walk officers dont even exist. I'm almost finished. After I'm finished with the IV I'll start the insulin line again. Its only been 15 minutes."

    Officer Wise successfully herds up the offenders into caged area, allowing me to go from room to room in search of an IV start kit, since the Emergency Cart was fresh out.


    ********** Nursing Check #7:

    -- a/ox3
    shows no difficulty answering or asking his own questions

    --- PERRL
    +3mm

    --- Skin warm, moist, and intact. Color is normal.
    nursing notes / later documentation explain cause of adjective "moist"

    --- Respirations even and unlabored anterior/posterior

    --- Breath sounds clear to auscultation anterior / posterior

    --- Abdomen is soft, nontender, nondistended, and bowel sounds are normoactive.

    --- S1&S2 auscultated

    --- apical pulse correlates to radial pulse
    Rhythm is regular.

    --- The offender was able to raise his hands and arms without difficulty to reach up and grab my fingers to squeeze, but can no longer lift his L arm when specifically assigned that task. This tells me the offender is lying about something

    --- grips strong are strong +2

    -- Capillary refill is < 3 seconds.
    If you are having difficulty judging perfusion on an African American, pull down their lower eyelid. If they're suffering hypoxia the inside of the eye lid will be white instead of red or bright pink.


    *************

    I establish a 20 gauge in the offender's LAC. First attempt. Offender tolerated. I'm beginning to lean toward the offender suffering from anxiety rather than actual chest pain. My notes describe the offender as tolerating the IV attempt, not tolerating well. He was whooping and hollering about how much he hated IVs and how much they hurt while I was I was sticking him, more than he was about his latest recourse of chest pain.

    I think to myself, this guy is faking. He's gotta be having anxiety or faking. He's talking too much and is terrified of one measly needle.

    Now that I've established IV access I administer one tablet of SL Nitro to the offender. "We're going to recheck your vitals in five minutes and I'm going to resume the insulin line. I'll be right here. Just tell me if you start feeling any worse than you currently do." I raise the gurney's side rail for safety.

    I restart the insulin line for five minutes. The offender suffering the chest pains is making conversation with diabetics as they enter the room. Its keeping me calm knowing that he's not bottoming out, but also irritating me because he was acting like he was dying 20 minutes ago.

    I repeat the VS and NITRO two more times with minimal drop in BP and no reduced chest pain per offender, but he has since significantly calmed down. I also recheck his O2 levels without oxygen. It immediately drops to 90% or 91%. I put the offender back on 2L.

    I finish insulin line before I start looking at my scattered sheets of paper with vitals on them and times. While the offender is stable, its to look through his EMR (Electronic Medical Record). I find several EKGs over the last few years that all say "Normal Sinus Rhythm. Normal EKG" in the EMR. I think that is unusual that the offender suddenly has an abnormal EKG. I look to the offender's paper chart in the Medical Records room and find the original EKGs and a few that were not entered in the EMR. Same results as the EMR. The EMR also states no further cardiac Hx beyond HTN.

    I silently curse at myself. I should probably call the doctor to report the abnormal EKG and chest pain.

    I page the doctor to call me back. I receive a call back within 15 minutes. I explain the situation to the Doctor; hi-lighting these things.


    ******* SBAR:

    Situation: I have an offender complaining of chest pain starting at 1620. He has allergies to aspirin. He has his own Nitro. He has taken three supervised doses without relief.

    Background: Only medical Hx includes HTN. He has no meds other than Coreg which he states he missed his AM dose today. Has several EKGs in the EMR, all of which show Normal Sinus Rhythm, Normal EKG.

    Assessment: Today's EKG, in tandem with chest pain show Normal Sinus Rhythm. Abnormal EKG." Oxygen levels started out upon arrival by wheel chair at 88%. Increased to 94% with 2L. When O2 is removed they drop to 91%. Pain radiates to L arm. Describes chest pain as if someone were sitting on his chest. No physical impairment is noted at this time.

    Recommendation: I'd like to send him out for further evaluation.


    ************************



    The doctor agreed with me and Officer called 911. I gathered as much of the offender's paperwork as I tried the best i could to gather pertinent information.


    Two days later I see the offender return to the prison. He had been diagnosed with severe anxiety. He was prescribed Xanax which our doctor took away due to its ability to be sold and abused within the prison. I later went to the doctor to ask if I did the right thing. My gut had been telling me this guy was faking and this was not a heart attack. The doctor said that because of the odd oxygen level and the new abnormal EKG my choices were sound.

    In the end, you must go by vital signs and lab results. Those are the things that will hold up in court. An offender has already proven themselves to be untrustworthy just by being in prison. As the doctor believes, trust only your objective data.

  • Jul 3 '15

    I am an LPN and worked in a level 2 correctional facility for 11
    months. The Prison's doctor was a wonderfully smart man and lived by a few simple rules, Never trust the offender regarding pain level. There are too many substance abusers who cry out in pain for attention and medication. You can only trust your objective assessment data.

    Chest pain was a daily complaint and between 1600 offenders,
    it was always something. Thankfully, all that drama and my insistence
    to pursue more nursing knowledge, nursing interventions, and perform
    proper assessment skills it landed me a highly coveted LPN position at
    a local Emergency Room where I see and even act as a primary nurse for
    varying levels of acuity. I wish to share with you my success in a
    correctional setting and tell you what I learned.

    1. Perform Immediate Visual assessment
    ---- Look for pallor (think deathly pale) clutching at chest, gasping
    for air, and extremely diaphoretic.
    ---- How did the offender get to the Health Services Unit?

    2. Take control of the situation, this is an offender who may need
    health care but simultaneously poses a safety risk to you.\
    --- Tell the the Custody officer to calm down (if in a panic), to
    release the offender, and not to leave you alone. If necassary ask
    unneeded personal or extra officers to leave to provide you room to
    work.
    ---Tell the offender to stand up.
    ---Tell the offender to get on the gurney.
    ---Tell the offender to take off his shirt in preparation for EKG.
    --- Above all, you must be persistent. Encourage the offender's goal
    of obtaining treatment only should he comply with your stipulations.
    You are in charge.


    Don't help or touch the offender until you have seen and noted what
    the offender is capable of. Measure his physical limitations. They may
    groan and complain the entire time about how it hurts to get their arm
    out from under their shirt but too bad too sad. If they can do it then
    thats a check mark in the "they'll survive category". If the offender
    refuses or honestly cannot, in your opinion, perform any of the above
    tasks then help him and continue to the next steps.

    3. Place on 2L Nasal Cannula ( if readily available- my correctional
    clinic rarely had easy access to supplies due to everything being
    locked up)

    4. Obtain Vitals.

    5. Obtain an EKG
    --- Familiarize yourself with a ST - elevation (STEMI) as would be
    seen on a 12-lead (often the machine will tell you too)
    --- Is the rhythm a regular? (If they have a pacemaker it will usually
    look a mess, but you should see very small notches at regular
    intervals that indicate the pacemaker is firing.)
    --- Is the EKG different than past EKGs? (This usually was info that
    required a bit of chart searching in the EMR, and even at times,
    required me to pull the hard chart.)


    6. Perform Hx with the following or similar questions:
    --- Do you have any other associated symptoms? (do not offer
    suggestions, but look for nausea, pain in L arm, Shortness of Breath,
    etc)
    --- Where is the pain?
    --- When did the pain begin?
    --- What does the pain feel like?
    --- What were you doing when the pain started?
    --- Have you ever had a heart attack previously?
    --- Are you on any Medications?
    --- Do you have any allergies?
    --- Have you ever taken Sublingual Nitro?


    7. Perform head to toe assessment.
    --- a/ox3 ?
    --- PERRL ?
    --- Skin warm, dry, intact?
    --- Respirations even and unlabored?
    --- Breath sounds clear to auscultation anterior / posterior
    --- S1&S2 auscultated?
    --- apical pulse correlates to radial pulse?
    --- bilateral extremities (lower and upper) overcome resistance?
    --- grips strong?
    --- capillary refill brisk?


    8. Give ASA 325 mg or 2-4 BABY ASA of 81 mg / tab - make sure he chews
    --- hold if allergy is present

    9. Give sublingual nitro if offender has on hand and has not already taken.
    --- Sublingual nitro is contraindicated for offenders who...
    ------ do not have their own SL nitro on hand and do not have IV access
    ------ have an SBP < 100, or DBP < 50 for fear of bottoming their
    blood pressure out.
    --- repeat up to 3 total doses 5 minutes apart and assess offender's
    supposed comfort level.


    Now allow me to describe a scenario for you. The exact one that
    happened to me a few months ago.


    The officers call HSU (Health services unit) while I'm working the clinic
    alone. There are other nurses in the infirmary and one nurse in the
    med room. It is a scorching, hot, weekend. The doctor is not on site nor is
    management. An offender is complaining of chest pain and an CO (Correctional Officer) radios in that he'll be bringing an offender up to the clinic.

    Its 1625. The peak of my insulin line. I already have 20+ offenders standing in a single file line outside of my open door waiting for their insulin. I have 30+ more offenders I am expecting to come before 1700. This is just not the time to deal with this CP (chest pain) crap. I yell back to my CO in the clinic, "How's he getting up here?" as I continue shooting my offenders with their insulin.

    Officer Wise shouts back, "They're bringing him up in a wheel chair." I roll my eyes and stab another offender with his Humulin R as she continues, "I'll meet them at the entrance". Little does the officer realize she's now leaving me alone with these 20 offenders. My concerns have been voiced repeatedly for this safety issue but have always landed on deaf ears. The considerations for the nurse's safety by the CO's is atrocious.

    "Hey." says an offender in front me, "While I'm here can you look up what my last A1C was?" he pleads as he towers over me as I sit at my station.

    "No. I've got to get as many people done before this chest pain arrives and we're not supposed to hold up insulin line for requests." I plainly state.

    "Awe, it'll not even a minute." the offender reckons.

    "I'm sorry. I have to get everyone else done. You'll have to put in a health care request where we'll write you back with the information or either you'll need to wait for your next chronic care appointment."

    "I don't see what the big deal is. The computer is right in front of you."

    "I said no. If you do not leave so I can get the next person I will call the CO". I state in my most authoritative voice.

    "Man, you used to be cool." the offender storms off muttering audible, derogatory curses under his breath.

    The next offender steps in and pricks himself with a lancet. He throws it away in front of me to a sharps container. We wait a moment for his accucheck to register when I hear Officer Wise yelling, "Get out! Get out of the way!" Her high pitched voice is chilling and filled with panic. "He's having a heart attack!"

    Not one, not two, not even three officers.... but FOUR officers were around this heart attack guy all trying to talk at once and explain what was going on to me, where they found him, his Hx, etc.

    "Hold on! Hold on!" Their panic is very contagious. I'm feeling overwhelmed already and haven't even made contact with the patient yet. Miss Wise can you move the offenders out of the hall?" She looks at me and eagerly nods.

    "OOHH! My chest. I can't breathe. I can't breathe. OH MY GOD. OH GOD. Its hurting!" The offender in the wheelchair moans. I look at the offender. He's white, in his 50's, and slim. No visible injury or trauma noted.

    ********* NURSING CHECK 1:

    OFFENDER CAN BREATHE
    as evidenced by his ability to coherently express his pain

    OFFENDER IS PROFUSELY SWEATING,
    is that from the awful heat outside or is he truly diaphoretic?

    OFFENDER IS BADLY SUNBURNT
    pallor cannot be noted at this time.

    OFFENDER ARRIVED BY W/C -
    gait not visualized at this time.


    ***********


    I take a deep breath and I hate this next part. I begin to take control of the situation by issuing orders to everyone.

    "Who has this guy's ID?" I ask the three remaining officers. One of them hands it to me with the offender's DOC #. With the officer's own out of breath pants informed me, "He was in the chow line when he collapsed and began screaming for help".

    "Sir," I address the offender, "I need you on this bed. We need vitals and an EKG." I state while simultaneously picking up my insulin sharps and throwing them into a random drawer. Officer Wise only cleared the offenders out of the doorway but did not take them out of the hall. My sharps are still at risk and need to be far out of the offender's reach.

    The offender momentarily just sits there, hyperventilating, moaning, and grabbing his L shoulder. The officers don't bother to wait for him to move but instead grab under his arms and begin to lift him from the wheel chair.

    "Wait! Wait!" I rush forward flaring my hands up to the officers. "No. I need him to do it. This is a nursing assessment." Test? Assessment? Its all the same right? Assessment just sounds better. "I have this. Just watch him..." I purposefully fail to verbalize "In case he falls" for fear of putting ideas into the offender's head. Hopefully the overeager officers will take the hint, but I doubt it.

    I look back to the offender and provide him with instruction. "Now, I need you to move to the gurney. The longer we put this off, the longer we delay treatment" I decide to tack on an enthusiastic, "and you look like you might need it, so let's get started."

    With much complaining, but absolutely no difficulty, the offender leaves his wheel chair and hops onto the gurney.

    "Okay, officers. Thank you so much for your help. Can you have Miss Wise come back in here and help me. You guys can go now, I'm good." The Officers grudgingly comply and are probably thinking about why I'm not calling 911 this very moment. I turn back to the offender and reach for my vital sign equipment. "This will probably be uncomfortable for you but I need you take off your shirt" The offender complies, slowly. His hyperventilation increases and the groans are still persistent.


    ***** NURSING CHECK 2:

    OFFENDER IS AMBULATORY

    OFFENDER'S GAIT IS STEADY

    OFFENDER APPROPRIATELY AND READILY OBEYS COMMANDS

    *********



    Now that this XXL T-shirt and jumpsuit are off of him, I notice he has a small baggy with a familiar dark glass bottle of SL nitro on him, attached by a safety pin to his pant's waistline. I inwardly groan and my level of anxiety jumps a notch. I'm starting to lean to the side that this may be real. I think it might be time for oxygen, at the very least to help his hyperventilating. I also think how odd it is that the offender is allowed a safety pin- I'd have thought such an item would be contraband. Pushing that thought aside, I reach to the cabinet, praying we have even one nasal cannula available. I open it and not to my surprise it was completely empty. I longed to be at my second job this instant in the hospital where supplies were abundant and I always had something I could use.

    Turning my attention to the Offender and getting a set of Vitals on him, I request Officer Wise to retrieve the Emergency Cart from an adjacent room. The gaggle of offenders in the hall are watching with enthusiasm. Others are yelling to get my attention telling me they need their insulin or they're blood sugars would drop, which of course made no sense. An odd few even left, cursed my name, and went to eat without taking insulin.

    Vitals read:

    BP: 132 / 84
    HR: 124 BPM
    O2: 88%
    Resp: 32 / min



    Officer Wise returned with the Emergency Cart. Thankfully, it was stocked with one NC. I put the offender on 2L O2, informed he must take deeper and slower breaths by inhaling through his nose and exhaling through his mouth, and immediately began to proceed with obtaining an EKG. Oxygenation levels out at 94% on 2L NC. As I hook the offender up to the machine I try to get a Hx and quick vibe for what he's going through at this time.

    ************ Nursing Check 3 & 4

    OFFENDER IS ON 2L OXYGEN
    putting someone on Oxygen, even if they don't need it often helps the patient / offender feel more at ease, trusting, and more secure with the nurse. This is something we do in the ER to allay fears and make people "think" we're actually doing something for them

    BLOOD PRESSURE IS SHOWING MILD HTN,
    a BP does not provide much information when experiencing an MI, but it is good to know none-the-less.

    HR IS SLIGHTLY TACHYCARDIC,
    this would indicate a compensatory mechanism for lack of O2 being perfused and/or possible stress.

    OXYGEN IS VERY LOW,
    is this due to the heart perfusing poorly or is the offender hyperventilating so much he's just getting very little oxygen period?

    RESPIRATIONS INDICATE HYPERVENTILATION,
    is this due to the lungs attempting to compensate for the heart perfusing poorly or is the offender just anxious and doing this to himself?


    ******************


    I ask him, as I place the electrodes on his bare chest, "What does the pain feel like?"

    "Its like someone is sitting on my chest. Its a horrible pressure and I can't get my breath, " he gasps. "It just keeps shooting down my arm. I don't think I can move it much."

    I respond back, "Well, have you tried taking your Nitro. You're supposed to take a tab when you begin feeling this way."

    "I've never taken it before. They just gave it to me over at RDC" states the offender. RDC is our sister prison that receives all new inmates and sends them to an appropriate facility for their sentencing.

    "When did the pain begin?" I'm having difficulty getting the electrodes to stick to his sweaty chest. The heat outside has been absolutely horrid lately and even HSU has been without air conditioning for the better part of the summer.

    "I was just standing in line for Chow when it just overtook me."

    "Did you have anything to eat prior to standing in line?"

    "No."

    "Have you ever had a heart attack before?"

    "Yeah. My first one was in September of 2009. I've had about 12 heart attacks since then."

    "How long have you been in prison?" My interest is peaked

    "Since Februrary of 2010."

    "Are you taking any medication?"

    "I'm on Coreg for my blood pressure." he says. I notice his respirations are slowing and becoming more regular. "I missed my morning dose because I slept in today".

    The EKG is ready. I hit the interpret / print button.

    "Do you have any allergies?" I ask.

    He responds, "I'm allergic to aspirin."

    The rhythm appears at even intervals. All components of the the rhythm, PQRST, are present. EKG reads, "NORMAL SINUS RHYTHM. ABNORMAL EKG." Heart rate, per EKG is now at 101 BPM.

    "Are you ready to give me my insulin?" I hear a shout from the hallway, reminding me my insulin line is still waiting.

    "Give me a few more minutes. I need to get this guy an IV. " Hoping those words would strike a profound sense of gravity to the waiting offenders outside. It didn't.


    ********** NURSING CHECK 5 & 6

    OFFENDER'S PAIN IS DESCRIBED AS SOMEONE SITTING ON CHEST
    as is typical with angina

    OFFENDER'S ASSOCIATED S/S INCLUDE SOB AND RADIATING PAIN TO LEFT ARM
    as is typical with classic male MI's

    OFFENDER IS NOT DIAPHORETIC AND COLOR IS INTACT,
    after seeing offender shirtless I conclude he is wet due to the raging summer heat and pigment is of normal color.

    OFFENDER HAS AN EMPTY STOMACH
    so this is not merely an episode of GERD

    OFFENDER STATES HE HAS HAD 12 PAST MI's,
    I find this highly unlikely that he's had 12 MI's and still standing here. Even more so, I wish to point out he is only on one medication, Coreg, a beta blocker for HTN. Most patients, after an MI, are put on an ACE Inhibitor and should take it every day for the rest of their life and the mortician should probably put one in their mouth after death just to be safe.

    OFFENDER'S EKG READS "NORMAL SINUS RHYTHM, ABNORMAL EKG".
    I really don't see what is abnormal about it, and I don't put too much investment in the computerized interpretation being that I'm 26 years old at this point and myself have an abnormal EKG with normal sinus rhythm.

    OFFENDER'S HEART RATE IS SLOWING DOWN AND RESPIRATIONS ARE DECREASING TO A MORE APPROPRIATE RATE WHILE OXYGENATION HAS INCREASED TO 94%.
    this is a good sign with the offender's vitals stabilizing.

    OFFENDER HAS NEVER TAKEN SL NITRO BEFORE AND UNAWARE OF ITS USE
    sublingual nitro can be very potent and the general population have varying sensitivities to it. Some people are so sensitive just coming in contact with it can cause a sudden and dangerous decrease in blood pressure. It is a nursing consideration and intervention to establish IV access before allowing someone to take Nitro without prior experience. Should things go badly and EMS be called, it will save valuable minutes having already established an IV.

    OFFENDER IS ALLERGIC TO ASA
    obviously we are not going to give it. Although, it would have been appropriate should it not have been contraindicated.

    ********************************


    I begin a necessary head to toe assessment to establish a baseline. As I proceed the offender is talking and talking. He is asking me questions about my choice in jobs at the prison. How much experience I have. What he used to do on the streets. What his past cardiac history has been like and what Correctional Doctors and Nurse Practitioners he has seen while in prison and so on. He's talking so much I'm beginning to think he's going to be just fine. I ask him to grab my two fingers and squeeze. He lifts his arms and squeezes well. I put my hands over both of his arms and tell him to raise his arms. His L arm is not overcoming resistance. I lighten my touch to just only the mildest of contact and tell him to lift his L arm again. He is still unable to perform saying it hurts too much. He begins moaning in pain. He says its starting to hit him so hard again. An important observation has now been made. Refer to Nursing check #7 below.

    "Calm down. Remember, just breathe through your nose and exhale through your mouth. That oxygen is going to help you." I calmly say to him, nodding my head.

    "So are you just going to deny us our insulin. This is some ********!" I hear a familiar voice yell. A regular insulin dependent offender has stepped into the doorway. There's another, older offender behind the accuser who speaks up also. "C'mon I need to go eat. I got commissary today and I already know my blood sugar is sky high. I didn't know I was given a death sentence."

    I ignore them. My temper is getting very short. I speak to Officer Wise. "Will you please escort everyone to the cage so I can open up a couple of locked drawers and start this IV without people yelling at me."

    "Alright you guys," Officer Wise begins as she swings her 250 lbs around in commanding five foot two inch height. "You need to give us some room. Get back there behind the cage and wait while we get this finished."

    "But Miss Wise, we need our insulin. This is some serious ****. If we leave and eat, you know the walk officers will tell us to turn around." a new diabetic to our camp says.

    I can't help but chime in, "That's never stopped anyone before. You guys come up here whenever you want like those walk officers dont even exist. I'm almost finished. After I'm finished with the IV I'll start the insulin line again. Its only been 15 minutes."

    Officer Wise successfully herds up the offenders into caged area, allowing me to go from room to room in search of an IV start kit, since the Emergency Cart was fresh out.


    ********** Nursing Check #7:

    -- a/ox3
    shows no difficulty answering or asking his own questions

    --- PERRL
    +3mm

    --- Skin warm, moist, and intact. Color is normal.
    nursing notes / later documentation explain cause of adjective "moist"

    --- Respirations even and unlabored anterior/posterior

    --- Breath sounds clear to auscultation anterior / posterior

    --- Abdomen is soft, nontender, nondistended, and bowel sounds are normoactive.

    --- S1&S2 auscultated

    --- apical pulse correlates to radial pulse
    Rhythm is regular.

    --- The offender was able to raise his hands and arms without difficulty to reach up and grab my fingers to squeeze, but can no longer lift his L arm when specifically assigned that task. This tells me the offender is lying about something

    --- grips strong are strong +2

    -- Capillary refill is < 3 seconds.
    If you are having difficulty judging perfusion on an African American, pull down their lower eyelid. If they're suffering hypoxia the inside of the eye lid will be white instead of red or bright pink.


    *************

    I establish a 20 gauge in the offender's LAC. First attempt. Offender tolerated. I'm beginning to lean toward the offender suffering from anxiety rather than actual chest pain. My notes describe the offender as tolerating the IV attempt, not tolerating well. He was whooping and hollering about how much he hated IVs and how much they hurt while I was I was sticking him, more than he was about his latest recourse of chest pain.

    I think to myself, this guy is faking. He's gotta be having anxiety or faking. He's talking too much and is terrified of one measly needle.

    Now that I've established IV access I administer one tablet of SL Nitro to the offender. "We're going to recheck your vitals in five minutes and I'm going to resume the insulin line. I'll be right here. Just tell me if you start feeling any worse than you currently do." I raise the gurney's side rail for safety.

    I restart the insulin line for five minutes. The offender suffering the chest pains is making conversation with diabetics as they enter the room. Its keeping me calm knowing that he's not bottoming out, but also irritating me because he was acting like he was dying 20 minutes ago.

    I repeat the VS and NITRO two more times with minimal drop in BP and no reduced chest pain per offender, but he has since significantly calmed down. I also recheck his O2 levels without oxygen. It immediately drops to 90% or 91%. I put the offender back on 2L.

    I finish insulin line before I start looking at my scattered sheets of paper with vitals on them and times. While the offender is stable, its to look through his EMR (Electronic Medical Record). I find several EKGs over the last few years that all say "Normal Sinus Rhythm. Normal EKG" in the EMR. I think that is unusual that the offender suddenly has an abnormal EKG. I look to the offender's paper chart in the Medical Records room and find the original EKGs and a few that were not entered in the EMR. Same results as the EMR. The EMR also states no further cardiac Hx beyond HTN.

    I silently curse at myself. I should probably call the doctor to report the abnormal EKG and chest pain.

    I page the doctor to call me back. I receive a call back within 15 minutes. I explain the situation to the Doctor; hi-lighting these things.


    ******* SBAR:

    Situation: I have an offender complaining of chest pain starting at 1620. He has allergies to aspirin. He has his own Nitro. He has taken three supervised doses without relief.

    Background: Only medical Hx includes HTN. He has no meds other than Coreg which he states he missed his AM dose today. Has several EKGs in the EMR, all of which show Normal Sinus Rhythm, Normal EKG.

    Assessment: Today's EKG, in tandem with chest pain show Normal Sinus Rhythm. Abnormal EKG." Oxygen levels started out upon arrival by wheel chair at 88%. Increased to 94% with 2L. When O2 is removed they drop to 91%. Pain radiates to L arm. Describes chest pain as if someone were sitting on his chest. No physical impairment is noted at this time.

    Recommendation: I'd like to send him out for further evaluation.


    ************************



    The doctor agreed with me and Officer called 911. I gathered as much of the offender's paperwork as I tried the best i could to gather pertinent information.


    Two days later I see the offender return to the prison. He had been diagnosed with severe anxiety. He was prescribed Xanax which our doctor took away due to its ability to be sold and abused within the prison. I later went to the doctor to ask if I did the right thing. My gut had been telling me this guy was faking and this was not a heart attack. The doctor said that because of the odd oxygen level and the new abnormal EKG my choices were sound.

    In the end, you must go by vital signs and lab results. Those are the things that will hold up in court. An offender has already proven themselves to be untrustworthy just by being in prison. As the doctor believes, trust only your objective data.

  • Jun 30 '15

    I am an LPN and worked in a level 2 correctional facility for 11
    months. The Prison's doctor was a wonderfully smart man and lived by a few simple rules, Never trust the offender regarding pain level. There are too many substance abusers who cry out in pain for attention and medication. You can only trust your objective assessment data.

    Chest pain was a daily complaint and between 1600 offenders,
    it was always something. Thankfully, all that drama and my insistence
    to pursue more nursing knowledge, nursing interventions, and perform
    proper assessment skills it landed me a highly coveted LPN position at
    a local Emergency Room where I see and even act as a primary nurse for
    varying levels of acuity. I wish to share with you my success in a
    correctional setting and tell you what I learned.

    1. Perform Immediate Visual assessment
    ---- Look for pallor (think deathly pale) clutching at chest, gasping
    for air, and extremely diaphoretic.
    ---- How did the offender get to the Health Services Unit?

    2. Take control of the situation, this is an offender who may need
    health care but simultaneously poses a safety risk to you.\
    --- Tell the the Custody officer to calm down (if in a panic), to
    release the offender, and not to leave you alone. If necassary ask
    unneeded personal or extra officers to leave to provide you room to
    work.
    ---Tell the offender to stand up.
    ---Tell the offender to get on the gurney.
    ---Tell the offender to take off his shirt in preparation for EKG.
    --- Above all, you must be persistent. Encourage the offender's goal
    of obtaining treatment only should he comply with your stipulations.
    You are in charge.


    Don't help or touch the offender until you have seen and noted what
    the offender is capable of. Measure his physical limitations. They may
    groan and complain the entire time about how it hurts to get their arm
    out from under their shirt but too bad too sad. If they can do it then
    thats a check mark in the "they'll survive category". If the offender
    refuses or honestly cannot, in your opinion, perform any of the above
    tasks then help him and continue to the next steps.

    3. Place on 2L Nasal Cannula ( if readily available- my correctional
    clinic rarely had easy access to supplies due to everything being
    locked up)

    4. Obtain Vitals.

    5. Obtain an EKG
    --- Familiarize yourself with a ST - elevation (STEMI) as would be
    seen on a 12-lead (often the machine will tell you too)
    --- Is the rhythm a regular? (If they have a pacemaker it will usually
    look a mess, but you should see very small notches at regular
    intervals that indicate the pacemaker is firing.)
    --- Is the EKG different than past EKGs? (This usually was info that
    required a bit of chart searching in the EMR, and even at times,
    required me to pull the hard chart.)


    6. Perform Hx with the following or similar questions:
    --- Do you have any other associated symptoms? (do not offer
    suggestions, but look for nausea, pain in L arm, Shortness of Breath,
    etc)
    --- Where is the pain?
    --- When did the pain begin?
    --- What does the pain feel like?
    --- What were you doing when the pain started?
    --- Have you ever had a heart attack previously?
    --- Are you on any Medications?
    --- Do you have any allergies?
    --- Have you ever taken Sublingual Nitro?


    7. Perform head to toe assessment.
    --- a/ox3 ?
    --- PERRL ?
    --- Skin warm, dry, intact?
    --- Respirations even and unlabored?
    --- Breath sounds clear to auscultation anterior / posterior
    --- S1&S2 auscultated?
    --- apical pulse correlates to radial pulse?
    --- bilateral extremities (lower and upper) overcome resistance?
    --- grips strong?
    --- capillary refill brisk?


    8. Give ASA 325 mg or 2-4 BABY ASA of 81 mg / tab - make sure he chews
    --- hold if allergy is present

    9. Give sublingual nitro if offender has on hand and has not already taken.
    --- Sublingual nitro is contraindicated for offenders who...
    ------ do not have their own SL nitro on hand and do not have IV access
    ------ have an SBP < 100, or DBP < 50 for fear of bottoming their
    blood pressure out.
    --- repeat up to 3 total doses 5 minutes apart and assess offender's
    supposed comfort level.


    Now allow me to describe a scenario for you. The exact one that
    happened to me a few months ago.


    The officers call HSU (Health services unit) while I'm working the clinic
    alone. There are other nurses in the infirmary and one nurse in the
    med room. It is a scorching, hot, weekend. The doctor is not on site nor is
    management. An offender is complaining of chest pain and an CO (Correctional Officer) radios in that he'll be bringing an offender up to the clinic.

    Its 1625. The peak of my insulin line. I already have 20+ offenders standing in a single file line outside of my open door waiting for their insulin. I have 30+ more offenders I am expecting to come before 1700. This is just not the time to deal with this CP (chest pain) crap. I yell back to my CO in the clinic, "How's he getting up here?" as I continue shooting my offenders with their insulin.

    Officer Wise shouts back, "They're bringing him up in a wheel chair." I roll my eyes and stab another offender with his Humulin R as she continues, "I'll meet them at the entrance". Little does the officer realize she's now leaving me alone with these 20 offenders. My concerns have been voiced repeatedly for this safety issue but have always landed on deaf ears. The considerations for the nurse's safety by the CO's is atrocious.

    "Hey." says an offender in front me, "While I'm here can you look up what my last A1C was?" he pleads as he towers over me as I sit at my station.

    "No. I've got to get as many people done before this chest pain arrives and we're not supposed to hold up insulin line for requests." I plainly state.

    "Awe, it'll not even a minute." the offender reckons.

    "I'm sorry. I have to get everyone else done. You'll have to put in a health care request where we'll write you back with the information or either you'll need to wait for your next chronic care appointment."

    "I don't see what the big deal is. The computer is right in front of you."

    "I said no. If you do not leave so I can get the next person I will call the CO". I state in my most authoritative voice.

    "Man, you used to be cool." the offender storms off muttering audible, derogatory curses under his breath.

    The next offender steps in and pricks himself with a lancet. He throws it away in front of me to a sharps container. We wait a moment for his accucheck to register when I hear Officer Wise yelling, "Get out! Get out of the way!" Her high pitched voice is chilling and filled with panic. "He's having a heart attack!"

    Not one, not two, not even three officers.... but FOUR officers were around this heart attack guy all trying to talk at once and explain what was going on to me, where they found him, his Hx, etc.

    "Hold on! Hold on!" Their panic is very contagious. I'm feeling overwhelmed already and haven't even made contact with the patient yet. Miss Wise can you move the offenders out of the hall?" She looks at me and eagerly nods.

    "OOHH! My chest. I can't breathe. I can't breathe. OH MY GOD. OH GOD. Its hurting!" The offender in the wheelchair moans. I look at the offender. He's white, in his 50's, and slim. No visible injury or trauma noted.

    ********* NURSING CHECK 1:

    OFFENDER CAN BREATHE
    as evidenced by his ability to coherently express his pain

    OFFENDER IS PROFUSELY SWEATING,
    is that from the awful heat outside or is he truly diaphoretic?

    OFFENDER IS BADLY SUNBURNT
    pallor cannot be noted at this time.

    OFFENDER ARRIVED BY W/C -
    gait not visualized at this time.


    ***********


    I take a deep breath and I hate this next part. I begin to take control of the situation by issuing orders to everyone.

    "Who has this guy's ID?" I ask the three remaining officers. One of them hands it to me with the offender's DOC #. With the officer's own out of breath pants informed me, "He was in the chow line when he collapsed and began screaming for help".

    "Sir," I address the offender, "I need you on this bed. We need vitals and an EKG." I state while simultaneously picking up my insulin sharps and throwing them into a random drawer. Officer Wise only cleared the offenders out of the doorway but did not take them out of the hall. My sharps are still at risk and need to be far out of the offender's reach.

    The offender momentarily just sits there, hyperventilating, moaning, and grabbing his L shoulder. The officers don't bother to wait for him to move but instead grab under his arms and begin to lift him from the wheel chair.

    "Wait! Wait!" I rush forward flaring my hands up to the officers. "No. I need him to do it. This is a nursing assessment." Test? Assessment? Its all the same right? Assessment just sounds better. "I have this. Just watch him..." I purposefully fail to verbalize "In case he falls" for fear of putting ideas into the offender's head. Hopefully the overeager officers will take the hint, but I doubt it.

    I look back to the offender and provide him with instruction. "Now, I need you to move to the gurney. The longer we put this off, the longer we delay treatment" I decide to tack on an enthusiastic, "and you look like you might need it, so let's get started."

    With much complaining, but absolutely no difficulty, the offender leaves his wheel chair and hops onto the gurney.

    "Okay, officers. Thank you so much for your help. Can you have Miss Wise come back in here and help me. You guys can go now, I'm good." The Officers grudgingly comply and are probably thinking about why I'm not calling 911 this very moment. I turn back to the offender and reach for my vital sign equipment. "This will probably be uncomfortable for you but I need you take off your shirt" The offender complies, slowly. His hyperventilation increases and the groans are still persistent.


    ***** NURSING CHECK 2:

    OFFENDER IS AMBULATORY

    OFFENDER'S GAIT IS STEADY

    OFFENDER APPROPRIATELY AND READILY OBEYS COMMANDS

    *********



    Now that this XXL T-shirt and jumpsuit are off of him, I notice he has a small baggy with a familiar dark glass bottle of SL nitro on him, attached by a safety pin to his pant's waistline. I inwardly groan and my level of anxiety jumps a notch. I'm starting to lean to the side that this may be real. I think it might be time for oxygen, at the very least to help his hyperventilating. I also think how odd it is that the offender is allowed a safety pin- I'd have thought such an item would be contraband. Pushing that thought aside, I reach to the cabinet, praying we have even one nasal cannula available. I open it and not to my surprise it was completely empty. I longed to be at my second job this instant in the hospital where supplies were abundant and I always had something I could use.

    Turning my attention to the Offender and getting a set of Vitals on him, I request Officer Wise to retrieve the Emergency Cart from an adjacent room. The gaggle of offenders in the hall are watching with enthusiasm. Others are yelling to get my attention telling me they need their insulin or they're blood sugars would drop, which of course made no sense. An odd few even left, cursed my name, and went to eat without taking insulin.

    Vitals read:

    BP: 132 / 84
    HR: 124 BPM
    O2: 88%
    Resp: 32 / min



    Officer Wise returned with the Emergency Cart. Thankfully, it was stocked with one NC. I put the offender on 2L O2, informed he must take deeper and slower breaths by inhaling through his nose and exhaling through his mouth, and immediately began to proceed with obtaining an EKG. Oxygenation levels out at 94% on 2L NC. As I hook the offender up to the machine I try to get a Hx and quick vibe for what he's going through at this time.

    ************ Nursing Check 3 & 4

    OFFENDER IS ON 2L OXYGEN
    putting someone on Oxygen, even if they don't need it often helps the patient / offender feel more at ease, trusting, and more secure with the nurse. This is something we do in the ER to allay fears and make people "think" we're actually doing something for them

    BLOOD PRESSURE IS SHOWING MILD HTN,
    a BP does not provide much information when experiencing an MI, but it is good to know none-the-less.

    HR IS SLIGHTLY TACHYCARDIC,
    this would indicate a compensatory mechanism for lack of O2 being perfused and/or possible stress.

    OXYGEN IS VERY LOW,
    is this due to the heart perfusing poorly or is the offender hyperventilating so much he's just getting very little oxygen period?

    RESPIRATIONS INDICATE HYPERVENTILATION,
    is this due to the lungs attempting to compensate for the heart perfusing poorly or is the offender just anxious and doing this to himself?


    ******************


    I ask him, as I place the electrodes on his bare chest, "What does the pain feel like?"

    "Its like someone is sitting on my chest. Its a horrible pressure and I can't get my breath, " he gasps. "It just keeps shooting down my arm. I don't think I can move it much."

    I respond back, "Well, have you tried taking your Nitro. You're supposed to take a tab when you begin feeling this way."

    "I've never taken it before. They just gave it to me over at RDC" states the offender. RDC is our sister prison that receives all new inmates and sends them to an appropriate facility for their sentencing.

    "When did the pain begin?" I'm having difficulty getting the electrodes to stick to his sweaty chest. The heat outside has been absolutely horrid lately and even HSU has been without air conditioning for the better part of the summer.

    "I was just standing in line for Chow when it just overtook me."

    "Did you have anything to eat prior to standing in line?"

    "No."

    "Have you ever had a heart attack before?"

    "Yeah. My first one was in September of 2009. I've had about 12 heart attacks since then."

    "How long have you been in prison?" My interest is peaked

    "Since Februrary of 2010."

    "Are you taking any medication?"

    "I'm on Coreg for my blood pressure." he says. I notice his respirations are slowing and becoming more regular. "I missed my morning dose because I slept in today".

    The EKG is ready. I hit the interpret / print button.

    "Do you have any allergies?" I ask.

    He responds, "I'm allergic to aspirin."

    The rhythm appears at even intervals. All components of the the rhythm, PQRST, are present. EKG reads, "NORMAL SINUS RHYTHM. ABNORMAL EKG." Heart rate, per EKG is now at 101 BPM.

    "Are you ready to give me my insulin?" I hear a shout from the hallway, reminding me my insulin line is still waiting.

    "Give me a few more minutes. I need to get this guy an IV. " Hoping those words would strike a profound sense of gravity to the waiting offenders outside. It didn't.


    ********** NURSING CHECK 5 & 6

    OFFENDER'S PAIN IS DESCRIBED AS SOMEONE SITTING ON CHEST
    as is typical with angina

    OFFENDER'S ASSOCIATED S/S INCLUDE SOB AND RADIATING PAIN TO LEFT ARM
    as is typical with classic male MI's

    OFFENDER IS NOT DIAPHORETIC AND COLOR IS INTACT,
    after seeing offender shirtless I conclude he is wet due to the raging summer heat and pigment is of normal color.

    OFFENDER HAS AN EMPTY STOMACH
    so this is not merely an episode of GERD

    OFFENDER STATES HE HAS HAD 12 PAST MI's,
    I find this highly unlikely that he's had 12 MI's and still standing here. Even more so, I wish to point out he is only on one medication, Coreg, a beta blocker for HTN. Most patients, after an MI, are put on an ACE Inhibitor and should take it every day for the rest of their life and the mortician should probably put one in their mouth after death just to be safe.

    OFFENDER'S EKG READS "NORMAL SINUS RHYTHM, ABNORMAL EKG".
    I really don't see what is abnormal about it, and I don't put too much investment in the computerized interpretation being that I'm 26 years old at this point and myself have an abnormal EKG with normal sinus rhythm.

    OFFENDER'S HEART RATE IS SLOWING DOWN AND RESPIRATIONS ARE DECREASING TO A MORE APPROPRIATE RATE WHILE OXYGENATION HAS INCREASED TO 94%.
    this is a good sign with the offender's vitals stabilizing.

    OFFENDER HAS NEVER TAKEN SL NITRO BEFORE AND UNAWARE OF ITS USE
    sublingual nitro can be very potent and the general population have varying sensitivities to it. Some people are so sensitive just coming in contact with it can cause a sudden and dangerous decrease in blood pressure. It is a nursing consideration and intervention to establish IV access before allowing someone to take Nitro without prior experience. Should things go badly and EMS be called, it will save valuable minutes having already established an IV.

    OFFENDER IS ALLERGIC TO ASA
    obviously we are not going to give it. Although, it would have been appropriate should it not have been contraindicated.

    ********************************


    I begin a necessary head to toe assessment to establish a baseline. As I proceed the offender is talking and talking. He is asking me questions about my choice in jobs at the prison. How much experience I have. What he used to do on the streets. What his past cardiac history has been like and what Correctional Doctors and Nurse Practitioners he has seen while in prison and so on. He's talking so much I'm beginning to think he's going to be just fine. I ask him to grab my two fingers and squeeze. He lifts his arms and squeezes well. I put my hands over both of his arms and tell him to raise his arms. His L arm is not overcoming resistance. I lighten my touch to just only the mildest of contact and tell him to lift his L arm again. He is still unable to perform saying it hurts too much. He begins moaning in pain. He says its starting to hit him so hard again. An important observation has now been made. Refer to Nursing check #7 below.

    "Calm down. Remember, just breathe through your nose and exhale through your mouth. That oxygen is going to help you." I calmly say to him, nodding my head.

    "So are you just going to deny us our insulin. This is some ********!" I hear a familiar voice yell. A regular insulin dependent offender has stepped into the doorway. There's another, older offender behind the accuser who speaks up also. "C'mon I need to go eat. I got commissary today and I already know my blood sugar is sky high. I didn't know I was given a death sentence."

    I ignore them. My temper is getting very short. I speak to Officer Wise. "Will you please escort everyone to the cage so I can open up a couple of locked drawers and start this IV without people yelling at me."

    "Alright you guys," Officer Wise begins as she swings her 250 lbs around in commanding five foot two inch height. "You need to give us some room. Get back there behind the cage and wait while we get this finished."

    "But Miss Wise, we need our insulin. This is some serious ****. If we leave and eat, you know the walk officers will tell us to turn around." a new diabetic to our camp says.

    I can't help but chime in, "That's never stopped anyone before. You guys come up here whenever you want like those walk officers dont even exist. I'm almost finished. After I'm finished with the IV I'll start the insulin line again. Its only been 15 minutes."

    Officer Wise successfully herds up the offenders into caged area, allowing me to go from room to room in search of an IV start kit, since the Emergency Cart was fresh out.


    ********** Nursing Check #7:

    -- a/ox3
    shows no difficulty answering or asking his own questions

    --- PERRL
    +3mm

    --- Skin warm, moist, and intact. Color is normal.
    nursing notes / later documentation explain cause of adjective "moist"

    --- Respirations even and unlabored anterior/posterior

    --- Breath sounds clear to auscultation anterior / posterior

    --- Abdomen is soft, nontender, nondistended, and bowel sounds are normoactive.

    --- S1&S2 auscultated

    --- apical pulse correlates to radial pulse
    Rhythm is regular.

    --- The offender was able to raise his hands and arms without difficulty to reach up and grab my fingers to squeeze, but can no longer lift his L arm when specifically assigned that task. This tells me the offender is lying about something

    --- grips strong are strong +2

    -- Capillary refill is < 3 seconds.
    If you are having difficulty judging perfusion on an African American, pull down their lower eyelid. If they're suffering hypoxia the inside of the eye lid will be white instead of red or bright pink.


    *************

    I establish a 20 gauge in the offender's LAC. First attempt. Offender tolerated. I'm beginning to lean toward the offender suffering from anxiety rather than actual chest pain. My notes describe the offender as tolerating the IV attempt, not tolerating well. He was whooping and hollering about how much he hated IVs and how much they hurt while I was I was sticking him, more than he was about his latest recourse of chest pain.

    I think to myself, this guy is faking. He's gotta be having anxiety or faking. He's talking too much and is terrified of one measly needle.

    Now that I've established IV access I administer one tablet of SL Nitro to the offender. "We're going to recheck your vitals in five minutes and I'm going to resume the insulin line. I'll be right here. Just tell me if you start feeling any worse than you currently do." I raise the gurney's side rail for safety.

    I restart the insulin line for five minutes. The offender suffering the chest pains is making conversation with diabetics as they enter the room. Its keeping me calm knowing that he's not bottoming out, but also irritating me because he was acting like he was dying 20 minutes ago.

    I repeat the VS and NITRO two more times with minimal drop in BP and no reduced chest pain per offender, but he has since significantly calmed down. I also recheck his O2 levels without oxygen. It immediately drops to 90% or 91%. I put the offender back on 2L.

    I finish insulin line before I start looking at my scattered sheets of paper with vitals on them and times. While the offender is stable, its to look through his EMR (Electronic Medical Record). I find several EKGs over the last few years that all say "Normal Sinus Rhythm. Normal EKG" in the EMR. I think that is unusual that the offender suddenly has an abnormal EKG. I look to the offender's paper chart in the Medical Records room and find the original EKGs and a few that were not entered in the EMR. Same results as the EMR. The EMR also states no further cardiac Hx beyond HTN.

    I silently curse at myself. I should probably call the doctor to report the abnormal EKG and chest pain.

    I page the doctor to call me back. I receive a call back within 15 minutes. I explain the situation to the Doctor; hi-lighting these things.


    ******* SBAR:

    Situation: I have an offender complaining of chest pain starting at 1620. He has allergies to aspirin. He has his own Nitro. He has taken three supervised doses without relief.

    Background: Only medical Hx includes HTN. He has no meds other than Coreg which he states he missed his AM dose today. Has several EKGs in the EMR, all of which show Normal Sinus Rhythm, Normal EKG.

    Assessment: Today's EKG, in tandem with chest pain show Normal Sinus Rhythm. Abnormal EKG." Oxygen levels started out upon arrival by wheel chair at 88%. Increased to 94% with 2L. When O2 is removed they drop to 91%. Pain radiates to L arm. Describes chest pain as if someone were sitting on his chest. No physical impairment is noted at this time.

    Recommendation: I'd like to send him out for further evaluation.


    ************************



    The doctor agreed with me and Officer called 911. I gathered as much of the offender's paperwork as I tried the best i could to gather pertinent information.


    Two days later I see the offender return to the prison. He had been diagnosed with severe anxiety. He was prescribed Xanax which our doctor took away due to its ability to be sold and abused within the prison. I later went to the doctor to ask if I did the right thing. My gut had been telling me this guy was faking and this was not a heart attack. The doctor said that because of the odd oxygen level and the new abnormal EKG my choices were sound.

    In the end, you must go by vital signs and lab results. Those are the things that will hold up in court. An offender has already proven themselves to be untrustworthy just by being in prison. As the doctor believes, trust only your objective data.

  • Jun 28 '15

    It was a state prison. When you by DoC standards it was preferred that when you address an offender you address them as "Offender Smith" or "Offender Doe". Most of the time nursing staff just called them "Mr. Smith" or "Mr. Doe". However, when you look at everyone's EMR they are rarely referred to as "the pt". Its always Offn or Offender.

    As far as nursing ethics went, most of them go out the door and caused a lot of grief for me being it was my first job, almost two years ago. The only real disinfectant you had was soap and water. There was no hand sanitizer, cavi-wipes, or alcohol to clean counters, gurneys, or exam tables with. Bleach was reserved only for the cleaning crew and due to DoC being under such a tight budget, would only afford one 1 gallon bottle of bleach per unit each month. It was the offenders who took sanitation jobs that controlled the bleach and bless their hearts they made that bleach last as long as they could but it was no good. The Community acquired MRSA was rampant unlike anything I'd ever have imagined. Most of the time nursing staff was encouraged to bring their own soap and water into work b/c we'd have gone through DoC's soap supply for that month.

    Continuing on with ethics, we did not wipe the offenders before sticking them with insulin syringes. Alcohol wipes were always being stolen and considered a very valuable commodity.

    In addition the health services unit became so obsessed with making budget management never focused on how to address offender issues or concerns. It became a viscous cycle in many cases - the offender would write a health care request form with a complaint. The offender would be seen by the nurse and if warranted be referred to the Doctor. The Doctor would then see the offender within 48 hours after Nurse Sick Call - supposedly. Instead no one ever scheduled the offender to see the doctor after being referred by the nurse. It caused a lot of grief and offenders would write back over and over again.

    Even more sad you could never believe nor trust the offender and his History. Most everything you ever heard was a lie and it took several hard lessons for me to understand that. And then in the few instances that someone isn't lying, they royally get screwed over. Examples of this included.....

    One offender would fake seizures and scared one of our senior nurses b/c she thought he was having the mother of all seizures. When the doc strapped the offender down and began cleaning his throat with betadine and opened a trach set he spoke aloud to the nurses that we'd have tube him with a trach. The seizure immediately stopped and the offender started yelling and apologizing calling the doctor several obscene things.

    A different offender had a terrible case of staff. A very young guy in his early 20's. He talked indepth about how he had an infection control doctor and how ever since he was 14 the staph infections he'd get could only ever be treated by IV abx like vanc. Well, the doctors didnt believe and this particular offender had developed staph on his scrotum- very very painful. It was lanced twice and every abx from Bactrim DS to Clarithromycin / clindomycin and Rocephin .... everything. Then finally after over a month of battling this horrid infection he was admitted to the infirmary for 1 month to receive IV Vanc.

    Prison was a very harsh setting and I dont miss any of that drama. I do miss the Signal 3000's which were our Emergency runs. There was a lot of great woundcare, trauma, and mental ailments that I miss treating.


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