Document Everything!

FurBabyMom, MSN, RN · Sep 14, 2015

Thanks for the entertainment folks! :) This was hilarious.

As a side note, about documentation, in all reality: I'm so thankful I work in the OR. I don't miss the asinine things I had to figure out how to document as a floor nurse (I would be better at it now than I was then though).

ixchel · Sep 14, 2015

That nurse told that nurse "I am the confused", this nurse states.

1915: received update from PCT that nurse not assigned to patient was charting on patient. Will file incident report for HIPAA violation. Patient to be notified by QA department. Will continue to monitor.

Adele_Michal7, ASN, RN · Sep 14, 2015

1900: Patient's wife brought in cake (angel food, white frosting) for staff consumption. This writer consumed 2 pieces at approximately 2045 accompanied by 240 mL whole milk.

sissiesmama, ASN, RN · Sep 14, 2015

1848: Patient found to be logged on to AlllNurses. This nurse, while looking over patient's shoulder, observed patient posting as OP on thread titled "This is what happens when the nurse becomes the patient". This nurse voided (just a little), high-fived patient, and then walked out of room to give report to the next shift. Will continue to monitor via app.

Hahahahahaha!

Anne, RNC

Farawyn · Sep 14, 2015

0956: Pt. reports chest pain 6/10. Non radiating. No shortness of breath noted. Skin warm dry color good no diaphoresis noted. Pt states "it hurts right here" pointing to 3cm x 4cm "fist sized" ecchymotic area to chest wall, noted by this nurse. Skin intact , no drainage. Pt. insists on wearing Cowboys jersey over bed gown. MD aware. Will continue to monitor.

Here.I.Stand, BSN, RN · Sep 14, 2015

Oh, yeah. Here's an actual excerpt, in its entirety, from such a fill-in-the-blank electronic chart I reviewed awhile back. Pt was very ill with complications from surgical misadventures.
Subjective: Pt states, "I feel like I'm dying, I am so scared." (Note to new nurses: anytime anybody ever says this to you, pay close attention-- they often are FTD, fixin' to die)
Objective: INR 6.0
Asssessment: Anxiety.
Plan: Listen.
Yep, he died. No charting anything else. But she did plan to listen to him.

Yup. I'll never forget my first exposure to a pt's sense of impending doom. He was POD#1 after a heart transplant, and couldn't tell me at the time because he was intubated...but he was flailing around looking terrified. A look at his chest tube however, showed a liter of frank blood in the chamber, and more pouring in. The anastomosis connecting his new heart to his native RA had come loose, and he was bleeding out into his chest. The surgeon was on the floor and helped run him to the OR and made it. He later said he didn't know what was wrong, but he felt like he was dying and needed to get our attention.

Another time, it was my first day orienting in a SNF rehab unit. This gentleman told us that he didn't feel right and was afraid he was dying. None of our other assessment data pointed to anything specific; his BP was a little elevated, but otherwise we saw nothing objective. However his statement of feeling like he was dying was enough to make us pay attention, and the NP to have him transferred to the hospital. It turned out he was having an MI.

Now if a pt thinks they're dying, I take that as seriously as any report of chest pain or any abnormal VS.

Farawyn · Sep 14, 2015

Yea that I just don't feel right line is a punch in the gut, innit?

Jensmom7, BSN, RN · Sep 14, 2015

Yup. I'll never forget my first exposure to a pt's sense of impending doom. He was POD#1 after a heart transplant, and couldn't tell me at the time because he was intubated...but he was flailing around looking terrified. A look at his chest tube however, showed a liter of frank blood in the chamber, and more pouring in. The anastomosis connecting his new heart to his native RA had come loose, and he was bleeding out into his chest. The surgeon was on the floor and helped run him to the OR and made it. He later said he didn't know what was wrong, but he felt like he was dying and needed to get our attention.
Another time, it was my first day orienting in a SNF rehab unit. This gentleman told us that he didn't feel right and was afraid he was dying. None of our other assessment data pointed to anything specific; his BP was a little elevated, but otherwise we saw nothing objective. However his statement of feeling like he was dying was enough to make us pay attention, and the NP to have him transferred to the hospital. It turned out he was having an MI.
Now if a pt thinks they're dying, I take that as seriously as any report of chest pain or any abnormal VS.

That feeling of impending doom is real.

When I was having an anaphylactic reaction at work, the last thing I remember before I stopped breathing was telling the totally clueless Nursing Supervisor was "I. Am. Going. To. Die".

She still refused to call a code and took me down to the ER herself. In a wheelchair. Turning blue. Because I wasn't breathing.

Farawyn · Sep 14, 2015

That feeling of impending doom is real.
When I was having an anaphylactic reaction at work, the last thing I remember before I stopped breathing was telling the totally clueless Nursing Supervisor was "I. Am. Going. To. Die".
She still refused to call a code and took me down to the ER herself. In a wheelchair. Turning blue. Because I wasn't breathing.

Well, you showed her, huh?

((((Jensmom))))

nlitened · Sep 14, 2015

this thread is hilarious!!

Jensmom7, BSN, RN · Sep 14, 2015

Well, you showed her, huh?
((((Jensmom))))

Since she never called a code, not really lol.

They did once I hit the ER, though. It was something you NEVER heard, and everybody and their brother showed up.

ixchel · Sep 14, 2015

My most recent "I'm going to die" patient was transferred to another facility and I've been waited to hear it happened or see him admitted again ever since. My first two happened the same week, same diagnosis (one primary, the other secondary to cancer), both had been discharged to acute rehab by me, one a few weeks earlier, one a month earlier. They both came back in worse shape than they were sent.

The one with cancer was doomed anyway, eventually, but he should have had more time, with more comfort. The other one, the rehab facility totally screwed up. Well, with both they screwed up. Both deaths were a complete shock. I knew they came back to us messed up, but I didn't expect they'd die. They both expected it.

I've had too many experiences with others and myself by now to know that anxiety is a symptom, not a diagnosis, for so many people and situations.