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bbuerke 3,254 Views

Joined: Jun 11, '12; Posts: 37 (76% Liked) ; Likes: 186

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  • Dec 17 '12

    This is a very interesting topic and a fabulous discussion. I have a couple of things to add.

    In 14 years of NICU/Peds nursing (plus 4 as a CNA), I have never seen a "slow code."

    However, in the NICU, we do sometimes have "limited codes" and in those cases the do's and dont's are clearly in the MD order. For example, a baby with overwhelming sepsis and metabolic acidosis on full ventilator support, fluid resuscitation, sodium bicarb, antibiotics, and pressors to maintain BP...the order (after discussion w/family about "futility of care") was no compressions if his heart rate slowed on its own. On the other hand, if the patient experienced bradycardia due to accidental extubation, we could do compressions while reintubating. And that plan of care crystallized something for me:

    (1st point) CPR does NOT 'bring them back.' What CPR DOES do is buy you some time while you correct the problem that caused the arrest.
    Read that again; it's important. In the case of overwhelming sepsis and acidosis, there wasn't anything more we could do to correct the problem (we'd already given everything we had to fight infection & correct acid/base balance), so chest compressions would not be indicated. In the case of accidental extubation, we could reintubate and "fix" the problem, so chest compressions would be indicated.

    (2nd point) It is vital to recognize that if CPR does happen to 'bring them back' (to spontaneous circulation - i.e. a pulse), that survival to discharge rates are quite low. That interim time results in huge financial charges, pain and suffering for the patient, and emotional distress for the family.

    (3rd point) Families don't usually REALLY know what they're saying when they say yes or no to resuscitation. I think we overburden them with the decision making. We are asking them to do something extremely difficult; we're asking them to say "Let my Mother/Husband/Daughter/Lover die." I think we would be wiser to make the decisions ourselves - in most cases. "Your father has had a debilitating stroke from which he will not recover his ability to speak, eat, walk, or talk. He probably does not recognize you or understand anything happening to him. Because of his co-morbidities he is now in multi-system organ failure. Despite our interventions, eventually this will cause his heart to stop and he will die. Would you like to be with him at that time? Would you like spiritual support? How can we help you through this sad and difficult time?"

    (4th point) We need to have more conversations around the topic of "futility of care," rather than just pressing on with treatment after treatment.

    (5th point) Advance directives (living wills) can help. Nurse know better: we should ALL have one. Here is one of the best I've ever found. Don't worry that it's supposed to be for Washington State because - GUESS WHAT - advance directives are NOT legally binding. Therefore, advance directives should be coupled with CONVERSATIONS with your loved ones. And I heartily agree with the earlier poster who made a friend (not her spouse) her DPOA.

    (Stepping off soapbox - thanks for listening)

  • Dec 9 '12

    Quote from TheCommuter
    The clinical hours were being cut short on a regular basis by this one particular instructor. Since this was a second job to earn some extra money, he did not really put his entire heart and soul into the task of teaching.
    This is a widespread problem, the pink elephant in the room that no one wants to acknowledge. I was a clinical coordinator for a short time, and I would hear officially (but mostly non-officially) that certain CIs always let their students out early. Part of my job was to evaluate the CIs, as well as the facility (was the unit the right fit for the level, etc). There were ones that I purposely went to later in the shift, after being tipped off. And sure enough, there were a couple of times where the group was MIA. Either never showed up, left early, or no one has seen the group in weeks. When my boss approached the CIs, there was always an excuse (Oh, I took them to a specialty unit this week, they stayed late last week, so I let them out early, or a bunch of other nonsense that could not be confirmed or denied). The bottom line was this: The CI was not reprimanded because a) no student would rat her out, either for fear of repercussion (which I totally understand, from their perspective), or b) the students were HAPPY to be getting out early, or c) we were so desperate for CIs. Sad, but true.

    Choice B (as stated above) was a real, legitimate thing in this setting. I was so embarrassed to be a part of an institution that would accept this type of mentality, much less having colleagues that would enable it. One of the full timers there adjuncted at another institution, where students complained about her because she never let them out early. Are you kidding me!! How on earth do you go to a higher up with a complaint like that??

    I am at a different institution now, and it's not all roses there either. But I keep my mouth shut when I hear of other groups who have the 'day off', or alternate arrangements have been made. I am not a coordinator, so it really isn't my business. So I stay out of it. There are times where my group has had alternate arrangements made, all on the up-and-up. I don't have to answer to anyone except my coordinator, my chair, and my conscience

    I am wondering if the student mentioned in the OPs scenario was one who was not part of that mentality, therefore it was maybe her word against the rest of the group?

    I hate to hear about all the underhanded things that go on in out profession. But, it happens in every aspect of life.

  • Dec 9 '12

    If you watch Weeds, Mahalia James says "Fair is what you pay on the bus." I keep that in mind in my nursing school experience. Sometimes it's little things like such and such clinical group got to do this and we didn't, or someone performed their skill in front of this instructor who was more exacting. Get. Over. It. There is no way that your experience is going to be exactly the same as everyone else's. Your job is to get through, not quibble over one or two points.

  • Dec 9 '12

    Quote from doeRAYmee
    When is nursing school the real world? I didn't like coming in the day before preparing all night for clinicals but some schools require it. We had to learn all of our meds and procedures the patients were having. Along with all the path of their various diseases. And we had a dress code for our clinical sites.
    Not to stray completely off topic...But what is the point of that? I have to know all of my meds, procedures, path of diseases, and labs for my patients too. And you know what? I have time (make time) to know them during the clinical day - because we have to hand off report to our instructor and other classmates at the end of the day and God help you if you don't know the answers to any question asked. Obviously, I understand that if it's a school requirement, it is a school requirement, but I doubt that I will ever understand or believe that there is an actual need to go to the clinical site to get information the night before. I still stand by that this definitely does not teach any time management - in fact, it hinders it.

  • Dec 8 '12

    The Nurse Navigators for cancer patients have nothing to do with the Medicare issues. The issues here are limited to CHF, MI, and pneumonia. And the readmission has to be related to those issues, as well, not if the patient fell 2 weeks later and broke her hip - - unless the fall can be directly related to a poor understanding of their meds!

    As a former home health nurse, meds and follow-up care are so incredibly important and often misunderstood. And few Medicare patients will get home health care - the patient must be homebound! I would like to see that more patients get to their PCP for a follow-up visit within a week following discharge, but I know that is not always possible.

    Med changes are such a big problem after discharge. People get so confused - - they don't want to go out and get all of the prescriptions filled if they already have some of the meds at home, and may not know which, if any, have been changed. And EVEN WHEN THEY HAVE BEEN TAUGHT about their meds at the hospital, they have NOT understood. All they understand is that they are going home. It is part of teaching that we insist that the patient REPEAT all of the instructions back to the nurse, not just nod their heads and say Ok, ok. Signing that discharge form means next to nothing. I am a nurse of many years and did not understand why I was placed on metoprolol post-stent placement; I am not hypertensive.

    And pneumonia is a tuffy, too. When patients simply do not perform any deep breathing exercises, or don't take their meds, they will frequently relapse. Some think, EVEN WHEN THEY HAVE BEEN TOLD OTHERWISE, that those exercises were something they did to please the staff!!! They just don't do them at home. Or they resume smoking. Really hard to deal with these patients, sometimes!

    EVERY time a med is given, EVERY SINGLE TIME, the nurse must tell the patient why they are getting this med. ASK the patient why they are getting these meds. Make sure the patient really understands long before discharge. And sit down when you are doing discharge teaching - otherwise, the patient just wants to get you out of the room so they can get dressed and then wait three hours for their ride to show up!

    This has little to do with 'Obamacare' and much more to do with Medicare. But it mostly has to do with PATIENT CARE.

    Teach, teach, teach! Make sure your patients what is expected of THEM when they go home.

  • Dec 8 '12

    Quote from Nascar nurse
    They were gone when I arrived but if you happen to have been a nurse along a highway in the midwest last night helping 3 scared teenage boys I will never be able to thank you enough!
    If you happen to follow any of the previous "Stop at an accident threads" you would know there was very, very little chance the ones that stopped were allnurses members.

  • Dec 8 '12

    Thanks for the added input, ladies! I am now in an LVN program. We will do clinicals at SNFs and I will probably look for work at a SNF when I graduate. Since the time I posted, I've had the opportunity to work in different settings as a CNA.

    I do think that a lack of funding is at the root of some of the inherent challenged LTC faces (as compared with well funded hospital).

  • Dec 8 '12

    Thank you bbuerke! Very helpful (and timely-i have an interview Thursday)

  • Dec 8 '12

    If I can add one thing to that wonderful *will* get close to your patients, it is hard not to, and it is one of the benefits of being in Onc. Never forget that you are not thier friend, you are their *nurse*. You must be their advocate, a good ear for their problems, and an excellent medical professional. If the relationship changes into a friendship type relationship, you are robbing them of being able to interact with you as their they may spare you important info because they do not want to bother you or hurt your feelings. I have seen nursing staff get inappropriately close with their pts and it really disturbs the ability to give good care. Do not get me wrong.....I adored my patients, and you will always get more involved with some than others, but never forget that they need you in your professional role. It is ok to cry with a pt from time to time, but otherwise, let off steam about your feelings with you coworkers, friends and family. That will allow you to be the strong, confident, kind and above all, professional, nurse your pts need.

  • Dec 8 '12

    Quote from bbuerke
    I think that's the main problem with codes - they can go on indefinitely if you let them. Meanwhile the person's chances of meaningful recovery decrease with every passing minute. There really should be a time limit on those things.
    Our local EMS service, which is contracted by the large city where I live, has a time limit of 30 minutes per internal policy. If the patient has not been resuscitated after 30 minutes of CPR (and there's no hope of resuscitation), they call it off and pronounce.

  • Dec 8 '12

    OP, I'm very sorry you were fired. It seemed that your workplace did not have an effective plan to nurture and train new grads. I can relate somewhat to your post. I made mistakes during my time in ICU, but my primary preceptor was awesome and we worked out the kinks.
    It was some of the other nurses on the unit that weren't so forgiving and felt that my asking questions was a sign of incompetence. Always, always, always asks questions. If you get that feeling in your gut that something isn't right, please ask. I learned the hard way as well. I am a natural leader as EchoRN described, so it was very hard for me to ask. Then, I had to reevaluate and realize that I had to have enough insight to know what I know, and know what I don't know.

    Even, with my mistakes I still was not fired. I did eventually resign, because I felt I was not a good fit with the unit and I'd rather resign than to get fired.

    Don't let this keep you down. Own what you did, and request to be transferred to another floor. Request a meeting with HR and your boss. I think a less acuity of patients would be great.

    Nothing is more painful then your first RN job not panning out. However, you have learned from this.

    Take care, and you WILL be okay.

  • Dec 8 '12

    What was your patient load as well as your patient acuity. You are new and some people expect you to catch on the first time, and have good time management skills as well. Yes hindsight is 20/20 but really get you some books or review your own nursing school books and review your weak areas while searching for a new position. Keep learning from your mistakes the only thing I don't like is people expect you to be perfect, question? How do you expect to get perfect results with imperfect people? Learn to be responsible for your actions.

  • Dec 8 '12
  • Dec 8 '12

    I know I should wish for an end to malaria or HIV or something of that nature, but I really wish my student loans would disappear.

  • Dec 8 '12

    theres this one girl in my nursing program I really wish ... I really hope ... but alas theres so little room for love in Nursing School. besides dont think the feeling is mutual. But if it was! and us graduating together! Best Christmas present ever! One can always dream