CaliRN2019

At my hospital it isn't up to the provider. The hospital offers it to anyone on discharge, just like the flu vaccine during flu season. There are no stipulations at all.

I guess the debate then is "mild illness". Many patients I discharge I feel are more then mildly ill. Many go home with after extensive multiple surgeries, PICCS for long term ABX, drains, complicated wounds, and many are so weak they are not able to currently ambulate at the present time. I know this puts them at high risk for complications from covid, but at the same time I feel like the possibility of adding harsh side effects from the vaccine might not be a good idea in their current delicate state. Perhaps the J&J vaccine has less side effects since it isn't MRNA like Moderna and Pfiser.

My hospital has been offering the J&J vaccine to patients on discharge. I feel uncomfortable with this because I know how many people feel quite ill for a time period after getting vaccinated and I don't feel this is the right time to be giving hospitalized patients their vaccine. They are already weak and still recovering from whatever brought them in the hospital and a harsh vaccine response may complicate their recovery. I also wonder if patients may delay coming back to the hospital for readmissions because they think they are just dealing with vaccine side effects when in reality it is their diagnosis that needs attention. Thoughts?

I haven't met the "perfect" example like many of you have wrote before me ( love reading them!) but I must say I am so lucky to have my first line supervisor. She has all our ( RN's) backs and will instantly squash any rude or demeaning MD that happens to glance our way. Anyone who gives any unnecessary rudeness or disrespect is immediately confronted and it is simply not tolerated. It sounds funny to type out loud but she protects us like we are her children. This makes our floor feel safe and gives us confidence to stand up for ourselves or our patients when needed.

That is an interesting comment about being most scared of SBO's. I work on a surgical floor and GI patients are our bread and butter. They rarely ever lead to demise. It's always the other ones that randomly pop in our floor such as ETOH Cirrhosis patients, Covids, end stage COPD'rs, or PE's that poop out on us. I feel like the GI patients are usually the most stable. I suspect you are a new nurse and just need a little more experience. Bowel movements need to be the least of your fears ( unless its on you)

Americans have their own culture, just like you have your own culture. What is normal and OK for one might not be OK and normal for another. Big deal. What is the point of this post?

I am curious on how other nurses and hospitals deal with patients who end up physically assaulting health care staff. My hospital is in an underserved community and we can have rough crowds, lots of homeless, lots of addiction, etc. I have read a lot about violence against nurses and was wondering what would be the appropriate action should a patient actually hit, punch, or hurt me. We do have an internal "code grey" which sends security staff to help assist, but I feel like if it ever got to the point of me getting hurt, it would be up to me to file a police report to take things to the next level. I feel like it is inappropriate to turn a blind eye to a nurse who got punched in the face or assaulted some other way. Has anyone ever done this and did you get any push back from the hospital or management for moving forward with a charge?

NRSKaren, to clarify RN's don't remove permacaths at my facility either. Patients go to IR for that at my facility, but they certainly don't let homeless and/or drug users leave with PICCS or permacaths to the streets for several reasons. Consulting psych would have been a good idea, thanks!

I am curious to know how everyone handles difficult AMA situations. Those who can just get up and go home are one thing. We have a huge homeless population and I have come into some questionable situations where I am unsure what the ethical thing to do is. What about the 02 dependent homeless patient who probably won't even make it off hospital property before collapsing? Or a homeless person who can't walk? Do I just wheel them out the hospital door and dump them on the ground and walk away? I had a very difficult patient, covered in massive wounds, lived in her car, not ambulatory, who would cry to leave AMA during her daily ( very extensive) wound/dressing changes. She had a boyfriend but he was not going to pick her up. So if I let her leave AMA I would have had to wheel her out and put her on the ground. Not to mention I would have had to remove her new dialysis line ( we never discharge homeless drug users to the streets with lines in). Needless to say I didn't let her leave during my shift even though she asked for it several times (only during dressing changes). She was able to make decisions but completely unable to care for herself. I was afraid for her, but also my license since it would have felt so wrong just dumping her on the grass. What is the right thing to do?

My hospital in the Central Valley has been at this point already for several weeks. I have seen Doctors talk to patients with poor prognosis ( but still hanging in on vapotherm around 90%) and pushing DNR's hard. Our success rate of getting covid patients off the vent is close to 0%. Even if someone is a full code, if they score poorly on an algorithm ( not sure exactly what it entails), the patient will not get a vent because they will take up that valuable resource for a long period of time and without success. From my experience over the past 9 months on a tele floor, once someone is maxed on vapotherm or on bipap, they are basically a dead man and its only a matter of time. Once they are made comfort, we hike up the morphine drip quick and whisk away the vapos and bipaps to the next patient needing it. It's dark and sad. However from what I have seen, the rationing of care has felt appropriate because it is rationed away from those less likely to survive anyways.

Stop telling people details. They don't need to know and you use PPE anyways. When people ask about exposure its my understanding that means without PPE, like household members. I used to be upfront about my job ( tele covid unit) until my therapist of 3 years whom I respected and trusted so deeply wouldn't have me in her office ( starting last April) while other clients where allowed in with masks. That freaking hurt.

YES! Please hire some ancillary staff! The hospital I work at in the Central Valley got rid of their CNA's 7 years ago for a few bucks pay raise for the RNs. I can't believe the RN's and union let this happen. We are understaffed, ICU patients remaining on the tele floor, lots of chaos and lots of death. We have no CNA's, LVN's, break relief RNs, or help of any kind. RT's only come for emergencies and to set up high flows and Bipap but we otherwise manage it all. It's reckless and dangerous and we burn through staff at a huge rate.

What is the appropriate response when family blames you for the patient dying, even if you did nothing wrong and death insists on taking its course? We have had so many Covid situations lately where patients are DNR/DNI but are in respiratory distress and family refuses comfort or hospice. Such a slow and awful death. The other day a spouse was fixated on the fact that we had not been feeding her husband ( Sp02 70-88%, lethargic, ALOC) and insisted I take off the non rebreather to give him his PO meds and feed him to "save his life". She continued to scream at me ( over the phone) that I was killing him. It feels so unfair to watch a patient slowly suffer and die without relief due to patients own specific parameters and then get blamed for it.

I had an 82 year old male with Covid who was clearly dying on my tele floor. He was on Vapotherm at 40L 100% Fi02 plus a non rebreather flush for 2 weeks. He was a DNR/DNI, yet not comfort care or hospice. You know, that icky and painful in between suffering. His family took many days to finally agree on comfort care. My last day with him he was becoming increasingly lethargic and his sats were 75-80% all day. His son was allowed to visit that day (which helped him decide it was OK to initiate comfort care orders). By the son's body language and general "feel" I got from him, I don't believe he realized the gravity of the situation and that it was probably going to be the last day he saw his dad alive. I felt the need to educate him, warn him, or let him know that now would be a good time to say your goodbyes but I didn't know how. As the bedside nurse, how do you approach the subject? I understand the Dr. is responsible for a large part of that conversation but the particular resident was new and seemed unfamiliar with our hospitals comfort care/hospice issues. I wasn't within earshot of their conversation at the time but I suspected she didn't get her point across.

It doesn't make sense to me that a patient in restraints would also need a sitter and be a 1:1. In my hospital, patients are either in restraints or a 1:1, not both (unless they are a very extreme case which is rare). Also, right now we are in the middle of a pandemic and things are different. I am in California and our strict 4 patients to 1 nurse ratios are currently out the window because of the influx of patients needing beds and the crisis we are in. All our ICUs are currently 3:1 as well. We are also now keeping patients that normally would go straight to the ICU on our tele floor as long as possible. Many are dying but ICU beds are full, so there isn't anything else to do. This is extraordinary circumstances, so if your hospital has a large number of covid patients, things are going to look differently then they normally would.