StealthyQ

-Please, PLEASE know how much fluid you gave this septic old lady. It's even better if you actually write it down. -If a pt has been upgraded to the ICU/CCU (I'm in the ER), please have an idea why. -If it's been crazy and you haven't gotten around to something, I'll understand, really I will. But please ask me to start that heparin drip, because an hour after you are gone the doctor will ask me if it was ever started, and I will say "What??" and be regarded as an idiot thereafter. -Please be on time to work. Please don't get there, say "gimme just a sec" and proceed to the lounge for fifteen minutes to gab and put on eyeshadow. If you want to do those things, get there fifteen minutes early.

Hi guys- pretty new poster/long time lurker here This actually happened to a colleague and not (yet) to me - I'm wondering what on earth would be appropriate in this situation. I was bored (working urgent care, you see) and rooting through the charts for pts in the waiting room and came across one which basically said "Pt refuses to answer any questions, states she will only talk to a doctor." I cannot recall if she even allowed vital signs. The patient in this case was apparently a young, comfortable-appearing woman with an attitude problem - the nurse who triaged her said he put her down as a "4" and left it at that- he didn't have the time to argue about it with her (which is undoubtedly true, seeing as how there's often a line of 20 to 30 patients waiting just to be triaged during the day). Now, MY first inclination, right or wrong, would be "Listen, if you want to see a doctor, you go through me. You don't want to talk to me, you can wait out there until you do. Have a seat." My patience over the one and a half years I've done level-one trauma has already become, shall we say, limited where triage is concerned. On the other hand, since you don't KNOW for sure that there isn't something serious going on (however unlikely that may be), what's the right thing to do? Not triage at all? Triage the way my the nurse did in this case? I mean, legally, ethically, etc., this could potentially be problematic- and undoubtedly the nurse would get blamed if anything were to happen. So what the heck would you do?

Thirded. Nothing much to add, except I'm familiar with all your described situations, including the mass exodus of nurses. Nurses are supposed to develop instincts and learn to trust them, and it sounds like you have.

We usually use Stadol/Phenergan. Occasionally Demerol/Phenergan, but Demerol has to be ordered after first jumping through flaming hoops and making sacrifices to the right gods, so mostly the residents will just order Stadol.

Hello nurses-this is my first post; I'm a little exhausted, so please bear with me. I'm an L&D nurse in a hospital in the Bronx; this is the first job that I have worked as an RN. I did a summer internship on this unit last year as a student and liked it well enough; it should be said that I had a wonderful preceptor and, though she kept me quite busy, I of course did not have the kind of responsibility that I have now. I knew after the summer that I had a job waiting here if I wanted it, and I chose the path of least resistance after I graduated, despite some little nagging doubts that I should have examined a lot more closely. I'm not so sure now that I can stay on that unit-I'll try to go point by point as succinctly as I can: -The unit is dirty. I hate to say that, but it's true. And in everyday life, I'm a big ol' slob, so I know it's not just me. That we're in the middle of construction right now is one thing, but that can't be helped. I'm talking about finding dried blood on walls and such in a supposedly cleaned room, BP equipment that is falling apart and actually smells sometimes, etc. I can go into more detail if you want it, but trust me. -We routinely have to do things without orders. Not during emergencies; I mean things like fluid boluses (with LR instead of D5LR), bicitra before sections; it's damn near impossible someimes to even get a Tylenol or Motrin order. Often the pitocin we give (as policy) after deliveries is never formally ordered. -Nurses don't do VEs. Which means we have to always hunt down a resident to do it, which most of the time is okay. Sometimes it's really not okay, as I'm sure you can imagine. Besides that, if I go somewhere else for L&D, this is a skill I have never done. (We also can't push narcotics, depending on who you talk to-I've looked at the policy and it's a grey area) -We don't stock uterotonics on the unit. An order needs to be in the computer and someone has to go down to the pharmacy physically. I'm afraid someone is going to bleed to death in the OR before the cytotec gets there one of these days. -Speaking of cytotec, we routinely use it for inductions. -We're chronically understaffed, of course. We're supposed to have 11 nurses; I've seen 8 quite a few times. Usually we're 9, 10 is a good day. Some days (or nights, as my case may be) there's one nurse in recovery and four sick patients. Fresh post-ops, mag patients, etc. -We will keep accepting patients even where there is truly no place to put them. No one EVER says "We cannot safely take on any more." Doubled rooms, etc. Once in a while you expect this stuff to happen. This is now almost par for the course. We try not to put active patients in doubled rooms, but it does happen. -Our nurse manager, at the last meeting, went on a long tirade about how we HAVE to take our lunch breaks. HAVE TO. Now believe me, we do when we can. Sometimes we can't. She sees no problem with someone watching three or four patients "Well, some people are inductions doing nothing." This woman is supposedly a nurse practitioner. We ALREADY usually watch two pitocin patients. -Why is it that no department in the hospital can deal with a pregnant lady whose complaints are not at all pregnancy-related? I'm sorry, a 20-weeker with chest pain should not be dealt with on L&D. I'm not sure if that's us or everywhere. Liability and all. -Triage! I used to like triage. I now no longer do it voluntarily. It violates so many ethical principles, not to mention HIPAA, that it could be a journal article on how NOT to do things. Our triage area right now is three-bedded, one-room, just curtains. There is NO place to do a FHR check on a patient. We literally have to stand them there in a closet doorway, which I find really horrible. Now, a FHR check is one thing. We're also apparently supposed to do a full set of vitals before they even register. (I'm not sure if that's us or it's part of larger triage guidelines-it wouldn't be a big deal if we had the space) Vitals and an exposed belly, no privacy at all. I got in trouble with the nurse I was working with last time because I wouldn't do an OB history in a crowded hallway (again, non-emergent cases, not someone we're running to the OR with and have no choice). I WILL NOT ask a person how many abortions they've had, or to describe in detail their two full-term losses, in front of other patients. There should at least be the damn curtain. The whole triage area, by the way, is cluttered and dirty, which takes us full circle back to my first rant. -I had a particularly bad night last night that I don't want to get into (horrible patient, nasty family, incident report for threats and profanity), but I ended up in the walk-through supply room sobbing and hyperventilating (which really feels awful. I never realized). Another nurse sat with me and told me that when I said I felt like me was on the line every day I was there (Yes, I said that. In the heat of anger and frustration and trying to breathe), it rang totally true with her. She's been there a year. I've been there four months. We're both about done. -I'm really sick of being abused by patients. I know labor hurts. I know we don't help by confining everybody to bed and basically turning a hose full of pitocin on them. The fact remains that usually we have ONE anesthesia resident and ONE attending; if there is an emergency going on in the OR, your epidural has to wait. It sucks, and I'm sorry. I also cannot go into another room and demand that anesthesia pull their needle out of someone else's back and come attend to you; you are not the queen of the world because you are in pain. But screaming at the top of your lungs at 2 centimeters helps neither of us, and means that you are not breathing effectively. I have had lately a lot of teenagers with zero pain tolerance; I know how subjective pain is, but many patients come in and do not want epidurals, which is fine. I don't push them on anyone; my nursing education was rather anti-epidural, actually. But if you decide you don't want pain relief, you need to also decide that you're going to be in pain, and you're going to deal with it (I've found they ALL want epidurals after an hour or so) I wonder about these women who come in at one centimeter screaming and clawing. That last one, I know, is not just my unit. That's just L&D. So I have an appointment to get to and I'm going to end there. I need to know what other nurses think (ones more subjective than the ones I work with). Yes, there are a lot of good people on the unit, doctors, nurses, and patients, among others. But right now it's hard not to be disheartened. Words of wisdom would be much appreciated.