LouleeRN

At our hospital, the sending unit (or ER) faxes a SHOT (Safe Hand Off Tool) to the receiving unit. The SHOT lists reason for admission/transfer, medical hx, background, VS, pain, IV, neurological, cardiovascular respiratory, GI, GU & skin assessments. Most of the areas are check-off assessments (eg Last BM____) with the right hand side of the form open for writen comments or concerns. Before the pt is transferred, the sending and receiving RN's have a brief telephone conversation, at which time the receiving nurse can ask any questions she has, or clarify any issues, and the sending RN can add anything forgotten, or new. This shortens the time of the hand-off report, and provides a written report for the next shift as well. In cases of emergency transfers (eg transfers to ICU post Code Blue or other unstable emergency) a verbal report is still given so that the transfer is not delayed while a written report is prepared.

In our facility we use an over the needle cannula for subcut locks (ie like an IV cannula where the needle is withdrawn after insertion, leaving only the plastic cannula in situ.) We always flush with at least the volume of the extension tubing, in our cases 0.4ml, for the same reason that a lot of posters have mentioned. Namely, since our tubing is primed with NS, you don't want the med to stay sitting in the tubing where it's not helping the patient. I would have the same concerns as others have mentioned about giving a med into a tubing primed with a medication instilled by someone else. You're really trusting that the other nurse got it right, and primed the tubing with what she said she did. To me, that puts your license on the line. We use a general rule that only a total of 3 ml including the flush be given at one time through a subcut lock, therefore you could give 2.5ml of medication, followed by the flush. If you're looking for a written policy to act as a guide for developing a policy for your facility, go to www.palliative.info and click on subcutaneous cannula insertion. It gives step by step procedures for inserting the cannula, and for giving meds, etc.

So glad that you're feeling better!

When we travel in the US, we often get asked about our "free" health care, usually prefixed by the comment "Is it really true that you don't have to pay for your health care? That must be wonderful!" When I explain that we don't pay each time we use the system but that our taxes are reportedly much higher than theirs, that we have a national sales tax (GST) as well as a provincial sales tax, and that the wait times for some surgeries or certain diagnostic tests are sometimes measured in years, or at the least, many months, their attitude changes. And in Manitoba, we don't pay a premium. I'll have to mention in the future that some provinces do. Usually they realize that while neither system is perfect, there are good and bad things about each.

You asked for suggestions that helped others get through similar experiences. I went through a time of work-related stress and ended up seeking counselling to help deal with what I was feeling. The previous suggestion of walking was a good one. Another thing that was suggested to me was to do something everyday just for yourself. In other words, "treat yourself" everyday. Doesn't have to be anything big--maybe a bubble bath,or curling up with a good book for an hour or so; maybe lighting some scented candles, or going for coffee with a friend, etc. Just anything that makes you feel good inside. I found that we as nurses spend so much time and effort caring for everyone else (our own families as well!) that we sometimes forget to take care of ourselves! Go ahead and treat yourself! Amazing how good even the little things can feel! Good luck.

oops, sorry! my mistake! it's a compliment to you and your great care that they wanted you back. don't let the other cases get you down! keep on caring!

Sorry to hear you've hit a rough patch. I too can identify with what you're going through. I went through a week one time where there was a code blue on our floor every night I worked (half of them my pts). Coworkers were teasingly starting to make the sign of a cross when I came on the ward! Stretches like that can really make us start to doubt ourselves, especially when families or others yell or criticize us. Continue to believe in yourself though. I, too, have enjoyed reading your posts, and gaining from your experience and advice. You always seem to put what's best for the pt's interest foremost, and that is probably why this is hitting you so hard. If you didn't care about your pts, you wouldn't take the time to follow up and check on them, or to feel badly about the eventual outcome. By sending them to hospital, you gave them the best chance for a positive outcome. Keep up the good work, and know that many of your pts. appreciate all you do for them, just we don't hear the positive often enough. Hang in there!

Some of the former posters don't know how lucky they are! I, too, work on a medicine ward. It's a 70-bed ward, divided into 7 ten-bed units. On day shift, a RN and a LPN work each unit, so we each take 5 patients, but of course, help each other out. We have no charge nurse, and our manager is not on the floor, so we're also responsible for doctor's rounds, calling lab results, coordinating all care, team rounds and as we only have 1 unit clerk for 30-40 beds, we often do our own order transcriptions as well. On night shift, we have 10 pts each, but our ER is usually packed with people waiting admission, and so our region's answer to this is to add a 5th bed into our 4-bed rooms. This often means we're caring for 11 acute care pts on night shift with 1 HCA to assist (and no unit clerk between 2300 and 0800).

I'm so sorry about the pain and turmoil you must be feeling after such a tragic event. I agree with many of the previous postings about accessing an employee assistance program if your facility has one available to you, or some other form of counselling. I made use of the employee assistance program after stressful events on my ward (though not near as tragic as yours). I found I just couldn't deal with the situations I used to, and one particularly upsetting event just was too much. The employee assistance program paired me with a counsellor who was also a RN and understood what nursing is like, and how nurses feel and react. Though the sessions were not easy, they helped me deal with how and why I was feeling as I did and coping mechanisms to deal with future situations. Hopefully you can connect with someone like this to help you deal with this awful event. Sounds like your patients are lucky to have such a caring nurse. P.S. Many times I too have felt like taking job in a store just stocking shelves or something. My husband however DOES work for Walmart and says that it has it's own stress too (but oh how some days I'd long for that stress instead!!)

I totally agree! By doing basic patient care, a lot of assessments can be done without being obvious, eg. skin condition, mental status, degree of bed mobility, etc, etc. I agree also that by working side by side with the aides, it also fosters a team unity, where the aides realize that they are an important and vital part of the team and don't feel shafted with all the "dirty" work. I am lucky to work with aides that are great with the patients and I rely on them to let me know if they notice anything unusual about my patients, but I still like to help as much as I can to do my own assessments. Rather than pts. thinking this is odd, I think it develops their trust in me; they know that they can ask me anything. I've never had a patient think that I was an aide--but I HAVE heard pts think an aide was a nurse because they were doing their care!

In my region, we have four levels of advance care planning (resuscitation status). Level 4 is all treatment, including full CPR. Levels 1-3 have no CPR, but vary in the amount of treatment provided. eg. Level 1 provides only comfort care--no ICU, tube feeds transfusions, IV's, no CPR--only measures focused on aggressive relief of pain and discomfort. Level 2 allows for treatment of reversible conditions,eg. pneumonia or blood clot, but no CPR. Level 3 allows treatment of all conditions, both reversible and nonreversible with no restrictions, except for no CPR. Pts. can be admitted to ICU, telemetry etc. on this level, even though if their heart stops, no code would be called. We've found that these levels of care help clarify how aggressive the pt &/or family wish to be.

I agree with the previous writers. Sometimes patients DO seem to wait to be alone to die. I always wonder if it is their way of "sparing" others the emotional pain of being there at the moment of death. I've seen families sit for days with a loved one who is barely hanging on to life, but the moment that they go for a bite to eat, or run home for 10 mins to shower, is the time the patient dies. Like you, families, too, feel guilt about not being there, but I usually tell them that maybe that was what the patient wanted. I think it's always nice if someone can be there so that they don't die alone, but the reality is that it's not always possible. It sounds like you did everything to make his last hours comfortable and dignified and peaceful--that's EXACTLY what comfort care means! Don't ever feel ashamed of crying over a pt's death--nurses are human too, and even though you may not have known the patient long, he still impacted your life and grieving is a natural process. We all do it in one way or another.