nerdtonurse?

What I'd suggest....scopalamine patch (wonderful for noxious secretions/"death rattle"), Ativan, and IV benadryl, along with the morphine. When I've had people with liver problems, they itch and scratch like crazy. You're doing great -- it's hard the first time you have a patient this sick. If the person has a really strong ETOH history, the sister may never come. You don't know how well they got along, he may have been the world's sweetest brother, or he may have broke into her house to find things to sell for alcohol or drugs (my cousin stole from his own parents, and beat up his dad when he was caught -- went to jail, got straight, and is okay now, but his sisters have never forgiven him and won't believe he's sober, even 20 years later). Just keep her informed, and know there could be the scene of all scenes if she did come in...might be easier for him and you if she didn't. I only hold morphine for respirations below 8; I've never had s/s of pain when the respiratory rate was lower than that. If I did, I'd still medicate because witholding the meds aren't going to make him better, it's just going to make him hurt. Be grateful you're on a floor where you can treat your patient's pain without some idiot wanting to give your dying cancer patient tylenol and your VIP with an "upset stomach" (read, I need a week to be waited on hand and foot because I don't want my visiting relatives to know I'm hooked on prescription meds) dilaudid, demerol, phenergan, etc.

Just give the narcs. You're not going to change them, and they'll make your shift Hades if you don't. An addict will seek their drug/ETOH until they decide to stop, and nothing you do or don't do will change them.

Also, if the patient has cancer, they usually have low albumin (either d/t the disease process or malnutrition); low albumin can affect protein binding, making more warfarin stay in the system longer. I know seems particularly tricky to anticoag someone with GI CA and liver CA who need something due to afib, artificial valves, etc. Lovenox works better than warfarin in those cases, in my experience.

I see this as a chicken and the egg situation. If you have depression, you tend to have feelings of inadequacy, poor self care, you feel like you're not worth looking after, you doubt your abilities, so I would tend to think these are a symptom of depression rather than independent feelings/behaviors. I mean, everybody has days where nothing goes right, the brief always falls poop side down, etc. However, consistently feeling that way is something along Axis I. If it goes into paranoia ("they're all out to get me") that's going into Axis II. Many people have untreated or undertreated depression, and that includes nurses. I had a grandparent who committed suicide due to depression, and the other was clinically depressed also. They are not fun to be around, particularly when they attempt to self-medicate with ETOH and valium, and I watched the "poor pitiful me" and the "I'm not good enough" and the "you all hate me" stuff all thru my childhood. The simple truth was my grandparents weren't good enough to be my caregiver, weren't adequate to the task, and I think (now) some of grandma's "poor pitiful me" moments were actually moments of clarity where she realized she shouldn't have been my primary caregiver -- but a valium and a beer fixed that. Dad was overseas, mom was working 2 jobs, and mom was in denial that she was leaving me with 2 depressed alcoholics. Borderline personality disorder is different, and those make any shift a living death when you work with them, but depression is anger turned inward; they usually don't do much beside dump all work on you and play Eeyore in the corner. Which still stinks.

I haven't had Spiderman, but I've had the incredible Hulk, Houdini (4 point restraints, and somehow got her feet lose and when we went in, she was sitting with her back to the foot of the bed, arms twisted behind her, and trying to "cow kick" the head of the bed lose), assorted "Presidents" and people who had been "chipped" by the CIA, wanted by the CIA, in the CIA, jonesing completely about the CIA, in the "fitness protection program" (all while she's busy trying to eat the fiberfill out of her bra, but ya know, Washington, anything could happen), and at least one that I would swear was demonically possessed. They bring in Spiderman, I'm clocking out and going home!

Particularly for my hospice patients, "Because you loved me" by Celine Dion. In ICU, "Highway to Hell" or "Another one bites the dust" depending on how the shift's going.

The ones that get me aren't the "end of a long life" people, or even the "had'm a long time as a patient" people. It's the ones that for some reason hit a cord. "Paratrooper," who was at Ft. Benning at the same time my dad was stationed there. I always wondered, was I the little girl riding in the shopping cart as he walked by to get get groceries at the commissary, neither of us knowing we'd meet in the last days of his life? Or Doll, who called everyone "Doll" and was the spitting image of my 3rd grade teacher. "Christmas" who came in just before Christmas with endstage COPD and the only thing she worried about before she was terminally extubated was who was going to look after her cat. You see sad stuff, stuff that will make you wonder what's going to happen when it's you or someone you love in the bed. There's no easy answer. But I suggest you also reach out to a local hospice -- they have excellent resources on handing death, dealing with family at that point, and also dealing with your own emotions.

But.... We've had to discharge people from hospice for addiction. When you place narcotics in the home, that's still your license, the hospice facility's MD's license, etc. And we've had people who took the emergency kit and had a party with the neighbors -- they were terminated from hospice for that, despite a end stage diagnosis. I've seen a bottle of 200 Vicodin from the VA be "used up due to pain" in 3 days. Uh, no. We're here to treat the sick, not be the dealer for the neighborhood. I don't know if in home diversion of meds from the patient to the other family members has ever shut down a hospice, but there are a lot of people who absolutely HATE hospice -- we're starving people to death, giving them "that last shot" and killing them with morphine, when they should be "fighting." You get the wrong DA or sheriff with a thimbleful of power, and you could lose the ability to help a lot of people because of a junkie. When we've had that situation, we go by the house and give only 1 day's meds, or put in a pain pump (that somehow always breaks because he "dropped it", and you can see the screwdriver marks where they were trying to get to the cassette to get the dilaudid). Push come to shove, we put them in a facility to monitor their pain control. We'll take them, but it's a huge liability and risk. You can't fix a life at it's end, but I wouldn't risk losing the ability to help a 100 people for the sake of 1.

DKA. Not the diabetic who's had a nasty GI bug, infection or surgery, or something that could reasonably make their sugars go wild, the ones we get every 2 or 3 weeks, usually young, and the biggest pains in tail you can imagine. They don't do fsbs or take their insulin, despite being taught multiple times, being sent home with FREE supplies for fsbs and free insulin pens, always come in with uncontrolled n/v/d (and the CT shows a full GI tract, it's called, "keep that dilaudid coming!"). Always have a positive drug screen, and not a single mark on their fingers that they've checked their sugars since their last admission -- but they're on disability because of their diabetes (makes you wonder if that's why they don't treat it). And I always look over at the person who's post-dialysis hypotension, or post BKA, or evolving stroke, or fresh MI, all from untreated diabetes, and I just want to drag them into the other patient's room and say, "This is your future. Right here. These smells. These missing limbs, these necrotic feet, that dialysis machine, that sign saying 'Patient is Blind,' that person who's trached, PEG'd and on their way to a nursing home for the rest of their life, just because they didn't treat their diabetes. Now do what you're supposed to do, not what you WANT to do."

One thing I will tell you -- pee before a code, if you know it's coming. And yes, I've looked at telemetry, and said, "everybody who needs to pee -- now's the time." Compressions on a full bladder sucks eggs. I am the proud owner of a 1000cc bladder. We were on a Texas vacation, somewhere between Midland and Abilene and I ended up having to use a large drinking cup. 1 liter, and I filled it up. The family was amazed, and I was kinda horrified.

Fun? No. Interesting, challenging, and ultimately worthwhile? Sometimes. Infuriating, disappointing, and gut wrenching -- occasionally. There were times when we were all cracking up laughing, and times when we were looking anywhere but at the person we knew had just failed the class. It's like nursing. It's good and bad, happy and sad, all swirled together.

Same here, that's why I have a fulltime job and a PRN job...right now, the PRN is making my check. And Pennywise...you're just freaking me out. I read "IT" when it came out and have been scared spitless of clowns and balloons ever since. :-)

The big thing I see is that people don't talk about death at all until someone's so sick they can't make their wishes known -- not a 20 year old that gets hit by a truck, but the 80 yo with end stage everything, mets'd CA, etc. I think the whole AND (and I like that term) discussion should start when person has a serious diagnosis, not when they're agonal and will never live the 10 feet to roll their bed out of their ICU cube on the way to a hospice room. We did a study of which of our docs do referrals and how long they were with hospice before they expired. Some of the renal docs are good about hospice referrals early, and one pulmo doc won't refer them unless the family insists. There are some people who are so terrified of their own death, they can't discuss someone else's.

I'm as tough as they come, but I've cried. When you're in a room with 12 people, and they are all quietly crying, while a child is in bed with their dead father begging them to come back (and you can't leave because the wife has a death grip on your hand), I can't imagine standing there like a stone. I've cried "off stage" when I know I'm about to have to code someone who's in their 90's, end stage everything, and the leeches in their family are crowing "do everything" in the same breath they're asking how long they can wait until they have to notify medicare/medicaid to stop the check. I've cried with families who've just received devastating news that a child is brain dead, all while watching the mom absently petting the teddy bear they'd brought from home for their little boy. I've cried when a patient is going for a nursing home placement to the crappiest place in town, and their only worry is who's going to look after their cat, when I've heard the family saying they're going to "take it to the dump" as soon as "mom's out of the house" and the mental image of that poor cat being thrown out, losing both home and human is breaking my heart (I managed to get them to give me the cat, and took it to the SPCA -- declawed, and they were going to throw it out). I see a lot of bad, sad, maddening things in my job; we all do. And the one thing we do a poor job of as nurses is getting to mourn. I think if you don't have some kind of mourning mechanism (tears, exercise, art, whatever), especially for patients you've had for long periods of time, it can hurt you more than you think.

What I would love to post: Your ego stops at the doors to my unit. I am not your mom, your wife, your significant other, or your therapist. I don't care if Dr. Oz said something different. I am busting my tail to keep your family member alive, and I don't have the time or the energy to stroke your ego like apparently everyone else you've ever met has. ICU is a serious place, and serious things happen here. Take your silly, self centered backside HOME.

I loved A&P, loved Micro, was okay with chemistry. Worst class? Statistics. I mean, what the fecal obstruction do I need to know about statistics for nursing? Yes, if I was going into research, or even if I was going for a MSN in management. But for a BSN? Loathed it.

I think we're all related. When she was in the ER, I thought if my Mom said, "...and Nerd works in ICU" one more time, I was going to just go to the car and drive home. Finally, I said, "Mom, you know I have to work here, and you are NOT making my next shift any easier."

While I don't usually watch shows about "work" like Grey's Anatomy, Jackie, etc., it hits me on other shows. On the 3rd episode of the Hatfields/McCoy's miniseries on the History Channel, one person gets shot right thru the subclavian artery -- gets up, runs around, not the first sign of spitting or coughing up blood, moving the same side arm, etc. I'm thinking about all the nerves that just got severed, if he didn't bleed to death, he'd have a sucking chest wound, permanent loss of function and structural deformity if it actually hit the clavicle, etc., and completely zoned out for the next 2 minutes of the show trying to think how you'd have treated that kind of an injury in the 1880's. It's a lot less stressful for anyone around if I just watch shows on archeology. Although, I was watching something on Pompeii and they talked about how the victims had silicosis, and I thought, "now how could they have lung tissue to analyze to know that, the people were hollow voids in the ash, not like their lungs were sitting there for 2000 years....

And what did HE weigh? Does he smoke, not take his BP meds, blow off checking his blood sugar? What secrets are in his healthcare closet? See, my mouth fires before my brain engages, sometimes, and I would have said, "Yeah, there's nothing worse than a fat nurse, except a rude doc."

We all grieve different ways, and we've all seen families blame themselves when something happens -- "If I'd just called Ruth to see how she felt..." or "He said he had a headache, I didn't think it was a stroke..." and it rapidly progress to "You NEVER called Ruth, and now see what's happened!" Some people react to grief by offloading -- loudly -- on someone else. I'd suggest being a listening supportive presence; these people are going to have to grieve, and I'd hope the house chaplains or maybe hospice resources are being utilized. I helped on another unit when one of the nurse's child was going down the tubes -- I was starting IVs and trying all I could do to prevent a code, but the "ice wall" was up in full force, it was the nurses being protective of the parent who'd thought the child was just trying to get out of school when it was meningitis. Had I suggested an inservice on recognizing bacterial meningitis (which would be a good idea) or "When the patient's a family member" they'd have eaten me up -- not that they didn't like me, or it was a "ICU vs. floor" situation, they just closed ranks as a protective measure for the coworker and even as an employee, I was not one of "us" I was one of "them." Wonderful idea. But in this case, I'd let it go.

*As you're coding your patient* "Hey, Mr. Smith, did ya hear the one about the -- 1 amp bicarb -- chicken and the duck who -- epi, please --- who went in and bought a time share together? Well, -- shockable rhythm, clear please -- the chicken decided to have an affair with the duck's wife, and ...." And the designs the blood makes as you're washing the 10th bedpan full of GI bleed down the drain -- they're just plain artistic! What a moron.

Interesting. Like a 80mg protonix drip as opposed to 40 mg ivp BID. Wonder if they'll end up creating special "drip" protocols where I work....

We have 1 hr either side. Some meds don't go together, but most of the time, I try to "bundle" my meds -- would you want me in your room every hour all night for non-emergency meds --- here's your 1am protonix. Here's your 2am lovenox. Here's your 3 am 81mg ASA. Here's your 4am q24h solumedrol. Here's your 5 am 10cc IV flush. In that case, I would do the 1 and 2ams as close to 1 as the computer will allow, and the 3 and 4 as close to 4 as the computer will allow. I'm checking on my folks all the time, but I try not to wake them if I've finally managed to get them to sleep. Your body doesn't make critical hormones unless you're asleep. I keep you up for a few days around the clock with only cat naps, I'm going to snarl up your endocrine system. Now, it it's cardiac or resp drugs and the patient's really sick? I'm in there with a syringe or pill every 30 minutes. It just depends.

I go "naked" from the forearms down. Last thing I want to do is bring home something on jewelry, watch or cuffs. It's a little odd when someone asks me what time it is when I'm not at work, because I look at my breast -- where my fob watch usually rides.

The things that I'm tired of: 1) Non-compliant drama queen/kings for patients. Won't take their BP meds, shocked when they have a stroke. Won't take their insulin/watch their diet, shocked when they have a stroke/MI/amputation. Won't monitor their fluid intake, end up in fluid overload, and the poor dialysis tech that has already been at work 15 hours gets to stay for 3 more to try to prevent them from getting flash edema -- every month for the same patient. 2) DKAs. These people make me crazy. It's one thing if you've been sick, post op, and your sugar gets out of whack, can happen to anybody. But the folks we see every 3 weeks, tell us "oh, I've been following the diet, taking my fsbs and insulin" and they've gained 5 pounds, have NO marks where they've been testing their sugar, and their a1c is 11, up from 10.5 the last time? And they act completely hateful. You don't like IVs, then treat your diabetes! 3) Family members who treat you like a dog. Million horror stories. 4) Docs who won't listen, then throw you under the bus. 5) Co-dependent families, weird families, and people who want to have sex while the patient's in the hospital. I mean, come on, that's just freaking nasty! 6) People who aren't nurses telling me how nurses need to be endlessly loving, endlessly approving, take anything without complaint because it's a calling and how wonderful my "calling" is -- well, I've got half a cup of "calling" all over my favorite shoes. It says "nurse" on my tag, not "saint." I need a vacation. I read that NASA was putting people in isolation for 4 months with no physical human contact (email and video okay) to see what would happen if a Mars mission went bad, and only one person survived to try to come back to earth. I really, seriously thought about signing up.