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.