Lisky90

Thank you so much to all of you for taking the time to read this...and thank you so much more to all of you who responded, and for some of your encouraging words. I feel so much better this AM after clearing my head and getting some sleep. What scares me however, about my charting is that everything is computerized where I work, so my charting was done in the computer under the pt's notes and that is where I charted every detail of the incident. If anyone chooses to read the notes about the incident...they can. I'm sure the MD will be looking for notes about the incident this AM, as he apparently called the floor as the pt was being tx'd to the ICU. The secretary, who was very aware of what went on, told me he sounded very surprized and nervous that her condition warranted such drastic measures. So, I do feel nervous that he is going to be PO'd and wonder how far he will go to cover himself. But, in many ways I just feel so disappointed in myself for knowing that this pt wasn't OK...and that if RT had not come back to reassess when they did, that I would have given in by giving her a drink. I didn't trust myself and my abilities and if RT had not come back in when they did, it really scares me to think about what may have happened. I owe RT a TON of credit on this one.

I'm so tired after doing 14 hours today...but, I can't get this off my mind and this is the perfect place to get some feedback...so I'll try to be as brief as possible. This was my first day back at work after being off for two days; however, I haven't been on my floor for over a week because over the weekend I was floated to another floor. So, first day back at work, on my floor, I get report on a pt who looked fine a week ago...chronic trach, weaning off the vent, been off for many weeks, on a trach collar, some confusion, always on the callbell, etc. I get report...taped from the off-going shift that she has "4+ BLE, very anxious overnight, given Haldol, Ativan and Benadryl, RT increased her FiO2 to 100%...but, I don't know why, the order is only for 70%, I think she has an EKG ordered but can't find the order...pt in same condition yesterday, but MD wrote in progress note that pt is stable." I first ask RT about her ?EKG...he says "She had an ECHO last night and it is showing Right atrial/vent enlargement with pulm. htn." Seems to correlate with the edema...feel that it is significant. Then the CNA tells me that she is cyanotic. I go in to assess...she is cyanotic, worst edema I have ever seen, O2 sats are in 70s to 80s. RT goes back in...we monitor her for awhile. MD arrives...ECHO on chart, he SEES pt himself, writes orders and leaves. I check the chart, the only new orders were for coumadin and a PRN lotion for her back and that she is essentially stable. I thought WHAT??? Did you even look at this pt??? I asked him if he saw her ECHO results? Did he want to treat that?!? He says "no, this is long standing...meds would only help long term...she has been this way for awhile." I know he saw her so, I thought "OK...he knows her, I haven't seen her for a week...OK?!? Pt starts asking for a drink. She can only have PO if she is capped...she is cyanotic without the cap...I'll kill her if I cap her. I call RT, they tell me to cap her for brief periods, let her sip, then remove cap. I held her off for a few hours...but kept thinking how is she going get nutrition if I withhold PO intake...I didn't know what to do...she kept asking...finally I gave in and sent the CNA for coffee. At the same time, RT comes to reassess...can't get an O2 sat at all, they call for me and my sup...who flips out because pt is in the condition she is...tells me to notify the MD...I explain I have already discussed this with him...he is completely aware of current situation...I explain that she has been this way for a few days...she says "I don't think so" but then admits she hasn't listened to her taped report from the offgoing shift (This is at 2:30 in the afternoon...we start at 7:00am!!! How does a sup do her job if she hasn't listened to her report???) she insists that I need to be "proactive" especially because pt is a full code and if we aren't treating the Right heart enlargement what is the sense of putting her through a code. So, on that, I call. The DR. flips out...he thinks I questioning his judgement, tells me that if I am concerned about her NEW change of condition I should call the House MD...I explain that she has been cyanotic since this AM...this is not a NEW change of condition. He tells me that he is "to stop focusing on the ECHO results" and that he is "seeing pts and I have no right to call him..." and then tells me that he is "ending this conversation" and refuses to discuss her code status. Well, her ABGs were in the toilet, she ended up having her trach changed, going back on the vent...and sent to the ICU per the covering MD's orders. I then sat down with my sup...and we listened to report together at 4:00pm...she still had yet to listen to report herself...we discover that this pt had in fact been this way since Monday...nothing has been done, as MD has continued to write she is stable...but no one has had the sense to question it. So, this mess fell into my lap today and I was so PO'd!!! Everyone said to chart, chart, chart everything. So, I did. Now, I'm worried that all my charting is really going to rub someone the wrong...especially the attending MD. I feel like what I did was right but, I feel in so many ways this situation was so wrong. I don't know what to do next...I've gone to the sup...should I go to the DON? I'm exhausted but, I just can't sleep because of this. Thank you to anyone who has gotten this far in reading this...and even more thank yous to anyone who has any words of wisdom to impart

I'm so tired after doing 14 hours today...but, I can't get this off my mind and this is the perfect place to get some feedback...so I'll try to be as brief as possible. This was my first day back at work after being off for two days; however, I haven't been on my floor for over a week because over the weekend I was floated to another floor. So, first day back at work, on my floor, I get report on a pt who looked fine a week ago...chronic trach, weaning off the vent, been off for many weeks, on a trach collar, some confusion, always on the callbell, etc. I get report...taped from the off-going shift that she has "4+ BLE, very anxious overnight, given Haldol, Ativan and Benadryl, RT increased her FiO2 to 100%...but, I don't know why, the order is only for 70%, I think she has an EKG ordered but can't find the order...pt in same condition yesterday, but MD wrote in progress note that pt is stable." I first ask RT about her ?EKG...he says "She had an ECHO last night and it is showing Right atrial/vent enlargement with pulm. htn." Seems to correlate with the edema...feel that it is significant. Then the CNA tells me that she is cyanotic. I go in to assess...she is cyanotic, worst edema I have ever seen, O2 sats are in 70s to 80s. RT goes back in...we monitor her for awhile. MD arrives...ECHO on chart, he SEES pt himself, writes orders and leaves. I check the chart, the only new orders were for coumadin and a PRN lotion for her back and that she is essentially stable. I thought WHAT??? Did you even look at this pt??? I asked him if he saw her ECHO results? Did he want to treat that?!? He says "no, this is long standing...meds would only help long term...she has been this way for awhile." I know he saw her so, I thought "OK...he knows her, I haven't seen her for a week...OK?!? Pt starts asking for a drink. She can only have PO if she is capped...she is cyanotic without the cap...I'll kill her if I cap her. I call RT, they tell me to cap her for brief periods, let her sip, then remove cap. I held her off for a few hours...but kept thinking how is she going get nutrition if I withhold PO intake...I didn't know what to do...she kept asking...finally I gave in and sent the CNA for coffee. At the same time, RT comes to reassess...can't get an O2 sat at all, they call for me and my sup...who flips out because pt is in the condition she is...tells me to notify the MD...I explain I have already discussed this with him...he is completely aware of current situation...I explain that she has been this way for a few days...she says "I don't think so" but then admits she hasn't listened to her taped report from the offgoing shift (This is at 2:30 in the afternoon...we start at 7:00am!!! How does a sup do her job if she hasn't listened to her report???) she insists that I need to be "proactive" especially because pt is a full code and if we aren't treating the Right heart enlargement what is the sense of putting her through a code. So, on that, I call. The DR. flips out...he thinks I questioning his judgement, tells me that if I am concerned about her NEW change of condition I should call the House MD...I explain that she has been cyanotic since this AM...this is not a NEW change of condition. He tells me that he is "to stop focusing on the ECHO results" and that he is "seeing pts and I have no right to call him..." and then tells me that he is "ending this conversation" and refuses to discuss her code status. Well, her ABGs were in the toilet, she ended up having her trach changed, going back on the vent...and sent to the ICU per the covering MD's orders. I then sat down with my sup...and we listened to report together at 4:00pm...she still had yet to listen to report herself...we discover that this pt had in fact been this way since Monday...nothing has been done, as MD has continued to write she is stable...but no one has had the sense to question it. So, this mess fell into my lap today and I was so PO'd!!! Everyone said to chart, chart, chart everything. So, I did. Now, I'm worried that all my charting is really going to rub someone the wrong...especially the attending MD. I feel like what I did was right but, I feel in so many ways this situation was so wrong. I don't know what to do next...I've gone to the sup...should I go to the DON? I'm exhausted but, I just can't sleep because of this. Thank you to anyone who has gotten this far in reading this...and even more thank yous to anyone who has any words of wisdom to impart

Ty-yen-ol...my preceptor for OB used to say that all the time...didn't feel that it was my place to correct her but, pts used to look at her funny when she offered it that way and she never noticed.

Love 12s...Where I work, there is still the same amount of pt care that needs to be squeezed in to 8 hours vs 12 but, at 3p I still have 4 more hours to complete things...charting, dressings, etc. Sometimes at 3p I can kind of sit for a bit and regroup after a crazy morning vs trying to get everything done and charted by 3p and more days at the hospital. Between 3p and 7p there are sometimes 16:00 meds and then 18:00 meds...definately no where near as heavy as a 9am med pass. So, I'm getting 4 more hours of pay, more time to finish up day stuff and 4 days off per week.

I just busted a gut out loud all alone in my kitchen after reading (my kids who were in bed had to come out and see what I thought was so funny)...OMG!!! That must have been awful...it was bad enough having it on my gloved hand and plastic gown...but on your head?!? you poor thing!! This is why I come to this site...no one who is not a nurse would ever understand why we CHOOSE to do what we do. So sorry to hear you had to go through that. Some lessons are learned to hard way but, that is just too much...I really feel for you!

I had a confused pt that had a capped trach. I took the cap off for trach care and put it down on his tray in front of him but, then thought better of doing that as he was confused so I said, out loud "better not put that there...he'll probably end up with it in his mouth." I was just kind of thinking out loud but, his wife took offense and said "oh come on he will not!" I apologized and finished what I was doing. I returned awhile later to do a fingerstick, and then left the room again. Upon returning to give insulin a few minutes later, I looked at this man and did a double take...his wife was sitting by his side...calm as could be...but he appeared to be chewing gum. A confused man with a capped trach...I said to the wife "did you give your husband gum?" She said "no, of course not." We fished out what he appeared to be chewing like gum...it was the alcohol prep pad from his fingerstick that was left within his reach.He had put it in his mouth and started chewing on it. Hmmmm...and I was the crazy one to suggest he might swallow the cap to his trach?!? He was found on other various occassion trying to eat his call bell, lick it like an ice cream cone...how can you not laugh sometimes?

This may sound like a silly question but, what makes an ICU nurse different than a tele nurse? I am still a pretty new nurse (one year since graduation)so, I really don't know what I would/should say if the small hospital that I work at asked me to float to the ICU. I've had orientation to the three depts in this hospital...the two regular floors with vented pts and no tele and the ICU. We just opened a tele floor this past week and I was one of the first nurses to staff it. I have taken tele training, and been ACLS certified and the pts I had all ran normal sinus rythyms but, I will admit I was still pretty nervous to have an actual assignment on this floor. I am now wondering if there is other training and/or certification that I should have to agree to float. Now that I have started on tele, I'm sure it's just a matter of time before this comes up.

Oh my...I hope I didn't totally gross everyone out with my Foley story. That all happened to have happened the day that I had posted it. I think my grossest medical story however, was when I was an EMT and we responded to a fight to find a man sitting on the side of the road holding his ear. When asked what happened he said, pointing..."that guy bit off my ear!" My stomach still turns thinking about that one...12 years later. Why would anyone ever bite the ear off of someone's head...cartilage, earwax...eeeewww!!! I think if I ever shared half of my stories with family and friends they would question my sanity in wondering why I would have ever CHOOSEN such a career...lol!!!

pseudomonas is a good one...there are now many strains that are becoming multi drug resistant...which warrants a "critical value" phone call from the lab, when sensitivities are finished. Also ESBL...got a call from the lab the other day that a pt had Kleb pneumo (a common bug) in his urine but it was found to be ESBL positive...I believe this is something that is being seen more frequently, and something to do with common bugs now becoming resistant to antibiotics.

I have a good one...from today as a matter of fact. One of my patients, who is a parapalegic called me in to tell me he thinks his Foley is clogged and needs to be flushed. His urine cx just came back with >100,000 Proteus and the urine in the bag looks like eggnog...sorry, for lack of a better description. Very purulent and sludgy...very gross!!! I checked the puter to see when the Foley was last changed and saw that it was changed on 6/3. So, I decide to just flush it. I tried and tried and couldn't get it unclogged, so I said "unfortunately, I'm going to need to change this again." So, I get set up to put in a new Foley, everything is within my reach, I deflate the balloon...and then thought about grabbing some extra chucks...only 3 feet away. I step away to get the chux, and I hear him go "OOOOHHHH!!!" There was so much pressure in his bladder, that it blew the Foley out of his member, sending sludgy, smelly urine EVERYWHERE!!!

The last time I did one, the sponge went directly onto the wound...I believe there was one once that I did that had orders to put gauze and then the sponge on the wound. You are right though, if there is a Tegaderm over the wound it will contain any drainage that the wound vac is supposed to draining. It should be the sponge, the tubing and then there are clear, plastic dressings, like Tegaderm but, made by KCI that go over the whole thing, to create a seal...they are usually much bigger than a Tegaderm.

Good morning...thank you to everyone who posted. I really needed some honest answers...to know if this is this crazy or if I am just new and slow...or whiney...lol. After I reflected back on the day...what seemed the most crazy to me was the timing...why would a supervisor want to tx pts from floor to floor while we're all getting ready to change shifts??? Why would she try to take report at the same time??? I get the impression that she waits until the last minute to take care of her responsibilities so that it appears to the oncoming shift that she did something all day...all the while wrecking havoc on the staff...leaving things feeling insane but so unsafe...I hated the feeling of getting a pt at the end of my shift, who I was now responsible for that I knew nothing about...thank God nothing happened. But complaining about it falls on deaf ears which leaves me feeling new and whiney, and wondering if this is the norm or not. So, thank you to all for your input. Re: vents and monitors...I agree that many of these pts belong on tele...but many of them are chronic, and no longer need it...they are alert, watching tv, do PT/OT while vented. Think of Christopher Reeves...he was vented. PMV: Passy muir valve PSV: pressure support ventilation...like CPAP, a weaning mode on the vent, where the pt does more of the work than with AC, which is full vent support PNA: pneumonia Sorry...I just start tossing in abbreviations when I start "nurse talk"...good to always ask for clarification, though...what might be an abbreviation in one area of nursing can mean something completely different in another area.

Today I started off my 7a-7p shift with 5 pts: 1. Pt on a trach collar tolerating PMV, with unsuccessful attempts to cap...very anxious and crying...high maintenance but, not too complex 2. unresponsive pt with hx of spiking temps, and a new PNA 3. Pt weaning from vent on PSV, who had chest pain tx to ICU 4. Pt with capped trach, with new onset seizures, hx of spina bifida 5. stable pt, hx of sepsis on 5week IV vanco...d/c to nursing home at the same time pt #3 is being transported to ICU...who got stuck in the elevator while being bagged. After losing these two pts, it was now 2pm...sat down to chart on all five of these pts...find out that at 3p, we have one nurse going home and the remaining three of us are going to split her assignment. So, I pick up a fourth pt...but now the 6th I've taking report on. But, things were still in control...it was 4pm, trying to finish up all my lose ends. At 5pm, supervisor starts shifting pts all over the building...I'm sure there was some rationale behind her madness but, had no time to figure it out. I ended up with a 5th pt at 6p...now the 7th of the day to take report on with no notice...while trying to wind up the day. While this is all taking place, she has CNAs cleaning up precaution rooms (no housekeeping available)...furniture and equipment going up and down the halls...CNAs not not available to do their own pt care. While trying to get report on my 7th pt and make sense of his orders and hx...my supervisor walks into one of my pts rooms and says that I need stop what I'm doing to give her a report. Is this crazy? or is it me? I have been working as a nurse for 9 months...so, I am still considered new. I have nothing to compare this to. Is this the way things are everywhere or is this crazy? BTW, while my vented pt was having chest pain, our doc on call was not available and when I called this same supervisor for help...she acted so annoyed that I needed help and kept saying "do you still need me???" We do not have tele on this floor; I put him on our portable monitor...he was having multiple PVCs...bigeminal, trigeminal...a run of 5...prolonged QT interval on his EKG and was a full code...I was scared that he would code at any moment and she was trying so hard to get back to whatever she was up to. Again is this crazy or is this me? I just need feedback.

I agree with you that it is an honor to be in the presence of someone in their dying moments and that it is indeed a profound and unsettling experience. I have sadly, had the honor, in the field of nursing that I have chosen, to experience this several times. I have never been able to express in words what the experience is like; your words describe the experience perfectly. It is truly a blessing for someone pass peacefully, if death is a certain outcome. I am sorry for your loss. In regards to the breathing. I think, and I could be mistaken that Kussmaul respirations are deep and rapid, with no real repeating pattern...regular or irregular, but with no distinct pattern. I believe that it occurs when someone is in ketoacidosis, a type of metabolic acidosis. The breathing that you describe I believe is called Cheyne-Stokes. Where there is a pattern of shallow breaths, that speed up, stop and then start again. It is also an imminent sign of death, from brain injury. I could be mistaken; without getting out the med-surg books...this is just from memory.