Kharma711

This is more a vent post than anything... Had a patient today who any reasonable nurse would say should be on hospice.. trach, tube feeding, dependent on CRRT and IABP... screams in pain (silently) to any touch/turn... extremely cachetic with mutliple pressure ulcers... and sadly "with it" enough to beg you to stop hurting them... The family refuses to withdraw care and after months in the hospital reluctantly agrees to a partial DNR that only means we can't do chest compressions but everything else must be done... Multiiple discussions have been had with family, including his inability to be listed for transplant due to weakness, multi organ dysfunction and EVERYTHING resisitant infection... they insist we keep doing... This type of patient breaks my heart so deeply.... even the ones who aren't "with it" enough to know... i feel the family is so damn selfish to allow their loved one to live this way... If someone did this to me, I would haunt them when I passed out of spite... the interventions are no longer for the patient but for the family and I resent causing pain and suffering for NO good reason... Ok thats all my thoughts... any commentary or ideas on how best to deal with a patient like this are appreciated... thanks for listening/reading.

Just this past shift I had an elder lol with dementia.. at the beginning of shift she was a little agitated and I reoriented her and gave her the remote/call light and told her to call me if she needed anything... her response, "I'd rather call roto-rooter" I had to walk out of the room because I could not contain my laughter!

Had a patient in DTs who was hallucinating very vividly all shift. All night she had been calling me Kiki and saying off the wall things... my two favorite quotes from this lady were: "Kiki you better clean this kitchen up" to which I responded ok we will get it cleaned up, "when" she replied and I said in a little bit. To which she huffed and "sure that's what you always say! I'm gonna spank you if it's not clean today" And As I'm washing my hands in the sink before leaving the room, "Get the **** of the kitchen, Kiki. You better not be eating my man's pork chops, you hear me?"

"Patients current hypervolemic state likely related to a TACO" It took 4 nurses and some help from Dr. Google to figure this one out. None of us, not even the charge nurse who had worked inpatient for 30 years, had ever heard of this acronym. I thought it was a typo or the doc was hungry while he wrote his progress notes... nope, turns out he meant "Transfusion associated circulatory overload" Afterwards, I just wanted a taco 😂

A few months ago, I come in and get report like any other shift. The final patient I get report on is one I had about a week ago so I remembered her. As the off-going RN gives me report, I'm looking at the patient and her vital signs. I've had many patients equally sick looking and with more extreme vitals but this was a total change from a week ago. The off going nurse reassures me that she has been like this since yesterday and the docs had been informed and seen her. The rest of the report is all mildly reassuring. Afterwards, I come back to the room to do a thorough head to toe assessment on the patient and the family had come in while I had been doing my start of shift routine of stocking my 100 pockets. I talk to the sister, whom I remember from the last time I had cared for the patient. I don't even truly remember the conversation now or what sent my spidey-nursr senses tingling, but I paged the on call provider after I assessed the patient and just knew she needed a trip to ICU. Her resps were now in the 40s and becoming even more labored. Long story short, cross cover doc came to assess at my urging and 100% agreed with me. ABG revealed that her case was emergent. Within an hour, the anesthesiologist tubed the patient and I started sedation. Charge nurse and bed management got me a bed and off we went to the ICU. It all happened so fast and afterwards I realize I haven't even fully assessed my other patients and it's 11 something pm and no meds had been given. Thankfully the lovely nurses I work with had passed meds for me and updated me on my other patients. This definitely could have gone way different had I ignored that sense. Thank goodness I developed mine early!!

I will preface by saying, I'm still a "new" nurse in my practice, with about 1 1/2 years experience. When I was in orientation, it took the full 3 months for me to get my required 3 successful IV starts to be allowed to place an IV independently. Fast forward 3 more months and I am still having trouble starting my own IVs. Naturally, I ask for help. A couple RNS on the unit also frequently pick up shifts in ICU. They are the go-to nurses for IV placement. I never let them place one for me without being there to watch and learn. Prior to this, I had no idea that the index finger and thumb had viable veins in some patients. I never even thought to look there, instead opting for the obvious hand/wrist/forearm. She also taught me they could be placed in the upper arm, which in my limited experience, I had only seen used for midlines. I would always try at least once, sometimes twice if I thought I could get it, before calling on these lovely vein whisperers. Fast forward 6 months and I have somehow become one of the whisperers myself. I practiced on my own patients until I had a bit of confidence and then would offer to help others if I noticed they were busy and/or said they needed a new line on a patient. All I can say is, practice made perfect. I am by no means the best ever and occasionally I still ask for help from the lovely nurses who taught me. Since my meager beginnings, I've started all sorts of PIV, including feet/legs when needed and that elusive upper arm vein that took much practice to figure out. Somehow, I have joined the ranks of these beloved nurses who can start a line in a pinch and/or hard stick. I've had nurses exclaim excitedly when I report they now have a working 18/20g in the forearm/had, etc. Or had doctors/nurses thank me when I place a 2nd IV when a patient is going downhill fast. I've even placed a couple in code situations. The point here is not to toot my own horn so to speak, but to encourage the nurses and students who struggle with IVs or are not allowed to practice in school. I got to start all of 2 IVs while in school, one on a classmate and one on a patient. And then a few months went by between those starts and graduation and nclex and moving to another state for licensure before I got to try again. To those that struggle, especially those like me who don't have IV teams at thier work, I encourage you to keep trying! And don't take your local "vampires" for granted. Take the time to observe and learn from them. Good luck and may your patients always have ropes for veins.

"Against medical advice" form... it's a way for a patient to sign out of the hospital without being discharged and the hospital is not responsible for the outcome or possible readmission.

If the patient had been a psych patient then I would have just refused to have them again. My unit is good about making sure not to burn one nurse out on a difficult patient and will rotate our nurses. Thank goodness it ended the way it did, is all I can say. I just wish they had said those magic words earlier in the shift. I was fried crispy after that mess.

Thank you so much for this and all previous replies... like I said, long shift and I had to restrain myself from skipping along happily once she said she wanted to leave. At leasthe I know I'm not alone! Haha

Oh boy it's been a shift... First off, I was the code nurse which means I'm responsible for being present if a patient is going downhill or coding and facilitating the process. Which is something I don't mind... However, this shift I started out with an ICU patient waiting on a bed who got moved 1.5 hours into the shift. No biggie. Also, had a DNR patient expire despite all allowed efforts. Again, dealt with it, did as expected. Also had a patient on the unit go into SVT and very nearly code. Once again, I did my job and helped in every way possible. None of this was an issue, just giving you an idea of the kind of hectic shift it was... Now, this one patient out of my four was an absolute nightmare. I've been told I have much more patience than some. I'm rarely phased at all by difficult patients. However this one took the proverbial cake. Except during each of the previous episodes mentioned, I was literally in this patient's room every 15 minutes. Some of these were because I was called by the patient. A few were other nurses or the PCT calling me to the bedside. Literally over a dozen were because she set off the bed alarm and simply would not call for assistance. Though, they would call for everything else under the sun. I tried in good faith to get this patient anything they wanted/needed within my scope. I was "rewarded" by the patient urinating in the bed multiple times, on the floor multiple times as well. I was "rewarded" with a million complaints and blatant lies and even fake seizures trying to seek more drugs... I tried every single method available to explain everything. I gave 8 mg of ativan to them. I gave pain medication several times though they only allowed one dose of narcotic. I literally did everything in my power and called up more patience than one nurse should ever have at her disposal. Yet, nothing I could do ever satisfied this person for more than 15 minutes at a time. After 12 torturous hours, they requested to leave AMA and I called the MD to the bedside. I was practically giddy to sign the AMA form. I even gladly unhooked them and removed the IV infusing diltiazem with great joy. After signing out, the patient tried to get the doctors or myself to arrange transportation. Which, as most of you know doesn't happen with an AMA. The patient even went so far as to ask for a bus pass. I desperately hid my relief as I explained the process to the patient. Said patient continued to complain, come to the desk, and trash their room for the next 30 minutes. I happily went in, helped gather belongings and sent them on their way. I'd have even been glad to call security had they not vacated. I didn't care one bit at the accusations of being "horrible" nurse or accused of stealing. I had never been more relieved in my life that I didn't have to pass this patient on to the next shift. Anyone have similar experiences? Should I feel bad for feeling happy/relieved that they signed out AMA after torturing me for 12 hours?

I hear that and understand but I feel like I was lacking... I didn't know how to talk to his family and was so afraid of giving him more pain medicine and I just feel inadequate in the face of this tragedy... I don't know how to just file it away now. I've been crying since I got off work...

I've seen a couple other people's patients pass on when DNR, but I just lost my first patient assigned to me and it was heartbreaking. First, it was a teenage boy... he was so young and never got to truly live his life. There was absolutely nothing I could do for him but I feel like I could have done something... He had a lot of family at the bedside when he passed and honestly I had a hard time dealing with the family... not because they were needy or anything but because I just didn't know what to do or say for them... I rationally know that losing patients happens, but this experience kind of broke my heart... I did as much as I could and awkwardly talked with the family... When he passed on, I printed the Tele strip of his last heart beat and gave it to his mother. She cried and hugged me and while I mostly kept my composure, I've never ever wanted to cry at work more than that moment... Now I'm home and I can't stop thinking about it... I've cried and talked a bit to family and friends but I still feel this sorrow in my heart. I feel for his family and I wish I could have said or done something more for them... How do I deal with this? Any advice welcomed

2.1 in a mostly asymptomatic patient that should have passed go (stepdown) and gone to ICU... he finally decompensated an hour after he got to my unit with a map of 53 and went to ICU but I stayed over 4 hours with just this one patient and another nurse helping me to keep him alive to see the ICU... and he lived after getting lots of blood and made it back to my unit to be discharged later. It was crazy but fulfilling to see my efforts to keep him alive be rewarded!

As far as the tech part, the tech was unavailable, but rather than accept my help with repositioning, she left the patient sprawled in what looked to be a terribly uncomfortable position until the tech came back from break. It didn't hurt my feelings per se as this nurse can be prickly, but my focus was on patient care. It didn't matter to me that it wasn't my patient. As long as I am able, no matter what is needed I will help whomevers patient. I don't believe in "tech jobs" as far as toileting patients, cleaning up messes or fetching a snack or more ice/water. Besides the very rare (I have had 2) nights where my focus is not at its sharpest, I stay busy and on top of everything going on to the best of my ability, which is darn near impossible with 6 patients. At my hospital, we always have patients that would be in the ICU at other hospitals. We just don't have enough beds in ICU (even though I think we have 50/60+). I've had shift where I have a full load of step-down patients and am holding an ICU patient on top of it. Sure it's stupid busy and crazy, but even then I don't let myself get burned out over it. I make my way through the shift doing as much as possible while respecting the patient/family experience. Now, I've had patients complain when they haven't seen me (but never pressed the call bell) and refusee my apology when I am sincerely sorry they needed something and I couldn't be there due to whatever was going on down the hall. I have so many thoughts and feelings regarding many of these issues but my point is that so many people in Healthcare don't seem to care past getting through the shift. They never offer to help others and will actively dodge patients that need something or hide at the desk/break room, etc. The "it's not my job" mentality is huge here. Heck, even if it is their job, they just don't feel like it/don't care. And it scares me that these people care for patients at thier most vulnerable and scared states.

Again, I'm on very little sleep at the moment, but I always prioritize life and death over touchy-feels so to speak... but I have been pushed to the max the last couple weeks. I realize I've been vague and scattered but that is truly how I feel and it affects the care I give to my patients. When every shift is a chore, it is hard to focus on my goals of providing care that I'm proud of... The last shift I did have a patient going south but he was within normal limits most the shift, even if I knew he was going bad. I felt as if I had this one patient going bad so I focused on him to a point of exclusion to my other patients once he fell out of WNL criterion. The intern actually argued against a bolus to the patient who had no history of CHF and was septic.... I feel like I spend too much energy arguing with interns and spending time filling ice bc my tech is avoiding high needs rooms. It is just rediculous. I'm mostly commenting on what I see and wondering what others have seen and if what I am experiencing is kind of a new norm. Please I'm hoping you all will tell me that what I see is not normal. So then I know what to look for in future employment. I want to be an idealist but I understand priority.