Rough Day, Need Help, encouragemnt

[Testing12345]

12/28/2016

I'm really feeling so discouraged after the day I had today. I was hoping that maybe by posting this, some fellow nurses ( who have the time to read my jumbled word salad description of today)would commiserate, offer support, constructive criticism.. etc……I don't know, something maybe? LOL!

The Day started uneventfully after getting report on only 6 seemingly very stable patients. I remember thinking HECK YES! Only 6 patients and only 1 blood sugar!! EASY DAY! The nurse I get report from leaves a lot of this out that I have to dig through the chart to find half the times, which is what I am supposed to do anyway, I know this.. but with all the stuff going on today, I honestly didn't even have the time to open charts period until midmorning… example of important information left out by this particular nurse: Pt has 02 ORDERED continuous, but was told in report it was PRN… another example: Skin blisters suddenly appearing the last few days but not reported or charted while she had them under her care… One Patient was being discharged, one had a family education scheduled ( where the case manager arranged the pt's family to be there while we discuss medications, wound care, etc). The day started like usual, I counted the narcotics with the night shift so I could start pulling meds, and happily chatted with the night charge nurse and her orientee as they waited to leave for the night. I finished pulling medicines early, and then completed my one discharge paperwork and printed my family education materials for another before passing meds ( Shift started at 7, it is about 745 at this point).

One Patient is tube fed and NPO, meds crushed. That morning for her scheduled tube feeding and daily meds, She was sitting up in bed watching Fox news, Alert and oriented, she knew her name, where she was, why she was there, that it was winter time outside and only a few days since Christmas. Physical Therapy was scheduled mid morning and I helped the tech transfer her from the bed to the wheelchair, the patient was then able to stand on her good leg and assist with the transfer.

Approximatey 15 mins after being taken to therapy, the Therapist brought the patient back, stating she would not respond to her and kept dozing off. This was the first time I had taken care of this patient, so I was unsure if this was normal for her or not ( going from Alert and oriented to drowsy and unable to follow simple commands). I asked the tech, who had taken care of her the previous weekend what she thought, and the tech also stated she had not seen her like this and that it was unusual behavior. Vital Signs were completely stable, pt was not on oxygen sats were around 97% on RA. Since the patient would not follow my commands, I left the tech with the patient with the vital sign machine hooked up for monitoring, called the nurse practitioner on the floor and returned with a blood sugar machine Even though the patient wasn't a diabetic, I checked her sugar and it was 172. Pt stated she was having a hard time breathing, although sats were normal for her, we placed her on 2 L O2. No adventisious breath sounds were heard with a stethoscope, but audible wheezing could plainly be heard when the patient was breathing. CT scans and other tests were ordered stat, and things were so hectic and we were so short staffed that in order to get the orders into the computer, I had to take the order sheet to another units secretary to have them entered because our secretary was on break. CT immediately calls to have her on a stretcher, my tech had disappeared, I paged her overhead with no response twice. Meanwhile, the phones are ringing non stop, no one at the desk and I'm trying to answer phones, refax orders etc.. knowing CT was on their way, I retrieved the stretcher myself, grabbed clean sheets and begged for someone to help me transfer the patient, who was by now unable to assist at all with her moving. I grabbed an OT from the hallway who was nice enough to help knowing nothing about this patient and we got her on the stretcher right when CT tech showed up to take her. As we were transferring her, I could smell that the patient had just defecated for the 2^nd time that day. The CT tech jerred at me, like Im some neglectful nurse for leaving my patient in her own poop, then also seemed annoyed that he had to wait while she was cleaned up. Keep in mind that I have other patients calling for me while this is going on, but with the tech now helping in another room and unable to assist, I again needed help rolling the patient, because she could not even roll at this point. Luckily, the wound nurse was walking by and she kindly answered my plea to help. It seemed like an eternity, but it was only 2-3 mins… meanwhile, the CT tech is waiting in the hallway, annoyed and offered no assistance whatsoever. Then he has the nerve to comment there was no ticket to ride in the chart… umm yeah, dude like I had time to fill that out between running around finding a stretcher and someone willing to help me transfer the patient safely, oh, and then cleaning the patient up. I think I might have gotten a little snippy with him. Patient is taken off to CT and Xray calls for them too.. I said she was in CT and couldn't they just coordinate something? They said they would…

It is now almost lunchtime, and I'm dashing to check blood sugars on my remaining patients. In between that, bathroom call lights are going off, which we aren't supposed to walk past even if they aren't our patient. The 2 techs working the hallway are still in another patient room, so I answered 2 lights before I could even check blood sugars and get stuck in the bathroom with a patient I know nothing about, assisting her off the toilet with her walker. Back at the nurses station, my head spinning Phones ringing mercilessly, I have too much going on, supposed to be going to lunch at 1145 myself but it is impossible and I can't escape this feeling that I'm forgetting something ( a lot of things actually). This patient wants pain medicine, other facilities calling in to give report no nurse to take the report. I run give the pain medicine, then dash back to take report. Nursing admin calls to say due to low census we are dropping a nurse and a tech on a floor that was dangerously understaffed to begin with. 4 admissions, 4 nurses, now losing one, down to 3 nurses at 3 pm. I'm terribly late for my scheduled lunch at this point, charge nurse wants me to wait to be last to go, which I'm fine with, except 30 mins before my rescheduled late lunch, my admission rolls in and is a hot mess. Trach, MRSA oozing infected old pacemaker site, new pacemaker site, stage 2 pressure ulcer on coccyx, stage 1 on heel, day old daikins soaked wet to dry dressings and complaining of 8/10 pain. I put an armband on the patient removed old ones, checked vitals signs were stable and no 02 needs for Pt at this time, asking some of the admission questions as I'm putting on pt armband and photographing all wounds. CT brings other patient back, MD now wants CT with contrast on that patient, meaning now patient needs an IV, family ed scheduled at 1430 and it's past 1400 now. Charge nurse says go to lunch, so I did. I stepped back on the floor after my scheduled lunch ( really honestly I had no time to take lunch, but our hospital policy demands it), CT calling back as soon as I come back from lunch wondering if IV started yet, Wife of pt receiving education at the nurses station, wondering where the heck I'm at.. I needed help and no one could help because there wasn't enough nurses. Finally charge nurse states she will do family ed for me while I start IV on CT contrast pt. CT contract pt also has meds due that have to be crushed and a feeding due. IV started, pt fed and given meds, CT notified to come get the patient, another patient needs her dressing changed as it was oozing and also needs pain medicine. Of course, no dressing supplies in the room… pt scheduled to go home the following day, had surgery the beginning of the month and as I look at the patients stitches, it is wide open with underlying fascia showing.. This dressing is to have been changed twice daily but what I was looking at was unbelievable. The skin was about to tear loose from the stitches! It had dehisced. In the middle of that, new admission calling for pain medicine that hadn't been ordered yet, and CT is here to get the other patient, only the stretcher has now disappeared. The CT tech did not want to transfer the pt in her Wheelchair, left again and said he'd come back later. OMGGGGGGGGGGGGGgg….Finally find tech to look for stretcher, Call Dr to get order for pain medicine for new admission he hadn't seen yet, give pain medicine and complete the patients admission, only I'm not able to properly dress the wound because I have no orders for Daikin's.. I did the only thing I could do, and that was to bring all necessary dressing supplies in the room and wait for orders. Dr comes in to see his new admissions, and as he's reviewing charts, I told him about the other patient with the dehisced lumbar incision. He just about **** a brick because he said he was never told about this, and proceeded to ***** the nurses out ( me included) for not letting him know sooner, instead of the day before pt is to leave. I apologized, and stated this was my first day with these patients, and I just wanted to make sure he'd seen it because it didn't look right to me. After seeing it, he just shook his head, told the PT she would not be discharging and wrote new orders for infectious disease consult and for the surgeon to evaluate the wound. Trying desperately to chart PRN meds and complete the admission paperwork, I'm handed 3 more patients to care for, since they are sending a nurse home. I was not given report on these patients, all I had was her notes from her own report, had no idea what patients needed treatments, which ones needed anything at all. All this is going on, and it's time to give report to leave, and give one more tube feeding and 5-7 pm meds. Overhead, a code is paged meaning a patient had fallen … to the room of one of the patients I was given in the middle of the day, after the original nurse was sent home.. Of course, as I get to the room, pt is lying in a pool of blood, is disoriented, claiming his arm is broken and that he called for help but no one came… more vital signs to check and pt to assess, night shift nurse attempting to help get pt off floor before even getting report.. Attempted to notify MD, MD on another floor admitting another pt, left message with secretary on that floor to have him come upstairs ASAP due to pt falling, Pt family had to be notified of fall, statements gathered from the person who found the patient and the tech for that patient, along with a fall report, electronic version and paper version, med report list of last 24 hours of meds from pyxis.. night shift nurse patiently waiting for report with what I think was pity in his eyes..

I make it through report, but still have narrative charting to finish and my fall report to complete. Every one of my patients, even the ones I inherited had all medications given on time, including PRNs and blood sugars checked and treatments done, but I did not complete the charting from the few hours the departing nurse didn't bother to close out her charts before leaving.. She did it but didn't chart it and I didn't think it was right or fair to chart something I did not do or even observe being done!

All of this, in one day.. Oh and I didn't mention that we also had a code that day too.. I've only been in nursing for a little over a year, but this was by far one of the hardest days I've ever had. What could I have done differently to manage time better and to prioritize? Any tips or constructive criticism would be appreciated. Is this normal to be this understaffed, with no one to help with patient care ( tech) and a charge nurse with a patient load the same as mine who can offer limited help? I'm scared I will get into trouble for not documenting something correctly, or for forgetting something.. or for not being able to tell the physician about the dehisced wound until later in the day, when I finally saw it myself? I mean seriously, the wound dressing was supposed to be changed 1 time every shift, and the pt had been there weeks apparently. WHY WOULD NO OTHER NURSE SAY SOMETHING? Agghh, I'm so frustrated.. and I have a feeling every hospital unit is going to be like this.. am I right?I feel these patients have too high of an acuity to safely care for 9 at one time… prime example is Pt falling. I like my job, I like being a nurse, but I can't understand how this is safe nursing practice???

[Davey Do]

Whenever I've had a tough shift, I've found that submitting a factual, objective letter utilizing paragraphs, to my superiors helps me deal with the sress.

I get a chance to get things out by documenting situations and it makes my managers aware of what I have to deal with in order to provide adequate care for those I serve.

[Sour Lemon]

It sounds like you needed to split yourself into two people ...maybe even three. Either that, or some resource staff should have been available to help- but I know that's not realistic considering that they actually sent someone home.

Your day sounds a lot like every day at my first nursing job. I survived by cutting corners in a big way and just trying to keep everyone alive. My situation didn't improve until I got the heck out of there.

[Testing12345]

Hi Davey Do,

Thank You very much, I like your suggestion and I think that is the best course of action for someone like me. I just need to be diligent and remember to document the occurrences shortly after the shift so that everything can be recalled with accuracy. Do you think if I made my above post a bit more professional sounding, it would suffice in my defense ( if something were to ever be questioned about it?)

I have had such a bad start in nursing to begin with, it's been an uphill struggle since the beginning of my short career. My very first job, I'll admit I was waaay under qualified wet-behind-the-ears new grad with no idea what I was doing... I started in the ER and was bullied and mocked and laughed at until I resigned.. looking back, I was in way over my head, and I often wonder why HR would have hired a brand new grad for a busy ER with absolutely no experience in a hospital and only given 6 week of orientation. Anyway, that's a different story.. The job I have now is basically medsurg which is good for the experience and range of skills to perfect, but it is a private hospital and therefore money is the driving force behind management decisions, even to the point that patient safety will be compromised , and other nurses will not say a word and just accept the patient loads..

How do I even address this? Or do I at all? Who would I go to? The nurse manager, or her boss, the chief nursing director? My family encourages me to report these events to the board of nursing, but I would rather not directly involve them...

Maybe I worry too much, but some of the things I have found makes me question if reporting it is the unofficial wrong thing to do because the hospital would be responsible for negligence ? My example of the patient with dehisced wound from a surgery 3 weeks prior.... photos of the incision when the pt was admitted to the unit show clean, healthy closed stiches.. what I saw yesterday was over an inch separated, the skin about to tear lose with white fascia underneath.. Like I said, DR was pi**ed, but he's also the director of the hospital. I worry that my so called "finding" will be twisted around into somehow being my fault?

I apologize in advance for my lengthy responses, but this is one episode I haven't been able to shake since my shift ended last night..

[Testing12345]

And Sour Lemon, thank you for your response too. This is not the first time I have heard the term short cuts by a veteran nurse like you, and I think I have an idea of what you mean ( as in certain things that are "safe" to do, and not compromise patient care) but is there some examples you can give me? if you don't want to post it publically I understand, but I am getting very discouraged with nursing but I know in my heart that God has lead me in this path for a reason... Thank You, I hope you have a good day :)

[Been there,done that, ASN, RN]

The charge nurse should have made it clear that cutting staff was not safe. You need to direct your techs, they cannot be "somewhere in a room".

This privately owned facility is NOT going to change. Take your experience elsewhere, there ARE better places to work.

[EllaBella1, BSN]

I have no real input to offer other than to let you know that I read your whole story, and to offer you a virtual hug. We've all been there in one way shape or form. I hope you went home and enjoyed a nice glass of wine while you were typing that, and cleansed yourself of all of the tough stuff mentally. I work night shift and many a time have gone home to have a morning wine when the **** really hit the fan the night before. Hugs.

[Testing12345]

LOL Thank You, I should have had wine I think, looking back now, instead I spent 2 hours in the bathroom soaking in the tub while daddy put our 2 yr old to bed and let mommy have a night off. I then spent another hour documenting everything in a 5 page word document and posting on here. I think next time, wine and sleep will be better.. haha. Thank you for commiserating.

One thing worth mentioning though, one of the seasoned motherly night shift techs took one look at my face as she was coming in ( which must have been terrible lol) and immediately gave me the biggest and warmest hug without saying a word.. That was amazing at how much stress it took away!

So from now on I guess the solution is wine and genuine hugs.. LOL

[Mr. Nightingale]

Take a couple days off or get sick for 3 days and have fun, relax, treat yourself for a successful shift. You made it thru! Your patients are alive. You called the shots made sure they were stable.

Ive worked Skilled and Hospital and I tell every person nursing is no joke. The day just like you described is the essence of nursing- it wrings the reasons why u want to be a nurse and what makes u stay.

Just a few points btw..

you had a stat ct scan and patient was dirty and tech was in other room... I advise you change your whole shift as u being the commander.

First tell your charge whats going on and ask dor help. If it was super overwhelming u have to communicate and say ur overloaded....

second be firm with techs.. I need you to stop whatever ur doing and come here its urgent.

skim thru the lights just to make sure theyre ok and will not code tell them to wait u will be back ( do not tell them how long)

This is where the REAL Sata questions, delegation and priority stuff come in.

p.s- you should have told that CT scan tech to throw that stinky poop if he was just looking.

Im sure you did awesome!!! You rock.

Ask for help! NEver take a patient without report period except an admission.

[ponymom]

Hi you submitted this horror story to the wrong people. The pigs in administration, the families, ombudsman (and hell, even the local news) are the ones who need to see this.

Good God, so glad I don't have to make a living this way anymore.

Good luck to you and polish off that resume. In fact, explore trade school if you are at all mechanically inclined.

[Davey Do]

Hi Davey Do,

Thank You very much, I like your suggestion and I think that is the best course of action for someone like me. I just need to be diligent and remember to document the occurrences shortly after the shift so that everything can be recalled with accuracy.

Do you think if I made my above post a bit more professional sounding, it would suffice in my defense ( if something were to ever be questioned about it?)

I apologize in advance for my lengthy responses, but this is one episode I haven't been able to shake since my shift ended last night..

In all honesty, and with all due respect, Poney, your post looked and sounded like the typical rant of a nurse.

I merely briefed over your post just to get a feel of what was going on. Obviously the other posters read and absorbed your post. At first glance, I knew it would be overwhelming.

Factual, objective documentation needs to be short, concise and to the point.

The words need to stand out that in a glance, so the reader gets hit hard with facts.

Having a few years as an administrator, I have an idea of the volume of correspondence and situations with which administrators have to deal.

My suggestion is to grab the reader with the basic, objective facts. Make them want to know more. Save the wordiness for your own records.

This approach has worked for me countless times.

Thank you for your inquiry and I wish you the best in your endeavor to remedy these situations in order to provide quality care for those you serve.

[ponymom]

Hi Davey, I understand. I'm not a nurse anymore. Just maddening to see and compare the difference between my career as a nurse and the current career I now have (actually the career I returned to). I really loved working as a nurse (and I actually wanted to work LTC) and miss it every day.

Even as I enjoy the higher pay and many more benefits, better working conditions and much more professional and positive experiences in my current career, I literally miss nursing every.single.day (I started classes several years before orinally leaving the plant). I then spent enough time as a nurse to not be considered a 'new' nurse anymore, however, I since let my license lapse and hopefully will never need to even think about reactivating it. I won't work under those conditions. I'll now stay in my coveralls and work boots, and keep all my hair...and enjoy all my breaks, and not face near-constant mandation, get 'counseled' re OT to finish tasks & charting, pay dues to a weak and kicked-in union, etc., etc.

Understaffing is at the root of why the OP had such an ugly day, it's at the root of 99.9% of all the problems with this field. Yes, I am opinionated about the cluster dance that is this field, and the relative weakness and unwillingness of those working in it to stand up for themselves as an individual and as a whole entity. Any factory/manufacturing position I've ever held has ultimately treated it's employees better than any nursing position I've ever held. That's the sad part, that a health care entity/model that is supposed to value human lives actually performs at a lower level than a factory.

I left nursing solely, solely because of chronic understaffing. Families didn't bother me, hours and shift didn't bother me, administration didn't bother me, charting didn't bother me, negative coworkers didn't bother me, patients/residents didn't bother me. But toss in chronic and unrelenting understaffing, that was it.