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  1. Share Your Nurse Ratched Moments We all know that a day in the life of a nurse is not always filled with warm and fuzzy moments. Challenges and frustrations are encountered all the time - many times at the most inappropriate times. Our co-workers, upper management, families, and even we ourselves can turn into Nurse Ratched. Please share any Nurse Ratched Moments you've had this week as you fly over the Cuckoo's Nest. Will be bumped each week so you can add any new 'Nurse Ratched' moment. Bookmark. Follow.
  2. There are people of all ages wanting to become a nurse. What would you tell them about nursing school or nursing in general?
  3. SerenityNow HealthWriter

    The Life of an Oncology Clinical Trials Nurse

    Have you ever seen chemotherapy or biotherapy administered by a nurse and marveled at how it prevents, reduces, or even cures cancer? Welcome to the outcome of oncology clinical trials! Recognized as its own nursing subspecialty, the oncology clinical trials nurse (OCTN) plays an integral role in cancer research. The Oncology Nursing Society (ONS) put forth nine competencies that guide the OCTN in this exciting and cutting-edge nursing role. As a former OCTN, I will review each competency as it related to my daily nursing practice in a community-based research department. First Things First A clinical trial is a research study offering patients a new device or investigational drug (ID); I will be focusing on the latter in this article. Since the ID is not FDA approved, the treatment is considered experimental. Patients use oncology clinical trials to access new medications that otherwise would not be available to them. Some of these trials focus on preventative medicine, whereas others hope to increase overall survival or progression-free survival. The ID can be administered as a single agent (alone) medication or in combination with standard of care (SOC) treatment. And yes, some clinical trials use placebos to determine the efficacy of their ID. There are four phases to a clinical trial. Most community-based research programs only offer phase II-IV trials due to the complexity and staffing needs required to implement a phase I trial. You can visit cancer.org to learn more about the phases of oncology clinical trials. Now, in no specific order, here are the nine OCTN competencies and how they influence clinical trial management. #9 Ethical Standards The OCTN is tasked with ethical assessments from the moment they meet and consent a clinical trial patient until that person comes off the research study. The OCTN maintains ethical guidelines by: Ensuring protocol comprehension: Confirming the patient is of sound mind and understands the risks of participation is essential to ethical integrity. I worked with a physician once who would consent any breathing patient to a clinical trial, even if it was not in the patient's best interest. Despite having a strong desire for a person to be eligible for a study, the OCTN must advocate for the person's safety no matter the outcome. Guaranteeing impartiality: Remaining neutral while presenting the study information prevents issues such as coercion and coaxing. Persuasion is unethical and should never be used to influence clinical trial participation. I assured my patients they would receive the same excellent care should they choose not to participate in the study. Providing exact details: It's imperative to be transparent about the additional time commitment, extra doctor visits, multiple lab tests, added procedures, and increased research study costs. I made mock calendars and budgets for patients so they could visualize the added obligations of participation. Documenting the truth: The OCTN must disclose adverse events (AEs) even if it results in discontinuing the ID, keeping in mind that any data not reported or under-reported impacts the trustworthiness of the trial. Over the years, I have had several patients minimize their side effects out of worry they would no longer be able to participate in the study. I found, however, that completing a thorough medical history before treatment helped decipher what symptoms were new or worsening, reducing the under (or over) exaggeration of AEs. #8 Informed Consent Before consenting the patient an evaluation of health literacy, cognitive capacity, and language spoken must occur. The OCTN is responsible for: Evaluating for compliance: Anyone with a history of gross non-compliance may not be a good study candidate as there are multiple appointments they will need to attend. Additionally, folks with untreated mental illness or substance abuse disorders should not be considered for a clinical trial. Their perception of health could be unreliable, resulting in false data collection. Offering proper communication: It's mandatory to conduct the consenting process in the patient's primary language. Using a medical translator to explain the trial and providing the consent in their primary language is also obligatory. I once had to have the drug sponsor create a consent in Mandarin, a first for our small research department. Assessing health literacy: Despite what language a patient speaks, the OCTN must present the study information in an understandable fashion. As a general rule, providing materials written at a 7th-grade reading level is suitable. Having the patient 'teach back' what they have learned is another way I confirmed their comprehension. Sign on the dotted line: Once the patient is deemed competent and fully informed, the PI and the patient can sign the consent. The patient should always receive a copy of the consent along with supportive documents. Reconsent as needed: The OCTN is also accountable for reconsenting the patient throughout the study if any amendments are made to the original forms. #7 Protocol Compliance Every research study has a set of policies and procedures called a protocol. This protocol is unique to each study and must be strictly followed; it is non-negotiable. The OCTN must implement all protocol elements by Having in-depth knowledge of each policy and procedure: When a new trial opened, I would study, highlight, and tab essential sections of these guidelines. Using the 'ctrl F' function on the keyboard was a lifesaver if a digital protocol was provided. Following the protocol entirely: If a patient needs to have a hemoglobin of 10.0 to participate in the trial but has a count of 9.9, they are not eligible, period. Over the years, many PIs provided me lengthy explanations about why they disagreed with the protocol; I patiently listened and then reminded them that their opinion is null and void, although they made valid points. Telling a hopeful patient they did not qualify due to one lab result, or a tumor not being big enough, or their disease is too advanced can be difficult for an OCTN. Without these rules, however, clinical trial data would be inconsistent and untrustworthy. Reporting missed data points: Forgetting to draw a magnesium level before administering the ID or performing triplicate EKGs two minutes apart instead of five minutes apart are two examples of errors I made as an OCTN (the list is much longer than that!). It never feels good to make mistakes, but they must be reported to the drug sponsor when it happens. Creating the dreaded CAPA: Errors are assigned deviations from the drug sponsor. Deviations are not a one size fits all punishment; they come in minor deviations and major deviations. Too many deviations can result in an FDA audit, and the site can be shut down. Each deviation results in a Corrective and Preventive Action Plan (CAPA) written and updated by the OCTN, as if admitting to the blunder wasn’t bad enough. Remaining the expert: Since PIs in a community-based research department are rarely given dedicated research time to study the protocol, the OCTN is relied upon to know the study rules and assist the PI in executing those guidelines. #6 Recruitment and Retention The truth is, clinical trials make money for hospitals and clinics, resulting in pressure to recruit and retain study participants. The OCTN meets these requirements by: Being a modern-day detective: Identifying folks whose cancer has progressed or not responded is key to clinical trial participation. Many research studies only offer their ID once a patient has failed standard of care therapies, so catching these folks before starting a new regimen is vital for recruitment. By reviewing the PIs schedule daily, attending tumor boards where patient cases are presented, and advertising with brochures and posters, the OCTN is sure to find eligible clinical trial participants. Retaining and maintaining: What good is it to sign patients if they quit due to barriers of care, side effects, or poor communication? Partial data collection leads to incomplete statistics; therefore, working closely with patients to remain on the study is critical. As nurses, we think outside the box and employ resources that mitigate obstacles to care. For example, referring patients to the social worker for help with rides, gas, or lodging, having the financial counselor arrange payment plans, or offering support through massage therapy, yoga, acupuncture, nutrition, and support groups are ways to keep patients motivated to stay on study. Preventing dropouts: Some drug sponsors limit the number of 'dropouts' a site can have. Withdrawing a clinical trial from an organization that exceeds the dropout number is an unfortunate consequence that the research department, at all costs, should avoid. #5 Clinical Trial Management Now for the fun part, delivering patient care! Each protocol is equipped with a schedule of assessments needing precise implementation. The OCTN accomplishes these tasks through: Attention to detail and efficient care coordination: The schedule of assessments outlines what and when specific procedures need to be done; this may sound simple, but it requires a great deal of work. Although complex and intricate, I reveled in the challenges of meeting the protocol conditions. Execution of the terms: Some OCTNs provide clinical care by doing EKGs, accessing ports, performing lab draws, and giving medications. Other OCTNs are non-clinical and coordinate those procedures with ancillary departments. Although I found joy in providing hands-on care, the flexibility of this role allows for nursing autonomy. Acting as the patient representative: Since study patients must report every new side effect, the OCTN is often their main point of contact. Having the ability to triage adverse events (AEs) appropriately requires comprehensive knowledge of both the ID and the protocol. Most studies use the Common Terminology for Adverse Events (CTCAE) to grade symptoms, and that grade determines how symptoms are managed. Communicating this information to the PI promptly is crucial to protocol compliance and patient safety. Ongoing patient education: Many new clinical trial medications are oral and require drug dosing diaries to be completed daily. Therefore, the OCTN educates patients on the importance of taking ID correctly and documenting that administration. Ongoing staff instruction: Some OCTNs will perform education with the infusion nurses who administer intravenous ID. Elements like the length of the infusion, the order of infusion, side effect management, and mechanism of action should be included in these teachings. Consistent interdisciplinary cooperation: Communicating with ancillary staff about specific study requirements is essential to maintaining protocol integrity. For example, many studies require Recist 1.1 to be used to evaluate CAT scan imaging, and this necessity needs to be relayed to the radiologist. The OCTN creates processes for these communication flows to ensure protocol reliability. #4 and #3 Documentation/Information Management These two are combined because they go 'hand in hand' (my attempt at a pun). Once the OCTN has performed all procedures on the schedule of assessments, it must be documented for the drug sponsor's data analysis team to evaluate. These duties include: Documenting and documenting some more: Electronic data capture systems (EDCs) are study-specific portals used to input the data collected by the OCTN. Some research departments have data coordinators that transcribe protocol-required procedures into the EDC, but the OCTN does this part in many cases. For example, imagine you hand-wrote all your nursing notes for an entire shift, then at the end of the day had to rewrite them electronically; this is how the EDC documentation works. The OCTN prints off the supporting documentation (labs, imaging, vital signs, dictations, etc.), provides this data pack to the data coordinator or enters the data herself. This was my least favorite activity as an OCTN. Double charting is never fun. In addition to documenting in the EDC, the paper forms must be filed in a binder for review by the study medical monitor during an audit. Following strict writing guidelines: The documentation instructions for all clinical trial staff are comprised of writing guidelines called ALCOA +, and the acronym stands for attributable, legible, contemporaneous, original, accessible, complete, credible, consistent, and credible. This type of charting will be taught during the onboarding process to a new study opening. If not followed correctly, deviations can be accrued. Maintenance of records: Since every clinical trial patient must be monitored closely for side effects, the OCTN must keep adverse event (AE) logs. These logs include start dates of the new/worsening AE, stop dates, the reason for the occurrence, the grade of the AE, and what the AE was related to. Even if the AE is not associated with the ID (broken finger due to being slammed in a car door, for example), it must still be reported to the drug sponsor. Concomitant medications are handled the same way. #2 Financial Stewardship A surprising fact about clinical trials is that they are not free. The OCTN plays a significant role in ensuring financial integrity is upheld through the following obligations: Budget awareness: Although the ID is provided at no cost, many standard of care procedures and medications will be billed to the patient or their insurance company. Therefore, having a solid understanding of the budget is mandatory for the OCTN. Prevention of 'double-dipping.' No, I'm not talking about chips and salsa! However, invoicing costs appropriately is vital to preventing financial fraud. For example, suppose a research study pays for patients to have an EKG before treatment, the OCTN must make sure the patient's insurance company is not also paying for that procedure. If so, this is considered double-dipping and could land the research department in big trouble. Therefore, having a streamlined communication process between the research department and the billing department is a must. Honesty is the best policy: Being completely transparent with the patient before signing the consent can decrease confusion when a request for a co-pay is received, or a bill from the hospital arrives. For patients with no insurance, a clinical trial could cost them a tremendous amount of money. Having the patient work with the financial counselor before study participation can help alleviate any financial difficulties the patient may have. #1 Leadership and Professional Development Research is pivotal to advancing cancer treatment, and OCTNs can spearhead that voyage by being: Trailblazers: OCTNs lead local and regional research-related activities such as shared governance committees, clinical ladder programs, and capstone projects. For example, the capstone project I chose for my master's degree in nursing was advocating for a nurse-led breast cancer survivorship program. After working countless hours with the breast cancer survivorship team, my recommendations were followed, and a nurse practitioner now leads that program. Mentors: OCTNs inspire and motivate new oncology nurses. Advisors: OCTNs evaluate and redefine the roles and responsibilities of OCTNs. Promoters: OCTNs advocate for clinical trials and disseminate results of research studies. Writers: OCTNs participate in and develop publications related to clinical trials and their impact on the nursing profession. Modern Day Heroes Being an OCTN was, perhaps, my most rewarding nursing role yet. The opportunity to offer cancer patients the potential of cure through a research study was a remarkable experience. Of course, some folks felt they were just a guinea pig, but most were honored and excited to participate. Although I believe all cancer patients are heroes, it's my opinion that clinical trial patients exhibit real superpowers!
  4. Shifting roles and responsibilities During the COVID-19 pandemic, my role and responsibilities quickly shifted from caring for only adult oncology patients, to medical patients, to ICU patients on ventilators. The challenges of learning how to care for these patients also provided an opportunity to experience a type of nursing I probably would have never experienced otherwise. In some of our first days as a COVID-19 ICU floor, I cared for two patients with COVID ARDS. Both of these patients had similar comorbidities: DM, HTN, HLD. One pt was in his eighties, and one was in his fifties. The patients with ARDS in our COVID ICU were very similar in terms of treatment approaches, sedation cocktails, vent settings, and pressor requirements. Having patients with very different backgrounds, but the same reason for ICU admission, reinforced the learning points for me. Every patient was approached systematically Their sedation and RASS scores were first. Dilaudid (until supplies grew thin, then switched to Fentanyl), Propofol (tubing changes every 12 hours!), Versed, Ketamine, Dex (a new kind) in some combination. Then came their recent gases, P:F ratio, vent settings, plan for prone vs supine, length of intubation. Then hemodynamics: pressor requirements (do they “like” the Vaso?, do they try to die on you when you change out a stick of Levo?), telemetry review, many patients with QT prolongation, CRP, Ferritin (numbers I’m familiar with, but no CAR-T cells in sight), clotting issues. GI/GU: tubes, tubes, and more tubes. What’s their tube feeding formula and rate goal? Does their Flexiseal leak? Do we have any bags today or do we need to become a mechanical engineer to empty the bag in the toilet? Is the skin intact? Do they have swelling and DTIs from proning? Do you have the cute infant gel pillows in the room? You worked so hard for twelve hours, documenting every drip, vital sign, vent setting (if they didn’t flow into Epic), you did mouthcare and repositioning every 2 hours and worried every time you interacted with the patient’s mouth, thinking of the constant viral shedding. You spent so long setting up the ipad just right so you could see your patients’ waveforms on the monitor, then the IV pole got bumped by someone quickly going by to empty the trashcan- probably holding their breath while they did it. You wanted to be a good nurse ... ... and, you wanted to take the time to really wash your patient’s matted hair, but you also counted the hours the N95 had already been on your face, and you started to think about retaining your own CO2, and how thirsty you were, and did you pee today? I hope I have a really good seal on my face. Will the patient even survive this? The next hour is approaching…we need to do our hourly documenting. It’s time for another full head to toe assessment. And, this nurse likes you to document a RASS score hourly. Will this nurse trust me to draw the ABG on my own? I’ve done it a bunch of times now. This partnership is amazing. This nurse trusts me. I can manage a patient with an ET tube. Lunch is being delivered today. The kids in the neighborhood drew chalk messages of hope and thankfulness for healthcare workers. A patient graduated from the ICU and moved to the yellow side. A patient is walking in the hall! My patient… that patient from the beginning, that patient who was proned 4 times, that patient who was extubated, then had to be re-intubated, then had to be trached and PEG’d…he sat up in the chair and Zoomed with his grandchild, while on room air. This is pandemic nursing. This is Lunder 9.
  5. KellyM RN

    Short Staffed: An Epidemic

    Talk to any nurse and they will have something to say about the staffing at their hospital or facility. More often than not, that something will be an unflattering depiction best summed up with three words: stretched too thin. Additionally, the COVID 19 pandemic, like a flare up of a chronic disease, has only exacerbated the issue. While the problems addressed here can be frustrating, the goal is to rationally examine the causes of under-staffed hospital units in order to then identify potential solutions. The Problem: Defining Short Staffing What is short staffing? That depends primarily on the defined nurse-to-patient ratios in each hospital and on each unit. Ask any hospital administrator and any nurse at the same hospital to describe the safe, ideal nurse-to-patient ratio on a given unit and they will be give completely different answers. Why is this? One likely reason is the perspective and roles of each side varies greatly. An administrator considers a completely different set of criteria than a nurse would for the same problem. The Fix If nurse-to-patient ratios are the foundation for safe, effective patient care then coming to an agreement on what those ratios should be is paramount. This requires open, honest communication between clinicians and administrators alike. Clearly defined and agreed upon criteria for what adequate staffing on each unit looks like gives everyone a solid foundation with which to start. Nurses are critical to helping define these standards in order to ensure that expectations are realistic. The Problem: Accounting for Census Changes There is no question that patient censuses can fluctuate dramatically in short periods of time. We’ve all left a shift with adequate staffing only to come back 12 hours later to twice the patients and half the staff. These variabilities are difficult to predict, although not impossible to prepare for. While floating nurses to other units is a commonly used solution, it is a temporary fix and not always seen favorably with floor nurses. Why is floating such a dreaded event? There are many perspectives and reasons although most of these boil down to one common element- the unknown. On any given shift, there is a lot a nurse can know ahead of time and a lot they cannot. We can know our units- where the supply room or code cart is or the policy for various unit specific procedures and processes, on the other hand we can’t know our patients, their conditions, or what may happen over the course of a shift until we are there. Floating to new units takes away the piece of the shift we can know. The Fix One option is to give nurses to chance to choose two separate units to work on and then provide full orientations to both units. Allowing nurses the choice of an extra unit gives them some element of control, additionally the orientation gives them the chance to be more comfortable and therefore safe on the unit. Furthermore, this would have the added benefit of reducing potential burn out from being in are place too long. Another option is to hire nurses specifically as float/pool nurses. Setting the expectation at the time of hire for their role and work expectations will allow the hospital and nurse alike to find and fill roles that fit both parties. The Problem: Nursing Burn Out and Turn Over It’s a true “chicken or the egg” type question: does short staffing cause nurse burn out or does nurse burn out cause short staffing? There are good arguments for either side, however ultimately addressing both issues is crucial. The Fix Hospital administrators have many parameters they use to measure their hospital’s success. There are internal considerations such as patient satisfaction surveys and even employee surveys as well as external influences such as various accreditations that can elevate a hospital’s standing. Including safe nurse-to-patient staffing ratios as a unit of measurement for success and then getting “dinged” every time a unit operates without appropriate staffing aligns nursing priorities with administration priorities. This alignment of goals puts everyone on the same page. Which, in turn, helps nurses feel protected by their hospitals leading to a reduction in nurse turn over. All in all, it is mutually beneficial to ensure safe nurse-to-patient ratios. The Best Chance for Change? While short nurse staffing can be difficult problem to address, it is not impossible manage. Ultimately, the best chance for change has everyone working towards the same goals: safe, effective, compassionate care for our patients. What are some of the issues you’ve found that contribute to under-staffing at your hospital? What are some possible solutions?
  6. Joe V

    A Rough Start To The Day

    I think all nurses have had mornings feeling like this. What gets you going in the mornings? Please click like if you enjoyed it!
  7. Each day I wake up for another day the same as yesterdayI make my coffee and turn on my computer, browsing my emails before anything else. For the last several weeks, there are constantly new updates surrounding Covid-19. New training guidelines, new questions to discuss with patients, changes from the CDC and updates regarding medication dispensing. Help for the fightThere are also constant requests from state governors, healthcare agencies and boards of nursing requesting additional healthcare personnel to help fight this virus. Requesting nurses to come out of retirement. Waiving reinstatement fees and extending licensure renewals. They are almost begging. My heart races and my stomach drops – I feel guiltyMy social media feeds are flooded with pictures and videos of nurses crying, quitting their jobs due to fear, risking their lives working without proper PPE, or simply braving the virus and taking a risk because of their oath of caring for others cannot be shaken. Should I be out there?I stepped away from the bedside in 2018. I was fortunate to find a position as a Case Manager with the added benefit of working from home. I am young and do not have a family I am supporting or worried about spreading the virus to. I should be out there. In fact, I did reach out to my employer about the possibility of taking leave to help on the frontlines, but this was not granted. I would be lying if part of me wasn’t a tiny bit relieved. I believe that most nurses, healthcare professionals in general, have a sense of needing to help. If you ask a nurse why they chose their profession, that is likely the answer you will receive. We seem to naturally possess traits of compassion, selflessness, and empathy. We are also (usually) stellar at teamwork and critical thinking. Unfortunately, the traits of a nurse can be detrimental. To ourselves. We tend to put the oxygen mask on someone else before ourselves, metaphorically speaking. We do not often make ourselves a priority. I partly blame our healthcare environments for this. They have conditioned us to accept more responsibility with less support. To be a “team player.” To pick up extra shifts when we are exhausted. To work when we are unwell ourselves. And now, nurses are being exposed to a deadly virus and are not being provided basic PPE, yet they are expected to accept these conditions without complaint. There is not a soul that does not support our frontline nurses during this time. Truthfully, I do not feel there is enough being done to support them (free donuts and shoes is barely a band-aid) but that is an article in itself… I am grateful and I am necessaryAt the end of the day I am grateful I do not have to make the decisions our frontline nurses do. I must remind myself that the work I do is also helpful and necessary. That I am still supporting my patients in a different manner by educating them, ensuring they have necessary supplies and medications and that they are staying home, in turn hopefully making a small dent in lessening the burden of hospitals and our brave nurses. I hope that nurses are feeling confident enough in their WORTH to make the decisions that are right for them and their families. To know that their fear is valid and if they are scared or feeling unsupported that they need to use their voices. Remember that nursing is so vast with so many opportunities, and if your employer does not value you in a crisis, they do not deserve you. LastlyI want our frontline nurses to know that we stand with them in solidarity. We are crying and praying along with them. We admire their sacrifice and will never judge whatever tough decisions they may make during this time.
  8. Joe V

    RULE #1: Never Say the "Q" Word

    Everyone knows that when you mention the "Q" word, hell breaks loose. And, we all know that there are some nurses that are just the magnet of bad things. Any stories you want to share? Any rules that should be followed?
  9. nikkulele77

    Texting with Flo

    Texting with Florence Nightingale Yo, Flo! Can u talk right now? (I like saying yo flo) 😊 Talk? Do you mean text? Yeah, I do mean text. Yes. But why do you say talk instead of text? IDK. I know we aren’t literally talking, but ….our fingers do the talking. 👋🏽 Yes, I see. I’m still learning this new technology. What can I help you with? Well….I still can’t believe I’m somehow talking to u. So crazy. 🤪 Anyway, I had a horrible shift the other night and I just wanted to talk it out a bit. If u don’t mind. Oh. OK…. No offense, but I think that may be a little outdated, Flo. It’s 2021. We talk. I think there’s, like, studies and stuff that say debriefing is really important. It helps people process and decompress. And it can lead to action. Changes. Studies, you say? I think so. Ummm, OK. So ... Apologies. You were saying? Yeah. My shift the other night was rough. We were understaffed, like usual, so I had to triple while being charge. Ridiculous! IDK how they expect us to work like that! Patient safety, anyone? Right? It’s just so frustrating when we tell admin over and over and nothing happens. I guess u dealt with that. Getting the men in the military to see that the medical facilities were unhealthy was very difficult. I can only imagine. Anyway, I’m still pretty new at being charge. Any words of wisdom? Ooo, I like that. I’m gonna take it to our unit director. Did you work in the Covid unit? Yep. So so sick of this pandemic. 😷 ??? 😶 I am proud of you for working through such an ordeal. How were your patients? Had a sweet little old lady who always said TY. Seemed lonely, so I gave her an extra long bath last night and talked to her. That was one good thing…. Says the Queen of Hygiene! 👑 Where would we be without u, Flo? I shudder to think…. Haha! True. And some people still suck at hand-washing. This poor lady is getting confused though. Maybe a touch of ICU delirium That interests me. Agreed. My other patient goes berserk whenever we try to wean his sedation. Nearly ripped his tube out. I had just got him settled when the docs came in and just HAD to get their neuro exam. I was like, EM? Let this dude rest! 😡 IDK what sine qua non is, but after they left it took a good half hour for my guy to settle back down. Even the monitor alarms got to him. Remember how I told u about all our monitor and vent alarms? Oh, yes. I must say that bothers me. Sing it, sister. I wish u could come teach us a thing or 2. Most of us could use your wisdom. So you are saying all my CE and classes aren’t a waste of my time? 😉 Flo, did u ever get scared about how nursing would go after u left it and your nursing school? I would be lying if I said I never feared. But I learned that ... I try. I don’t have to tell u how tiring it is. Feels like all I do is work, eat, and try to sleep. I know nursing was like a calling for u, but how did u find any time for urself? Netflix and chill, am I right? 👊🏽 Yes! See, u get it! They can scream self-care at us all day, but until we feel like we are being listened to ... I guess I don’t have to tell u. I don’t mean to complain. Keep that in mind if you want to ignite change. Who was your 3rd patient? Oh, right. I had a 42 yo woman who probably won’t make it. So sad. Married and has 2 kids. She’s been here so long they are starting to talk about what the goals are with her. Like, should we extubate. IDK. Usually I’m pretty on board with it, but this time . . . she’s so young and I don’t think her husband is ready. I know u didn’t deal with this exact thing, but u had some moral dilemmas, right? Oh my ... 👍“The world does nothing but sketch.” I’ve talked to her kids on the phone. So nice. But that just makes it harder knowing she probably won’t make it. Curse Covid! Flo, u dealt with a ton of death. What do u think? It’s never easy. I’m sorry. Remember though ... Hmm. Can I share that with the family if I need to? Of course. 💜 Thx. Hope I don’t have to. I have a few days off and I’m going out for the first time in a long time. TBH, I feel a little guilty. TBH? Guilty? To be honest. Yeah. I guess bc there are all these people and their families who are suffering and here I am going to a movie and eating popcorn. So trivial. Dear, with this pandemic the war you are fighting is different than the one I engaged in. But my response is the same ... Beautiful. TY. Makes me feel better. References Florence Nightingale Quotes from BrainyQuote
  10. Aliceozwalker

    Hate My Job But Feel There Is No Way Out

    Just wanting to know people with more life experiences take on my situation. I work on a busy general medicine floor and absolutely have come to hate my job. I have managed to tough the job out for about a year and a half (new grad). Honestly, I am amazed and somewhat proud of myself for even managing that with my anxiety. I had hoped that with time my anxiety would get better but it feels the longer I am there the sicker, heavier (gaining lots of weight) and more miserable I feel. I work a ton of nights between my two jobs so feel like I rarely even get to see the sun and have no motivation to do anything but watch TV. I definitely want a way out but it is easier said than done. The patient assignments have gotten ridiculous with how short staffed we have been, on night shift nurses who are supposed to have 6 patients sometimes take on 12 patients (an entire POD with IVs, climbers, drug withdrawals, etc) with a nursing student extern. It's gotten so bad people have started to message our union about unsafe conditions but were sent back an e-mail saying that we are allowed to work outside our scope due to the current pandemic. I have posted a few times on here and recently made the decision to move away from bedside. I've had such an awful experience with bedside, I doubt I will ever return. I am feeling so frustrated because for the past month I have been applying and feeling like I am getting nowhere. I have applied to several more office-based jobs or jobs out in the community such as vaccine centres as people on here recommended. I have had a few messages back all stating that I needed more bedside experience which was crushing. The only really positive lead was my manager who stated that he would hire me for a clinic at the hospital that works Mon-Fri 8-4 (but more like 8-5). This sounds like the best-case scenario for me, but the problem is that he says a position likely won't open up for another 6-10 months. I asked if he would consider me still for the position if I went to a temporary job for 6 months and he said he would so long as I stay on casually. I am at a loss of what to do here. My parents think I should stick it out for another 10 months at my current part-time hospital job with my other strictly nights casual job. I am going to be honest in saying that I can't imagine how much sicker I will feel and how much I will mentally struggle. It's been bad enough living like this for a year and a half I can't imagine going through another 10 months. I would definitely be open to working at the hospital unit casually if I could find a better job that would take me part-time somewhere else. But all of the less stressful jobs people on the site have mentioned (clinics, offices, etc) won't seem to hire me until I get at least 2 years of bedside nursing. Did anyone else feel they were locked into 2 years of bedside nursing? Are there any other positions someone could recommend that would be lighter on me mentally or have more regular hours? I just feel so stuck and frustrated. 😞
  11. JBMmom

    Memorable Firsts

    Our careers are often impacted by single events, especially first experiences. I think sometimes we dwell on negatives, like med errors or negative outcomes with patients, and those can be very impactful, but we also have positive first experiences that can be equally as important for shaping our future. Do you have any particularly memorable first experiences? One that I can think of was about six months into my job in the ICU. I was so nervous about missing important things. Would I know when there was an emergency, and would I know what to do? Our unit is split mainly into two sides with monitor banks on each side. I was walking past the monitor bank on one side and I happened to look up and thought "that looks like Vtach", but it wasn't alarming. I picked up my pace and went over to the other side of the unit and just about the time I got there the alarm picked up and my coworkers were heading to the room. I grabbed the code cart and we started CPR. Got the patient back and he ended up being okay. I realize it's a pretty obvious rhythm, but it was such a confidence boost to know that I could see it, and I would be able to react. Looking forward to hearing what first experiences stand out for others, thanks for sharing!
  12. CarlyCastaneda

    Teacher Issue...

    I'm mainly just venting, but I'm also wondering what others would do in this situation. I had a teacher send in a student complaining of arm pain. The student was pointing to a small area in the crease of his elbow saying that it was hurting him. He was acting like he was in a lot of pain for it for a minute or so, but then was acting normal and not complaining about it. I assessed him and sent him back to class. There was nothing significant to note. Not even redness. About an hour or so later, the teacher comes back in with the student and says that his arm is getting worse and is swelling so he called his mom and his mom is on the way to pick him up. There was nothing...and I mean, nothing on his arm. It was not swollen. No pain. No red. His mom arrived within a few minutes before I was able to call her because I was dealing with another situation. I hear the mom call the front office that she was here because "the teacher said my son may be having an allergic reaction." I was furious. I went straight outside to the mom and apologized and told her not to panic. She said she had seen an ambulance and was scared her son was in it. The student walked out to the mom and I explained the situation. She took her son home anyway because she thought maybe he was having a bad day and didn't want to be there, but was just as confused as I was about why she was notified that she needs to pick him up. How would you go about talking to this teacher? Do I just let it go? My two main issues is that 1. He went over my authority as the health professional in the school. and 2. He "diagnosed" a student, leading a parent into complete panic mode.
  13. The patient is in her late 90s and is here for rehab following an accident. She has absolutely zero cognitive deficits-sharp as a tack. She also has no diagnosed psychiatric history. Her medical history is surprisingly minimal, and her prognosis is great once she completes rehab. I'm willing to bet she will make it to 100 at least. However, she is at high risk for a pressure ulcer because of a behavior. She is absolutely insistent on sitting on the bed pan for as long as physically possible, even when she does not have to go. She is mildly incontinent of urine but only ever wore menstrual pads for this at home. It is worse due to her current situation. She has briefs, and our call bell response time is usually about 1-3 minutes (not bad given our ratios; everyone's a team player, even the director of the facility will answer call lights when making the rounds). She denies urinary urgency. She states that sitting on the bed pan makes her feel prepared. She has no fear of involving staff in her care, as she makes very frequent use of her call bell. I think she is struggling emotionally with needing what she considers to be a diaper. She has, however, refused all psychiatric consults including psychotherapy. Attempts to bring up the subject gently or casually have failed as well. She has been educated ad nauseam and in many different ways that she is placing herself at very high risk for a pressure ulcer, and what the consequences of an ulcer would be. She has also refused any and every intervention, even those strongly focused on her dignity. We have thought about taking the bed pan away as an option but the ethics of that are quite thorny. After all, since she is a totally competent adult, that would be paternalism. I am documenting, documenting, documenting so legally I think we are in the clear. It's just the ethics/morals of the whole thing. I hate seeing someone set themselves up for so much pain and a worsened prognosis.
  14. TLDR (cause I can't edit): Patient loopy and sedated arrived to unit, requiring lots of work to keep safe. Came more awake shortly before shift change, safe, pain acceptable, respiratory status stable. Patient fired me as an RN for the next day saying I was incompassionate and didn't manage pain. Management says I should have given more pain meds. Long version (story time!): I work on a post-surgical floor that also gets a fair bit of non-surgical patients. Hospital was at capacity and we were being pressured to take more patients while the charge RN was trying hard to keep beds open for our surgicals. Meanwhile, PACU was being slammed and out of room. It was a mess waiting to happen. I already had a full load and took report on a patient coming up to us from PACU. Report was unremarkable. They mentioned that they had trouble meeting pain needs and keeping the patient breathing, but the patient was having itchiness from the narcotics given in PACU. Again, not unusual. I live in a marijuana-legal state, and recreational MJ use really messes up narcotics effectiveness, and most of our patients won't admit to MJ use (and most of our surgeons don't screen for it). I mentally prepared to use non-pharm methods of pain control and set up my room. Patient arrived writhing in pain, screaming, and clawing up her bed. She also was completely unresponsive to me and the PACU RNs. She was doing all this essentially in her sleep. If I could, I would rate her RASS a +2 and a -2 at the same time. Her husband was in the corner constantly asking "Is this normal?" No sir, it is NOT. The PACU nurses that brought her in had already fled, and I was trying my best to both get her to respond to me and improve her comfort. The CNA came in (probably because of the screaming) and asked if I needed help. I told her "Yes, go get the charge". Charge came in with one of the management RNs and we spent the next 30 minutes trying to settle this patient, who was still not responding to us and intermittently crying in her sleep. Remember that I had a full load before this patient showed up, so I was essentially neglecting my other patients until I got this one safe enough for me to leave her. We finally got her a little more comfortable with ice packs on the surgical site and warm blankets on non-surgical sites. The consensus was that she came to the floor way too quickly from PACU and we just needed to wait out the anesthesia. I checked the charting while I was staying in her room to make sure she didn't claw off her oxygen (which she did frequently) or try to flop out of bed (slightly less frequently). PACU had her RASS at -2 when she left them. I had never seen that, at most (least?) a -1. I don't know what their criteria for transfer are, but this was odd from my end. I was finally able to step away from this patient and check on my other patients, who all needed something, some anxious, some grumpy, some cheerfully waiting for something they should have asked for instead of silently waiting. I ran my tail off filling needs and darting back to this patient's room to ensure safety and check for improved rousal. Needless to say I did NOT get a lunch. Hell, I didn't even get to pee. Sometime after 3 hours of checking this patient every 15 minutes or so, she started to mentally clear and was able to converse with me. Fortunately, she didn't remember much of anything of the last 4 hours. It was not a good time for teaching, but I expect to repeat teaching anyway, so I oriented her to the room, discussed medications, and filled in the gaps of my assessment now that she could talk to me. Pain wasn't bad, a 3/10 and I told her this is a good place to be as long as she can sleep and isn't afraid of movement. She got up and peed. She was wobbly, so we didn't go far. I talked about pain medication as part of my standard orientation to floor. She said she doesn't like morphine because it makes her feel weird. That wasn't the drug she had available IV, but I shrugged it off as a refusal. She was still dry heaving often, which cut out oral pain meds. Besides, her pain was manageable through non-pharm methods, so I didn't dwell on it. At this point I mostly left her alone. CNA walked her to the toilet and into the hall, but again didn't get far. I raced time to finish the tasks my other patients needed done before the end of the shift. I continued to pop in occasionally, and she was much more stable. I was even able to titrate down the oxygen a bit. Patient was still pretty nauseated, for which I gave PRN antiemetics. I honestly don't remember discussing pain again. Before end of shift, I felt pretty proud about keeping my patient safe, getting her non-formulary home med checked by pharmacy so it was ready for next shift, checking in with the husband before he left, getting this patient ambulatory, and using all my tricks for combating nausea and pain. AND I got out on time, due to all the charting while sitting (standing) with this patient while she was still unsafe to leave. We did bedside shift report, which I hate doing "bedside", but I was being a good nurse example for the new hire. At one point I mentioned that she had not had any pain medications yet due to being sedated on arrival, I discussed the non-pharm methods used, and suggested that she could probably get something for pain if nausea came more under control. Said "bye, I'll see you tomorrow" and went home. The next day the noc charge came to me and said "no matter what anyone says, you are a good nurse and you did what was right" and left without another word. Bewildered I asked the day charge (same as the previous day) what the heck that was about. She told me the patient fired me as her nurse because she thought I was not compassionate enough and didn't care about her pain. This charge disagreed and thought I did a pretty good job of maintaining safety in that situation. Even if it was wise to give medications when she was unsafe, we were locked out of most medications simply due to that most were DCed when she left PACU (as they should be) and the ones remaining were too close in time to when they were given in PACU. After I could actually talk to the patient and get a response, I had assessed her for pain and at a 3/10 she was OK then. I probably should have reassessed pain before end of shift, but I remember her complaining more of nausea than pain at that point. I checked in with my manager and the manager said I should have given IV pain medication, and that I was being too cautious. I didn't really have anything else to say, but I am rather flabbergasted by this entire situation.
  15. VivaLasViejas

    Epic (Nursing) FAILS!

    I once destroyed a patient room within five minutes of starting my shift. It was fortunate that the two ladies who occupied the semi-private room were AA & O and had a sense of humor. You have to know your shift is going to be a bad one when you walk into a room and trip over someone's catheter, then dump a custard in the other patient's lap. As an encore, you then open a cabinet, and 500 little paper cups fall onto your head. Then, after you've retrieved them all and stand up, you forget the door is still open and thump your cranium so soundly that you see stars and go sprawling on your posterior. The cups wind up on the floor again.....and in the meantime, two very concerned women are peering at you over the counter. And YOU'RE supposed to be taking care of THEM. A good friend of mine was a champion IV starter who could get a line in a rutabaga if it needed one. One day after several of us tried without success to stick this 400-lb. patient with an active case of DTs and no palpable veins, we called Anna in to try to locate something so we could get some meds on board. Bless her, she got a 20g in the cephalic vein on her very first try and flushed the line.....but then she got all bollixed up in the tape while trying to secure the site. She must've had a yard of the stuff wrapped around her fingers. She couldn't pull it loose, and no one else in the room could help her because we were using all our muscle power to hold the patient down while the nursing supervisor and the tech were trying to buckle him into four-points. "Tape is our friend," Anna quipped. Speaking of tape: regardless of purpose or design, there are only two kinds of medical tape---1) that which will not stick, and 2) that which will not come off. I was a Med/Surg tech back in nursing school days who was allowed to D/C everything but a central line, and I went into one room to take out a saline lock for a patient who was going home. She was a frail elderly lady with extremely thin skin, only I didn't know HOW thin until I took the op-site off.........and took the entire top layer of skin with it. To say the least, I was horrified and began to apologize profusely for the awful thing I'd done. The patient herself merely shrugged. "Oh, for goodness sake, it's just skin!" she admonished. "I can grow more---it happens every time." (That was when I learned the trick of removing the skin from the tape instead of removing the tape from the skin.......there really is a difference in techniques, and I've never ripped another single layer of parchment paper that serves some elderly folks as skin ever since.) Then there was the time I nearly got written up for multiple patient complaints. It was one of those full-moon August weekend nights that are just ripe with possibilities......if you're looking for trouble, that is. As it was, I didn't know if things happened the way they did because I was on my fourth consecutive 12-hr shift, but I couldn't help being goofy......I found myself snickering at every silly thing that happened that night, and I'd already infected several of my co-workers with the giggles as well. Anyway, an LPN and I were working together in one room, changing a patient's soiled linens and cleaning him up while trying not to wake him totally, when I backed into an enormous flower arrangement and sent it crashing to the floor. That made his roommate wake up and swear, stringing profanities together in such creative combinations that it struck me as absolutely hilarious, and I broke up. I am NOT quiet when I laugh, and when you get my mad cackling going on in the hallway of a hospital at three in the morning, suffice it to say that patients aren't going to be amused, and neither is the nurse manager. The only thing that saved me from a written reprimand was a few quotes from the gentleman I'd awakened with my klutz du jour performance; I guess the NM figured a good cussing-out was punishment enough! These are a few of my more memorable nursing FAILS. How about sharing some of yours?
  16. I always had a soft spot for Anna and knew her for the past three years. She came off and on for BP check and diet counseling. The last time I saw her was over a year ago for a BP check before Covid started. She looked very happy to see me! "Everything is GREAT!" "Dr. Annie! How are you?" "Great! It is so nice to see you today! You are looking spiffy today! Typical New Yorker! We laughed as we went into the exam room. "Anna do you need to pee or do you need a drink of water before we start?" "No, I am good Dr. Annie!" "OK. You are here for a BP check today aren't you? I see that Dr. Sue Kin had a telephone visit with you two weeks ago and wanted you to come in to check your BP." "Yes!" "How is everything?" "Great! Just great!" We proceeded with the visit and everything was going smoothly. The Phone Call - "What Do I DO?" As I got ready to print her after visit summary with her next appointment, her phone rang. I nodded my head as I typed as she looked at me as phone calls during visits were strictly discouraged. She took the call and her face blanched as she listened. She stood up shaking, looking very upset, wiping her brow and sweaty hands. "Anna, what's the matter? You look upset!" "This is not good! This is not good!" "Anna, talk to me!" She kept wringing her hands muttering, "What do I do? What do I do?" I am sure her BP had shot up and her PTSD was kicking in. She was sitting on the examination chair rocking herself. "Anna calm down! May I have your phone please? Who are you speaking to anyway?" "It's my aunt Sarah!". She gave me the phone. I put it on speaker. Aunt Sarah's Story of Abuse "Hi Aunt Sarah! How are you? This is Nurse Annie. Anna looks upset. What's going on?" Aunt Sarah launched into a long story. The short version was that there was a woman, Red, staying in Anna's section 8, government housing apartment that Anna's ex- boyfriend coerced her into staying with her. Red in turn now had been giving copies of the apartment keys to others who came in and out of the apartment at all odd hours. Red made Anna move out from her bedroom and sleep on the couch while Red took over her bedroom. Earlier in the day, Red walked in at 3am with a strange man and a baby. When aunt Sarah, who lived one floor up, confronted her an hour ago, Red slammed the door on her, almost slicing her hand off! Aunt Sarah called the cops who shrugged and told her that since this apartment was in Anna's name, she would have to make the complaint. That's when she called the patient. Anna was visibly shaking and wringing her hands. In addition to depression, PTSD, head trauma and abuse, she also had an intellectual disability and was socially inept. Nurse in Action "Are you her health care Proxy, Sarah?" "No, I don't have any papers. I took Anna's care once my sister, Anna's mom, was put in a Nursing home for dementia as Anna cannot safely take care of her and I have to work most days." "OK. We have to get you some kind of paper or the police won't listen to you as she is an adult. Let me call you back!" I hung up and got Anna some water to drink. "Sit tight! I'll be back." Anna nodded quietly as I walked out of the exam room. I went to her primary care doc, Dr. Sue Kin, who was in another room catching up with her notes. I briefly explained what was going on. "Sue, I think if we give her a letter stating that she has these medical conditions and that her aunt is assisting her based on her needs, the police will take them more seriously. She needs to file a police report and aunt needs to advocate for her." "I agree, Annie." Sue quickly typed up a form letter with her medical conditions, stating that her aunt was assisting her. She printed it, signed it and gave it to me. I made 2 copies and gave it to Anna. We called the aunt again from the room and I spoke to her. She planned to take the letter to the police station and both of them were going to file a police report against Red. I gave Anna an appointment for one month for a follow up for BP check and she left. I huddled with her provider and the administrator as I wanted to discuss the possibility of adult abuse at home. The team agreed of the possibility and I ended up talking to the social work manager offsite who agreed. I called Adult Protective services and they gave me a case number and asked me to call the next day to find out if the case was accepted. I did and was told that her case was accepted. I ended up talking to the case worker and her manager there and she received a home visit within two days. They helped her get Red evicted and continued to monitor for a whole month. The Outcome Last week Anna came back for her BP check, which was normal and told me that the police case and order of protection against Red was still in effect. She heard that Red had got arrested for something else and was in jail. She had also gone to family court with her aunt. The judge ordered the landlord to change all locks of the apartment and the front door so that Red or her cronies would not have access to the building. Anna looked happier and continues to see a therapist who helps her with her issues. Her mother is fully demented and in a nursing home. Anna's aunt watches over her and helps her with her appointments, groceries and any help that she needs. Anna loves to come to our clinic and says we are her family and we are nice! There are many young and older adults like Anna that are taken advantage of and my antenna is always on high alert when I see them. I always feel grateful to be in a position to help the Anna's of the world as in their case it truly takes a village to raise them and keep them safe! References What is Intellectual Disability? Traumatic Brain Injury and Concussion
  17. You may also be interested in Prioritization: Helping New Nurses Transition into Practice. When I've interviewed new graduate nurses about what they find most difficult as they transition from student nurse to professional nurse, the majority admit that they struggle with safe and effective delegation. This is because the artful skill of delegation can take a couple years of experience to master. The mastery of delegation includes transferring responsibility from the nurse to support personnel, while remaining accountable for outcomes of delegated tasks. This role is very different for new grad nurses to get comfortable with, especially since opportunities to practice delegation in nursing school are slim to none. Considering that new grad nurses are hesitant in transferring responsibility of patient care tasks, this brings on additional stress to the transitioning nurse, which often results in poor time management and overwhelming workloads. The truth is that nursing is not a one-person job. It takes an entire team to safely and effectively care for patients. Since it is essential for nursing to remain a team effort, it is vital that the new nurse master strategies for safe and effective delegation. How To Delegate Effectively and Safely STEP 1 This is a test. Ask yourself: "When should I delegate?" When in doubt, you should consider to NEVER delegate what you can E.A.T. Remember that RNs are responsible for Evaluating, Assessing and Teaching. Once the RN has assessed the patient and considers the condition and needs of the patient, delegation can begin. Let's not forget that initial assessment (including vital signs) are to be done by the RN, and therefore should not be delegated to the nursing assistant. Once you have assessed your patients and have considered their needs, now you can begin to think about whom you may delegate to. STEP 2 Carefully consider competence of support personnel It is essential for the nurse to understand the skill set of each team member to match the task assignments appropriately. An easy way to accomplish this is to know your co-workers. You will want to be able to answer these questions before choosing whom to delegate to: Are they licensed or unlicensed? How long have they worked within their role? Have they been validated for competence in performing the task? Will they feel confident that they can safely and effectively perform the task? Do they need any additional training or instruction to complete the task independently? Once you have asked yourself these questions, you will be able to safely move onto providing instructions for the delegated tasks. STEP 3 Clearly communicate when delegating For tasks to be effectively and safely delegated, you must give clear, concise and detailed instruction to the support personnel. This will include purpose, limits and expected outcomes of the task. Additionally, you must ensure that the person to assume the task can complete it within an expected time frame. You should consider that the person you are delegating to will be working with several other patients, so be mindful and set realistic and attainable goals. Finally, you should always ask if there are any questions or concerns which will promote clarification and opportunity for supportive personnel to discuss any questions or concerns related to the task. STEP 4 Be available to supervise and give feedback To be sure that the delegated task has been completed appropriately, you will need to offer direct supervision and feedback. You will also need to be available in case an unexpected outcome occurs. Prudent nurses never assume that the task was completed without validating it by checking that all components of the task have been accurately carried out. One way to help the transitioning nurse build strong relationships with nursing support staff, you will want to identify areas of success and offer suggestions for improvement. When your support personnel do a great job, don't forget to say "thank you"-it goes a long way! STEP 5 Always evaluate the outcomes of delegated tasks To ensure that the patient received the care needed and that the team worked together efficiently, RNs must evaluate that task completed is effective and that it met the needs of the patient. If an unexpected outcome occurs, it's important that RNs develop a new plan to correct the deficiencies if possible. Sometimes the RN needs to go back to the drawing board by reassessing the patient and their needs. If this is the case, don't fret - patients are complex and ever-changing, so keep your focus on patient-centered care and you'll develop the most appropriate care plan for your patient. So as you hit the floor running, remember that learning to delegate effectively and safely takes time and diligent practice. One final tip - be sure to always follow the nursing process and find areas to improve upon your practice every single day. Before you know it, you'll be confidently, effectively, and safely delegating tasks to your nursing supportive personnel. Good luck -you got this! If you have any tips for effective and safe delegation, please feel free to share your thoughts in the comments section below!
  18. The Drama Begins - The Phone Call When I picked up my ringing cellphone, I didn't realize the drama I was going to plunge into! It was one of the attending in the clinic, Dr. Needy. She could not get hold of anyone in the clinic ("The phone just keeps going to voicemail)", and called me on my personal cell. She wanted to get an elderly patient June, to come in and get labs done today. Apparently, June had taken too many medications last week and was still feeling sob and fatigued. "Annie, she took 3 Lisinoprils, 3 Metoprolol, and 3 Aspirins on the same day, a few days ago!" "She didn't bottom out or have a heart block?" "Apparently not! I just finished a televisit today and she seemed fine but I just want to be sure and get some labs done". "No problem! I will schedule her today and call her to come in." By the way, she had Covid one month ago and she is off quarantine!” “O.K. thanks for letting me know.” Appointment Scheduled I looked outside. It was snowing a little more intensely. The roads were slushy with brown snow. I scheduled her for the next available slot at 2 pm and then picked up the phone and called our lab in the clinic. "Sandra, I just scheduled a patient June Smith for labs today and put her on your 2 pm slot. However, she is 79 and it's snowing hard outside. It's 10.30 am now. I am going to call her and inform her about the appointment. I wanted her to come in ASAP, get her in and out. Can you see June before her time?" "Sure, I can Annie!" "I'll tell her about the appointment and to be here before 11.30 am as I know you are closed for lunch from 12- 1 pm!" "Sounds good Annie". I thanked her hung up, called June's home, and informed the niece Jennifer, about the appointment. This was a Friday. “Is this urgent? Can this wait till Monday?” “Yes, it is urgent. The doctor wants to make sure that there is no ongoing issue that needs to be fixed, like low potassium. Otherwise, June may end up in the hospital ER unnecessarily. If you bring her in today, we could check her blood and call you back if any issues by tomorrow or right away if any of the labs come back really abnormal.” Jennifer convinced reluctant June who felt tired and wanted to sleep, to come! Blister Pack Medication Confusion While we waited for her to come, I reviewed her electronic medical record and noticed that she used the pharmacy on the same floor as our clinic. I spoke to Tom the new pharmacist and asked if the patient’s medications could be blister packed to avoid future mistakes. “Annie, she is getting her medications in a blister pack. Matter of fact, I gave the niece a new blister pack last week and she seemed to understand it well. So I am not sure how the mistake was made. She apparently took the am medications for 3 days on the same day!” “Maybe she is getting forgetful, she is 79 after all!” “Maybe!” Tom agreed. “I wonder if she’s taking her own meds or if someone is giving her the medications. Either way, they may need visual cues. What do you suggest?” “How about rubber-banding it?” “What do you mean?" “I mean putting a rubber band on the blister pack under each day so that they know not to go below it.” “That’s a cool idea and how about we draw a line with a red marker under each day where the rubber band would go?” "Sounds like a plan!”, Tom agreed. “I am coming over. Can you give me an empty blister pack and a rubber band? I’ll get a red marker.” “No problem.” I went over with a marker that I got from my Nurse Manager who was horrified when he heard the story. Tom who was new, turned out to be a tall 6.5 ft and hefty guy. “I am putting that I want to be as tall as Tom on my this year Christmas wish list!” I joked. We laughed and he gave me the empty blister pack with the rubber band. I drew red lines under each day, thanked him, and went over to the lab. I briefly told Sandra from the lab what happened. She was horrified. Sandra and I went way back when I was an ED nurse and later on the evening manager of the ED and she was an ACLS medic. We both knew the ramifications of what could have happened when all the meds were taken together. “She is lucky to be alive!” Sandra said amazed. “Yup! Her guardian angel must have been working overtime!” We both laughed. “Anyway, here is the blister pack, marker, and rubber band. Call me when they come please.” “No problem, I will.” Office Visit I got the call half an hour later and went to the lab. I saw June shuffle into the lab, her niece Jennifer holding and guiding her gently. As Sandra did the labs, Jennifer and I discussed what had happened on the day of the medication error. “I normally give her medications but on that day, I had to go in to school as I am a teacher. So my mom who is her sister and June figured out how to take the medication! Instead of taking the morning, afternoon, and night medications that are placed in a row horizontally, she took the morning medications that were vertically placed three times on the same day! I didn’t realize till the next day when I took the blister pack to give her morning medications!” “Ah! I see how that happened now!” “When I asked her, she told me Isn’t it from Top to Bottom?”, Jennifer shook her head ruefully. “I can see them both figuring it out, sisters!” Jennifer and I chuckled. I reviewed the “rubber band and red marker method” with Jennifer. “This is brilliant! I am going to teach my mom and aunt. They will understand it and I have plenty of red markers at home!” “Sounds like a plan!” Now that the safety issue was taken care of, I wondered what her vitals was and if she needed an EKG. The shortness of breath could be from the Covid or the residue from the medication error just because she was older. It would be wise to be careful. I had not seen any follow-up appointment on her schedule. So I talked to Laura, one of the attending doctors, and put her in for a same-day appointment. She saw June and checked her out. Her vitals and EKG were perfect and the family left satisfied that everything was done and that June was safe---for now! Problem Solved I went back to my office realizing that it was always important to not assume that instructions were always understood. There is so much more than prescribing medications and doing a medication reconciliation. It is important to know if there could be potential complications like health illiteracy, cognitive impairment issues, inability to read or write, lack of family support, and a host of other social issues that could affect medication compliance. As we assist our patients to navigate and manage their health needs, nurses as critical thinkers should remember to investigate issues from top to bottom! In this case, June’s labs came out good and she continues to be mildly short of breath and fatigued, a residue from her recent Covid infection. Jennifer, June’s niece reported that the rubber band method is a hit at home and June strums on her medication blister pack while she waits on her water to wash them down! Apparently, June was always a wannabe singer and guitarist who never plucked her courage to act on her dreams. Now she gets to fulfill them with her medication blister pack and her vocals although I am not sure how good she sings! June is a wise woman and knows that it is never too late to follow your dreams! References The Most Common Medication Errors for Seniors, and How to Avoid Them Medication Errors Made By Elderly, Chronically Ill Patients
  19. The Boss, and it's Urgent My phone buzzed. It was a Friday night, but it was my boss, so I picked up. “Beth, please, please, can you come in tomorrow to orient a group of California Department of Public Health (CDPH) Strike Force Nurses?” “Who? What? Tomorrow...on Saturday?” “Yes, it’s urgent. They need mask-fit testing and skills validation before we can send them to the floor. They’ll be flying in in the morning, and be escorted straight to Human Resources. Charlene in HR is coming in to do their ID badges. They’re only here for 72 hours, they’ll go straight to the floor from you, and then work Sunday, Monday and Tuesday”. “That’s it? Seventy-two hours?” It sounded crazy to me, but we were in surge and desperate for nurses. Many of our own nurses were off sick themselves or working far too much overtime. The CDPH Strike Force CDPH had apparently reached out and contacted active and non-active CA nurses to recruit them to work short contracts during the pandemic. They were assured that they would be of help no matter what their background, and that they would be doing a great service in time of the pandemic. Our hospital was in disaster staffing mode, and nurses were streaming in from all different agencies to be oriented and sent to the floors. My job was to make sure they were competent on our Alaris infusion pumps and glucometer machines, to validate their Restraint competencies, and make sure they could document in our platform, Cerner. It was basically a week's orientation compressed to one day. Saturday morning I turned up early at 0730 to greet the new nurses. At 0800, a group of four nurses walked in. "Oh. My. Goodness.", I thought. This was a non-nurse-looking group if ever there was one. Hippy Harry Leading the pack was Hippy Harry. He walked in wearing a triangular red bandana on his deeply tanned and lined face, like a cowboy on a movie set. He wore a black T-shirt, khaki cargo shorts, leather sandals, and sported a puka shell necklace. Whenever he talked, his makeshift bandana slipped down off of his nose. I pointedly handed him a surgical mask and he reluctantly stuffed his red bandana into one of his pockets, donning the mask. I learned Hippy Harry had been volunteering in Africa and had not worked in a hospital in 15 years. I guessed Harry to be 73, but he volunteered that he was 68. He was warm and charming with twinkly blue eyes, and he struck me as quite the ladies man. Geriatric Barbie Next was Geriatric Barbie, a frail-looking, petite, retired school nurse in a pastel blue matching sweater set complete with a strand of pearls. She had bony hands with age spots and pink painted nails. Her manner was kind and gentle, and she really tried, but after several attempts, Barbie simply could not bar code scan the glucometer strips. Later, while I was teaching basic computer documentation, she needed 1:1 help with commands such as “right-click” and “re-size your window”. Dapper Dan Dapper Dan was a tall man with a chiseled face and artfully trimmed beard, looking as if he’d stepped right off of a GQ magazine cover. I could not mask-fit test him because of the beard and asked if he’d shave it. He stroked his jaw protectively “No way, my partner would kill me”. ‘OK, well, last I heard we were out of PAPRs but let me check again”. “Thanks”, said Dan, “and, I’ll need some scrubs to change into. Size medium but medium/tall if you have them. The agency said you’d provide them”. Right. Let's see if I can get those from Surgery. Tattoo Tonya Next was Tattoo Tonya. In the computer room when I was standing over her is when I first noticed the tattoos on her scalp, in between her dyed-blonde cornrows. The tats were black and swirly, vaguely matching the ones on her arms. She had ear cuffs and a nose piercing. She picked up on everything super fast, and leaned in to help Barbie frequently. It didn’t take long before I saw past her colorful presentation and realized she was the star of the group. She documented easily in Cerner and knew how to use the Alaris pump and NovaStat strip. I had no qualms sending her to ICU. Nurse Beth Pulls it All Together While they were busy on the computer, I started to make preceptor arrangements. I called the ICU Charge Nurse to find a preceptor for Hippy Harry. “Hi Ashley, I know you’re busy but I have a Strike Force nurse here who needs to be precepted from 1400-1930 today.” “Beth, my preceptors are all so burned out <sigh>, I hate to ask them. Let me ask Lindsey...no, she already has someone with her. I’ll call you back”. Later, Ashley called to say she had persuaded Stephanie to precept Harry. “Ashley, thank you so much! I appreciate it”. Right about then, Harry approached me. “Beth, I know I’m hired for ICU- and I can do it, don’t get me wrong, but you know- it’s been a while. I think I’d be more comfortable in ED”. He smiled charmingly and all I could say was, “Let me call ED and see what I can do”. After all, they were volunteers, right? ..Update Monday morning Harry walked into my office, hospital-issued scrubs neatly folded and badge in extended hand. “I’ve realized this just isn’t going to work out. I worked a half shift in ED and things have changed too much. I'm too far behind. I’m sorry to have taken up your time.” I smiled ruefully. It had truly been my pleasure to meet Harry and the whole group. Perhaps Harry was a romantic, responding to the plea for help, and seeking an adventure. I wished him the best. Later, I talked with Karen, the ICU educator. She said Barbie was not assigned patients but kept herself busy by going around patting patient’s hands and smoothing their covers. She was going to work one more shift. Tonya was a superstar as predicted and they were trying to recruit her to stay longer. A PAPR was found for Dan but it was discovered he did not pass his Basic Arrhythmia exam and he had to be pulled from the floor. Then she confided a bit of gossip. Apparently Harry and Barbie had spent quite a bit of time together in the hotel. Actually, the term “hooked-up” was used. Maybe Harry found his romance and adventure, after all.
  20. Patient Presentation "She did what?!" "Yup! She threw the stool and urine straight at Dr. Clean!" "You gotta be kidding! So what's her story?" "Well! Apparently they found her 2 days ago at GreenMart unconscious by the milk refrigerator. One of the employees called 911 and they brought her here. They can't figure out what language she speaks. She has no ID or cell phone." "Great! So what's the plan for her?" "We don't know her history but she might be Diabetic. Her finger-stick glucose at the scene was 46. So the glucose is being monitored. Her labs were OK and her EKG and chest X-ray were negative. Since she was combative, she was restrained. She has been registered as Jane Doe!" "Looks like this is going to be an interesting day! See you tonight?" "I'll be here!" "Well, get some sleep, Tess. Thanks for the report." Tess turned as she reached the door and laughed. "Annie, she spits across the room! Be careful!" I sighed and shook my head. "Just what I wanted to hear to start my day!" Nursing Assessment I made quick rounds on all patients and peered through the door glass into Jane Doe's room. She looked like she was sleeping. Her telemetry rhythm was sinus and the vitals on the telemetry monitor at the nurse's station was within normal range. Her next order was for a finger-stick glucose in 2 hours, so I had some time. I quickly settled my other patients, scanned through her paper chart and then gowned up in full PPE's before I opened the door softly. These were before the days of formal language interpreters, electronic charts and iphones. I walked closer to the bed and silently observed her sleeping. Her hair was uncombed and there were tear stains on her cheeks. Her hands and legs were tied. She wore a long gown and a scarf lay on the floor amidst straws and blood soaked gauge and band aids. One of the hands was in a fist and was clutching on to something. I took a step forward and peered at it. It was a wooden Tasbih, an Islamic prayer bead. The woman was a Muslim! She probably had a dialect that was Beuodian (an ethnic group of nomadic Arabs). How Did I know All of This? Five years before, I was working in Saudi Arabia in a remote village with Beuodians and spoke fluent Arabic. I knew their culture, customs and dressing. This woman was most probably from Saudi Arabia. I went over and took the scarf and shook it. It looked clean. I went and touched her arm gently. Her eyes flew open and she stared at me with frightened eyes. I must have not inspired any confidence in my full PPEs! Praying that she wouldn't spit at me, I took off my face shield and mask so that she could see my face. "Salam Malaekum Ukht " (pronounced uktu) meaning greetings sister! Tears pooled in her eyes as she whispered back, "Malekum Salam" (greeting to you!) I motioned with my hand and spoke to her in Arabic. "May I put your scarf back on your head?" She nodded, the tears flowing freely now. I gently combed her hair with my hands and tied the scarf around her hair. For an orthodox Muslim woman leaving her hair uncovered for others to see is considered "haram"(forbidden) and a scarf or Hijab is an easily identifiable sign of her faith. Just like some people wear a cross as a Christian identity. Gaining Trust Putting her scarf back on showed my respect for her and her faith. This also was a tiny step to gain her trust. I gently patted her hand and pulled up a chair and sat by her bed. Even though I spoke Arabic well, her dialect was hard to understand. The words poured out amidst sobs. She kept saying the words over and over again. "Untie me now! Please. Untie me now!" I raised my hand slightly and spoke to her. "First give me your name." "Saida." "What is your husband's name?" "Ismail Mohamed". "OK. Do you know your address?" "No." "Do you know his phone number?" "Yes." "That's very good. Give me the number." I wrote it down and then touched her. "I am going to untie your hands now. Promise you won't hurt me." "I won't." I gingerly untied her hands (left the legs tied, just in case she lunged at me). Massaging her reddened wrists with some hospital lotion, I smiled at her and asked, "Shall we call your husband?" She sat up eagerly as I dialed out and was connected to her frantic husband. I calmed him down, told him what happened and gave him the phone number to the room and the address of the hospital. Saida tearfully spoke to him. I found out that they had come to visit their son Ali in New York and only been in the country for 2 weeks. The first week, the father had a fall, broke his ankle and was on bed rest. Ali gave his mother money and taught her to buy essentials like milk, eggs and cheese from the local Greenmart. He went out of town for the weekend on work and the father did not have his number. Ali had given his contact numbers to the mother who had kept it safely in the apartment! Anyway, he was supposed to come back that night. The father did not know the emergency systems (call 911, call hospitals, police, etc.) and barely spoke English. So he was home worried and helpless. Now that Saida was calmer, I untied her legs, took her to the bathroom and helped her with a warm shower and a clean gown. I put her back on the phone with her husband and made her a cup of hot tea. Her finger-stick glucose and vitals were fine. Her husband had given me a brief medical history-HTN, DM and an allergy to Penicillin. No surgeries in the past and 2 hypoglycemic episodes a few months ago in their country, Saudi Arabia. I called Dr. Clean who was very glad to hear the news, discontinued the restraint order and asked me that he be paged as soon as the son arrived. Ismail, her husband, was going to send their son Ali to the hospital as soon as he came back. I called and alerted the security desk and let them know to let him up whatever time he came, given the circumstances. I then called the kitchen and requested a tray with rice, salad, fish and olives. I also got her a stash of teabags and sweet and low instead of sugar! I also gave her a cotton sling wrap to cover her hair as she had washed her scarf and it was hanging in the bathroom to dry! We both laughed when she put it on, as it looked so different from her ornate scarf!! I also called the Nursing office and asked for help to get an Arabic interpreter ASAP. I went back to my other patients and checked in on her periodically. She was a bit anxious but otherwise a model patient for the rest of the shift! When Tess came back that night to get report, I showed her a wet spot on my uniform (water spill) and mournfully told her "Spit" to pull her leg! I then told her what happened and that it was not spit! She promised to look out for the son Ali and page Dr. Clean when he arrived at the hospital. I told Saida that I would be back the next day and went home feeling good inside. Cultural Competence and Knowledge On Other Faiths Looking back to this incident, I realize the importance of cultural competence and knowledge on other faiths and what is important to them. EMS was following protocol when they removed the scarf and put her on a C-Spine collar and board. She grew agitated when she saw where she was, couldn't communicate and had her hair uncovered. It just went downhill from there! As a new graduate, I had gone and worked in a remote village in Saudia as a Public Health Nurse with poor nomadic villagers while my classmates landed hospital jobs from Medical Surgical, Telemetry, ED, ICU, CCU to NICUs and Cath labs. I always wondered what good my experiences there would be in America and worried that I did not have their kind of expertise. I realize now that my experience there helped the right patient at the right time and made a difference in Saida's life at that moment. Even later on in life, the Saudian experience has served me to break the ice and gain the trust of many Muslim patients especially post 911, when many innocent Muslims were targeted. At the end of the day, I find all experiences useful to bring warmth and kindness, when our patients are at their most vulnerable. Patient Discharge Teaching Saida was discharged the next day home and showered me with blessings before she left. When discharging her, I reminded her to always carry some ID, a phone and a medical card with medication names and allergies in her purse. She shook her head and said she was not stepping out of the apartment again! Matter of fact, she just wanted to go back home to Saudia with her husband! I told her that Inshallah (God willing/by the grace of God) things would get better and she would start enjoying her visit! We also reviewed DM, causes, treatment, diet and signs and symptoms and treatment of hypoglycemia and hyperglycemia before they left the hospital. She came back with Ali, a week later, with a gift for me - a Tasbih (prayer beads). I have it next to my rosary! References American Diabetes Association (ADA)
  21. At some point in our lives we all decided to become a Nurse. Maybe some of us decided to be a Nurse after reading the stories on allnurses.com. Now, some of us have days when we feel defeated and want to quit and never look back. Other days, we know we've made significant differences in the lives of our patients and are convinced we've made the right career move. Do you remember when and why YOU decided to become a Nurse? allnurses welcomes you to share your stories.
  22. "Go check the waiting room!" I looked up sharply from the ER nursing schedules I was doing. It was 10:30 p.m. I would be done by 11 p.m. Did I hear that or was it my imagination? There was no one in the office but me! I got up and stretched. Slipping on my white coat and stethoscope I walked out to the waiting room. It was packed. I stood by the security desk casually making conversation with Tony, the guard while my eyes swept across the big room. Hopeful eyes looked at me. My eyes stopped at the older African American gentleman sitting quietly between four young white men. He was answering their questions in monosyllables. I saw them exchange worried glances at each other. I walked towards them observing the grey pallor on the man's skin. "Something is wrong" ... "Hi, I am Annie the ED manager. Who is the patient here?" One of the young guy's piped up, "It's Mr. Gary!", and nodded toward the older gentleman. "Hi, Mr. Gary! How are you?" "I've had better days!", he mumbled. "And, you are--?" I asked looking at the four young men. "We are Gary's friends. We work together as caddies at the Green Meadows Golf Course!" "OK! So what's going on? Why did you come to the ER?" "Cause, something is wrong! This is just not him!" "What do you mean?" "Gary is very fun loving and is always joking around! He has changed in the last one month!" "Yeah! Ever since the fall!", one of the other guys chimed in. "What fall?" I asked casually as I watched Gary rubbing his temples. "He fell backward last month. I think he slipped. He was checked out in the ER and was sent home. He's been different since then! He's very lethargic!" "His balance is off and he vomited today!" "Mr. Gary! Do you have a headache?" "Yes! The worst headache in my life!" "Have you been taking something for it?" "Been popping Aspirins and motrins! Nothings working!" History, Assessment and Action "Let's get you in. I am going to triage you inside!" I grabbed a wheelchair and told his friends to wait outside. As Tony, the security guard, swiped me into the ED, I motioned Claire the secretary and asked her to send in for a stat registration to stretcher A1. "Any medical problems?" "I have a funny heart rhythm! Can't remember the name!" "Atrial Fibrillation?" "Yes!" "Are you on coumadin or warfarin, which is a blood thinner?" "Yes, 7.5 mg every night!" I groaned inwardly. He could be a bleed! I had Joan, the ED tech, hook him up to a monitor, get vitals and a stat EKG as I triaged him. Got Vilma, the nurse, to throw in 2 large bore lines in him and send labs including Type and screen. I went over to Rick, one of the Attendings in the ED. "Rick! We may have a bleed. Guy in A1, name's Gary, 72 years old, no allergies, had a fall 1 month ago and has the worst headache of his life. He has been taking Asprin, motrin and coumadin! A Perfect cocktail! His friends noticed a change in his behavior and brought him to the ED!" "Great! Let's get a stat CT Head!" He quickly examined Gary while I called over to CAT scan and informed them. Within 10 minutes we were looking at the films with the neurologist who we paged - a large subdural bleed. It was a short matter of time before his airway got compromised! Gary was getting disoriented. He was electively intubated and arrangements made for his transfer to our main hospital Neuro ICU. Vilma gave report and Claire called for an ACLS transport. It was 11:30 p.m. "He's like a dad to us" I went outside to speak to Gary's friends! "How is he doing?" They were all anxious as they had not seen him for an hour. "Well! He is stable and I want to thank you for being good friends!" "What's going on?" "Your friend Gary was behaving differently because he was having a bleed in his head! It was getting worse as it was causing a headache and Gary was taking medications for the headache like motrin and aspirin that are blood thinners and made him bleed more, a vicious cycle. He is also on a blood thinner coumadin which worsened the problem!" "Is he bleeding in the head?" "Yes, the bleed is putting pressure on his brain and so we had to intubate him as it would affect his breathing at any point." "He's on a ventilator?" "Yes, he is. The good news is that his vitals are good but he needs to be transferred over to our main hospital for further treatment. Does he have family?" "He has a sister in North Carolina but we are his family here!" "OK! That's good! I will have Vilma, his nurse, keep you informed. If you can find out his sister's information, let Vilma know!" "OK ! We will! Thanks, Nurse Annie!" "Thank you! Gary has great friends in you! You saved his life bringing him in today!" "He's like a dad to us! We just want him to be OK!" Reflection I smiled and walked away back to my office thanking God for the humanity those young men, all New Yorkers, showed to their coworker despite their age and racial differences! As I headed out of the ambulance bay, Gary was being loaded up for the transfer by the ACLS team. The young men anxiously watched and planned to follow him to the main hospital. As I drove home, I reflected on the story of the good Samaritan and thought of the right choices those men made to help Gary! I wondered which of their Guardian Angel's spoke to me in my office! I had plenty to choose from! Thank God for good people in the world! References/Resources WebMD: Subdural Hematoma
  23. I remember when I first made the decision to go to nursing school. I was 31-years-old and struggling with the idea that I had spent 9 years working in a career that I didn't really like. In fact, I hated my profession. I had spent nearly a decade selling medical equipment to hospital operating rooms, traveling up and down the west coast, schmoozing with doctors and hospital purchasing managers so they would buy my stuff. But even though my heart wasn't passionate about my profession at the time, I was passionate about working hard and performing well. So, each year I met my professional goals and advanced in the profession. Which, in turn, also made it harder for me to leave. But then one day, it hit me. I didn't want to just work in the medical profession. I wanted to be an actual medical professional. I remember thinking how bored I was sitting on the sidelines as a device rep, watching procedures and literally thinking, "this is SO lame, please shoot me!" So (a few mental breakdowns later) I finally did it. I signed up for the 7 prerequisite science classes that I needed to take before I was even able to apply to nursing school (as a prior journalism major, I hadn't taken very many science classes at that point). I took my classes in the evenings after work. And I started studying to take the TEAS. It all took me about a year to complete, and in 2010 I started my journey to become a nurse. Things You Need To Know... #1 Nursing school is crazy hard (and expensive) Not only will you have daily classes, labs, weekly exams, and intense competition from classmates, but you will also be working clinical shifts as a student nurse. Many nursing programs also advise against outside work during the program because they warm that you won't be able to keep up with the work. And in California (like many other states), hospitals are no longer hire nurses who don't have a BSN. As a result, many nurses are graduating from nursing school with 50-100K or more in student loan debt. #2 You will probably have to work night shifts, at least in the beginning Nurses are needed 24 hours a day, 365 days a year. Since many nurses don't want to work all night, seniority is often the deciding factor when it comes to assigning nurses to the day shifts. Some hospital units even have a rule that new nurses must work night shifts for at least the first few years of being there. You will want to invest in a great set of blackout shades, at least one pair of blue blocker sunglasses, and a box of ear plugs (so the guy mowing his lawn at 1100 doesn't wake you up). #3 Working three days a week as a nurse isn't as easy as it sounds I remember thinking how awesome it would be to only have to work 3 days a week. I mean come on, its only 3 days! But that also means that the days you do work are incredibly long. Nursing shifts are often advertised as being 12 hours, but they are actually more like 14-16 hours once you factor in oncoming nurse reports, overtime due to short-staffing, and your commute to and from work. #4 You will be afraid that you might kill someone This one is a real fear because, for example, if a nurse makes a medication error or forgets to check vitals or a patient's neuro status's per order, then you actually accidentally could kill someone. But as you grow more tenured in your career, you develop a sixth sense for things that might go wrong and you figure out how to triple check in the most time-crunched circumstances. And you learn how to assess your patients quickly enough that if there are any vital or neuro status changes, that you can get the help you need before things go downhill. #5 You will learn to balance more information then you have ever had to before There really is no such thing as multitasking, because our brains can't actually focus on more then one things at the exact same time. But nurses developed the uncanny ability to juggle multiple ongoing tasks for multiple patients for up to 12 hours a day - such as medical orders, patient requests, vital signs, medications, allergies to medications, lab values, care plans, etc ... We forget too eat and pee all day, but we remember the important medical information we need to know for our patients. Being a nurse stretches your brain further then you even thought it could go. #6 Nurse abuse really does happen Sadly, abuse against nurses isn't uncommon. In fact, nurses are expected to put up with levels of abuse that would NEVER be acceptable in just about any other professional setting. I have been cussed at more times than I can count, in just about every colorful way you could imagine, for just doing my job. Even worse, violence against nurses is prevalent (especially emergency room nurses) and it usually isn’t even routinely tracked. I have been lucky not to find myself the victim of direct physical violence as a nurse as of yet. Many nurses have not been so not lucky. #7 Your whole body will start to hurt There is alarming evidence now that even proper lifting techniques expose nurses’s spines to dangerous forces. If that's not bad enough, chronic back pain in the nursing population is a common ailment. An evidenced-based review at the Texas Women’s University reported that estimates of chronic low back pain among nurses range from 50%-80%. You may not be able to escape some of the wear and tear from being a nurse at the bedside. However, you can pick up healthy habits outside of the hospital like yoga, running or weightlifting to help recuperate on your days off. #8 You will find that there are multiple types of job opportunities away from the bedside One thing that I Iove about being a nurse is that there are so many job opportunities away from the bedside for nurses. So even if you decide that beside nursing isn't for you anymore, there are other nurse occupations to look into. Here are a few examples from some of my nurse peers: aesthetics nursing legal nurse consultant nurse blogger/freelance writer medical/pharmaceutical sales professional nurse coach nurse recruiter Despite the Intensity, I Love Being a Nurse I'm proud of what I do to help humankind, all within a 12-hour shift. I get to help people in some of the worst moments of their lives, and I am surrounded by other co-workers who enjoy being helpful as much as I do. And, I am always being inspired to keep learning more. References Violence against nurses in hospitals not routinely tracked, reported Violence Against Nurses Working in US Emergency Departments Even 'Proper' Technique Exposes Nurses' Spines To Dangerous Forces Mind-Body Exercises for Nurses with Chronic Low Back Pain: An Evidence-Based Review
  24. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. Presentation A 45-yr-old, white, premenopausal woman presents for her annual exam. About 5 weeks ago, she noticed a small, painless lump in the upper outer quadrant of her left breast. “I didn’t think much about it because I’ve had so many lumps – they always pop up when I get my period.” She states that usually the lumps become palpable and bother her about 10 days before her menses, but then they go away. Right now, she is about 4 days from her expected date of menstruation. She is a nonsmoker, nondrinker and denies recreational drug use. She only takes PRN medications occasionally. She has a supportive partner and two children ages 13 and 17. Chief Complaint “My breasts have always been cystic, but I found a new lump in my left breast that has me worried.” History of Present Illness She has no history of dysmenorrhea, but the lump hasn’t gone away and seems to have grown in size. She denies tenderness, pain, nipple discharge and skin changes in her breasts and no masses in the axillary region of her left arm are found. She states that she practices breast self-exams, “but not as often as I should.” She has never had a mammogram. Several years ago, she had a breast biopsy that was consistent with fibrocystic changes. Her only Pap smear was done two years ago, and the result was normal. Past Medical History Her medical history is unremarkable except for a broken arm in grade school. Menarche was at age 11. Her first pregnancy was at age 27 and her second at age 32 – both pregnancies were full term and deliveries were vaginal with no complications. Family History Paternal grandmother diagnosed with breast cancer before menopause at age 48. Mother died of breast cancer at age 75, though the cancer was diagnosed when she was 45. She had two periods of long-term remission, but it recurred again 16 years ago. Her father is 88 and has HTN, history of stroke, type 2 DM and Alzheimer’s disease. He lives in a nursing home. Social History Drinks 6-8 cups of coffee weekly, exercises 3x weekly, has a degree in communications from a local college, but she now works as a personal life coach. Allergies Latex and adhesive tape cause a rash. Questions What are the possible reasons for this lump? Is it just another cyst? How many reasons for breast lumps can you come up with off the top of your head? How many risk factors for breast cancer can you spot? What labs do you want? What other diagnostic tests should we run? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  25. ✔️ When you need the money, your shift is cancelled; when you have a weekend planned, you have to do overtime. ✔️ Realizing the patient you've just injected has a serious infection causes you to stab yourself with the used needle. ✔️ A 500 pound patient needs all care, while your 80 pound patient needs a finger dressing ... and your colleague has a "bad back." ✔️ It's you're first night shift for three years. And it's a full moon. ✔️ You're doing the "Only 27 more minutes of the shift from hell happy-dance", only to turn around to see your supervisor standing there. ✔️ In a critical situation, the most highly qualified clinician will offer the most advice and the least support. ✔️ The absurdity of the suggestion is directly proportional to the distance from the bedside. ✔️ As soon as you finish a thirty minute dressing the doctor will come in, and take a look at the wound. ✔️ The disoriented patient always comes from a Nursing Home whose beautiful paperwork has no phone number on it. ✔️ Your nose will itch the very moment your gloved hands get contaminated with bodily fluids. ✔️ The patient who has been dying all night finally meets his maker 12.5 minutes before shift change. ✔️ You walk out of a patient's room after you've asked them if they need anything: they will put the call bell on as you are about three quarters the way down the hall. ✔️ The patient furthest away from the nurses' station rings the call bell more often than the patient nearest to the nurses' station. ✔️ The doctor with the worst handwriting and most original use of the English Language will be responsible for your most critical patient. ✔️ You always remember "just one more thing" you need after you've gowned, gloved, and masked and gone into that isolation room. ✔️ The correct depth of compression in adult CPR is a bit less than the depth you just reached when you broke those ribs. ✔️ When you cancel extra staff because it's so quiet, you are guaranteed a rash of admissions. ✔️ If you wear a new white uniform, expect to be thrown up on. ✔️ Corollary: Residents always poop on your brand new shoes. ✔️ When management smiles at you, be very, very afraid ... ✔️ Staffing will gladly send you three aides--but you have to float two of your RNs. ✔️ As soon as you discontinue the IV line, more fluids will be ordered. ✔️ Mandatory meetings are always scheduled after you've had the night from hell and just want to go home to bed. ✔️ You always forget what it was you wanted after you get to the supply room. You always remember when you get back to the other end ... ✔️ Doctors only ask your name when the patient isn't doing well. ✔️ Success occurs when no one is looking, failure occurs when the boss is watching. ✔️ As soon as you've ordered the pizzas, 25 patients show up at the ER registration desk along with three ambulances all with cardiac arrests! ✔️ For every action, there is an equal and opposite criticism. ✔️ Ten seconds after you have finished giving a complete bed bath and changing the bed, the patient has a giant code brown. ✔️ If a patient needs four pills, the packet will contain three. ✔️ Your buddies who were reading the paper at the nurses' desk a minute ago always disappear when you need help ... ✔️ Expect to get your pay raise the same day the hospital raises the parking rates (and other charges) ✔️ The better job you do, the more work you can expect to be handed ... ✔️ The amount of clean linen available is inversely proportional to your immediate needs. ✔️ The more confused and impulsive a patient is, the less chance there is for a family member or friend to sit with the patient. ✔️ The perfect nurse for the job will apply the day after that post is filled by some semi qualified idiot. ✔️ If only one solution can be found for a problem, then it is usually a stupid solution. ✔️ When the nurse on the preceding shift has surrounded the patient with absorbent pads, the code brown will hit every sheet and miss every pad. ✔️ Rest assured that when you are in a hurry, the nurse's notes have not been written. ✔️ When you are starting an IV on an uncooperative patient, or dealing with a huge code brown, there is a phone call for you and it's that crabby physician that you have been paging all morning. ✔️ Fire drills always occur on your day from hell ✔️ The first person in line when the clinic opens will not require urgent care. The sickest person will arrive 5 minutes before closing: "I thought I'd feel better" The Nursing Catch-22: If you're running around horribly busy, you're unorganized and need to prioritize, but if you're not running around horribly busy, you're lazy and need to find more work to do. Remember folks - Murphy was an optimist! Add your Murphy's Law below! Murphys-Laws-of-Nursing.pdf