Terrible clinical day, nurses don't seem to care.

[Koyaanisqatsi-RN]

I may get a lot of flack for this from the more experienced nurses, but I would like some help in understanding this situation.

Today, I walked by a patient's room in the hallway. Keep in mind she is not my particular patient today. She calls out to me in a frail voice for help, and sounds like she is in very bad shape. I go in to see her and she is crying, and very frail. She must have been in her 80s or even higher. She stated that she could not move her arms, and that she was desperate for some water. My first thought was that she might have been having acute MI or something similar because she couldn't move her arms, I really didn't know. I held her hands quickly and asked if she could feel my hands in hers. She said she could, but that she can't move her arms, and continued to cry and beg for water. She kept saying that she did not know where she was or why, and to please help her.

At this point, I noticed the restraints. She was strapped into her bed, this is why she couldn't move her arms. I was horrified. This is a med/surg floor, not a pysch ward. I asked one of the tele people what was going on and they stated 'it's just some crazy old woman, she's weird don't worry about her'. I asked her nurse and this was the same answer I got from her, again. She stated this woman had previously tried to pull out her IV and so they restrained her.

So...

Help me understand. They clearly had to get an order for these restraints. Why did they not choose a chemical restraint or sedative instead of strapping her into the bed? Why does no one care about this woman, writing her off as a crazy old lady; when she is, in reality, a frightened human being who was strapped into her bed in a strange place and scared to death. Not to mention thirsty, as she was apparently NPO and no one would explain to her why.

I went into the stairwell and cried for about 5 minutes. This is not why I wanted to go into nursing. I see things like this every day, but never this bad before. Restraints! They strapped this poor woman down and wouldn't explain anything to her. I spent some of the rest of the day talking to her and trying to help her relax even though all she wanted was to get out of bed and get some water.

It broke my heart. And if this is what nursing means, that eventually you become so burned out that a fellow human being suffering in one of the worst possible ways becomes just some 'crazy old lady', then I want no part of it.

[ReconSN]

Unfortunatly, physical restraints have to be used from time to time for the safety of the patient. Chemical retraints are very rarely used and Im not a fan of them. Depending on the state of practice, The use of any retraints is very regulated and requires a Dr's order. The pt needs to be very frequently rounded on and be reassessed for the need to continue the use of restraints. I think that this could be an oppertunity for you to discuss with your instructors the use and rational of physical and chemical restraints.

[suanna]

......I spent some of the rest of the day talking to her and trying to help her relax even though all she wanted was to get out of bed and get some water.

It broke my heart. And if this is what nursing means, that eventually you become so burned out that a fellow human being suffering in one of the worst possible ways becomes just some 'crazy old lady', then I want no part of it.

\

Thus the problem- I would be glad to spend a large part of my day keeping a confused, noncompliant patient in bed rather than use soft restraints, but unfortunately my other 2,3,5... patients wouldn't get the care they deserved and the patient I was hand holding may not be any better off for the time I spent. If you are my patient my first priority is to keep you safe- even if it is from yourself. Chemical restraints are nice, but they can cause resp. depression, and often increase the patients confusion. Not knowing why she was confused of why she was NPO I don't know what the reasoning was for the restraints, but with the vast documentation required to restrain someone I'm sure it was not a decision the nurse made lightly. We do many things for our patients that they find unpleasant drawing labs, starting IVs, dropping an NG, suctioning.... The goal is a safe and healthy patient at the end of the road. Soft restraints aren't the worst thing you may have to put up with as a patient.

[nursemike, ASN, RN]

How do you manage to keep it from leaking over into your patient interactions? I am honestly curious. I have vented more than my fair share in my day, of course. I know what you mean, but I guess I'm not sure the best way to keep it from affecting my patients. In the past when it was a job where I needed to vent all the time, it was increasingly difficult to hide it from others. How do nurses manage this?

This is a very good question. For starters, I think if you find yourself in a situation where you have to vent a lot, you're probably in the wrong situation. A little griping and grumbling may not be such a big deal--I call it an important part of the healthcare-worker bonding process. Some of my favorite coworkers, mostly very good nurses, have a rather sardonic sense of humor. But if you are seriously frustrated on anything near a daily basis, it's likely time to do something else. It could mean one is just not cut out for nursing, but I think it's more apt to be you're in the wrong unit, or facility.

I think it's prudent to be concerned that cussing and kicking the med cart may be reflected in how we treat our patients. Those who most believe they are as sweet as can be to the patient's face, no matter how badly they feel toward the patient, may not be quite the actors they suppose they are. I think most of us are pretty good at distinguishing someone who is seriously interested in our well being from someoone who pretends to care.

Even very confused patients aren't necessarily stupid, and a lot of times they don't have much else to do than observe their caregivers.

On the other hand, I once described a unit clerk as being like your mom: she'll drive you nuts, but you gotta love her. And I think that's typically true of our loved ones--we don't always get along, all the time, but we love each other even when we're annoyed. Personally, I find that to be true of patients, as well. I don't stop caring about them, even when they get on my nerves. And it might appall any nurse managers reading this, but I don't even think it's necessarily wrong to let a patient see that they're getting on your nerves, as long as they can still see that you genuinely care about them.

But on yet another hand, I think we need to be careful not to let our occassional gallows humor and/or venting condition us to become heartless. Call someone a "crazy old lady," often enough, and you could just start to really see them that way. And, as the OP demonstrates, it doesn't look very good to others who may not share the same jaded mentality.

One of my touchstones has been that nursing is a human endeavor. It was pretty clear to me before I ever got out of orientation that I was never going to be Supernurse. If I have to place a Foley in a female, especially one my age or younger, it makes me a little uncomfortable. I'm simply not able to carry off the impression of a consumate professional who has done this a thousand times, so I settle for looking like what I actually am, a decent guy trying to perform an awkward task with the least necessary fuss. Similarly, if a patient wants an extra blanket during my 2200 med pass, I get it. If they then ask for ice water, I get it. If they then say, "I hate to be a bother, but can I have some pain meds?" I don't tell them it isn't a bother, unless it truly isn't, but I probably will say something like, "That's okay, they pay me to do this," or possibly even "they pay me to put up with you." And sometimes I recognize that people who are on the call button a lot may just be lonely, so when I have a little time, I'll just pop in to hang out with them. I hope that isn't coming across as too saintly, because I probably will also report to the nurse that follows me that the patient is "needy," or "kind of a PITA."

To summarize, you don't necesarily have to be hypocritical to be a good nurse. Sometimes schizophrenia works just as well.

[Roy Fokker, BSN, RN]

A few thoughts, based solely on my experience (which along with 50 cents, will buy you a cup of coffee :chuckle :imbar )

* I'm not sure if anyone has pointed this out but why is a chemical restraint an "alternative" to your situation? A restraint is a restraint.

* It is also my experience that folks, especially the elderly (and especially those elderly who are opiate/benzo naieve) tend to go bat-**** crazy when administered meds. I can't count the number of times I've administered sedatives to that sweet, confused lady only to have her repeatedly strip naked 20 minutes later while screaming at the top of her lungs that she wants to have my babies...

* Continuous re-orientation is not always a good idea. Sometimes, constant interaction only serves to aggitate 'em some more.

* I'm sorry you had such a hard experience and you furthur felt that your questions/concerns were "blown off" by the staff. I'm judging neither you nor the staff in question - I wasn't there.

But welcome to "our world" :). Now imagine you were the patient's nurse and you asked the doc for sedatives. Doc says no.

What would you do?

I'd also like to share a tiny bit of advice - from a now practicing nurse who was in your shoes not too long ago. And I mean this in the most sinciere, non-condescending way possible. This is genuine, heart-to-heart:

Until you graduate, hold a license and take care of patients by yourself (no more teacher or preceptor or anyone else to turn to - you. are. it)... until you truly realize the bone crushing, mind numbing responsibility that is 'patient care' - until then... you cannot possibly understand what it's about.

Again, I'm not trying to be a smarty pants or put you down. And I'm not trying to let the staff 'off the hook'.

I'm just saying you do not understand the enormity and the entirety of it all. It's like trying to do calculus without learning how to do algebra first.

That you're willing to question, unafraid; is a wonderful thing. You're to be commended for it.

What can you take home from this whole incident?

Learn. The good and the bad.

And when you do work by yourself, resolve to incorporate the good it into your daily practice while you discard the bad.

And that is the only way you will truly make a difference.

Don't be "that bad nurse" or "that lazy nurse" when you practice one day as a nurse.

I wish you much luck.

cheers,

[Rascal1]

I think Roy Fokkers' post has provided the highest amount of illumination here thus far. And I admire the sensitivity shown. :redpinkhe

[Koyaanisqatsi-RN]

This is a very good question. For starters, I think if you find yourself in a situation where you have to vent a lot, you're probably in the wrong situation. A little griping and grumbling may not be such a big deal--I call it an important part of the healthcare-worker bonding process. Some of my favorite coworkers, mostly very good nurses, have a rather sardonic sense of humor. But if you are seriously frustrated on anything near a daily basis, it's likely time to do something else. It could mean one is just not cut out for nursing, but I think it's more apt to be you're in the wrong unit, or facility.

I think it's prudent to be concerned that cussing and kicking the med cart may be reflected in how we treat our patients. Those who most believe they are as sweet as can be to the patient's face, no matter how badly they feel toward the patient, may not be quite the actors they suppose they are. I think most of us are pretty good at distinguishing someone who is seriously interested in our well being from someoone who pretends to care.

Even very confused patients aren't necessarily stupid, and a lot of times they don't have much else to do than observe their caregivers.

On the other hand, I once described a unit clerk as being like your mom: she'll drive you nuts, but you gotta love her. And I think that's typically true of our loved ones--we don't always get along, all the time, but we love each other even when we're annoyed. Personally, I find that to be true of patients, as well. I don't stop caring about them, even when they get on my nerves. And it might appall any nurse managers reading this, but I don't even think it's necessarily wrong to let a patient see that they're getting on your nerves, as long as they can still see that you genuinely care about them.

But on yet another hand, I think we need to be careful not to let our occassional gallows humor and/or venting condition us to become heartless. Call someone a "crazy old lady," often enough, and you could just start to really see them that way. And, as the OP demonstrates, it doesn't look very good to others who may not share the same jaded mentality.

One of my touchstones has been that nursing is a human endeavor. It was pretty clear to me before I ever got out of orientation that I was never going to be Supernurse. If I have to place a Foley in a female, especially one my age or younger, it makes me a little uncomfortable. I'm simply not able to carry off the impression of a consumate professional who has done this a thousand times, so I settle for looking like what I actually am, a decent guy trying to perform an awkward task with the least necessary fuss. Similarly, if a patient wants an extra blanket during my 2200 med pass, I get it. If they then ask for ice water, I get it. If they then say, "I hate to be a bother, but can I have some pain meds?" I don't tell them it isn't a bother, unless it truly isn't, but I probably will say something like, "That's okay, they pay me to do this," or possibly even "they pay me to put up with you." And sometimes I recognize that people who are on the call button a lot may just be lonely, so when I have a little time, I'll just pop in to hang out with them. I hope that isn't coming across as too saintly, because I probably will also report to the nurse that follows me that the patient is "needy," or "kind of a PITA."

To summarize, you don't necesarily have to be hypocritical to be a good nurse. Sometimes schizophrenia works just as well.

Thank you so much for your perspective on this. Based on what you described here, you sound exactly like the kind of nurse I want to be when I "grow up". :)

You touched on exactly my concerns when you mentioned that if you actually call someone a crazy old lady enough times, you will start to believe it. That interests me because I have YET to meet anyone who can do stuff like that literally on a day to day basis and not let it affect their work, and how they interact with others at that job. I hope to approach it like you do, with common sense and a clear head.

Thank you again for your advice.

[SunnyAndrsn]

It's not always easy to arrange for a 1:1. Unfortunately, it often comes down to cost. When I was doing my last rotation of nursing school, there were two women who needed a 1:1, so they re-arranged rooms and then were able to financially justify having someone in the room at all times.

Also, it's been my experience that I can explain something to a confused pt. a dozen times or more, they will verbalize understanding, and forget what has been explained (PRAFO boots, bed alarms, you name it) to them within a very short time frame.

[lamazeteacher]

I agree, but I have never seen anything like this before. I'd never before really thought of getting a sitter for anyone, but this seemed literally the very definition of when you would want to have one.

Since she isn't my patient I couldn't look at the chart, but I heard she had a son. Lord only knows where he is though. Sure wasn't at the hospital with his mother.

I hear what you are saying. I do understand that you simply can't have patients yanking out IVs and catheters and wandering about. I guess I'm just confused as to why no one could at least pretend to care. Maybe it wouldn't have made a difference either way, but the patient did seem to be comforted somewhat by my limited interaction with her. I realize I have more time as a student than do the nurses, but again, just pretending to care doesn't seem like it would "cost" that much.

Who said you can't look at her chart, because she wasn't "your patient"?

Her NPO or IV order may have been dc'd, and you could tell the nurse assigned to her, that you wanted to help her out. The human contact you provided this patient was priceless. Your tears, as were hers, provided therapy.

There is a theory that tears contain (for want of a better word) "toxins" that need to leave the body when it (and the mind) have received an insult, stressing both. That substance is not in the tears that occur when cutting onions. I learned that in a conference about post partum blues/depression, and ever afterward taught my classes that it is essential to cry when the need arises (for any gender).

I was just discharged from the hospital where I was NPO and had IVs (GI bleeding). While I haven't gone into dementia yet, I felt like I wanted to (it's sometimes the only escape older patients have from their dismal reality). I cried over not being given the correct medications (for me) that I'd taken for 20 years, because the hospital's pharmacy didn't stock them. When did that happen? One was prevacid, for God's sake! :angryfire

I've told my 2 children that my will has a condition regarding their inheritances. If they ever allow me to be put in an assisted care facility, nursing home or other vegetative state, they will be automatically disinherited, and due to the expense of same, there won't be anything left, anyway........ Home health aides (good ones) help considerably, can prepare meals, do minor housekeeping, and some errands. Being home avoids confusion for the elderly, and provides comforts unavailable in a facility, and avoids the indignity of exposure to anyone walking down the hall! Nurses! Pulease shut the door or at least ask patients if they want it open, when you leave their rooms!!!!!

[suzy253, RN]

Absolutely brilliant, Roy!!! thanks

[ktwlpn, LPN]

Your post illustrates what I see as a systemic problem. Babies,children,cancer patients,head trauma victims etc. all receive specialized care-why not the elderly? Where are the units with the required specialized staffing for them? I'll tell you-they closed because they lost money..I have hope that the baby boomers will change this ...Roy's post is great-it explains what can happen to a patient like this-until you have restarted an IV 23 times in 4 days on a confused LOL you can't understand how frustrating it is.Even JCAHO has refused to acknowledge the problem... If an elderly person developes a pressure ulcer in LTC it's sentinel event- and you can be citied..if it happens during a hospital stay it was considered acceptable (I don't know what the latest regs are) The goal in med surg is getting out fast and alive and that's hard on the elderly. There is not enough staff to feed,turn and re-orient..Sitting them at the nurse's station is awful-no dignity there.What do you do when the facility has no funds for sitters and the family does not or cannot attend to their loved one? I think your niche may be in geriatrics-I love it and seem to have endless patience.I can get the most confused and agitated resident to take meds,accept redorection and direct care.I't a knack I have...The LOL I mentioned before-the one that pulled out her IV over and over again-I wrapped her wrist with kling and wrote with black marker " Doctor says do not touch this" Guess what? -it worked...It was a shame that I had not had her before she went through all of those sticks...

[Koyaanisqatsi-RN]

Who said you can't look at her chart, because she wasn't "your patient"?

We were told very clearly that we can not look at the chart of patients who are not ours. We were told it was a HIPAA violation.

[Rascal1]

We were told very clearly that we can not look at the chart of patients who are not ours. We were told it was a HIPAA violation.

Wow that's news to me...