What is med surg like these days???

grinnurse, RN · Jan 4, 2006

this guy's a dnr, but there i am w/ blood in one port of his ij, fats/tpn in the other and numerous iv meds in the other (you're right, the doc is offended when i suggest that given his respiratory status and code status, should we be doing all this ****?) btw, this guy is swollen like a ballon all over w/fluid. just slow the stuff down and give him lasix, is the answer.
i often wonder these same things on our dnr pts from the nh?????? what the heck?? i will try to get things changed-usually to no avail, but i figure if i don't try, these pts are going to come back and haunt me!!
what i'd like to ask my fellow nurses is this, i've only been a nurse for 6 yrs, so a lot of you could give me some advice, i bet. what do you do when you have a pt like this and you have another one that goes bad and all of the other nurses also have a heavy assignment? and why the hell do we give dnrs on their death bed all this stuff when all it does is torture them.. one of these times i'm going to tell a doc, "you go torture that old lady w/a ngt, foley and iv, i'm not-i have morals."
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i have had this happen a couple of times and to tell the truth it was extremely "hair raising" esp since i am a "new" nurse. i based my work (right or wrong-i don't know) on the pt that was not a dnr. i would love to see how others have handled this in the past.

General E. Speaking, RN, RN · Jan 8, 2006

Patients on med/surg floors now are much sicker than those we cared for even a year ago. We're doing insulin drips, dealing with all sorts of high-alert medications and taking care of people with multiple IVs, tubes, drains etc. who were considered critical care pts. only a short time back. Staffing, of course, has not kept up with the higher acuity, although I certainly can't complain about our ratios as compared with much of the rest of the country (we usually have no more than 5 pts. on day shift, 7 on nights). The problem is when you have two (or more) going bad on you at the same time, or when you get a critical-care move-out, a fresh post-op, and a new admission all at once, or when you have several total-care pts. and no aide.......unfortunately, these occurrences are becoming more the norm than the exception.
Don't get me wrong---I love my work; it's the job I hate sometimes. My advice to anyone re-entering this field after an absence of more than a year or two is to take a refresher course, or make sure to get a decent orientation period (at least three months) in order to get back up to speed.......believe me, you'll need it.
Good luck to you. I don't want to scare you away from Med/Surg---Lord knows we need everyone we can get!---but I do want you to be prepared.:)

:thankya: couldn't have said it better myself!

General E. Speaking, RN, RN · Jan 8, 2006

And why the hell do we give DNRs on their death bed all this stuff when all it does is torture them..

I wonder this myself. One doc told me in a sarcastic tone that "Just because they are a DNR doesn't mean we don't treat." Treat being the operative word. Treat? Treat what? All we are doing is prolonging the inevitable.

This is ALSO true for the ones who probably should be a DNR but the doc's keep right on ordering MRIs, CT Scans, G-tubes or TPN/lipids, Xrays and lab tests all the while stringing the family along and IMO giving them false hope.

Long Term Care Columnist / Guide · Jan 8, 2006

I wonder this myself. One doc told me in a sarcastic tone that "Just because they are a DNR doesn't mean we don't treat." Treat being the operative word. Treat? Treat what? All we are doing is prolonging the inevitable.
This is ALSO true for the ones who probably should be a DNR but the doc's keep right on ordering MRIs, CT Scans, G-tubes or TPN/lipids, Xrays and lab tests all the while stringing the family along and IMO giving them false hope.

I agree that DNR does NOT mean 'do not treat'. To my mind, however, 'treatment' should be limited only to those things which promote comfort........antibiotics for reversible infectious processes, pain/fever/antinausea medications, oxygen, and/or fluids. Everything else---TPN, lipids, tube feedings, expensive tests and surgeries etc.---seems to me to be a terrible misuse of limited resources, and waste always irritates me.

This is why I've made it clear to my family that under NO circumstances am I to receive anything beyond hydration, antibiotics and comfort measures should I become gravely ill or injured. I don't want to be one of these 80-somethings with a failing heart, brittle bones, and dementia that medical science keeps rescuing........what in the name of all that is reasonable is the point in this?? When I was still in med/surg, I was (and continue to be) appalled at some of the things we do to keep people alive who by all rights ought to be in Heaven; I'm not an advocate for euthanasia by any means, but I do believe people should be allowed to die naturally when it's their time. The money our society spends on desperate measures to prolong life would be so much better spent on preventing the diseases that rob so many of their quality of life.......but nobody's getting that message.

OK, stepping off my soapbox now. :rolleyes:

Katillac, RN · Jan 8, 2006

I can't say what Med/Surg is like these days, though I can assume it has only gotten worse since I left it 3 1/2 years ago. That was after a year on a tele floor, working nights on a 36 bed unit. I was often charge PLUS my own assignment of eighteen patients, sometimes with no licensed staff working with me so I was responsible for all my own meds, tx, admits, charting, you name it. And that was. . . are you ready? As a GN. Pray nobody codes or goes bad, because your other patients won't see a nurse for the rest of the night or the crasher goes to critical care, and pray nobody asks what "Graduate Nurse" means as you are pushing some cardiac med or other and they find out you haven't even passed your boards. I was ignorant enough to think that if it was unreasonable or illegal, I wouldn't have been asked to do it. Unsafe, scary, and illegal, but as far as I know it's still happening.

As to DNRs, yes, it's frustrating when we are torturing patients who have no hope of recovery with invasive and useless treatments and tests. But as far as I know, a DNR only means "If my heart or breathing stop, don't mechanically restart them." Until the doctor is made to believe that the patient or HCP wants to give up on attempts to fix the patient, he or she is obligated to continue the full court press, aren't they? We can't assume that because a patient is a DNR they are "comfort measures only". Sure, it's up to the docs to broach this with the patient or family, but until they do (and some NEVER will) as health care professionals we need to do what we can to keep them alive. And believe me, I have run into these maddening situations a lot as a hospice nurse who gets called in when the proxy or POA won't let the person go peacefully.

SOME med/surg units aren't as I described though. The trick is to find them. When you interview and ask about ratios, listen for phrases like, "We like to have XX nurses for the floor on X shift, with X UAPs." Or, "Well that changes with acuity." Those phrases mean absolutely nothing. Visit the floor, and ask nurses what their assignments are like that day, or check out the white board. And good luck to you.

Thunderwolf, MSN, RN · Jan 9, 2006

i wonder this myself. one doc told me in a sarcastic tone that "just because they are a dnr doesn't mean we don't treat." treat being the operative word. treat? treat what? all we are doing is prolonging the inevitable.
this is also true for the ones who probably should be a dnr but the doc's keep right on ordering mris, ct scans, g-tubes or tpn/lipids, xrays and lab tests all the while stringing the family along and imo giving them false hope.

treat=justification of the hospital stay, unfortunately.

therefore, if a dnr pt is in the hospital, it means something needs to be medically addressed to warrant the stay...makes dnr sort of meaningless, doesn't it? how many dnrs have you seen admitted to the hospital er for a uti, sob, or a change in mental status?...too many. if the body is dying and breaking down, there are going to be changes which signal decline. the medical system is broken, abused, and needs changed.

simple solution-->dnr needs to equal no need for hospitalization...period.

dnr needs to be recognized as nature being allowed to take its course...with treatment being seen as simply providing for the comfort needs of the patient during this process, nothing else...which is still a lot of care giving! folks are just not allowed to die in peace any more...which is just a plain shame imho.

ecfs/snfs should be able to or to be expected to meet these type of comfort needs...not a hospital...like they used to at one time in our not so distant past. ecf/snfs can order labs, give antibiotics, provide breathing treatments, et cetera...just like any hospital nowadays. it just doesn't make any sense any more.

but it is a business, so dnrs get admitted again and again and aggressively treated in the hospital until the insurance pot runs dry or god says enough and steps in himself.

we just had a dnr death today who family was lead to believe that all would be well. god called the patient home today. she heeded his call, for she was obviously worsening each day. the doc only scratched his head and couldn't understand it because "she looked like she was doing better a couple hours ago when i saw here"....no, she wasn't...talk about denial! ask any nurse who cared for her (they tend to be a little bit more honest). do you know how thick this patient's chart was from all the aggressive treatment she received?...two whole charts couldn't hold it all! family had a difficult time of it of course....given false hope. :crying2: and yes, hospital nurses are expected to pick up the pieces after the doc gives his 5 minute condolences to the family and leaves...if he shows at all. very frustrating.

barefootlady, ADN, RN · Jan 19, 2006

What I see on med/surg today:

1. Inexperienced staff given high acuity patients without benefit of help.

2. Experienced staff given higher acuity patients without benefit of help.

3. Charge nurses who NEVER make rounds, step in to assist assigned nurse

when a crisis situation has developed.

4. Nurse managers who are inexperienced, inept, and invisible most of the

time.

5. Doctors who are high tech but low touch, terrible manners with patients

and families, do not even mention their treatment of staff.

6. Facilities that operate with a "do the best you can motto; and we can

blame the nurse mentality."

7. Nursing students who are only interested in the pay scale, not in humanity

or the Golden Rule.

These are just a few of my thoughts, if I am wrong, just chalk it up to one nurses opinion.

Nascar nurse, ASN, RN · Jan 19, 2006

Hello. I've read a couple comments about DNR's should just be treated in the nursing home (I don't think this was in anyway intended to be a flame war NH vs hospital - so don't anyone go there please!!) Just so you all have an understanding of the NH point of view - we really are "trapped" in the same game you are. We clearly see that a resident is dying, we TRY to prepare the families for this.. spell out pros/cons of Gtubes, etc... but jeez, some just refuse to get it - they "owe it to Momma to keep her ALIVE!". Or sometimes the person themselves just wants "everything" done. When the family insists and the Dr. gets pressured by the family, they are coming to you (the med-surg nurses), we don't have any choice. I would much rather keep them here with us, surrounded by those of us who have cared for them for years and one of us holding their hand to die in peace, but families and sometimes Docs just don't get it. I will haunt my children if they EVER put me thru some of this stuff.

Sorry, I know this was off topic, but feel we (all nurses) need to educate each other better on how the "other half" is working.

General E. Speaking, RN, RN · Jan 19, 2006

Hello. I've read a couple comments about DNR's should just be treated in the nursing home (I don't think this was in anyway intended to be a flame war NH vs hospital - so don't anyone go there please!!) Just so you all have an understanding of the NH point of view - we really are "trapped" in the same game you are. We clearly see that a resident is dying, we TRY to prepare the families for this.. spell out pros/cons of Gtubes, etc... but jeez, some just refuse to get it - they "owe it to Momma to keep her ALIVE!". Or sometimes the person themselves just wants "everything" done. When the family insists and the Dr. gets pressured by the family, they are coming to you (the med-surg nurses), we don't have any choice. I would much rather keep them here with us, surrounded by those of us who have cared for them for years and one of us holding their hand to die in peace, but families and sometimes Docs just don't get it. I will haunt my children if they EVER put me thru some of this stuff.
Sorry, I know this was off topic, but feel we (all nurses) need to educate each other better on how the "other half" is working.

thanks for the input- you make some great points

Thunderwolf, MSN, RN · Jan 19, 2006

I second that, Kriso.

Thank you, Nascar nurse.