Published Oct 24, 2016
You are reading page 2 of WILTW 10/22: ENT and the Priapism
I'm a month into my new job and I feel like I'm drowning. Today I learned that no amount of squishing down feelings will stop me from crying at work. Also the tissues turn into powerdery snow that sticks to your face. As far as actual nursing info, dilt drips require Q2 BP checks. Which I did not know and subsequently did not perform. Discharges can go south real fast when the patient sundowns. I have no ability to distinguish between a drug seeking patient and one in actual pain. Because of this I treat them all as if they are in pain. This can rankle the other staff at times. Also my time management really sucks right now. I think I need to make an appointment with EAP. I don't have anyone to talk to about work stress that understands the pressure I'm feeling and it's really eating me up. Tomorrows a new day. Hopefully I can avoid crying.
As far as actual nursing info, dilt drips require Q2 BP checks. Which I did not know and subsequently did not perform.
Discharges can go south real fast when the patient sundowns.
I have no ability to distinguish between a drug seeking patient and one in actual pain. Because of this I treat them all as if they are in pain. This can rankle the other staff at times.
Also my time management really sucks right now.
I think I need to make an appointment with EAP. I don't have anyone to talk to about work stress that understands the pressure I'm feeling and it's really eating me up.
Tomorrows a new day. Hopefully I can avoid crying.
I'm not liking this because the content, but to give you internet hugs.
xoemmylouox, ASN, RN
I don't feel like I have learned much this last week. If I did my sleep deprived brain cannot retain or recall it at the moment.
I did win a scholarship to pay for a membership to Phi Theta Kappa. I've been invited every semester, but didn't join due to the cost/not knowing what the membership would actually do for me. Since it is free with this scholarship, I figure why not join?
The more I am learning in school, the more I learn how little I really know.. That's the scariest thought at the moment I suppose. As an LPN I thought I received a decent education, and I did, but this transition program is really teaching me so much more. Again, just not having much luck recalling it tonight.
nrsang97, BSN, RN
This one? :barf01:I've learned that it is exhausting going back to work after a vacation. I need a vacation to recover from my vacation?
I've learned that it is exhausting going back to work after a vacation. I need a vacation to recover from my vacation?
Thank you. I couldn't find it.
I don't feel like I have learned much this last week. If I did my sleep deprived brain cannot retain or recall it at the moment. I did win a scholarship to pay for a membership to Phi Theta Kappa. I've been invited every semester, but didn't join due to the cost/not knowing what the membership would actually do for me. Since it is free with this scholarship, I figure why not join?The more I am learning in school, the more I learn how little I really know.. That's the scariest thought at the moment I suppose. As an LPN I thought I received a decent education, and I did, but this transition program is really teaching me so much more. Again, just not having much luck recalling it tonight.
I also got an invite to join Phi Theta Kappa today. I thought the cost said $50. This is through my online classes at Clovis in New Mexico where I am taking classes to finish my BSN. I also was invited to join Simga Theta Tau as well and did so through my BSN program.
I would join. I think you get access to research sources, and other things. I can't remember what the brocheure actually said right now.
poppycat, ADN, BSN
Not nursing related but I learned it's really hard to live in a house with the gas turned off & no shower for 4 days (cue the puking smiley!). I also learned how much I hate owning a house. Last Monday (10/17) we had a furnace company come out to clean & inspect our furnace so it would be ready to run when we need it. The guy came up from the basement when he was done & told me he smelled a very faint odor of gas down there but couldn't tell where it was coming from. My husband & I didn't smell anything. I called the gas company to come check it & they found not one but 3 leaks! They shut off our gas until repairs were done. Well, the furnace guys were scheduled to come back Wednesday to replace the humidifier on the furnace so I called & asked them if they could repair the leaks. They said yes & I figured ok, no gas for about 48 hours; we'll survive.
Wednesday comes, the furnace guys come back & take a look where the gas company marked the pipes & they say, "we don't have wrenches big enough for those pipes; you'll have to call a plumber"! Went to the Yellow Pages & called 3 plumbers before I found one who could come out that day. He comes & looks over all the gas piping in the basement & says he can repair those 3 places but all the pipes are so old that other leaks are likely to occur in the process of repairing them. He said it would be less expensive to just replace all the gas pipes to begin with. Wonderful! How soon can you do it? Tomorrow morning (Thursday). Okey dokey!
As part of checking all the gas pipes, the plumber also noticed that the water main pipe running through our basement was badly corroded in one area. Wth! If this was a movie script, it would just be too unbelievable!
We live in a condo so I called our property management company hoping that maybe the water main might be their responsibility. They said it depended on where the corrosion was: before the water meter, their problem; after the meter, ours. They sent yet another plumbing company out to check it. Finally, we got a break: the corrosion is before the meter! The plumber who came out for that called our town's public works department to come look, too. The building we live in is over 70 years old. It's a duplex as are all the other buildings in our area. I will never understand why, when they were built, the village allowed the water main pipes to be run from building to building through the basements. The public works guy who came out just shook his head! In order to fix that pipe, water has to be shut off to the entire block which requires a 5 business day notice to all residents. Therefore, repairs won't be done until Tuesday, 11/1. Hopefully the pipe won't burst & flood our basement before then!
Back to the story. Thursday morning comes & we get a call from the company that's coming to do the gas pipes. The plumber who was scheduled called in sick! Rescheduled for Friday. Remember the gas was shut off Monday!
Meantime, we put a down payment on a bathroom remodeling project back in September wherein we were having our whirlpool bathtub (which we never used) removed & a walk-in shower the length of the tub installed. Guess when it was being installed: FRIDAY! We were promised when we ordered this project that installation usually takes only one day but if, for some reason, it couldn't be done in one day, it would be finished the next day even if that was a Saturday.
So Friday morning comes & we get calls from the plumber & the shower installers saying they're on their way. Everyone descends on our house before 9 am. Let the noise begin! Six hours & $3,000 later, the gas pipes are replaced, gas company comes out & says everything is fine & turns the gas back on. Yay!
At 6:50 pm the shower installers start loading up their truck to leave. Like idiots we assume they'll be back tomorrow (Saturday). They go outside & call their boss who tells them to tell us to call the office Monday to schedule the rest of the project! Mind you, by now we have not had showers since Wednesday because there was no hot water. Ewwwww!!
We looked at them & said we were promised the job would be finished the following day. They said their boss has them scheduled on a different job Saturday so they can't come back. I got out our contract & let them read it but there was nothing they could do.
I spent the next 3 hours texting & talking with our salesman & doing an online chat with the company on their website. The salesman claimed there was nothing he could do for us so I gave up dealing with him. I told the person on the website chat I would be contacting the BBB Saturday. Lo & behold, late Saturday morning we got a call from a different installer saying he would be there between 8 & 9 Sunday morning. He said he wanted to come Saturday but he was finishing another job.
He arrived Sunday morning just before 9 & asked what had happened so we told him the whole story. He looked at the bathroom & saw all that had been done Friday & how much more there was to do & said it should have been scheduled over 2 days right from the start. He got right to work & finished just before 3. It's absolutely gorgeous but after all that hassle it should be! The most disappointing part was when he told us we couldn't use it for 24 hours. So no showers from Wednesday to Monday! I could hardly stand myself!
Did I mention that through all of this we had our 4 year old grandson at our house? He thought it was all pretty cool!
calivianya, BSN, RN
Poppycat - all of that house stuff made me laugh! That stuff is why I bought new construction in 2014... but I am going through my own drama with mine because I'm putting in new countertops. Well, it's not super drama... it's just expensive. It's supposed to be my Christmas present, but it doesn't feel much like a Christmas present when it's going on MY card because I have a card still in the 0% interest phase! I will be happy once it's paid off!
I'm a month into my new job and I feel like I'm drowning. Today I learned that no amount of squishing down feelings will stop me from crying at work. Also the tissues turn into powerdery snow that sticks to your face. (...)
I'm guessing that's a non-titrating dilt drip? I would be crapping my pants only checking a BP q2h with a critical drip... that stuff's q15min where I work. Even the healthiest people on no drips get q1h vitals, at least, on my unit. The thought of q2h vitals on anyone makes me want to whip out the puke smiley. :barf01: It's funny how different the places we all work are.
Good for you with your pain management! You're doing it the way it needs to be done. Tell your coworkers if they have a problem with your methods, they need to update their practice. Too bad that would actually make you public enemy #1, probably.
We all cry sometimes. I thought I officially had a heart of stone at this point, but I burst into tears at work three weeks ago myself right in the middle of the hallway. None of us are immune. Being human is not a bad thing. It sounds like you are doing well to me - good luck!
My own stuff:
I had a couple shifts where they started orienting me to rapid response lately, and I learned some areas of the hospital are really getting abused. Badly. I got a call for an EKG that said STEMI up on the cardiac stepdown - ended up not being a STEMI and the physician could care less, but the truly terrifying part was their staffing.
The nurse that called me said something about how she just wanted another set of eyes on it because she was so tired she couldn't think between this guy having ST elevation, her three (!!!) insulin drips, and the other patient who wanted pain medicine all the time. I about died. I asked her in a disbelieving tone, "Now HOW many patients do you have?!" And she said FIVE! Holy crap. Three stepdown patients is my idea of a terrible, horrible assignment (but I just hate stepdown patients), four is just about unimaginable... but five stepdown patients, most on critical drips? All alert and able to use the call bell?!?! Many POD 1 after open heart surgery?
...I will never complain about my assignment again. I have never had a night that bad ever. She said they were trying to get their staffing better, but there had been nights she'd had six patients. SIX stepdown patients. I had to bite my tongue to keep from telling her to make an anonymous report to the Board of Nursing... and I'm still half tempted to do it myself.
I have learned that this semester, school is really eating me alive - but I'm enjoying it!
I miss you guys. I need to come back more often.
nutella, MSN, RN
Since my work is palliative care, most of what I researched further or somehow worked on/with is related (once again) to it.
I had interesting discussions with primary nurses around end-of-life decision-making in American-Chinese / South-East Asian patients. Nurses verbalized moral distress over families requesting "not to tell" the patient if a terminal diagnosis is found and not to provide the diagnosis and prognosis to the patient. This had become a topic especially for nurses who see a patient come back re-admitted for shortness of breath, pain, or weakness related to a terminal illness when it was suspected that the patient "does not know" or "does not understand".
The distress that the nurses experienced was rooted in their belief that "there is an obligation to tell the patient" and they felt that by "not knowing" they would "feed into denial". This was stronger when patients with a terminal diagnosis were a "full code" and nurses felt that by "telling them the truth" the patient and family would decide to change the code status to DNR/DNI.
There is a Self-determination Act (from 1991) that requires patients to be informed of their right to chose or refuse a treatment plus the right to an advanced directive. How all of this is executed is another question. Since we live in a diverse country with patients from many different cultures and beliefs it is important to reconcile how different norms and beliefs fit into our nursing practice.
Patients and families with Chinese heritage/ South-East Asian heritage/culture often regard end-of-life care within their traditional view/beliefs and it is important to them that healthcare professionals honor that. It is commonly requested by the family "not to tell the patient" about a terminal illness or an imminence of death because it is considered disrespectful (don't worry the dying person), brings bad luck, shortens life, takes away hope and is not something to discuss openly. Instead, family members, especially the oldest son, will make decisions for the patient. It is the duty of the children to take over and make decisions for the parent who is seriously sick - this is commonly expected within several cultures.
Nurses who value autonomy and the person's right to be their own decision most can have problems with the family's request to "not tell". It is important to distinguish between the patient 's wish, the family's wish, and the nurse's wish. The above scenario has nothing to do with "denial" but is centered around a cultural norm that deals differently with serious illness and terminal diagnosis. Patients often see the family as more important as the individual and most often are in agreement with the family members who request "not to tell". Commonly, the patient also values not to talk openly about death or dying and is more than willing to accept any decision made by the family and does not want to know any details. Knowing that the family will take care of him/her and will ensure comfort and care is often all the patient wants to know.
How do we know what the patient would want? This is a very valid questions and comes up frequently because there is an assumption that if the patient has been living in the US for "a long time" or was born in the US the patient adopts the American view of self-determination and individual decision-making, which I found often not true.
The way our team approaches this scenario by:
1. Get an interpreter if fist language is not English - best is in person but sometimes we use the language line or Ipad interpreter services.
2. Ask the patient about their preferences about information "how much would you like to know about why you are in the hospital, your illness and what is going on?" and "Would you prefer us to talk to your family about everything, would you like to know some things?"
and also ask "would you be ok with whatever your family decides for you?"
3. Make sure the healthcare proxy form is filled out. I usually explain that we would like to fill out a form that tells us who will make health care decisions for the patient, that no lawyer is needed. If the patient is unable to read I usually make sure that a trusted family member is there as well to look at the form.
4. Talk to the HCP. If the patient does not want to know the diagnosis and prognosis is is best to talk outside of the patient's room.
There are some other important things to know. When physicians/NPs talk about code status they often ask it like this "do you want us to do everything?" which of course the patient will say "yes". But often it does not reflect the patient wishes because they did not understand what "everything" means. When providers talk about the code status it is important that the patient and family understand that resuscitation with chest compressions/intubation is basically "trying to reverse death" and if the diagnosis is terminal will not change the overall outcome. It has been my experience that most patient from above culture actually want a "natural death" - they do not want to suffer but they also want "things to go the natural way". Sometimes it is important to point this out to providers who have a code status discussion in terms that are unclear.
Here is some more information:
Cultural Relevance in End-of-Life Care — EthnoMed
Other important topic that came up was family requesting treatment that appears to have no benefit to a patient with a terminal illness and the decisions are made by the HCP but the patient does not seem to want any treatment but can't make decision due to confusion / dementia etc. . There is no ethical obligation for providers to prescribe treatments that are non beneficial - the ethical principle on nonmaleficence is "do not harm". But in practice this is much more complicated as the fear of litigation drives decisions as well. Some states have laws regarding futile medicine but even with those providers may order treatments because they are afraid of being sued.
Nurses who feel that they are adding to a patient's suffering are at a high risk for burn-out, moral distress, and general distress.
I read the article "Burden versus benefit: When family has to decide how much is too much" in the latest Journal of Hospice and Palliative Nursing that talks about this topic. The main points were that when family makes decisions it is important that they have comprehensive information to make decisions, advanced care planning needs to move upstream (PCP instead of crisis talk in the hospital), that family is not always rational in decision-making, and that providers need to remember it is not "their journey" but the patient and family's journey.
Quality of life is hard to measure but there are attempts to get a handle on it :
Measuring What Matters | AAHPM
it is a lot to read though and very "dry". My view is that quality of life is very individual and hard to measure as it depends on the person's view/belief/ situation. When I ask "how do you feel about the quality of your life?" patients or families often just say "good" or "bad" or "I have no quality of life". In that case I ask further to find out what it is that is important to them and defines "quality of life". One patient who was above 90 years old and still able to read books and newspaper told me that if he becomes unable to read a book or newspaper - he would not have any quality of life. For somebody else it could be "if I am in constant pain" or "if I can not go to the bathroom anymore".
Bedside nurses have a huge influence in how families and patients make decisions. They tend to ask the bedside nurse "what would you do?" if faced with choices example "should I send him to rehab to try one more time" or "should I just decide on hospice care". It can be very helpful for families to guide them towards thinking about "what is important" and "will this choice help you achieve this". We can not make the decision for them but we can help them to think about it from a different perspective and look at it from the quality of life/goals for care perspective. That is more important as our population is getting older and sicker with more and more choices to prolonge life. Just because we can extend the life expectancy to a certain degree does not mean that it will result in a gained time with quality of life!
I also learned that my supermarket offers a couple of low-carb pita bread choices and carb-smart ice cream. The low-carb diet with exercise has been more successful for me that the other 2 diets I had tried. But it is not always easy to stick with it and temptation is everywhere ....
I started my Capstone course in which I will develop the Capstone project and after that I have the actual Capstone project left - those are my last 2 courses left for my MSN.
Burden versus benefit: When family has to decide how much is too much by Plakovic, Kathy
Journal of Hospice & Palliative Nursing:
October 2016 - Volume 18 - Issue 5 - p 382â€“387
I've had a migraine for 3, going on 4 days. I don't know what to do. I went to the ER & all they could give me was Benadryl (didn't help). I was hoping to hear back from my OBGYN's nurse but not today. I'm in so much pain.
Oh, the ER also gave me Reglan for nausea. Hello Panic Attack city. I've never had that kind of reaction to medication before. After I got it & the panic attack set in all I wanted to do was rip off my blood pressure cuff, take out my IV & run home. Ugh. That was not a fun feeling.
Had a first (& hopefully last) for me. Had a pt come up from anesthesia reporting details of an assault. Took a bit to understand & realize what was being repeated over & over and then it hit me like a sledge hammer. Pt never varied from what was initially stated even after becoming more fully awake. Did not want to speak to police but spoke to a social worker who was called in to PACU (pt did not want SO to know anything). Made for an interesting day.
When I've hit all my pre-op IVs on the first try for my pts 60 & older, I will miss on the 16 yr old...twice. Ugh.
A class for learning US guided IV starts is offered this weekend, but I can't make it. Hoping the doc will make time to do another class.
Nutella - I always appreciate your posts so much. I see the families struggling to make the hard choices a lot - and the overall health literacy in our society is just so low I don't feel like we can get full "informed consent" for anything we do. No matter how many times we tell them how much harm CPR does, no matter how many times we tell them how terminal Mom's disease is, it's always, "Well, someone I read about on the internet did fine!" Or, "But people are fine after CPR all the time!" Or, "I have a friend who's a faith healer who says she just needs to be prayed over again!" Just...
I wish there were some sort of X-ray glasses we could give the patient's family members that would cut through all their BS illusions and show them how the patient is really doing, so we could focus on the patient's comfort and not a prolonged ICU-torture death.
I learned that our State Board of Nursing provided a non-existent website address for our semi-annual license renewal.
Can anyone here point to a single example of a governmental agency getting anything right?
Everyone has always told me to go to medical school. I applied, got accepted, then put the brakes on. I realized that this is not a time in my life to be taking on a 200k debt, and give up the next 8-12 years before I start a career. So I decided on nursing school. Did an accelerated bsn,
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