Another ER busy week for me; between lots of sick kiddos, boarding, and overtime; although ordering breakfast at a late night diner the last two scheduled days of work certainly helped improve my mood.
I had a near miss at work; I caught it and realized I needed to report it; I haven't had a near miss happen in about ten years; my eagerness to report it is reflective of the atmosphere that I work in and how we report errors; I'm also more reflective that I feel as though having three patients as opposed to four high acuity patients makes a difference, and the need for a quiet place to draw up meds is needed (which we don't have).
What I also learned this week:
Sharpnel can still cause through and through trajectory for a gun shot wound;
Serum sickness can occur 10-14 days after exposure to antibiotics, but can appear faster if one decides to continue a course of said antibiotics, despite given instructions to discard them after the therapeutic date.
That I develop borborygmus after an unsuccessful code.
I learned that when I disciplined myself to go cold turkey, no more Allnurses, I felt better and got a lot more done! At the very least I limited myself to only check Allnurses after I had finished my chores, taken care of some duties, read a book!
Sadly I have had a relapse! I feel like the stereotypical computer troll/nerd sitting at my computer all day in a dark room gaining 100's of pounds. I need AA for Allnurses!
Specializes in OR, Nursing Professional Development.
I learned that when I disciplined myself to go cold turkey, no more Allnurses, I felt better and got a lot more done! At the very least I limited myself to only check Allnurses after I had finished my chores, taken care of some duties, read a book!
Sadly I have had a relapse! I feel like the stereotypical computer troll/nerd sitting at my computer all day in a dark room gaining 100's of pounds. I need AA for Allnurses!
ANA (allnurses anonymous) is in the break room. Meetings are very infrequent and pretty much all of us are still here.
I learned that I'm starting to resent my job, but not for the reasons that everyone might think. I resent it not because it is hard and I feel confused (though there are still those days), but because it is boring and in no way intellectually stimulating or challenging. The most challenge I feel is when the DON decides it is my day to get nitpicked to death. Sadly with the other new nurse taking up all of her negative attention even those days are few and far between. Now I spend my shifts as a medicine dispenser/secretary with the occasional challenge of fixing the other girl's paperwork since she can't be bothered to chart properly (or at all) most days...or she'll manage to get herself sent home because census is low. I can't afford to miss shifts really right now but it would be nice to be asked once in awhile. I knew going into this that I get bored easily but I thought the job would stay challenging for awhile yet (I've only been there 6 weeks). It's tough to suck it up and stick with it at least to the 6 month mark when it would be so easy to just put in my notice.
I've learned that I'm not very good at being off work & not being able to do much because my right hand is in a splint. I've always known my left hand is only there for decoration & to make me look balanced. Now I'm being forced to learn how to use the stupid thing. Ever tried to eat soup using your non-dominant hand? Not a pretty sight!
Never grasp the spoon in your fist; the soup will dump on your lap as you bring the spoon to your mouth! After that first mess, I watched how a lefty did it and learned fairly quickly.
I was 10 when I broke my right wrist. Wearing a splint made it almost impossible to use that hand. I had to stand up at the chalkboard to do my arithmetic left-handed.
I remember getting into BIG trouble with my mom. She caught me playing badminton by stuffing the racket down into the ace wrap holding my splint in place.
On the bright side, I did learn to write left-handed, although I am slower with that hand.
Specializes in M/S, LTC, Corrections, PDN & drug rehab.
I am getting everything together so I can take the TEAS test early next year (the program will start in 2018). I'm so nervous & excited at the same time! If anyone has any suggestions on books, apps or websites to study with let me know. I am going to buy the ATI study guide but I want all the help I can get to blow the test out of the water!
I am getting everything together so I can take the TEAS test early next year (the program will start in 2018). I'm so nervous & excited at the same time! If anyone has any suggestions on books, apps or websites to study with let me know. I am going to buy the ATI study guide but I want all the help I can get to blow the test out of the water!
I'll be taking it in January! I'm using the TEAS Mastery app - the initial bit is free, but you have to pay for the good stuff. I think it was around $20.
Specializes in M/S, LTC, Corrections, PDN & drug rehab.
I'll be taking it in January! I'm using the TEAS Mastery app - the initial bit is free, but you have to pay for the good stuff. I think it was around $20.
Good luck! I'm shooting for January as well. I LOVE that app!! It's helping so much!!
What I learned this week is (again) a lot related to palliative care. And November is the National Palliative Care and Hospice month.
I learned that even though there is outreach and education, many nurses, case managers, and providers in the hospital still have not wrapped their mind around the fact that palliative care is not the same as hospice. Early palliative care in patient with serious illness improves the quality of life. We, as nurses, often "see the writing on the wall" - meaning we know that a patient with advanced cancer who goes through cancer treatment may have problems and we see when somebody declines and the chances of a recovery gets less. One of our strategies to help patients with a serious illness is to connect them early with palliative care. Not necessarily to have heavy duty conversations when they just started treatment for cancer or dialysis for ESRD or endstage heart disease - but to establish a relationship. We do address emotional stress, symptoms, and help with the coordination of care of course and if needed we have goals for care discussion. But as a hospital service, we also "think ahead" and want the patients who will need more help in the future or who are getting worse because of repeat admissions or a lot of illness/symptom burden to know us and to not be afraid of "palliative care". First of all, patients (and nurses) are human beings, and as such we have the need to connect with people around us and with those who care for us. So when the patient who has metastatic cancer and who tries to get some more time with aggressive chemotherapy or targeted therapy gets re-admitted to the hospital with yet another episode of dehydration, weakness, shortness of breath they already know us and see a "familiar face". Makes it much easier and we can support those patient better. Families and patients see us more as an ongoing support because they have known us at that point already and do not think "they just come to talk me into hospice". So when a coworker mentioned yesterday "I do not even know why you are seeing that patient - they are not there yet" I explained exactly the above and that palliative care is life affirming and helps to find out how to live best with a serious illness. That includes physical comfort but also spiritual and emotional well-being of the patient and family - and the patient determines what is important to them - not us - we help to facilitate. Sometimes it is the extra time I have to sit down and listen that give the extra comfort that a patient needs. Sometimes I can make a recommendation that helps, sometimes I refer further to connect to more services, sometimes I educate the patient, family or nurses.
I learned that there is a podcast about "when is it ok to lie to patients" that provides the view of some providers. There are also other podcasts. This on is about 27 minutes and I enjoyed listening to it. This topic comes up regularly - I have written about it before. Mostly in the context of family members who do not wish to worry the patient or in cases where a patient has problems comprehending the full extent.
Fall/winter is also the time of COPD related ED visits.... I have been looking into some tools to assess the shortness of breath, There is a numeric tool that uses the numbers 0-10 similar to the pain scale. There is also the Modified Borg Scale (MBS) that correlates the subjective complains with a number , this link also talks about the validity of the tool:
I like the MBS because it is relatively easy to use and if a patient has problems with numbers you can read the "severity" explanation to help them rate.
But I also like the FDS - the link also has a short explanation how to assess. I like this tool because it allows the clinician to summarize an observation into a "finding" that correlates with the stage of illness. For example - if Mary tells me that her self rated dyspnea with the MBS is 0.5 at rest but I see her short of breath with putting on her clothes as evidenced by a high respiration rate and visibly labored breathing, and perhaps I also measure the SPO2 - that tells me as a nurse that the patient feels and seems "ok" when not doing anything but with a certain amount of exertion the symptoms get severe - and that is when COPD patients, especially with stage 4 COPD, tend to go to the ER more often. Granted, now that it is almost winter, there can be other things that exacerbate the COPD like a pneumonia or cold, but most often it is the ongoing decline with COPD stage 4.
I like to use scales to evaluate if symptom control is working when the patient is ordered for a small amount of roxanol sublingual to help with symptom control COPD. Typically the providers order for 5 mg of sublingual roxanol (it is concentrated so it is a small amount and gets absorbed that way and works within 20 minutes if dose is sufficient) PRN every 4 hours to begin with. When it is a new medication in the hospital for endstage COPD to assist with symptom control (because there is no cure and at that stage symptom burden becomes a problem for most patient at home) I have the patient rate their dyspnea at rest and with activities before the medication. After the primary nurse gives the medication I wait and come back, let's say 30 minutes later, and ask again and also look at the functional level. If possible and appropriate I have the patient walk a bit as well so they can get an idea of how this medication can be a helpful tool to use before exertion (example : I will ask Mary to take the ordered roxanol in the morning before she gets going with showering/getting ready and to wait 20 minutes before activity).
So - it turns out that many patients get discharged with roxanol and home care nurse for ongoing assessment /teaching but short time later they are back in the ER with the same complaint : SOB but no new pneumonia or infection.
What now? I do another assessment and most often it turns out that the patient got the roxanol but never took it and is afraid to use it "because of addiction" or "once you are on that trail you die". Although I address those items with the initial teaching, it does not always help.
I do more teaching but also have the patient use the roxanol while in the hospital so they can experience first hand that it is really just a tool and will not "kill me". And I emphasize that this tool is not just for emergencies - I do not want them to wait until thy are highly SOB, take 5 mg of roxanol and call 911 because they waited too long and now are in a panic. I want them to realize when they experience most symptoms with SOB and to use the roxanol as a tool before that exertion or if constant SOB as ordered by the physician and that can mean several times a day. Labeling the medication as a "tool" has helped a lot of patients to realize that this is really an intervention for symptom control that gives them more control over their symptoms ! Pro - Tip: the concentrated roxanol for home use comes with a special cap you can screw on and a small 1 ml syringe fits on there to measure the right amount. Patients/families/home care nurses can draw up a couple of syringes with a cap and put them for example on the nightstand so that it is available and ready for use.
Of course those patient also need a bowel regimen....
My other big topic to do more research for caregiver tools was dementia with difficult behavior. Families have a hard time understanding the functional decline that is related to dementia. But when there are behavioral problems that are hard to manage at home it creates a lot of stress for the caregiver and the patient.
I like that it gives real life perspective and some tools. There are for free resources from the National Institute on Aging and I like this one for nurses in acute care, especially the section about catastrophic reactions and what to do as a nurse :
Sadly enough, there are many tools to assess pain but it remains a challenge to use a validated tool for patients with dementia who can not self-report as in some cases the observational tools also do not result in meaningful action. I learned that this study looked at 28 different tools and the conclusion is that we do not need more tools but we need to look at the how and when to use which one and what the evidence is as well as feasibility:
But here is my problem - there are patients in the hospital who have surgery, for example after a fall to fix a broken hip, and they also have advanced dementia. The nurses pain assessment using the pain assessment tool does not indicate pain so no PRN pain medication is given but logically we know that 1. this is surgery and painful after - we need to give something 2. the patient shows other behavioral problems that are not captured but are most likely related to pain 3. we often do not know the baseline and have problems putting it all together.
As part of my assessment I call the facility if the patient was in a facility (resident of rehab) and ask specifically about their previous functional level and what strategies they have been using for different problems. It is time intense and I can see why the primary nurse does not have the time to talk about it. It does provide good information most of the times and I convey the information to the primary nurse and nurses aids - sometimes we brain storm together.
And I found this great blog about sickle cell disease - it is from the UK. Our patient population includes few patients with sickle cell disease - it seems that most go to the city to get their care at a center that is more specialized (which makes a lot of sense to me). But we do see some younger folks who come to the ER because of the severity. I was looking for some information about life style and sickle cell disease because when young adults transition from pediatric care to adult care they are also often at an age that is challenging in terms of life style. I wanted to get some solid information about how life style influences sickle cell disease so I can give out some information to this subgroup and incorporate it into nursing teaching. Here is the blog - it is my favorite of the week because of the way the author conveys information to people who have sickle cell disease :
After that first mess, I watched how a lefty did it and learned fairly quickly.
brownbook
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I learned that when I disciplined myself to go cold turkey, no more Allnurses, I felt better and got a lot more done! At the very least I limited myself to only check Allnurses after I had finished my chores, taken care of some duties, read a book!
Sadly I have had a relapse! I feel like the stereotypical computer troll/nerd sitting at my computer all day in a dark room gaining 100's of pounds. I need AA for Allnurses!