Getting better at this nursing thing

Last night, step-down unit. Elderly patient admitted with sepsis. Around midnight she became hypotensive, confused, and agitated. She pulled at her lines, her oxygen, she yelled that the blood pressure cuff was too tight. She kept moving her arms and occluding the IV delivering her fluid bolus.
"If you can't keep your arm relaxed and stop pulling at your lines, I'm going to have to tie your arm down," I told her. In a calm voice, really!
"Just because you're pretty doesn't mean you won't go to hell for that!" she said.

She got more cooperative after we started the dopamine drip.


I've been working on my own now, without a preceptor, for just over a year. Finally! The details are coming together! My understanding is starting to gel. This month I've had a lot of complicated patients and I've been working in the step-down unit quite a bit, which I'm really enjoying even though there's a lot of suffering back there. I feel like I'm a better nurse: When my patient is vented, I feel there's more emotional connection. I like the details! I like the charting! I like it when I can fix my patient's problem. And I like playing the supportive role to the patient and family through the dying process. It seems like something changed almost overnight, and I'm not sure what it was, but I'm glad it happened.


In other news, the City of Berkeley passed this fabulous resolution supporting RNs in negotiations with Sutter Health. To see it, go here, scroll down to "This just in..." and click on "Berkeley City Council Resolution." It's really touching! I love Berkeley. Berkeley loves nurses.

What I've been doing

IMG_1063.JPG, originally uploaded by a bird with a stethoscope.

A whole lot of gardening. Vegetables mostly, with some herbs and flowers to attract bees and hummingbirds. It's helping to find the balance.

I've been a nurse for a year now. It's getting a little easier. I'm still working on the same unit, and I recently took a critical care class and oriented to the step down unit. It's good to be developing my career: learning to manage vented patients, titrate drips, and expand my comfort zone a little. I had a real moment of competence a few weeks ago: I was starting an IV on an ALOC patient while the family grilled me about why we weren't feeding her. I calmed them, educated them, and got the IV on the first try.

To those of you still checking in--and I hope there are a few of you--thanks. I still want to blog about nursing, but lately I just want to blog about gardening, so. We'll see what happens here.

Venting

My phone woke me up. I didn't answer it, but I couldn't fall back asleep. I listened to the message. "Hello Birdy, I'm a nurse manager on another unit at your hospital calling regarding a stroke patient you cared for... She went on to develop a pressure ulcer so we are required by law to report this to the Department of Health and Human Services. I just wanted to let you know that a rep from the DHS may be contacting you. A routine matter. Feel free to call me if you have any questions..."

So. Now I'm awake and I'm grumpy. I was grumpy going to bed because after my shift I had to sit through an hour lecture on AIDET, my hospital's solution to low patient satisfaction scores. We're among the best hospitals in the country for clinical excellence, but our patients aren't satisfied. Would you be satisfied if the unit where your mother stayed for 3 months was inadequately staffed and she developed a bed sore? I might as well have said, "Hello, my name is Birdy and I'm one of the nurses who will be caring for you. I want you to know that it will take about three months of sloppy nursing care to give you a bedsore. Bedsores are completely preventable and my manager and I care very much about our patient satisfaction scores, but we are inadequately staffed to ensure that there is someone available to turn you every 2 hours and clean you immediately after you get wet. Thank you for cooperating with the plan of care." AIDET looks good and sounds good, but it's not addressing the real problems. Duh.

I was a little ragged this morning anyway because I cared for a set of very sweet patients, two of whom are about to be diagnosed with fatal conditions: Brugada syndrome and pancreatic cancer. I hate knowing things like that about my patients when they don't know yet.

Sounds like I need a vacation. Luckily I'm going to Hawaii next month.

The inappropriate transfer

Hello! Yes, I'm still alive. No, I don't hate nursing.

It's been an interesting week. I saw DIC at the clinic and then I got a completely inappropriate transfer from med-surg who I immediately sent to ICU.

Here's what report sounded like. "...88 year old female admitted with pneumonia, history of COPD and GERD. She's DNR--er, she has an old order--"
"But there's no current DNR order?!"
"No, it's like an advance directive or something... Started desatting into the 80s, we have her on 15 liters nonrebreather mask--"
"She's COPD and you have her on 15 liters nonrebreather?!"
"The doctor's aware."
"What are the transfer orders?"
"It says, 'Ok to transfer to tele, follow Protocol C'"
"What's Protocol C?"
"He said you would know."
"Hang on." To the charge nurse, "What's protocol C?" No one knew.
"Okay I'm going to need new orders because we don't have a Protocol C here. Did you get an ABG?"
"No. Here are her vitals: 99.1-125-28-195/95. I started her on cardiazem last night...."

And on and on. The charge nurse called the supervisor, but the patient came to our unit anyway. She was blue and her O2 sat was in the 70s. The charge nurse called the pulmonologist while RT and I worked with the patient. The doc didn't know the patient either, but after I told him what I knew he said, "So they really didn't do anything for her down there, huh?" He came right up, we transferred the patient to ICU and she was immediately intubated.

The totally annoying thing is that we have resources at our hospital to help in situations like these so that the appropriate decisions get made. We have pulmonologists. We have RTs. We have the pre-code team to call when a patient starts to crash. I don't know what was going on down on that other unit, and I don't know what they thought we would do with that patient with orders for "Protocol C."

Anyway. I woke up too early today. I'm hungry for Ethiopian food. Maybe I'll get take out on my way to work.

Finding the balance

Well look at that, two months have gone by since I last blogged. I haven't had much to say: tension has been running high on my unit. And I sure will be glad when this first year of being an RN is over.

A while back, I made a mistake. I hung blood without a consent. There was a lot going on that morning: my patient was new to me from ER, very sick: critically low h&h, blood glucose, serum proteins. I was very busy with this patient. At 0630, the blood bank called: my blood was ready. As the morning nurses started drifting in, a patient suddenly coded down the hall. The relief nurse checked the blood with me, then went to the code. I started the transfusion and got the three sets of vitals.

When my manager spoke to me about it, she offered to place me on days. She said she feels there are more resources on days to help a young nurse, but that she just can't offer any more "resources" to night shift. When we spoke, she had me cornered in the break room just I was leaving. I was too tired and feeling bad about myself to register what she said.

Since then, I've realized that she basically acknowledged that there are problems on night shift but that she isn't willing to step in: not for patient safety, not for possible legal consequences, and not for the health of her employees.

And I'm mad about my job. Why do doctors even order blood without getting the consent? Why is it my job to make sure everyone else does theirs? Why do I have to be the gatekeeper between the medical chaos and my patient, while simultaneously acting as a waitress, secretary, hostess, family therapist, and nanny?

I think that's when I started not wanting to go to work, when the anxiety dreams got bad, and when my right wrist started bothering me, and my left knee, and my upper back.

It's starting to get better now, though. I had a week off. I moved to a much nicer house with housemates I know and love. I've started working out again, which has hugely improved my general outlook.

How do you find the balance?

Nurse dreams

Even when I'm asleep, my brain is at work. Tell me, nurses, what do you dream about?

RT love

Last night was the kind of shift that makes me not want to go back to work, but of course it was night 1 out of 3. My patient went south on me in a serious way, which I wasn't surprised about because when I walked in the door that evening I just knew she would be my problem child-- 89 year old hot hemorrhagic stroke, full code, nonresponsive. Around midnight she started having airway issues: lots of secretions and noisy breathing/rattling. Her oxygen saturation was fine, but she sure sounded occluded. I called the respiratory therapist for a consult and he helped me manage her airway for awhile. We didn't know whether we were dealing with aspiration or brain stem involvement or what so we called the RAT (Rapid something-or-other Assessment? Team) and we all talked some more about aspiration vs neuro issues. I called the doctor who ordered an ABG and a chest xray. "Aren't you worried about brain stem involvement and her stroke progressing?" I asked. "She is a hot stroke," I reminded him. He wanted to see the xray first.

...Anyway, after all night of monitoring her closely, she went into worsening respiratory distress. I called the doctor and got him to come up and have a look at her. We intubated immediately and sent her to ICU. The RT joked, "I've been waiting to do this all night."

It was so stressful! My other patients didn't get enough attention from me, which was mostly okay because they were stable, but still there were a few things that completely fell through the cracks, and the nurse I reported off to was so bitchy to me!

The two RTs I worked with last night though were angels. We discussed the situation as equal professionals even though I'm obviously so young and inexperienced. They went over the ABG results with me. They taught me so much and were so helpful and supportive. Thanks, all you respiratory therapists out there. I couldn't have done it without you.

Lemme tell you, this being a new nurse thing is sure tough. It's way harder than school ever was. It's challenging in so many very personal ways. I love it. Even times like right now, when I hate it.

I think I dreamed that this patient opened her eyes. I hope while I slept I also grew a thicker skin.