I'm OK - You Need Meds

Relaxation technique

2007-08-31T07:57:00.000-04:00

Step one: plan a vacation. make it simple. a week at the beach sandwiched between two or three days of just doing nothing. and i do mean nothing.
Step two: avoid stuffing anything else extra into your time off. like thinking.
Step three: why are you thinking?

My symptoms began innocently enough. Irritability, anergia, hypersomnia, anhedonia, dysthymia... my mind began wandering to greener pastures. Suffering from sheer exhaustion and lack of patience, my thought process turned on me and I began to envision finding a new place of work.
For as long as I can remember, I've employed a certain sense of all-or-nothing to cope, or otherwise entangle myself in what I perceived as proactivity.
Just go on a diet? Not enough. Let's try loosing weight while stopping smoking, and throw in a new radical haircut to deal with, too. Frustrated with work? Why not look for a new job while going back to school, joining a few committees, and plan a move out of state, too!
The latter plan of action is exactly what I employed to being about change.
What am I, nuts? Don't answer that.

For some time now, I have been estranged from my spouse due to his work obligations. We have endured the separation by frequent visits and thrice daily phone conversations, but recently have been hoping and/or planning to regroup sooner rather than later.
Where he resides offers more opportunity for professional growth - and a higher rate of pay - yet the cost of living and general frustration are out of control. Sounds like a good option so far, right?
As luck would have it, one potential employer I had my eye on advertised an opening that got the ball rolling. (that would be the little red ball in my head that spins around on a hamster wheel)... I spoke with the recruiter, who was so very interested and so very encouraging she suggested I consider the next level of responsibility (supervisory!) and booked me an interview complete with shadowing for half a day and lots of anticipatory angst. This was to take place at the tail end of my vacation; I intended to cut my beach-time short by two days to attend the meeting.
The next few weeks were fraught with worry and planning, browsing rental property, preparing the resume and references, shopping for "the" outfit that would be just perfect to land the position, reviewing successful interview techniques and pondering how best to pack up ten years of crap and whether to sell this place or rent it out. That is just how delusional I am. On the one hand I know that a single interview does not mean I'm going to GET the job, but, you know, what if? I found myself drifting away at my present job, emotionally separating myself, subconsciously letting go and forcing myself to not drop too many hints of intention. Add to that the fretfulness about performance and compatibility, and did I really think I could do this job, it's a huge leap, was I ready, is it too much, ad nauseum...
As it turns out, someone with the power to HIRE, not just recruit, reviewed my experience and called me just a day before I left for vacation. Would I consider applying for the lesser position available? The supervisory position availability was kinda "iffy" from the get-go, she said, they preferred to staff it from internal resources, and maybe I would feel more comfortable as a staff nurse. It's like she read my mind. Yes, perhaps the level I option would be more in my comfort zone, but.... the salary structure was not what we required to make the move. We would barely be able to exist in that metro area, we'd have to find a place out in the sticks, and I was not looking forward to a two hour commute each way. I decided to cancel the interview, and told them I appreciated their consideration, in a "keep the door open" kind of way, and they will hold onto my information for a year just in case I change my mind.
My vacation was so much more enjoyable. Rather than thinking about the maybes, I focused on the present, and completely vegetated while working on my tan. We fished, we packed our cracks with sand, we ate at restaurants (actual sit-down-and-be-served places!), and I didn't even wear my watch the entire time. We had no plans, no obligations, nothing to worry about except the SPF15 not holding out. It was AWESOME, and just what I needed to gain a little perspective. Upon my return, people commented on how relaxed I looked, and that I was positively glowing (the SPF15 did not hold out, I'm sorry to say).
All in all, I'm refreshed, rejuvenated, and ready. Bring it.

On a hospitable workplace

2007-08-17T10:12:00.000-04:00

Reading the latest posting over at Mother Jones', and pondering the phenomenon of nurses eating their young, I would like now to discuss those ornery coworkers who strive to find issue with everyone else on the team.
You know the ones. The people who complain about others to the point you just roll your eyes and walk away from the conversation.
I've long since decided that getting caught up in the gossip wheel is too much like junior high. To quote F0rrest Gum.p (sort of), "My mamma always said... if they is talking about her, they is gonna talk about you, too."
In the distant past, I worked in the corporate world. Women outnumbered the men in my office 5:1. I learned back then that women rarely get along with each other. I noted that I had very few female friends from the get-go. Just too much cattiness and insincerity. Maybe I had trust issues; maybe I still do. I was burned several times during my formative years, and I have the char marks to prove it.
The antagonist in my present tale is a young nurse with superb talent and skills, someone who I actually enjoy working with. She is unhappy. With what, in life, I am mostly unclear, but I do know she has anxiety issues and unchecked OCD in a mild yet workable format. She has tried medication in the past, but being newly married and desiring a pregnancy in the near future, she decided to let her brain chemistry go au natural. I mention this because, if I were allowed to do a little psychoanalysis, this gal has some baggage.
She came to psych directly from nursing school, and has not yet lost her touch with the med-surg side of things. If she were to transfer to a medical unit, she would shine, I am sure of it. She doesn't wish to do so, because 1) they won't take her anyway because she's wasted four years on a non-medical unit* and 2) she feels as though the pace on a medical floor would push her over the edge. Thing is, I'm not sure she belongs on psych. She quickly becomes frustrated due to lack of control of patients' behaviors, and her therapeutic communication often resorts to hugs and "Awww"s. But mostly, her attitude toward other nurses and ancillary staff is surprising, due to her sympathetic nature.
*(her words, not mine)
Her expectations of others are rather lofty, and she lets that be known. Not to your face, of course; she'd rather complain about you to anyone who will listen. Not a shift goes by that one doesn't hear "I don't know WHY so-and-so can't keep up/didn't do more/isn't swinging from the light fixtures while charting and transcribing orders and wiping poo with her free hand!"
When we used to listen to taped report, there was eye rolling and heavy sighs that signaled her growing frustration, and the occasional comment about whomever/whatever she felt could have been said or done to her exacting standards. Now that we're doing face-to-face report, the reaction has been muted to a neat little silent treatment and an "I'm too overwhelmed to discuss your mistakes with you" demeanor.
Can everyone say PERFECTIONIST?
I'm not sure if her childhood was wrought with never living up to daddy's expectations, or if her new husband is the culprit. Perhaps the spouse is what keeps her on the level and offers support and encouragement out the wazoo. Any way you slice it, my take on the chick is that she has some self esteem issues. By striving to be perfect, and taking down anyone who stands in her way, she is feeding her need to be lauded as A-number-one and attain recognition.
I must admit, I have not noticed any mistakes made by this little princess. I'm sure they're out there, but I don't play that game. In my opinion, she does her job (and then some), and does it well. But, so does everyone else on our crew, no matter the shift. We have some seasoned staff who are able to do a little more, and we have some that just do the bare minimum - and that is acceptable, too. We all have "our days" when things go in slow-mo and you just can't find the gumption to do one.more.thing.extra; these days are often interspersed with full throttle doitallness, and things just balance out.
I hope with some experience and maturity she is able to find her happy medium and some satisfaction in herself.

Strong-arm tactics, and (possibly) Dumb Luck

2007-08-15T10:58:00.000-04:00

It has long been a concern that physician's conversation with patients in a hospital setting is anything but private. Besides the nurse, physician's assistant, intern, students, and any other staff (housekeeping?) that may be in the room, there is also the roommate who can hear every last detail about the patient's complaint(s) and what the plan of care might be. Sure, the curtain between the beds will be pulled as a visual shield, but the audio is at times more interesting by a long shot.
Unlike the med-surg unit, our psych unit can -and usually does - afford a little more anonymity to what meds are being given to whom, who has what diagnosis, and what their follow-up care will entail. This is not fool-proof, of course. We still have some semiprivate rooms, and community group sessions are a staple; in addition, for any patient who has a psych history with occasional (read: frequent) hospitalizations, one pretty much 'knows', or can certainly guess correctly, the potential diagnosis of their peers. Not to generalize, but yes, sometimes you can tell by looking at/interacting with someone that they are most likely schizo.
Our (newish) psychiatrist that covers the majority of our inpatients understands the need for privacy, and has established a suitable, if rather inconvenient, location on the unit for treatment team sessions. The other shrinks prefer the "walking rounds" method; one in particular likes to create an impromptu "office" smack-dab in the middle of the hallway near the dining room. I often wonder if the patients we bring out for him feel a bit like they're in a spotlight. None of our staff cares for this set up, but he has done it for years, and he's a bit of a diva anyway, so we comply. (To our defense, we keep the the audio to a low level, and do provide a human barrier to the visual access.)
Aaaanyway... on with the story.
One patient is a good candidate for ECT. Over this past week, various members of his healthcare team have suggested this to him as an option. He is on our unit as an involuntary committal. To get the ball rolling, we would need him to sign consent for this treatment, as well as agreeing to stay with us for a while without the court's involvement. As the treatment was intended to occur, like, tomorrow, Dr. Bigshot stepped up the process by hounding the patient all.day.long. In an act of desperation, I can only assume, the physician enlisted my help. Although he had to look at my name tag twice during our conversation, he did personalize the request by addressing me, by name - twice. Really gave me the warm fuzzies. He felt I showed a good rapport with the patient, and he needed a witness to the signatures he felt sure we could obtain.
We went to the patient's room to coerce him some more. Long, detailed explanations of the procedure had scared the patient before, in my opinion. This time, short descriptions were offered and loads of encouragement were piled on top of it all. Finally, the doctor warned him that he might be forced to seek out a guardianship if the patient wasn't willing to agree voluntarily. That tactic *sort of* got the patient's attention, but only momentarily. Then, in what I can only describe as an amazing twist of luck, the patient's ROOMMATE intervened.
Yes, for all the harping we do about invasion of privacy, this time it worked to benefit a patient.
The roommate came over and and simply stated, "I've had ECT before, and it really helped."
When I thought Dr. Diva might just spin around and growl, he said nothing. He laid his hand on our subject's arm and said, kindly, "You know we want what is best for you."
The patient (who does not make eye contact), turned to his roommate, looked him in the eye, and spoke to him about his experiences! I was floored.
We got the requisite signatures, and began an immediate clearance workup for therapy to begin in the morning.
I fully expect the patient to backslide on this decision many times until the treatment begins to show efficacy, but I am glad this first step was taken.
Of course, I can't end the story without a touch of irony thrown in for good measure. We got what we wanted at the expense of violating whoknowshowmany rights, a point that was beat to death during report at the end of our shift. One nurse went so far as to say that the roommate was out of line, and should be reminded to stay out of other people's business; he was being "intrusive". That was a fine line, I admit; had I the opportunity to do it again, I'm not sure I'd even agree to be present.

All over the place

2007-08-03T01:12:00.000-04:00

Where to begin...? I'm having flight of ideas!
~~~~~~~~~
Today, two families presented with our new admissions, and both parties agreed that "This unit isn't what we thought it would be."
Today, two families and the patients themselves complained that the degree of dementia our other patients were suffering was making them (the new admits) actually feel WORSE and they wanted to leave. The doctor replied with a terse "You need to be here" and told us they could sign their 72-hour notice(s) if they really wanted to, but otherwise they would be leaving AMA, which of course means no meds or follow-up.
Today, one husband said he would be contacting his lawyer.
And, today, three of our staff nurses have penned letters to the nurse manager and director of the unit regarding the (in)appropriateness of our current clientele.
It's what we have been saying all along.
We are not intended to be a dementia unit.
It's not that we don't enjoy the Alzheimer patients. Being that we are a geriatric psychiatry unit, one would expect to find a certain degree of cognitive decline and behavioral issues that are associated with dementia... along with the accompanying psych issues that we are intended to treat. But! But...
We also are supposed to care for patients who have a major depressive or anxiety disorder, schizo-affective disorder, schizophrenia, bipolar, and post-traumatic stress disorder (to name a few). None of these are an ideal mix with the wandering, yelling, confused patients who drive them to the absolute brink of violent madness. The depressed patients become more withdrawn and isolative, helpless, hopeless, needy, and at times, even suicidal. (If I'm going to end up like that one day, there's no point in going on...). The anxious patients become even more anxious, to the point of hypomania if not full-on manic. The psychotic patients become nearly unmanageable because their thought process is already disordered, and this new distraction is too much to handle.
We are asking that some consideration be given to the psych patients that need our services. The ones that can benefit from group therapy, activities, medication management, and a safe environment with caring staff who are attentive to their needs. Instead, our time is spent changing diapers and feeding patients who have regressed to the point that a meaningful conversation is out of the question. We have no gripe with providing ADL support and the usual nursing care that any patient might need at any given time, I promise you that. However, the purpose of this unit is to treat psychiatric disorders, not provide a holding bed until a nursing home is chosen.
At our last unit meeting, fingers were wagged because there haven't been afternoon/evening groups held for quite some time. When we do manage to get one logged on paper, it reads "nutrition" or "hygiene" because all we can get done is feeding and showering.
The patients we have had recently include a 79 year old completely with-it woman who has been bipolar for 40+ years. She is severely depressed and very worrisome. She sensed a worsening of her symptoms and requested to be admitted before she goes "over the edge".
Today, she said she couldn't take it here anymore and did sign her 72. She said she'd rather lay in her own bed all day than listen to patients X, Y, and Z one more minute. Then there's the 70-something patient with worsening DM, hemodialysis, and a BKA. She's pissed at life, herself, and her doctors. She wants to die. SHE needs help with her ADLs, of course. But she belongs here. We can work with her, try to improve her mood, her outlook, her hope. Sadly, she gets to wait in line because patient Y just pooped himself and is crawling out of bed again.
A 50-something patient with history of severe depression and SI, who is also a cutter, wanted to be admitted to our unit. She had been here a few years ago, and we had helped her. She has been seeing a therapist who helped her uncover some demons, and she knew she needed a safe haven to protect her from herself. Most of us got to see her once or twice a shift.
Yes, there are some serious safety issues at play. We get 'spoken to' when a patient maneuvers their way out of the w/c with alarm, seatbelt, pummel cushion, and lapbuddy, and still manages to fall; yet when we try to afford the treatable patient with the appropriate therapeutic milieu, we should have been somewhere else, like babysitting.
We had a 64yo woman with newly diagnosed CRF who receives peritoneal dialysis. Her depression over her health issues was overshadowed by complete irritation at the demented ones. She said she had hoped we could help her with coping skills and positivity as she adjusted to her new medications and lifestyle. Instead, she attended one group that centered on "some memory-trivia game for the old folks" and colored some pictures. We have been offering one-on-one sessions for therapy as appropriate. The rest of the time, these folks are bored! The social worker, COTA, mental health technicians and nurses all agree that holding "groups" for two or three patients who would benefit, is all but impossible, when all available staff is needed to monitor the wanderers and fall-risks out there. And, when the day shift office people are gone, you can bet we use geri-chairs with.the.trays.up. Just don't tell anyone, mkay?
~~~~~~~~~~
I have been considering a move to the adult psych unit. Or back to med-surg. I really don't *want* to, but if I gotta, I will go.
That's what sucks about the geropsych situation.
As a rule, I do like my job.
But I see two possible scenarios.
One, we limit the admission of dementia patients who can be managed at their current facilities. Or,
Two, we make some serious structural changes to our unit to accommodate the needs of those patients; invest in adaptive equipment; and add some more staff, for Pete's sake! Then, they can divide up the dementia pts from the regular psych pts, and everyone is warm and fuzzy.
~~~~~~~~~~
In other news, as the fall semester looms on the horizon, I have yet to get my three 12's, as promised. They're working on it, I am told. I even offered to work the goofy 3P-3A to help out the evening/night crew (which I currently work on, anyway). Waiting.
And, I joined a committee to placate my NM and fluff up the ol' resume'. Why is it, all committee meetings tend to be a boring rehash of the previous meeting's minutes and intense planning of what to accomplish at the next meeting (and so little tends to get done!)? Then there are those action words we all love to hear: utilize, implement, exercise, augment, accomplish, enhance, enrich, efficient, proficient, fiscally sound. Bah! ::vomit, hurl:: Now I know why my bandage scissors have the nub at the end of the blade... Julie doesn't need to handle sharp pointy objects.
~~~~~~~~~
Ahhh. Well now that's off my chest... I have little else to offer right now.

Here's to a wonderful end to a sensational summer season! Cheers!

Safety

2007-07-25T01:12:00.000-04:00

A respiratory therapist in our hospital was assaulted in a stairwell the other day. She was knocked around a good bit and the man took her ID badge and ran off. He has not been identified or found. He didn't attempt to steal anything else from her, keys nor phone; there was no attempt at rape. The badge was immediately deactivated, so I guess he'll have to pay the $2 to get out of the garage. When I think about the things that could have happened, I get the willies.
Our hospital has been involved in some acquisitions in the past several years. As they continue to grow and expand, the other facilities are converted for use as necessary. The building I work in, where this occurred, is one such facility. Once a hospital of its own right, for the past 10 years or so it contained mostly admin. offices and - of course - psych. Slowly, they began to add one medical floor, and then another, and now plans for yet one more. They have built a cross-over to connect the two hospitals and now have a tunnel for patient transport between them as well.
The tunnel has cameras every few yards.
The major public access areas also have security cameras.
We have security personnel who make rounds at least once per shift.
While the bulk of the secure-ness is maintained at the "main" campus (especially the ER), we never really worried much about our building.
On our floor, we have three security cameras to monitor the patients in the hall and the people who wish to gain access at the front door - but none of these have feeds to the security office. If we aren't sitting at the nurses' station to watch the monitors, we have no idea what is going on.
They don't record.
There are no cameras in the stairwells, nor near the entrances to the stairs or elevators.
Whoever did this probably had a pretty good idea of when the last security officer passed through, and just waited for the right moment to jump.
What did he want? Why her? She didn't have keys to any med room. Her badge didn't allow access into our top-secret alchemy lab. She holds no clout with the HMOs.
Coming off shift tonight, walking the long empty halls to the parking garage, knowing that one camera's view drops off for about 10 yards before the next one picks up, and peeking into every cubby hole, blind corner, and sunken doorway along the way, I wished I had my pepper spray. Or an alarm. Even a whistle. But who would hear it? The areas I had to navigate are quiet and without traffic at midnight. Should I have asked for a chaperone?
How safe do you feel at work?

Luckily, my neck broke my fall.

2007-07-03T09:40:00.000-04:00

I receive several visits a day, though my lack of comment(er)s seems to prove otherwise.

Along with random landings and those lent in my direction from other's lists, I garner some unusual search hits, as well.

Today's weird inquiry :

"Do rectal swabs hurt?"

My guess is, you may feel some slight discomfort.
I'm saying, is all.

Can't quite figure out what content in my blog led this person to me of all places, but what the heck.

And anyway, I should be thankful for the attention. Seems I have fallen off of some high-profile blogrolls, and it sort of makes me sad. Sure, my content hasn't been all business lately, and that's because I have a life full o'crap going on at the moment. Glad I don't need to feel validated or anything trivial like that.

As such, I'm sure the bloggers I read appreciate positive affirmations too; therefore, I'll try to be a better blogger & commenter, and I will finally put together my very own link-list. So there.

How 'bout this weather, huh? Friggin' awesome. Now, if I could just get my ice-cold coworkers to realize its effing JULY already and we can turn the thermostat down past 75, all will be right in the world. Put on a durn sweater, I'm dripping over here.

Finis

2007-06-21T18:50:00.000-04:00

They took MaryAnn off the vent this morning. Funeral tomorrow. I'm sad for her family. She will be missed.

palliation

2007-06-19T04:41:00.000-04:00

They've weaned back the complete sedation so she can nod her head and squeeze your hand for communication.
Her husband says the "plan" is to get her back to "where she was" (meaning, three days ago when she was bucking the BiPAP); his goal is to 1) keep her comfortable, but 2) able to carry on a conversation. He wants the family to be able to have final moments with her.
There are discussions about a hospice center vs home care.
Funeral arrangements and a plot purchase.
How does she do the bills? Utilities must be paid. Mortgage is due. Car payments can't be late.
She's 57. Fifty-seven years old. Bald, pale, swollen with fluid. There are many boxes of kleenex in the room, for family and friends, and to wipe the tears from her eyes and the drool from her mouth.
She'd bought a purse like she always wanted. She worried he'd be mad she spent the money. He cried now because she even had to ask.
She'd had a sudden burst of energy recently; was able to do some quilting and finish a few crafts. Started cleaning out her closets and drawers, clothes that didn't fit.
I called her house, to leave a message for her family. It was strange to hear her voice on the machine. When I was leaving her bedside today, she raised her hand up from the soft wrist restraints and gestured with a few fingers. I have no idea what she wanted to say, but couldn't. But she knew I was there. Her husband gave her a foot massage. Her sister rubbed lotion on her scalp. The flowers her son gave her are at the nurses' station.
Too many thoughts, jumbled.

Fingers crossed

2007-06-16T22:41:00.000-04:00

My very good friend with the SCLC is in ICU; they were sedating her for intubation when I left. Her family is terrified of the vent. I'm just sad.
It's hard just being there for them when I can't fix it and make it all better.

Ouch

2007-06-15T23:41:00.000-04:00

I'm writing today to seek advice for hastened healing and pain management.
Lateral epicondylitis. Tennis elbow. Awful. Horrible. Ow.
I've had it for a while, off and on, but lately it has flared up and I'm getting zero relief.
It all started a good 15 years ago when I injured my rotator cuff, pulling a patient up in bed. Since then, I favored hauling dead weight from the other direction, which in turn has created a situation with the opposite elbow.
It has enhanced itself to the point that I have difficulty grasping and lifting objects. Sleeping is torture, it seems to hurt more at rest, and I never can find a comfortable position to lay my arms.
The mechanics of the musculoskeletal system are simply amazing; something I've never been quite so much in awe of until mine isn't working properly!
I've been icing it, and taking NSAIDs. I do not want a cortisone injection if I can avoid it. I try my best to rest it when I can, but the nature of my job is such I can't just *not* use it at all. Besides that, it's my dominant arm! Ugh.
Any advice?

Back in the saddle again

2007-06-10T17:16:00.000-04:00

I went on vacation, and all I got was this nasty rash.
PLE/PMLE, what ever you want to call it, it sucks.
I used to tan well, without even trying. Now, I still don't burn, but I get this itchy nasty funk on my arms and face. It's not an allergy; I get the rash even if I don't use sunscreen (but yet I do, of course, mostly).
So, anyway, my trip was rife with unfortunate events large and small, and all the petty inconveniences aside, I did not enjoy my leisure time. This may be the only time you hear me say it, but it's good to be back at work. (!) The 18 wildly demented people I was in charge of the last two 12 hours shifts are CAKE compared to the nimrods on I-95.
Have you ever sat on a highway (parking lot) for 3.5 hrs? Completely shut down secondary to an accident. My legs still ache. And swell.

A new GN will be starting orientation soon.
I might get to start my three 12's *sometime* this summer.
The time off I have coming in August will be plan-free. I am leaving it up to the fates. If I sit here in the a/c watching DVDs the whole time, it will be fine. I will be okay. Promise.
Back to school to complete my BSN in September.
Am astounded by how much I really like my job. Guess I just needed some time away to truly appreciate it.
Was unable to attend my 20-year H.S. reunion. From the looks of the photos, nothing has changed. You know how certain cliques can be? Well, they still are. Funny how none of my friends back then were in any pics. Perhaps they didn't bother to go either. I'm glad I'm all grown up now and stuff like that doesn't bother me anymore.

Ok, I found this link over at yorlor's, and I'm particularly pleased with my new title.

My Peculiar Aristocratic Title is:
Most Noble and Honourable the Carnivorous of Nether Wombleshire
Get your Peculiar Aristocratic Title

yawn...stress stress stress....yawn

2007-05-11T21:44:00.000-04:00

Wow, It has been a while since I posted. Thank you, Marcia, for checking in on me, and to the others who have left comments.
I'm okay! Busy at work! Things are just great.
We managed our way through JCAHO. Lost one nurse, gained another. Survived the winter doldrums. Keep getting readmits of the same patients, over and over.
Why, you may ask?
Because.you.can't.fix.dementia.
The bane of the unit is the need to keep beds filled. When I came here, the lure was that of psychiatric patients who just happened to be geriatric as well. Say, a person who had battled schizo-affective d/o all their adult life, and now just happen to be over 60 years of age. Simple?
If I had wanted to work in a nursing home, I WOULD HAVE STAYED IN THE NURSING HOME.
Everyone is so completely burnt out. We have had a flux of call-offs and people (even myself) who will not reply to a call-in because we just can't bear another minute of it.
The number one diagnosis we try to pre-cert? Dementia with behavioral problems. Please understand that these individuals are inappropriate for the therapeutic milieu.
1) If they are unable to attend or participate in groups, they are not appropriate for the unit.
2) If it is merely medication management that is required, that can be achieved at the facility where they currently reside.
3) The facility where they currently reside likely has the adaptive equipment and necessary staff available to properly care for these individuals.
4) If the person is returned to us in under two weeks of discharge, conversations must be had regarding alternative placement.
Currently, the most pressing issue is that of providing 1:1 observation for the acutely psychotic patient(s) who are a risk to themselves and others. Staffing seems to feel this is a minor issue (as we are a locked unit), and they offer preference to manning the patients who need this on the medical units. While that sounds like plausible reasoning, it is not. They need to hire more people. They ask us to "cover our own". We don't even want to work our scheduled shifts right now, much less come in extra for that. We have a seclusion room that doesn't lock. That's a restraint. ICU pt pulling at an IV? Soft wrist restraints. Hallucinating male pt who punched an 87-year old female in the face and knocked out her tooth? IM haldol and level 1 observation.
Right.
We have an 'executive' level person employed by our managing entity who is in charge of marketing (i.e. patient recruitment). This person has little to no actual healthcare experience. She is not a nurse, nor a social worker, nor has she spent any time on the unit to see how it works. Received a call the other day from her, while she was visiting a far-away facility. "We need to direct admit this man, for blahblahblah reason." Did he sign consent? No, he's too confused. Does he have a POA? No. But don't worry, she will spend some time to try and get him to sign the voluntary! Of course! Because that's appropriate. And legal. Not.
First, you need to have him medically cleared; he needs to come through the ER, and the physician and consulting psychiatrist need to determine his need for admission. You are not a doctor. Then, if they believe he will benefit from our program, or is a threat to himself and others, he can be involuntarilly committed. That's how it works. You should already know this, that's why you get paid the big buck$. Furthermore, there's the little issue of insurance. If I have to spend an hour on the phone trying to convince Big Insurance Company that he would be better served here than at his own facility, then Miss Marketingpants needs to come and do my charting, meds, and assist with ADLs.
Argh. Just venting a little frustration.
Since I began this post many moons ago, things have shifted much more pleasantly of late. After running at full capacity with no fewer than 5 patients surpassing the one-month milestone, we suddenly find ourself near half capacity, and are calling off or loaning out staff to other units! From the big picture standpoint, this isn't such a good thing, but right now, it is bliss. And, as we know, will be short-lived. Hey, I take what I can get.
In other somewhat-related news, several of our staff have expressed an interest in doing the three-12s offered. I'm one of them! Since the previous 6 months were so craptacular, it seems as though we'd rather concentrate our pressure rather than spread it out over 5 days a week. Makes sense, right? We have one girl going part time, two others wanting to go back to school, and a GN who expressed an interested in working with us. Wow! (sucker.... you have no idea. heh heh)
So, maybe I'll find more time to write again. Who knows?
If I have an extended absence again, I wish each of you a terrific summer!

I'm not okay - I need to up my meds

2007-02-10T01:26:00.000-05:00

There just aren't words. At least not appropriate words that I can muster right now.
I am prevented from discussing much of this case, but I will give it to you in a nutshell.
Psychotic patient self-aborts 32 week fetus.
Professionally, I am having a hard time dealing with this one; everything from how it managed to occur on the unit, to how on earth can you face a patient like that, with an open mind, objectivity and empathy?
Personally, I'll tell you this much: I'm am a mess.
I have tried to hear the information, file it away in my private mental library and lock it deep inside that little repressed safe. The door won't latch.
As a woman who has battled secondary infertility, and multiple losses, I am downright pissed.
As I am facing the 2nd anniversary of my stillborn son, 35 weeks, buried at the feet of his grandfather, I am absolutely nauseous knowing the mistreatment that baby received at the hands of his mother.
As a nurse, I can't wrap my head around this one. It cuts way to close to home, and I feel it is absolutely OK for me to step away from any and all involvement.

Crossing the line

2007-02-08T13:22:00.000-05:00

Sometimes, your personal life and professional life meet each other head on, and you're left dealing with some massive casualties. Tonight will likely be *that* night for me.
Due to the ignorance of a co-worker who believed herself to be doing the right thing, I have been forewarned of a situation that occurred last night (thankfully I was OFF); the whole department is still reeling. And I, having minimal information and a few hours to dwell on it, am trying hard not to get all worked up before I need to.
For now, I must face this with an open mind and empathetic heart, and do my best not to bring preconceived opinions into my workspace. My private thoughts, on the other hand, might be on their own.

Brrrrrr

2007-02-07T05:38:00.000-05:00

It's pretty cold. Right now, my thermometer reads 3 degrees. That is downright balmy compared to Monday. Two days ago I woke to minus 8 degrees (-8), with the wind chill factor making it minus thirty-five (-35)!
So, the boy has had two snow days off school (only a delay this morning), and since I also happened to be off (legitimately, I might add), we have pretty much just lazed around. It has been AWESOME. Thanks to the magic of Netflix and my rather lax nutritional standards, we have been very, very naughty. Looks like I'll be going a few feet farther on the old treadmill.
The best thing about winter is *Hockey*Season*!!!! I dusted the Dorito dust off my chin and headed out to catch an outstanding game last night. The boy's team tromped their opponents, and I was there to see it. Too cool. Since I am primarily 2nd shift, I miss most of his games. I'm so glad I was able to be there for this one. I narrowly escaped acting as the medic, however, because I was about 3 minutes later than she was in arriving (also late). Had to get my coffee, you know. Almost immediately after my arrival, one of the refs went down. The man landed hard on his coccyx after a nasty crash between several players and himself. (Remember, they don't wear pads). He was dragging his right leg afterwards, and though he tried to complete the period without putting any weight on that skate, he decided to remove himself and use a sub. Poor guy.
Here's another chilling story... unauthorized charges on my check card. No, not a fraudulent breech-of-security kind of thing, more like an alleged computer malfunction that took a week to clear up. I made an online purchase of some scrubs from a catalog floating around at work. I have three favorite places that give good service and decent products (read: affordable), and had not used this retailer before. Never again! For some reason, three weeks after our transaction they re-posted the charge to my account - the exact amount as the previous purchase. Seems something happened at the first of the month that caused all previous purchases to be posted again. WTF? As this was my Mad Money account, the balance remains low (really, really low) until I decide to plump it up a bit. Had I not been trolling around for more needless spending, and poised to transfer some funds, I probably would not have even noticed I.Was.Overdrawn. Ack! Several frustrating calls later, I was promised that the charge would be removed "soon" (fact: two more business days [Friday, Saturday, Sunday, Monday]). My bank said they would "probably" be able to undo the NSF charge once the error was corrected, and all I could do was wait. I'll spare the details, but will report that all is well currently, and I am a little less freaked out. This is exactly the reason I refuse to participate in automatic debit payments. I really don't care too much for the autodeposit of my paycheck, except it does free up some time. And I'm forced to. What's the worse that can happen, they pay me TWICE? heehee
Well, I'm off to my conference. Have a nice day, and stay warm.

A feel-good post

2007-02-06T02:47:00.000-05:00

I love my job. All my groaning about the little things that irritate me are merely a way to vent some steam. And we all need that from time to time, don't we?
I love my boss. My nurse manager is an absolute god-send, and if I could send her roses every day, I would. I mean that sincerely. We all love her.
I have worked at some pretty shitty places in my life. I can count on one hand the number of employers I have had that made me want to show up every day. Three, to be exact. It's a shame that during a nursing shortage/crisis that more organizations don't take a look at how they treat their staff. But this post is about greatness, so I'll go back to my happy place.
Currently, we are faced with a new nurse who recently resigned. There are many reasons for her departure, and concessions were discussed before she ultimately made her decision. We are sad to see her go. Besides feeling like we didn't keep her happy, we are also trying to juggle scheduling around as a result.
As you may have noticed from my previous posts, this is a tough job to do day in, day out. Not a lot of people can work in psych. Tensions sometimes run pretty high, and that fact is not lost on my NM. She stated in a recent staff meeting that morale seemed low. We, her loyal charges, didn't immediately agree. We thought we were doing well, and things were running smoothly. She, however, managed to pick up on little subtleties that suggested otherwise. And perhaps she's right.
I can't speak for my cohorts regarding their possible perks, but I am just tickled about the 1:1 we had the other day. For starters, she chose me to attend an upcoming conference. She also commended my effort and abilities, and soothed my frazzled nerves with compliments and encouragement that made me feel like a good investment rather than just a warm body to meet staffing regulations. Everyone needs a little ego stroking now and then, am I right?
She has given me confidence and added some fuel to the spark under my long-term goals. I think, after my son graduates this spring, I will start working towards my next degree - with tuition reimbursement and an extended contract, of course. If she believes in me, then I can, too! Warm + fuzzy = one happy nurse.

Customer service

2007-01-24T08:54:00.000-05:00

As evidenced by our latest P-G surveys, patients' families are not altogether pleased with our services.
Besides the usual "pillows were hard/flat/lumpy", "unit was too cold/hot/dreary", and "food could be better", we did get some valued feedback that pointed to actual issues that needed addressed. And that is another post for another day. Let us focus on my bellyache for now, 'k?
As with any business, a well-timed smile and weighted sincerity can go a long, long way.
It is not enough to display clinical competence and take the very best care of the patient - our number one priority.
We must appease the sons and daughters and sisters-in-law in a way that makes them feel valued and justified.
Seeing as how the family members are most often the ones to complete and return these surveys, one must pander to the offspring and siblings as though they are every bit your responsibility as well.
Staying well over an hour past posted visiting hours? Offer them a beverage.
Alerting you the very moment mom's foley drained 100cc into an empty bag? Give her a complete bed bath.
Complaining that dad's parkinsonian tremors are due, in fact, to the temperature on the unit? Put mittens on him. This is helpful to staff as well, when he digs in his diaper and then claws at you when you try to change him.
It says on the activity board that there was a group for coping skills earlier. Why didn't mom attend?
Wrong answer: Your mother is confused, disoriented, and spells the colors of the numbers that are floating by. That group was not appropriate for her needs.
Right answer: Oh my goodness! That was an oversight on my part, and I'm deeply sorry for the inconvenience. We will be having another session on self-care activities starting very soon. Would you like be the first in, to find a good seat? I could assist you if you'd like. (insert warm smile here)
There are the family members who are an obvious asset to have around. These are the ones who have a clue. Perhaps their loved one has battled bipolar for decades. They are used to the behavioral issues and abilities the patient can, will, or did possess. They are patient, kind, and understanding. They applaud your efforts, steel will, and patience. They are often grateful to have this bit of respite.
The ones that are red-flagged are the supposed "new onset dementia" patients' families. New onset dementia is a bit of an oxymoron. This patient has been exhibiting a steady decline, and the family has been in denial. Push comes to shove, and they just can't deal with it any more. Possibly the physical demands have become too much. There is also the factor of incidental depression and anxiety for the family member. This tends to weigh heavily on their own behavior. The son or daughter tends to expect or demand results far beyond their own capabilities, and transfer their guilt and frustrations onto the staff. Sometimes, we are left with the feeling that if you think you can do it any better, then please, take her back home. Instead, we grin and bear it.
I think, because we are often frustrated, we tend to avoid the family. This is w-r-o-n-g. The family wants - needs - to be involved, to know we're there for them. Sure, this burdens us with another patient, if you look at, but if we don't tend to the family's needs, we appear to be unavailable, uncaring, and possibly even incompetent. That nurse never stopped in to check on mom the whole time I was here. What if she needed something? I bet she is ignored all day long.
Currently we have a patient whose daughter is perplexed beyond all reasonable doubt about her mom's abrupt change in mental status. We received the patient after a lengthy stay on the medical floor. This woman was put through every diagnostic test one could think of, without a cause found. She does not exhibit the typical symptoms of dementia of any type. Depression, maybe. Psychosis, maybe. Basically she just sits there, mute, no eye contact, no response except to neuro stimuli. According to the daughter, she was driving her car, shopping, playing pinochle, and cleaning her house up to a week before she ended up like this. No CVA, no seizure activity on the EEG, no indication to what might be wrong. Unfortunately, the daughter is a wee bit on the manic side at this time. This poses a challenge to us, because she is more needy than the patient. She has submitted bulleted memos to the physician and social worker about what her mother needs, what she wants, and how these feats are to be accomplished.
A couple of days ago, she rushed up to me to ask what was going on with mom. She had heard the doctor prescribed her THREE new medications! Does that mean he has a diagnosis?? Because I was involved in about a gazillion other more important tasks, I told her I wasn't sure without reading her progress note, but I would do that soon, and get back to her. I never did. She left without further inquiry, and I forgot about it. During a rare moment of solitude, whilst enjoying a cup of very bad coffee, it dawned on me that I had neglected to complete a task. I hate loose ends. And I felt a little guilty. As aggravating as these family members can be, I really do try to put myself into their shoes and pretend it was myself worrying about my loved one. And, as every good nurse does, you visualize your own parent/spouse/sibling in that bed, and treat the patient accordingly.
So, I called her. The doctor had placed her mother on aricept, haldol, and celexa. She wanted to know what each pill was for, and what the diagnoses meant. I summarized the information she requested. I explained that sometimes medications are started not because of an assumed diagnosis, per se, but to treat specific symptoms. In short, her mood should brighten and her thoughts become more clear. Since the daughter displays a strong inclination for research, I offered to print her out the med-teach sheets on each drug, and told her they would be attached to the front of her mother's chart for her when she comes in. And then I did just that. Mission accomplished. Took less than 10 minutes start to finish. The bad coffee got colder but the warm feel-goodliness of my attempt gave me a boost.
She mentioned me during treatment team, stating I was an asset to this unit, because I offered her information and hope. And a moment of my time.

Yuppers

2007-01-10T08:27:00.000-05:00

Kick back, relax, and be glad you're on night shift this week. That's what I keep telling myself.
It's that time again. State inspection. So much better here than that last place I was at. Yikes.
Are all the "i"s dotted and "t"s crossed? Every form filled out in full? Signatures, initials, dates, times? If it's not documented, it didn't happen!
Blah!
You gotta love the restraints. Chart the same thing in three different places.
It amuses me how the medical floors (it seems) can tie anyone down for petty little reasons, and we have to jump through hoops backwards for our own protection. Not that I advocate restraints or anything. Nope. Just an observation is all.
Really though, we're not worried. We run a pretty good unit, and do what we're supposed to. It's just the prep work and double-checking that leads up to this visit that makes me a little wrought with exhaustion.
That, and adjusting my schedule to accomodate the shift rotation.
I'm getting too old for this. But I love it; keeps me on my toes and gives me a change of scenery. Some patients actually do have an "off" switch! And my LPN partner this week is just awesome - what a team! She knows the paperwork and routine better than I do. Indispensable, I tell you.
Off to bed now, have a great day everyone (all 4 of you)!

Puncture resistant. Who'd a thunk it.

2007-01-06T03:56:00.000-05:00

Dear Tide -
I'm writing to say what an excellent product you have! I've used it since the beginning of my married life, when my mother told me it was the best. She was so right. Now that I am older and going through menopause, I find it even better! In fact, about a month ago, I spilled some red wine on my new white blouse.
My unfeeling and uncaring husband started to berate me about how clumsy I was and generally started becoming a pain in the neck. One thing led to another and I ended up with a lot of his blood on my white blouse. I tried to get the stains out using a bargain detergent, but it just wouldn't come out.
After a quick trip to the supermarket, I stopped and got a bottle of liquid Tide with bleach alternative, and to my surprise and satisfaction, all of the stains came out! In fact, the stains came out so well, that some detectives who came by yesterday told me that the DNA tests were negative and my attorney said that I would no longer be considered a suspect!
I thank you, once again, for having such a great product. Well, gotta go. I have to write a letter to the Hefty bag people...

A new year, A new me

2007-01-01T19:21:00.000-05:00

The Bitter Woman's Guide to Zen

To know Nirvana, you must understand these four noble truths:

Anything that angers me will incur my wrath.
All suffering is caused by my wrath.
You can avoid my wrath by not being stupid.
You can avoid being stupid by following the Four-Fold Path.

Do not say anything to contradict me. This is called "Right Views."
Strive, at all times, not to anger me. This is called "Right Intentions."
Do not say anything you know, or even suspect, will anger me. This is called "Right Speech."
Keep a chocolate bar and a twinkie for me on your person at all times. This is called "Right Conduct."

You can find the road to Nirvana by contemplating these ancient koans, or riddles:

What is the sound of my fist slamming against your head?

All beings tremble before violence. All fear death. All love life. Knowing this, would a wise man poke a snake?

Tabibi once asked Baso, "What is Buddah?" Baso answered, "Damned if I know. Where's my twinkie?"

Right Views. Right Intentions. Right Speech. Right Conduct. If a student has the patience to wait until the mud clears, the student will not get his ass kicked.

Peace be with you.

A funny thing happened today....

2006-12-30T01:05:00.000-05:00

Well, okay, every day is an adventure. But - boy howdy - today just about took the cake and smeared it all over me.
For starters, our little 18-bed unit had been operating at 1/3 to 1/2 capacity for the past few weeks. Thus, I was allowed a few PTO days, while a few unlucky souls had to float to other floors. Suckers.
Suddenly, wham-pow!, we were slammed with 6 admissions on the second shift yesterday. One discharge today, and two more admissions this morning. I ended up working 12 hours (unscheduled) just to try to fill in the gaps and tie up loose ends. I didn't *have* to, I'm just a team player. With a cash flow problem. ::grin::
So, as the chaos commenced, we borrowed another RN from our sister unit, and the (covering) attending took a deep, ragged breath as we began rounds. Phones ringing off the hook, 4 or five lines in use/on hold at a time. Unit clerk slowly losing her grip. Dementia patients getting into their usual mischief. Manic patients slightly more escalated than we'd prefer. Younger "gero" patients that belong down on the adult unit becoming unglued at the aforementioned dementia patients. Oh, yeah, and I'm attempting to quit smoking. 'scuse me doc... but that brick wall with my forehead imprint? Yeah. Can ya hook me up with sumthin'?
UC slams the phone down and comes storming out of the dining room. I ask "who's that?" at the very moment she's exclaiming "Jesus Christ!" Without missing a beat I look shocked and ask if *he's* here now, too? She said Yes, and he wants an ativan. Raucous laughter ensued.
You just had to be there.
Good times.
Today's top contenders for causing Julie's meltdown:
Behind door number one, we have 400lb neglected woman whose daughter is lodged downstairs (the other psych unit), and unfit family members #3, 4 and 7 all wish to take over DPOA. One such transgendered individual showed up waving a 'legal' document that he/she insisted mom needed to sign TODAY. Sorry, bud(ette), but that just ain't gonna fly in the courts. *We* aren't going to witness the signatures, the notary isn't going to get involved, and there is the little issue of an inpatient committal that defers the patient from making such decisions when they are not operating at full cognitive capacity. Buh bye.
Behind door number two we have... oh who am I kidding. Wearing a path in the carpeted halls is pacer number #2 who is withdrawing from morphine for chronic neck and back pain and really really really wants his xanax right now at home I usually take it at 5am and noon and three and at bedtime or supper depending on how wound up I am so can you please change those inconvenient times that are standard hospital protocol for me because I really am kinda worked up in case you couldn't tell.
Number three is a sweet little old lady with an incredible swearing vocabulary whose family insists was a church-going saint until dad died a few years ago. This year she has begun wandering away from home, and doesn't recognize any of them. A nursing home is out.of.the.question. Why, mom only set the house on fire that one time. And she hasn't fallen yet. Why can't she continue living in the only home she's ever known? Never mind she isn't sure where the bathroom is. They've been utilizing their vacation from mom doing Valuable Internet Research on DAT. Because that's what one friendly nurse told them she had. How can you say she has Alzheimer's? they wail. We challenge that diagnosis based on hours spent googling the signs and symptoms and onset and our own personal denial. One Loving Granddaughter went so far as to tell the doctor that he's "just guessing", because *everybody* knows that Alzheimer's can only be diagnosed on autopsy. Stupid doctors. All those years spent at Harvard, and this is the best they can do? She went on to tell us that if gramma really does have it, then they need to know RIGHT NOW so they can all be checked out. Because it is "generic". Oh, and by the way... while she's here, we want an endocrinology consult to address her hypoglycemia, a "nerve-ologist" to check her out, and a podiatrist to cut her toenails.
You want fries with that?
At the end of the day, I am thanked by my co-workers for helping hold it all together, one nice family lauded me for being sensitive and kind (!), and my husband asked what I planned to make for dinner.
Tomorrow:
Thank you notes to Tide and Hefty.

Perplexity

2006-11-07T08:19:00.000-05:00

Mrs. Smith resides at the far end of the long hall. A sound-deflecting acoustic wall on wheels is perched outside the door. She has been with us for weeks, minus a four-day visit to the medical floor for dehydration, uti, and... whatever else they came up with to give us a *little* respite. Sure, we certainly could have managed these issues right here, but... But.
She is aggravating the other patients. Since her stay on our unit, violent outbursts of behavior by patients has increased dramatically, as have our use of seclusion and restraints.

She is a screamer.
That is all she does.
She is not a walkie-talkie.
She is not a danger to herself or others.

She is extreeeeeeeeeemely demented. And the nursing home doesn't want her back. That is how she came to reside with us. She came in for evaluation and medication adjustments. And now she's dumped.
Dementia with behavioral disturbance, her chart asserts.
Ativan and haldol help in small ways. Very.small.ways. Neurontin worked for the first few days, then waned. I could go on and on about the antipsychotics and antianxiety meds that have failed.
She does not converse spontaneously. Sometimes, when questioned, she will answer. Sometimes it is appropriate, often it is not. When asked if she is in pain, she will say yes. She will not articulate where. Palpation does not elicit a flinch. So, she must be in pain. Percocet worked. For three days, until she vomited twice, and her medical doctor cut it. Supershrink initiated duragesic. It also worked. Or, is currently working, as of last night. Medical doctor doesn't believe she needs narcotics. It was pointed out that one could - theoretically - inquire if she believes she is a duck on rollerskates wearing a tutu, and she would likely reply 'yes'. But that would be unprofessional. The point is, the patch is working. (and no, it is not to be applied over the oral cavity).
I should explain that this poor soul's screaming is not an occasional holler. I am referring to all-out, full-on, NONSTOP shrieking that will stand hair on end. *This* is how she becomes dehydrated. She will not close her mouth long enough to take in an appropriate amount of food or fluids. She will, at times, sit bolt upright in bed, and then fling herself backwards with enough force to rattle the teeth in her head, but that's about it. With the advent of the fentanyl miracle, her wailing has decreased significantly, and there are no excessive sedation effects noted. She is awake and responsive, and has long periods of silence. She gets sleep, she gets nourishment.
She was up for discharge today. Wouldn't you know it, yesterday she developed an aversion to swallowing. Not difficulty swallowing, mind you. Seems she might have forgotten how.
Medical doc wants her off the patch.
Anyway, to make a long story longer... she'll be getting a speech eval and swallow study. She probably will go medical again. Family is trying to accept the scenario that end-stage dementia could lead to a peg-tube for comfort measures. Hospice had already been consulted for f/u at the LTC facility. And we know, in the back of our minds, that the first weekend the nursing home gets to enjoy the unending screaming, she will be right back here.
For management.

The other side of the curtain

2006-11-05T09:45:00.000-05:00

The Wizard? No, it was me!
IV Anzemet and a few liters of replenishment, and I'm all better. I still feel as if I've had my ribs kicked in and a raging case of whiplash, but I'm back on my feet and ready for my shift. Only two days of bed rest and a full liquid diet. Go, me.
The whole time (when I wasn't wishing I would expire), I thought "This would make a good blog entry." Now, for the sake of kindness, I won't be ripping on anyone's bedside manner. Only one nurse was a bit of an appendage, but I *did* get a visit from my favorite flight medic, so they cancel each other out. Everyone - from the desk clerk to the physician - were absolutely fabulous. Five stars, people, and I mean that with utmost sincerity.
I think I have time for one more nap before I head to work.

A moving post

2006-10-26T22:00:00.000-04:00

Remember back in the day, when grandma had to have her prune juice and grandpa swore by his Colon Blow? Simple dietary adjustments would make your day, well, more regular.
I received a frantic call from my parents, who were more than a little freaked out by mom's new prescription for m!ralax. "Julie!" they said. "It's made out of plastic!"
Wha?
Yes, the container is shatterproof, I assured them.
"No, you don't understand! Polyethylene glycol! That's plastic!"
Followed by a five-minute tirade about how they didn't think that drinking a toxic substance would help matters all that much, and if it really was recommended, couldn't she just gnaw on some Tupperware or something?
I vehemently hated chemistry, so with my meager body of knowledge, I expressed a doubt that they were, indeed, about to ingest plastic. At least not in it's final form, that is. Besides, I've read that my all-time favorite drink ever carries PEG in its ingredient list.
(I love you, Dr. Pepper!)
So it was with great interest that my sleuthing led to learning all about polymers and polyethers, and the miracle of lubes and G0lytely. I feel well informed and light of spirit.
Mom, may the force be with you.

I don't wanna

2006-10-26T16:02:00.000-04:00

What do you do with a patient who is refusing select portions of their treatment? You push, and plead, and bargain. You explain, educate, bribe and *sometimes* just go ahead and do it amid their complaints. It's for their own good, you rationalize. Depending on the patient's mental status, health condition, and nature of the care they are hesitant to participate in, you strive to do "what's best", even if they don't immediately agree.
So it goes with the protagonist in my current saga.
85 yo well nourished white female who looks to be of stated age. Health history includes HTN, CHF, CAD, and numerous fx including bilat wrists, right clavicle x2, and compression fractures of thoracic, lumbar and sacral regions. Recent ORIF of right femur, and currently in a sling for management of right clavicle (3rd fx).
Will she wear her Kendalls? No. "They hurt." For whatever reason, they opted for ace wraps instead of TEDs, and more often than not they are too loose to do any good.
Does she do her incentive spirometry? No. Partly because "It's too hard", and mostly because she can't coordinate inhaling instead of exhaling on the mouthpiece. She has a weak, non-productive cough.
Four days ago I playfully tweaked her toes to check for blanching. She yelped in pain. I took a good look at her feet. Horribly edematous (chronic), I didn't even check for pitting. No discoloration present, but her RLE was notably warmer than her left. Incision site looks great. Minimal discomfort up there. I attempted to palp a pedal pulse - poorly. She could not bear to have me move that leg. I passed it on to the staff. I told her daughter, who looked at me blankly. "She needs to wear those compression stockings," I stressed. "And teach her how to suck air out of that contraption!" Well, she told me, mom was refusing. She's a grown woman, we can't FORCE her to do anything, she continued. "Like hell", I thought.
Somehow, I'm the only one who is complying with the doctors' orders. Even her nurses are letting her fall by the wayside, I assume because it is easier than arguing. WTF?
Am I wrong? I mean, she's not actively fighting the anti-DVT measures (and she is on Lovenox) - she just says "No" and then bitches about it until the other caregivers give in and let her have her way. I'm not meaning to imply I'm the "only one" who does anything the right way, but my word, people... there are protocols to follow, and her minor discomfort now will be a fond memory when her condition accelerates to ICU. Is it unethical to force compliance on a patient? What if it is your own family? Does that cross the line from professional to personal measures?
She goes today for non-invasives. Followed by a CT, if I'm as good at predicting outcomes as I like to believe. And I hope I am wrong, this time.

Press This

2006-10-24T21:39:00.000-04:00

Ahhh.... those adorable Press Ganey surveys. Usually we only hear about the things that need fixin', but apparently, I made a lasting impression on someone recently. He said I was incredibly helpful and informative during his mother's stay, and I deserved an A++. Double plus, people... hotdamn!
This, from a week when I felt so insanely customer-UNfriendly it would make you weep. If I had to defuse one.more.situation regarding misplaced clothing or why our free-range patients are allowed to wander into daddy's room instead of being tied down... well... all I can say is the census is full and there is no room for me in the program at the present time. And, yes, Mrs. Smith, you mother is still screaming, and please feel free to call me in another hour "just to check".
So, a little housekeeping. Mother-in-law spent a lovely 2 weeks in our grand hotel's ortho unit, and as of today, was discharged to a LTC centre with a rehabilitation programme that promises to have her up and moving in no time. Sister-in-law has instructed me to "be the bad guy" and keep them on their toes (pun!) so that she doesn't go the way of many before her. Nice. Because there's nothing more than I'd like to do after a string of 12 hour night shifts than to sit around the nursing home pestering the staff. Oh, but I'm so qualified! You're right. My bad.

Up next: a shiny happy post about something I most assuredly will be making up. ::grin::

m.i.a.

2006-10-10T21:38:00.000-04:00

Just a heads up for all those sure to miss me... ::grin::
My 84 year old mother-on-law "fell and broke her hip" at some point today; I am told she is still in the ER awaiting a bed, but she will be visiting the OR in the AM, PDQ.
Anyway, as luck would have it, I'm burning the midnight oil this week, so I should have ample opportunity to visit and meddle and interfere PRN. I'll become one of those family members that make me cringe. Yay, me!
As witty as I am trying to be about it, I know all too well the unfavorable developments something like this tends to carry. Our sizeable, competent, high-dollar and highly-skilled facility is a good place for her care, but there's only so much anyone can do for someone in her age bracket and with her health status.
Add to this my 57 year old friend with SCLC that has metastisized to her right femur and is enduring chemo at this time... well, I'm feeling a little dark and dreary.
I'll be back when I need to unload.
Ciao.

Mirror-Go-Round

2006-10-09T07:54:00.000-04:00

And yet we imagine still
Change love life
Piece of peace
Of mind

October 9, 1940
December 8, 1980

Torment = HTML

2006-10-07T21:51:00.000-04:00

Do I look like a web designer?
No! But my new friend over there is. Heeheehee.
A special thanks to At Your Cervix for the idea. Yes, okay, I totally stole it from her.
Her monkey boy is awfully darn cute, but in the spirit of All Hallow's Eve, I figured I might as well jump on the Puca and get all creepy and stuff.
Spent hours tonight trying to get my sidebar to show where it is supposed to. Had to tweak some margins, and so on. But isn't she CUTE? She'll even eat the fly. Play with her!
Oh, by the way, no. I don't have a life. How sad is that?

hmmm

2006-10-06T08:36:00.000-04:00

As a teenager, he used to beat his girlfriends. At 45, he drugged a cat then beat it to death with a shovel. His wife is very controlling and condescending. She is embarrassed that he sought help for his depression. She calls him "weak", and "avoiding the real world". Their son, a podiatrist, lives several states away. They are very proud of him, though he is so busy and so important, that he finds it difficult to visit. Their daughter is "a disgrace" and they are raising two of her children. Over several days he began to unearth long-buried guilts on a variety of topics. His wife was shocked, she had no idea what a "sick and twisted" man she was married to. She had tried so hard to mold him into the perfect citizen and she once considered him to be "respectable". Now, her visits even make me uncomfortable. I wonder what his relationship with his mother was like...

I told you I was sick

2006-10-04T18:14:00.000-04:00

... that's what I want on my headstone.
One of the fun things of being a nurse is you get to imagine every single symptom as a precursor to some fantastical malady that you've learned about. Or, to be fair, potentially exposed to. I have an amazing immunity, so unless I come across monkey pox sometime soon I'll just continue to imagine my gas is probably ovarian torsion or that next headache surely is an aneurysm. And of course, I'll continue to work right through it. We're short-staffed as it is!

Mother Jones tagged me. This meme asks you to name the five songs you'd like played at your funeral. I'm going to resist the urge to use "Had a Bad Day" as an example. Too easy. ::grin::
But I honestly can't trim it down to "just" five songs. Call me extravagant, but whatever.
So here goes, in no particular order:

Take it to the limit - The Eagles

One More Day - Diamond Rio

Second Hand News - Fleetwood Mac

The Dance - Garth Brooks

Wish You Were Here - Pink Floyd

Strawberry Fields Forever - The Beatles

Freebird - Lynyrd Skynyrd

I really don't know who to tag; I think everyone in my little corner has done this already!
If you haven't been tagged, consider yourself "it"!

Its not easy being green

2006-10-03T21:03:00.000-04:00

Bambi. Newbie. What's another term for those warm and fuzzy interns? I mean no disrespect, honestly. But they're so cute!
June brought us a new batch of 'em from the family practice program. Plugging a post from Dr. A., I will admit that I do appreciate the family docs for many reasons. It is true, not everyone can know something about everything, and while a specialist is necessary at times, the down-and-dirty basics are still there.
What I find a entertaining is that the same dude who can manage a K+ of 6.7 with kayexalate, EKGs, O2, and IV push insulin with D5 50 without breaking a sweat - yes, this happened on our non-monitored unit - is the same guy who is hesitant to order an antifungal cream for yeasty skinfolds.
Early the other morning, Dr. Dearest comes to see his patient. I brought the gloves.
He does his physical assessment, tries to talk to her about how she is feeling, and generally ignores me. He mentions a few orders he will be writing, and I ask him if he would mind tossing in some nizoral lotion for her groin and abdominal folds. He wanted me to get her in to bed so he could see it. It happens every time, and each time I hope like crazy that it won't. This is why I brought the gloves. He looks interested, and I can sense the wheels turning in his mind. But does he write it, in the end? No! Mama Doc will be rounding with the whole group later in the day; he'd be back. At the end of their visit, I mention the skinfunk again. He says he examined it earlier. And? Mama Doc asked for his assessment. She said it sounded fungal. The patient is a morbidly obese diabetic. What is your plan? He writes for lotrimin cream. I ask if it can be a lotion, due to the area that needed coverage. He wrote for the nizoral lotion I previously requested. He shot me a look. Mama Doc smiles at me. It will be a long year.
I know docs have this status thing and granting requests from nurses might seem like we're undermining them, but really we're not. You can call it evidence-based practice, experience, or just trying to save you some precious time. I'm sorry I stepped on your ego.
So, she's reviewing their progress notes on their assignments, and periodically would quiz them.
And what are the indications for Abilify? How does the efficacy compare with the cost? Are there alternatives that might be available? Complements? What are the risks associated with antipsychotic drug therapy in the demented population?
Good times. Good times.
The PA students though - what a fun bunch those wacky kids are! I look forward to sharing counter space (and a phone) during dictation. Seriously though, this one guy looks like Doogie. I was listening to him the other day, and asked where he was from, (his accent seemed a bit weird). Utah, he tells me. He goes on to explain how he tends to pick up other people's accents, and he doesn't know why. I can empathize, being from Oklahoma, and living in Virginia for a decade, I can revert back to a southern drawl quite easily. My family used to think it was cute when we'd be visiting family up north and I'd pick up a slightly Canadian intonation. Back to Doogie. I asked him if he was from New Delhi, Utah. He laughed. Dr. Patel laughed. As time rolls on though, I find it distracting and strange. He got to do a rectal swab today though, so it all works out in the end. :-)

PS - this is one of those irreverent posts that someone might find offensive. All in a day's work, I say. All in a day's work. Lighten up, save the professionalism for the paycheck. Relax, and enjoy some snark. It's good for you.

Damn it, Jim. I'm a nurse, not a lawyer!

2006-09-30T00:18:00.000-04:00

ER: "I'm calling to give you report on Mr. x."
Ok, one moment, let me get the intake form....
How old is the patient? (used to verify the correct unit he will be admitted to)
Ok, and who was the psychiatrist who cleared him? Has he been cleared medically?
Did they sign the voluntary? Who has power of attorney? Well, was crisis involved? I think you'll need to get a 302. No, I CAN'T just take them based on a psych history. Please check with your nurse supervisor, she should have the protocol. That's what I'm trying to tell you. Because it is illegal. No, we have to have a copy ON.OUR.CHART. We can accept a fax until they bring in the original. Yes, we have a bed, please call back when you get in touch with the son.
Four-point leather restraints, IM Haldol/Cogentin/Ativan.
DEM attending calls to inform me that the son is "legal guardian", and he is signing the 201.
Does he have durable power of attorney?
He is the legal guardian.
But there is no DPOA?
A judge signed him as his guardian, that is acceptable.
Do we have proof of this claim?
He said he'll bring it in this weekend.
We can't hold someone here on a statement that someone is allegedly responsible. He will need to be 302'd.
The family is refusing involuntary commitment.
...what the f...?
Well, I'll look into this further, I do know we were expecting him today, but our rules work just a leeeeetle bit differently than do yours.
(For instance, restraints - either mechanical or chemical - are NOT as easy to just slap on to any old body we feel is a wee bit testy.)
[In addition, the ER has a tendency to get voluntary signatures in a not-quite-full-disclosure manner. "Here, you need to sign this paper so we can admit you". Or, "This will allow us to treat you for three days, then you can decide if want to go". Don't even get me started.]
Call placed to the director of our program, my nurse manager, and the social worker. Messages left.
Five minutes later, but what to my wondering eyes should appear...
Yup. Accompanied by three security guards, the daughter who is NOT to have any information shared, and a handful of ER staff to assist this unruly gentleman into his new digs.
Where is the son? The guardian? The man you are accepting direction from?
Argh! This sucks on so many levels. I have a foley that should have been placed an hour ago, a dressing to change, readminister medications that Miss P. had cheeked earlier, and 15 or so notes to chart.
In the interest of patient safety, we do place him into a room, assign a 1:1, place a call to the on-call shrink just in case we need PRNs, and goddamnitineedaciggerettenow.
Two calls returned, both with an emphatic NO to the legality of 'guardianship' for this whole shabang. Well, guess what, they sent him on over anyway, so now what? ::gritting my teeth::
You need to obtain the documents.
well.duh. um... how? (and just when did this become my job anyway??) ???
As luck would have it the social worker is familiar with the family, esp. the son with the super powers that transcend state law, and Mr. x is spending the night tucked away in a nice cozy bed down the hall.
Why can't this ever be easy?

Therapeutic Communication

2006-09-23T08:02:00.000-04:00

Shifting from LTC to inpatient psych hasn't proved to be much of a challenge, but I do find myself needing to approach my residents/patients/clients in a different way. For starters, the majority of our interventions and planning begin with "approach in a calm, non-threatening manner", which is a given. What I hadn't anticipated was the absence of touch.
While an elderly demented patient might benefit from a warm hand on the shoulder as you gently guide them out of the garbage and into the sensory room, your average schizophrenic will tell you directly, "don't touch me", if you're lucky.
At 0600 yesterday, as I began my final rounds administering the synthroids and checking the blood sugars, I gently woke the lofty dutch woman whom has enjoyed her 23 days at the all-inclusive resort we call "gero". She was quivering and tearful, and I asked what was wrong. She was up for discharge, and was frightened. She had been slowly weaned from her 4mg of klonopin, and the cymbalta did not work. So far, it appeared as if the zyprexa and trazodone were helping her a tiny bit; the panic was less frequent, she was sleeping (although she denies this) and an axis II dx was being considered.
I asked her if I may sit down. She said yes, and began to talk more than she has in the past three weeks. She is lonely, the staff had decided early on. She states she is unable to enjoy any hobbies or outings with friends, she just can't concentrate. She denies SI, although there is a hint of a passive death wish. She laughs when she tells me her house is "very, very clean". She wonders if a pet might be a good idea. She is picking at her gown, the sheet, the edge of the paper souffle medicine cup. Tears are welling up in her eyes. I feel detatched. On the one hand, I want to reach over and hug her; on the other hand, I wish she'd just snap out of it. Call bells are going off, bed alarms are screaming, and I have to go tape report. She has until monday to decide if she's going partial or if we have to 304 her to a more long-term program. She doesn't belong with the psychotic patients, she is just wound too tight. I've seen much worse. Why is she here, and why for this long? Meanwhile, Mr. OCD with diabetes insipidus in the next room has taken himself to the bathroom, urinal in hand, to try his luck at the spring water in the porcelain reservoir. She can tell I'm distracted, and I hate that I am. I acknowledge her concerns, state that I am needed to tend to some urgent matters at the moment, and tell her we can discuss this more after breakfast. I forgot I wasn't going to be there at that time. After I took care of the risk-for-water-intoxication gentleman, I returned to let her know I'd stop by at the end of shift instead. She reached out and grasped my hand. I was taken aback, in a big way. People don't touch here. Unless we're wrestling someone down, but that's another story. I didn't have time to sit with her. She began to plead with me. My heart went out to her, yet I had many other (more important) tasks to tend to. There are limits to be set, boundaries to enforce, levels of caring that one has to be careful not to breech. This is mental health, not a nursing home, and... well, shit. What do you do? In the hour that followed we started an IV, sent one patient medical, did two bladder scans and a straight cath, and documented all the 1:1 and chemical restraints.
I did return to tell her I was off, I hoped she would participate in group, and ensured she contracts for safety. She wasn't paying attention, because she needed 2% milk, not skim, she preferred cranberry juice to apple, and she needed to know why all she ever got was decaf coffee and tea. Did she have to sit at this table with those people, why aren't they allowed to eat in their rooms, and what inane craft did they have planned for today? Did her son call yet (make sure she gets it), did that social worker ever bother to schedule the family meeting, and make sure I get the wet towels off the floor and change her linens. And by the way, her toast was cold.
Axis II, indeed.

Initial Consultation

2006-09-15T07:52:00.000-04:00

Welcome to my first post - of sorts.
While I blog regularly elsewhere of my life in general terms, I have felt the need to express my views on things of a more professional nature.
That is to say, that I will not be providing intentional, methodical, relevant education in any purposeful manner, but the occasional random reader might find my thoughts to be mildly amusing. At the very least, an adequate way to waste valuable time.
Through blogging, I have a found a rich fabric of others who share similar views to my own on a variety of topics. What I lack among my real-life contacts, is an acceptable vehicle for which to unload work related issues from my short term memory; hence, this medium shall be my talk therapy. My feedback loop.
Although I am a nurse of 16+ years, and I hold myself to high professional standards with a responsibility to all of my clients/patients/families/peers, et al. - this blog is NOT to be considered reference material, peer-reviewed, or helpful in any way. Many of my posts could be considered offensive to some, humorous to others, or simply extraneous to the masses.
Descriptions of people, places, or events will be modified to protect identities. Any similarities to actual situations are completely coincidental. The information contained herein is for entertainment purposes only, and not a substitute for a proper evaluation. I am full of good advice, use at your own risk. Side effects may include uncontrollable drooling, somnolence, ambivalence, and a burning sensation when you urinate. Use of this product should be limited to a PRN basis; more frequent dosing may lead to idiopathic dementia, which should improve after discontinuation. If bothersome dryness should occur, please consult your physician.