Tuesday, July 29, 2008

One of those days...

Even though I’ve been learning some interesting stuff and becoming a bit more independent in my unit, I haven’t been blogging much. Why? Two reasons: night shifts that destroy my sense of time completely and idiotic papers assigned by my idiotic school. I was informed that the point of consolidation was to gain clinical skills, not to churn out steady streams of bullshit. As it stands, I’ll be working three night shifts in a row this week and then right after the last one I’ll be going to my idiotic school to hand in a paper and do a mock licensing exam. Tell me how this works please – all summer we’ve been working ungodly hours for FREE while writing papers that will have no bearing on our lives and then expect to study for the licensing exam? I’d really like to have a few words in a dark alley with the no talent ass clowns who thought that the current set-up would be a good idea.

In any case, I can’t not write a little bit about hospital life so I’ll end this rant with a little anecdote. The nurses on our floor were recently told by the manager that we are no longer allowed to call computer on wheels ‘cows’. A big boned (read morbidly obese) patient complained that the staff were making fun of her when we said, “go get the cow to bed 04B”.

People are morons.

Thursday, July 3, 2008

Fight Club

Lately, I’m finding that I’ve been spacing out a lot. During my last shift, I forgot to hook up the IV into the patient after programming everything perfectly! After that, I forgot to do my 1700 meds for two of my patients. Maybe its exhaustion, or maybe its boredom but I find that I’m not focusing as well on my day to day routines. But boy oh boy did my attention span ever increase when I had to deal with David, an 87 year old with mild dementia.

He has had an operation on his knee and a pressure ulcer on his foot, so walking is extremely difficult for him. Yet, he insists on walking. So what are we to do? We bring him on over to the nurses’ station in a geri-chair to keep a close eye on him. Usually he just talks to himself, but on this day, he was particularly agitated. He tore apart his pillow so he was surrounded by polyester fluff for a while and then he tried to undo his gown by any means possible, including chewing on it.

While my teacher and I were busy with other patients and transcribing doctors’ orders, David soiled himself and was trying to remove his clothes to try to clean himself up. Now, before I go any further into this story, I should mention that David is MRSA positive and he is suspected to be positive for C. diff. Naturally, we do not want him to try to clean himself up in front of everyone and then touch other surfaces with dirty hands. I should also mention that the smell around the nursing station was so pungent and palpable that it felt like a physical blow to our olfaction.

He needed to be taken back into his room as quickly as possible to prevent any further olfactory trauma. When I started to wheel him back into his room, David started to whip at the air with his gown and a flat sheet yelling, “YEE HAW” and “Giddy up horsey”. Being the professional I am, I started to laugh until my sides hurt and tears started to flow freely! Truly, it was quite funny. However, the laughter stopped when we got to his room because his mood immediately changed. He saw his neighbor’s family visiting and thought that there were intruders in his room. David started yelling incoherently and held on for dear life to the doorway frame so I couldn’t push him into his room. Slowly, but surely, patients and their families started to peek out their doors to witness the spectacle that was about to unfold.

David is a big man. He weighs at least 200 lbs and he is about 6’2. The brakes on his chair weren’t working too well. This meant that I had to hold onto the chair with all of my strength as David tried to get away. For once in my life, I was extremely happy that I am not built like a frail sprite! Nonetheless, I managed to calm him down enough that he stopped struggling – which is when I quickly wheeled him into his room. I know that’s very deceptive but at the time I thought that this was the best way to prevent him from trying to get away and to stop the other patients gawking at us. I drew the curtain around his bed and reassured him that he was in his own room and that the ‘intruders’ were in their part of the room. I learned something then – placing your hand on a patient’s chest while kneeling down to be at their eye level and saying “stop” gently usually works for a little while.

My teacher then came into the room and wheeled over a commode chair for him. Like I said, he is a big man and extremely unsteady on his feet. As a result, he was very difficult to transfer, but we managed to wheel him over to the toilet. He finished his business and but when he stood up to go wash his hands, he nearly fell over and that would have been BAD… calamitous bad. I panicked and called the emergency alarm and yelled out for anyone else to come and help me. I think the alarm and my cries for help frightened David so he took a swing at me – and got me in the stomach. That literally knocked the wind out of me. I now have an angry looking purple bruise right in the middle of my stomach. Luckily my teacher was got there to hold down his wrists and managed to get him into the chair. Not so luckily, he swung his fist again and socked her one in the jaw. Now we were both momentarily incapacitated and David tried to walk. This is where professional nursing practice falls apart. I knew that if he stood he would fall and split his head open. I got up and almost tackled him back down into his chair and tied a restraint around him, which of course infuriated him. David started to swing his fists again and despite my best intentions, he got me in the ribs this time. “David! Don’t you dare hit us! You’re hurting us”, I told him. “You guys are trying to kill me” was his emphatic response along with another attempt to punch me. ‘That’s enough of this bullshit’, I thought. I went out of the room and drew up 3 ml of Haldol while my teacher called a code white. I knew that it was a prn med for him, but I wasn’t sure of the dosage. Nonetheless, I stuck that needle in good. Coincidently, that was the first time I’ve ever given an IM injection. What a way to start! A third nurse and two security guards finally arrived to help us get him dressed and back into his chair. 3 ml of Haldol and he still didn’t calm down for 20 minutes! When we finally managed to wheel him back to the nursing station, he was sleeping every so gently. He actually looked quite sweet.

Despite getting a good story out of this incident, I don’t think we handled it well at all. Here was a man who has dementia and felt extremely threatened by strangers descending down on him so he tried to defend himself. We became equally defensive and our response was to chemically restrain him and then call more strangers down to help us out. When I rechecked his MAR, his Haldol dosage was only 1 ml – I gave him three times the ordered dose. Of course we had to fill out an incident report, but I did not feel particularly proud at the thought of having to explain this to his family. Hopefully, the next time I see David, he’ll be feeling a lot better and I won’t have to be a part of a code white. For now though I will be nursing my own bruises.

Wednesday, July 2, 2008

Shifts Happen

Ah night shifts. Gotta love ‘em. I’ve come to like night shifts because usually they are a lot more peaceful than day shifts. I also happen to like the fact that call bells don’t go off as frequently, giving me more time to document, review charts and getting to know the unit. But night shifts also mean that I have to get used to dealing with some bizarre situations. A typical night shift goes something like this:

I get to the hospital and my first stop is the friendly Tim’s, where the server has my order prepared as soon as he sees me – large black with two creams and two splendas on the side. The urge to get a honey cruller at times is quite strong but I have to begrudgingly walk away. The thought of seeing myself as a patient scares me! I’d much rather be the one who starts the IVs, not receives them.

Make my way up five flights of stairs (again, refer to comments about not wanting to be a patient) and get report from the day shift. At this time, I’m usually praying to any deity that comes to mind to give me a set of patients that won’t ring the call bell.

1930 – 2200
After getting report, I make my around the rooms introducing myself and doing initial assessments. I’m finding that lately I’ve been doing more mental status assessments than before. One patient told me to “fetch some tiger shrimps waitress”. He was on strict orders to not eat anything for 12 hours to prepare him for tests. When I told him this, he looked at me with puppy dog eyes and asked me, “why can’t I get some goddamned tiger shrimps?” I have to restrain myself from asking non-patients questions like, “Are you in any pain?”, “Did you have a bowel movement today?” and “Can I take a look at your feet?”

Oh but wait, what’s this? “Maha”, my preceptor calls out. “New order for Mr. K. We’re giving a unit of blood stat. Get the paperwork ready and lets take a trip down to the blood bank”. So I rush through my assessments, run down to the blood bank, get a new unit of blood, run back up, take baseline vitals and start to hang the blood. That is until my preceptor gently, but firmly reminds me that I need the Y-type tubing a 500 ml bag of normal saline. D’Oh! Off I go to the clean room, get tubing and saline, start to do baseline vitals but remember that they’re already done and hang up the new unit. Since I have to check this patient’s vital signs q5mins, I run out of the room to prepare a heparin injection for the patient next door. Back to do vitals – looking good! Run out for another 5 minutes, give the heparin injection, sign the sheet and run back to do more vitals. Now I have 15 minutes until the next set of vitals. ‘Great!’ I think. ‘Just enough time to get two sets of meds done!’ Finally, his transfusion is finished and he looks a lot better. Goody goody gum drops, I can sit now!

Documenting time – lots and lots of documenting. When I first started, I thought, ‘this isn’t too bad – 10 minutes and I’m done’. What a chump I’ve been. When I first started, I only documented 2 people’s vital signs. Going through all of the assessments for 10 patients gets very tedious, very quickly. Truly, it becomes a struggle to not check email, facebook or another equally insidious site.

What’s this? Peace? Quiet? Calmness throughout the ward? Can’t be. I’m nervous. Better do the first set of rounds to make sure patients are still in bed and alive. This sounds morbid and it is. I hate standing over patients, watching them breathe a full cycle with a flashlight pointed at them. First set of rounds go great, and since (for once), I’ve finished my documenting, I can get started on other jobs. We all start checking various machines to make sure they are working, medication carts are restocked, narcotic counts are done and new narcotic records for the next day are made.

Its first break, which means that I can now sleep, while the second break staff takes over the patient load. I would have preferred second break (from 0330-0530) because when I wake up, there is only 2 more hours to go! But I’ll take what I can get.

I feel groggy and slightly nauseous from having slept so little and needing so much more sleep. Nevertheless, I grab some fruit and start another round. This time I find a man trying to climb his bedside curtain. “Sir, what in God’s name are you doing?” He looks rather like a feral animal on the hunt hanging from his curtain while I point the flashlight at him. “Get back into bed!” He obliges and I thank my lucky stars that he didn’t pursue the matter further. When I come back to check up on him, I find him sitting up in his bed, shaving himself. In the dark. With a piece of paper. I thought I was on a cardiology floor, not a psych floor. My eyes are on fire so I go back to the nursing station to sit and pray that no one uses the call bell.

The guy who got a blood transfusion is not breathing well. I can hear coarse crackles from the doorway to his bed. Not good. My first thought was that he was having a reaction to the blood but when I went to take a look at him and went to take his vital signs, he was not displaying any telling symptoms of a transfusion reaction. He did not have a fever, chills, pain, fainting or dizziness, or bloody urine (those were the ones I remembered). Also, wouldn’t these symptoms start showing almost immediately after the transfusion? He finished receiving blood a few hours earlier. Coarse crackles were the only new development. I called my teacher over who pointed to the IV pole. “Notice anything there?” she asked. My blank bleary eyed look said it all. “He received 2 units of blood along with 500ml of normal saline all within the span of a few hours. Potential fluid overload perhaps?” I responded to her with a blank bleary eyed look once again before garbling something along the lines of “lots of watery stuff in lungs means Lasix make man feel better”. I’m so smooth. When we went to check his MAR, it turned out that there was no order for Lasix! That meant that we had to get a doctor, any doctor, to give an order for 20 mg of IV Lasix. Calling doctors and begging for obvious orders is one way to wake up. My teacher was visibly annoyed and told me that usually 20 mg of Lasix is a standard order with a blood transfusion. At least we got the order and the patient’s breathing finally sounded normal. Job well done!

A burst of activity and I have to stay awake! We start checking patients to make sure they’re still in bed and if they need to be cleaned up. The nurses on my floor call this the five o clock train because we all line up, take adjacent rooms and start cleaning patients up (if they need to be cleaned). Since its almost end of shift, foleys need to be emptied, I&Os need to be documented, CHF patients need to be weighed, 0600 meds need to be given out and report for the oncoming shift needs to be prepared. I feel myself getting increasingly restless as the clock ticks closer to 0730 because the only thing on my mind is a shower and my soft lavender and vanilla scented bed (courtesy of Downy). But when its finally quitting time, I run out to the train station where I’m greeted by fabulously well dressed people while I look like a smelly homeless person who stumbled across a pair of scrubs. It doesn’t matter because my day (err night) is DONE!