When they injure you

I had a patient, I'll call "Felipe". His primary language is Spanish but he speaks English as well. I heard mostly English until he unexpectedly got ticked off and we unwillingly had to reapply soft restraints on his hands so that he didn't pull out his suprapubic catheter and IV. He nearly succeeded at both. Even on a 1:1 observation. The man was strong for an "advanced age" gentleman. Picture this: two nurses and two techs holding down a man who needed his IV changed after he dislodged it from constant picking. The IV nurse was trying to hold his hand because the only good vein was near his thumb. The tech let go for a second and he grabbed her finger, nearly bending it backwards to the breaking point. (I had suffered the same near-breakage just a few minutes earlier and was surprised that she hadn't learned from my yowling in pain). The IV was finally placed and everyone was kind enough to hold onto my dear swearing-in-spanish rail jumper until I could safely push Haldol. We all breathed a sigh of relief...until it became apparent that the wonder drug was wonderless. He agreed to take some pain medication (from repeatedly attempting to d/c the catheter by the old yank and pull method). I brought the pill in a cup. He was docile. He shook his head affirmatively that he would, indeed, take the medication to relieve his pain (and hopefully the situation). Instead, as I handed him the cup, he grabbed my hand and tried to bite my fingers off. I managed to wrestle my hand back but not before he purposefully and knowingly dug his fingernails into my hands. Through the gloves. Blood seeped all over the gloves inside and out. The pill had to be wasted. And he continued to screech in a language in which, despite not knowing exactly what he said, made it clear he was swearing violently at us. After turning the lights down and asking all to leave him be and the observer to whisper, he finally settled down. Not too long after, he was again smiling and calling me "Bella" or "Chicca" when I entered the room. All's well that ends well, even if the nurse is one finger short of a ten.

It was so bad it was funny

Last night's shift was so, so bad it was too hard to cry and easier to laugh. In short, I had five patients, two on contact precautions, one who was combative, spoke only Russian and took swipes at me whenever I neared his bed, one who suffers from psychosis and her pastime is picking holes in her skin and heiney, one who had an NG tube which didn't stop him from scarfing down a cookie he had smuggled into his room, and two rapid responses.

My shift began with 328 screaming monotonously for someone to help her because she was wet...that would have caught my attention but she has a suprapubic catheter so I was sure her psychosis was playing pee pee tricks on her mind. 324 only spoke Russian and was on a 1:1 because he snatched body parts that came within five inches of his bed. He spewed meds crushed in applesauce as some sort of retaliation for offering him care. And he was a turn 2Q so we had the joy of being assaulted six times in one shift. I won't mention that he was also incontinent. 326 was a recent DNR but that doesn't mean "do not treat" so when her heart ran aflutter with a-flutter and a-fib, I had to call in the cavalry. She ended up on a monitor and bedrest but didn't go to telemetry because of her DNR status. That and the doc wasn't feeling particularly "order-writing" that evening. When I asked him for an order for Restoril for 328 and/or me because 328 wouldn't stop her relentless calling in a mono-syllabic chant, he told me sure, but I had to call the attending to make sure it was okay first. Way to take control. Thanks for the help, Dr. Doesn't-Do-A-Lot.

My Creature Double Feature came to a head when 327, who had been calling me all night, and not via the call bell (why when yelling my name got my attention so much faster). She was AAOX3 and wanted to get on the bedside commode, one day post op for an open choley. Sure, I said, and I got her on the porta potty. I grabbed the IV pole to swing it closer and that quick she pitched to the side and her eyes glazed, unresponsive. And, true to Hollywood form, dark brown liquid gushed from her nose, just poured out like the perfect horror show. It flowed out her nose and mouth. I yelled, and I do mean yelled so that the other side of the hospital could hear me, that I needed help in 327. Another rapid response which ended in her being intubated and me nearly coding myself. However, we all survived. Okay, not all. J's patient expired. Dr. Didn't-Help-A-Lot didn't come up for several hours, making body bagging a little more challening.

After my two rapid-run-down-the-halls, I visited 326 for a check-up. She needed the bedpan so I complied and when I took her off, POOF, her ostomy appliance came apart, spewing smelly sludge all over her, me, and the sheets I had just changed for the fifth time (I'll spare you the tinkle and spurting blood from IV site details). So here we were, in a contact room with an ostomy that had herniated to the size of a small child's head and no replacement appliances. So what is a critical thinking nurse to do? Slap that Tupperware part back together, use some 3M shield and 2" tape and put in a consult for the ostomy nurse to bring DD sized ostomy softee molding stuff for this woman's protruding pouch of poop.

At first, after the first rapid response, I was almost ready to tear up. However, the second cured that and all was funny post intubation. The broad street bully in 24 was funny, the coffee snitch was funny, the ostomy like an fx gold star was funny. Even 328's picking poopie out of her pooper scooper was funny. Going back tonight for the same group; not so funny. Ah well, I can do anything for 12 hours.

Feces in the Face

This one will be short only because it is truly the reason why nurses shouldn't wear white. Last week, while turning a rather...physically endowed patient, I experienced what I hope to be a singular event.

As the patient was turned on her side, I leaned in to be certain that I had adequately wiped her behind.

"Pfffffft," was all I heard as vile green poopie squirted from her heiney. It missed my nose by inches but got my gloves and scrubs in a most horrific fashion.

Please, Lord, let someone come up with a rectal pouch that actually works.

The Pregnant Lady and Percocet

The past two weeks, I've had a patient who is fifteen weeks pregnant. Very pleasant woman. Easy to talk to, doesn't ask much, if you compare her to the previously mentioned Precious (see previous blog).

She came in with a respiratory issue which quickly cleared. Then, magically, as she was about to be released back to her large home, husband, and three children under the age of five, she developed wicked headaches. Headaches that required that a fifteen week pregnant woman take 2 mg Dilaudid every three hours and 2 tabs of Percocet every four hours...around the clock. You could set your watch by her pain meds. In addition, she occasionally took Tylenol #3 (codiene), and Robitussin. Her baby will enter the world needing rehab.

Despite her sweetness, I felt like a fly on sticky tape with each answer of the always-on-time call bell ring. I am uncertain as to whether the phenomena of being unable to cluster requests exists soley in hospitals can be researched and documented but I am certain it does, in fact, exist inside the not-so-sterile walls of my hospital.

Each call bell was met with an 8/10 headache, much conversation (on her part), and requests for half ginger ale, half cranberry juice, light on the ice, please. "Is there anything else?" I learned to ask. No, she said. But, as research would pan out, I was met with a request to refresh her multiple ice bags (for her head). These requests were difficult to hear over her blaring television. The Democratic National Convention was in full swing and apparently she didn't want to miss a word. I could easily follow the speeches from across the hall in the med room where her mythical personal supply of drinks and snacks were located. Again, I would ask if there was anything else. I could see her eyelashes blinking rapidly behind her sunglasses when she realized she needed new pillow cases, or towels, or whatever other wish she desired. No doubt she was OCD. Every entrance to her room was met with requests of three.

I am certain she had some pain, but it was difficult to ascertain the true level of pain when she was eating the freezer clear of ice cream meant to be shared among the entire floor of patients. After two days our pantry was similar to Old Mother Hubbard's. She had a tough time chatting while shoveling in pints of ice cream in Olympic Record fashion.

Every single nurse on the floor was astounded that she was emphatic to take both Percocet and Dilaudid IV exactly on time around the clock for two weeks straight. The baby will probably have an affinity for tye dye.

Although she was a wonderful conversationalist, it was difficult to continually administer meds that no matter what any doctor said, I would have refrained from taking while pregnant myself. I truly liked this patient. I just have to wonder if her infant will emerge grasping for the pill administration cup.

Delegation: The Fine Art of Manipulation

Delegation is a precarious thing. Ask in the wrong tone and you're in the doghouse. Ask too nicely and you're ignored. I once read it's not about getting them to do what you want but getting them to do what they think they want. While there is some truth to that, the same doesn't apply at all times in nursing. It is not possible to make a nurse's aid/tech think they WANT to change a poopy diaper. (Oh, and in nursing school, they threaten you under penalty of expulsion to use "incontinent product" instead of diaper.) Face it. It's a diaper. It's not degrading to call it what it is. People have to tinkle and drop the kids off at the pool and need something to catch it. You can label it fancy names but if they're wearing an "incontinent product" it's because they can't hold their post-products long enough to make it to the throne and that's nothing they would ever choose. It shouldn't be an embarrassment or something to be politically correct about. It's life and if you kindly refer to it as a diaper outside of the patient's room, it's not demeaning. But all the same, I doubt I'll ever meet a tech who gleefully races in to fecal matter. Be nice. Be firm. Offer to help. Be the nurse who the techs love to work with and in time, you'll find that most will respond by taking good care of the patients without your having to ask.
And there's ethical/legal dilemmas to conquer as well. I have a patient this week who's been bedridden for 17 years. He has Parkinson's, some Alzheimer's, and is contracted from not using his muscles. His elderly wife has been taking meticulous care of him all this time...feeding him, changing him, caring for his skin, and now is in charge of his feeding tube. She told me about the many different medical supply companies she uses to get bargains to afford the enormous amount of full-time care that her beloved husband requires. One item she pointed out is particularly costly. It's a moisture barrier for patient's perineum area so that the tinkle and fecal stuff doesn't break down his skin. Comes in a small tube but is very costly for this fixed-income family. Legally, she can take leftover supplies with her because they have already been charged to her husband's bill. So whatever is in the room is technically hers. He's also on contact precautions for MRSA so whatever enters the room stays.
Legally, I crossed the line. Ethically, I stand by my actions. When she came in to sit vigil, she was talking about the additional cost of the feeding tube supplies. I asked her to look in his nightstand. She opened the drawer to find that two tubes of the moisture barrier had magically appeared during the overnight shift. "Gee, once something enters the room, it's really the patient's, so, you know, if you wanted to take those home so they don't go to waste, I think it'd be alright." She had tears in her eyes and held them like they were Coach bags. Legally, I know I can't do this often. Ethically, I bless that woman for the consuming care she gives her beloved. Life's not always about doing what's right by the legal world. At least she won't have to eat as much mac and cheese this month.
This same woman asked that the tech change her husband's "incontinent product" without dropping the bed totally flat because she truly feared he would aspirate, even with the feeding tube temporarily turned off. The tech balked and did it per hospital routine. Delegation was tough but I had to request that my favorite tech leave the bed at 15 degrees to allay the fears of the patient's wife. It wasn't easy to go up against my favorite tech, one who's been at the hospital for six years. But it wasn't harmful to the patient and gave the wife enough peace of mind to leave early to get sleep. She told me she has never left early. But she knew that because I followed her meticulous care routine, she could trust that her husband would be just fine. Delegation and leadership are not easy. Especially when I'm the new guy. The tech grumbled but agreed with my explanation that this patient is so loved by his wife in the care she gives him that it's probably worth doing things a little bit differently this week.

When you want to smother them

Sometimes, there are patients who really try your patience. Take for instance, a patient of whom we all dubbed, "Precious". She truly believed she was a precious little thing, so needy and sickly. Apparently, she also believed herself to be the only patient on the floor. We were put on this earth to answer her every beck and call bell.
Now Precious really did have some health issues, but certainly none that required a nurse or tech being present in her room at all times to fetch her tissues (because she claimed she couldn't reach them on the bedside table which was hanging over the edge of her bed), fluff her pillows (she felt we should "refresh" them every 30 minutes), or wipe her bottom ("three times because if you do less than that, I can still feel the moisture").
For twelve hours, her primary nurse and tech answered her multiple, multiple, did I say multiple call bells every hour. It would have been nearly bearable if Precious was in a regular room. However, because she had a history of MRSA five years ago, we were required to put on a hot plastic gown and glove up each time we crossed her threshold. It was like the Roach Motel...we could get in but couldn't get out. Precious always had multiple, multiple, did I say multiple requests which kept us trapped for long periods of time.
Twice I jumped in to rescue her primary nurse from having to go in there because, after all, she had five other patients, some in worse shape than Precious. The tech had fifteen patients, almost all back-breaking completes to change and turn, and toilet every two hours.
The third time I went in to see what earth-shaking event caused Precious to require us to rush in there ,I gowned and gloved and toileted her. Getting her out of bed and onto the bedside commode was a ten minute process. Precious felt she was unable to withstand the indignity of a bedpan. That's okay, we don't mind injuring our backs hefting her 170 lb frame to and from the bed when she refused to carry even part of her own body weight. We can always get a chiropractor for our aching backs. Dont' worry, Precious, we really don't mind putting ourselves at risk. You certainly can stand and have the easy ability to walk. Nothing is wrong with your legs but we understand your need to be babied and certainly can carry you two feet to the bedside commode.
So I toileted her, gave her tissues, tucked her in and took off my gown as I was exiting the room. "WAAAAAAIT!" she cried. She needed me to fluff her pillow, she whimpered, threatening to cry at any moment. I regowned, gloved, and fluffed. Ungowned, walked out the door only to hear, "WAAAAAIT!" again. (Mind you, I had already asked, saccharine-sweetly, "Is there anything else I can do?" before she released me from her clutches). She stated the blanket she had under her back "just isn't comfortable. I need it repositioned," she welled up with tears. So I did it, and once again was allowed to leave. But no, "WAAAAAIT!" I heard as I turned the corner. Regown. Reglove now sweaty hands. These gowns don't breathe. Oh, the touch, the feel of cotton would have been nice....This time, she was shaking, begging for a refreshed cup of ice water, not too much ice, just a bit, and don't forget a lid and new straw. So I ungowned...again....got a "fresh" ice water, not too much ice, new lid and straw, regowned, and handed it to her. The woman actually began to sob, "It's too big, I can't drink out of it...I need a smaller (hiccup) cup." Mind you, it was the same size cup she had previously and before that and before that, and, well, you get the idea. So I ungowned, got a smaller, more acceptable cup, lid, and straw, regowned, and gave it to dear, sweet, Precious. I was leaving once again when she sobbed, "I need a pillow." Yeah, I'll give you a pillow, I thought.

When I finally emerged, over thirty minutes later, I ran into her doctor to which I stated, straight-faced, "Just give me thirty seconds with a pillow and I'll put her out of everybody's misery." Now, mind you, I could never actually do that, but still, the comical thought of it made us nurses giddy with laughter. Sure, their eyes got big but they were all chuckling anyway. The doc, by the way, laughed and said that sometimes instead of drinking, he goes to Pierre's chocolates and eats a box to calm himself.

So, my advice: Don't smother them. Instead, go buy a box of really good chocolates and eat every last one. And truly, please refrain from any serious urges to smother your more challenging patients.

This isn't your A & P book

As a new nurse, I can tell you that there are many, many things that don't quite line up with nursing school "textbook nursing". In nursing school, we practiced inserting Foley catheters into perfectly proportioned female mannequins. On the nursing floor, well, those who need Foley's are usually almost past their expiration date. Things down in the pee pee area have lost their elasticity. They droop kind of like a cow's udders. And that can make it challenging to insert the Foley into the right hole.

Four of us went into an elderly female patient's room to utilize "sterile procedure" to relieve her bladder issues. Three held her down and her legs open. (It's surprising how strong a 90 pound octogenarian can be). I had the kit opened and was gloved, ready to follow the numbered procedures that I handily recalled from the nursing lab. But then I inspected her perineum for placement. Goodness gracious, it looked like a mound of sloppy flesh.

A seasoned nurse helped to guide me through the process. I was certain I had found the puckered area. No, she said, "Girl, that's her clit. Try lower." Surely, she was wrong. "No, look, it's a little hole, just like the urethra." "No, it's her clit. But go ahead, you can try," she sniggered. Of course, I was sure to get it on the first try. Except I was wrong. It was her clitoris. "Hey, you, get outta there!" the patient roared.

Here's a hint: at advanced ages, often the urethra is located up inside the vagina. In and up and you got it.

Once I saw urine, my nurse pal said, "put it in further, further" to which the patient replied, "If you put it in any further, it's going to go through my tongue."

Note to self: avoid inserting Foleys on anyone over the age of 50.

First patient death and the straight cath

This is an email I sent to my former nursing instructor when I was still on orientation. But I think it accurately shows how the beginning of a nursing career looks...I was still on day shift at the time. Thank goodness I work 7pm to 7am now.

When people say "there's a special place in hell for..." I truly believe I glimpsed that special place for nurses last week. I worked three days. Had three different preceptors. Worked three different units. With three different sets of patients. By report Friday morning, I was nearly in tears. Half of my patients were psyche and nearly all were on contact/droplet/or some other horrible communicable disease precautions. I was gloved and gowned and masked and ungloved and ungowned and unmasked enough times that I am certain there must be a Guinness record in there somewhere. Monday greeted me with the night shift vampires telling us to hurry up with report because they had such a busy night they HAD to get out of there. The horizon looked bleak. Call bells and bed alarms permeated the air with the tell tale stench of C. Diff. It only got worse from there. Wednesday was a gem. Started upstairs but then the moved me downstairs. I was on about an hour and a half and was doing meds post report, post chart checks, post answering call bells despite my desperate attempts to finish assessments when I finally managed to get back into the room with a DNR patient. The night nurse told me she'd gotten a priest to say last rites but the other nurses told me this woman had been predicted to get a visit from the Grim Reaper all week. Therefore, I was not tremendously concerned. But as I was talking to her, I saw a change in breathing pattern. Ah, yes, from somewhat labored to agonal. Then to apnea. Then to...? Okay, time to call in the big dogs. Sarah, the preceptor of the day, came in and we watched the patient take her last breath. After hours of going back and forth with Kidney One, it was decided no organs could be harvested, including her eyes which were large, round, and very much open. By then, thepatient was stiff, mottled, and smelled.Unfortunately for me, I was sent in to do post mortem care with Barbara, a patient care tech who was absolutely creeped out by our contracted, glaring body. I was okay except her tongue was kind of sticking out of her mouth. I had a cat that died once. Her tongue lolled out, too. Attempted to open her jaw to see if I could slip it back in, but rigor mortis had begun to set in. (The patient, not the cat). So I had to wash the patient while Barbara stood by and kept reminding me how much the patient's staring at us creeped her out. I was able to close her eyes with a washcloth. Did I mention we were gloved, gowned, and masked? The room had begun to smell. All of it made us giddy. The rolling of the stiff curled up body back and forth as we wrestled the thin plastic shroud under her. We were laughing so hard I was crying. However, we weren't too disrespectful. I opened the window to let her spirit out, in case it got the idea to attach to oneof us and haunt us. Fly, be free. Just get away from me, I said to myself. I didn't say it out loud to Barbara. She was already threatening to puddle the floor. So us two ninnies wrangled the body into the shroud, and used the ridiculously thin shoelace ties to bind the arms, waist, and feet. I had a terrible time with keeping her head covered. I could not get the wrap to look like the diagram on the bag. So I used critical thinking. Medical tape works wonders. Hey, I'm not being graded anymore. So we finally completed our creepy duty. Or so I thought. I asked Barb if she tied the toe tag on tight enough. "Toe tag?" she said. So our masterpiece was unwrapped and we managed to get the toes apart long enough to slip the tag on. I was sweating. I was tired. And I really didn't want to see any more dead bodies. By this point, I asked her if I could call Transport to take the body to the morgue. I told her we could call down there, "Uh,yes, this is Shannon on 2 West. We need a transport. Could you please send up a stretcher....uh, no, we don't need any oxygen." It could have been so easy.As we laughed our way out of the room, we smacked straight into the nurse manager. Surely, she was not as amused as we were. I said, "it was either we laughed or cried. I still have eight hours here so take your pick." Friday was the "let's ring the call bell simultaneously" day. All four patients on the call bell. Constantly. Three required morphine q hour. I'm new. I'm slow. Ten minutes for each patient to sign it out, draw it up, and log it into the computer before I give it. Three of the four were also bedpan divas. Ten minutes to put them on/take them off/clean them up. I'm sure you can do the math. Not a whole lot of time to look at new orders, give meds on time, and do wound care for 326 who had four areas of staples, two open stomach wounds, two groin puncture wounds, and a fasciotomy on her left calf. And, to boot, a nurse friend of the patient who has terminal cancer decided to ambulate my patient without my knowledge or consent. That call bell was to inform me that my patient had fallen. With a platelet count of 54k. And whom the doctor had just cleared for discharge. Now, the week is funny. But having to do three straigh caths and one foley in one day wasn't funny. Giving an enema to a patient who was fighting me tooth and nail while his mother kept saying "just get it in there and give it!" was not fun. I swear he had the furriest butt I have ever seen. 18 years old, CP, and ornery as heck. Ducolax to another patient who, after I was done, asked me to reglove and try to get it up further in her. My fingers can't get any longer but I tried just to make her feel better.If my family had any idea where my hands have been this past week, they'd never eat dinner again.

New nurse hits the floors...the journey begins

I graduated from nursing school in December, began orientation at the local hospital in January, and encountered my first deceased patient in March. This isn't my mother's nursing anymore. When she began nursing, the nurses wore sparkling white dresses with squeaky shoes and little dixie cups perched on their heads. I wear printed pajamas, really. I am still wearing the college's required squeaky white shoes. Hideous things they are. What I need are sporty yet functional sneaks. Ones that can allow me to sprint down the hallway to answer a code or that 85 year old senile man who keeps leaping out of bed as he attempts to yank out his foley cath. And I need shoes that resist stains; no more stopping off at the grocery store after work with urine, feces, blood, or vomit dripping off the soles. Yeah, I need a new pair of shoes. Super-snazzy-stain-resistant Sauconys.

It's amazing, really. In just one NCLEX, I went from being the lowly student nurse to "they actually pay me for this?" new nurse. (I'm still in the honeymoon phase). Years of studying until my brain threatened to hemorrhage lead to years ahead of learning the ropes as a new nurse. Oh how many nights I fell asleep on Lewis' "Medical-Surgical Nursing" only now to be startled awake with medical-surgical "Oh my gosh, did I remember to..." thoughts. There's one difference between being a student nurse and being a "real" nurse: as a student, you want to take the test and forget everything. As a nurse, you want to forget nothing.

This blog is a means for me to document the journey from being a new nurse to somewhere in the very distant future when I retire. Or when I feel like I kind of know what's going on while on the med-surg floor, whichever comes first. New nurse to Nurse Ratched if they keep short-staffing us.

The stories are true, yet wildly exaggerated, of course. My days of writing starched, dry, and medically sound papers are over. Okay, not over, I begin my RN to BSN journey in the fall. But at any rate, feel free to post up your own stories as we could all use a good laugh...and learn some nursing tips in the meantime. The truth is, I love what I do. Nursing is what I expected and more fun to experience the things I could have never suspected. But it's stressful just the same...trying so very hard to keep all six patients still breathing at the end of each shift. It probably wouldn't be a good thing reputation-wise to pass along a corpse to the day shift. Laughing is the gift that allows me to dress a stage 4 wound and still smile when I get home.