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.