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Seeing a patient go from gray to pink.

 

 

* Combating work-related negativity since October 2010

Flexibility.

I’m hard pressed to come up with any job that is as flexible as mine.

Our unit makes our own schedule.  If I miss the deadline for the official schedule, I have many nurses to call and ask to switch shifts.  I do the same for them.

Every hour that I work adds up to more paid time off.

When I do take a vacation, I take weeks at a time.  What other job would let me take off over two months in a year?

 

 

*Combating work-related negativity since October 2010

** “How To Love Your Life Even If You Hate Your Job” by yes and yes

They finally hired someone to replace our manager that was fired last September.

First they said they would replace her.

Then they said the position was dissolved.

Now they’re walking a new guy around the unit.

I’m hoping he’ll bring some positive changes to the place.

I’ve heard nothing but good things about him – and not just from administration.

I’m still looking.

I had the pleasure of finding a patient non-responsive during my first morning rounds.

Shaking. Drooling.  Axillary temp 105.  O2 sat 82%.

Long story short – confused patient had foley removed the afternoon after urine cultures were positive for E. coli.  Son stated that patient had been unable to void over the night.

I placed a foley and had an immediate return of 1200 cc of milky, yellow urine.

Pt responded only to painful stimuli for most of the shift.   Non-rebreather in place for most of the shift.

He began to follow simple commands and answer questions (after a sternal rub) around dinner time.

Patient status returned to baseline 12 hours later.

A doctor’s nurse came up to me at the station and asked if I’d be interested in a similar position for another cardiologist.  I am most definitely interested in a change of pace and environment.

I’m very excited about the possibility for change.  I’ve been keeping my eyes open for local opportunities, and this one just fell into my lap.

I’m calling the office Monday morning to ask about the opening in order to send in a résumé.

I got a call today from a co-worker warning me of the latest events at my station.  Apparently, the nurses are being forced to clock out at 7:09 on the dot – whether or not they are actually done with their documentation.  Even though we’re not technically late until around 7:22.  Even though we are constantly receiving flyers with the newest things that we are expected to document – most of those new things involving double-charting.  Even though this meant one of the nurses had to leave without charting on one of her patients that left her for surgery.  Who ended up coding during it.

The joys of cost containment.

In my 3-year nursing career, I’ve cared for maybe two or three patients with a listed history of schizophrenia.  However, they were taking their medications and had their symptoms fairly controlled.

I finally had the pleasure of experiencing 12 hours with an actively hallucinating schizophrenic.

Not my patient.  The patient’s daughter.   And she wasted no time.

I had just introduced myself to her when she started telling me about the voices.  At first I thought she was just being upfront about her condition.  You know…something like : “Hi.  Just thought you should know that I’m schizophrenic, and I sometimes hear voices. Just in case it comes up…”

I started to respond by saying something like, “It’s good that you’re aware of what they are.  Is this something that you expect to cause you trouble today?  Is there anything I can do to help?”

And that’s when I realized that she was not hearing me at all as she was in the middle of her own conversation.  One of the voices being Bob Dylan.  Oh, and the government had killed her mother and dog and was actively trying to kill her father now.

That entire day was the strangest experience for someone who had never really seen the schizophrenic symptoms in full display.

It was also the most frustrating shift that left me with a raging headache by the end of the day.

Her two sisters called early that morning to warn the staff of her condition and noncompliance with meds.  They reinforced that this lady was not to be allowed in any decision-making process regarding their father’s care.  She was not a threat, but she was certainly a hindrance to her father’s care.   She would verbally deny anything we prepared to do, but she did nothing more to stop us.

She had no expressions. She was unable to hold a normal conversation.  She would approach me with a question, but by the time I answered she was off on random, mumbly tangents.  During this time she would look down to the side and seem unable to hear me for a long period of time.  It got to the point that I finally started excusing myself as politely as I could and just walked away.

No matter what needed to be done, she’d question the action and who was behind it.  Of course, there was no explaining anything to her.  She would start to tell me I was talking too fast, repeat a few of the points I made, and then be off on another conversation without me.

She would walk up between me and another person I was talking with to interrupt and start all over again.

It was a long day.

It became more interesting  when the patient was discharged and I was preparing to transfer him back to his nursing home.  This daughter was insistent that he didn’t go.  After I repeatedly told her that he was going that night, she then attempted to get me to delay the transfer.  I had already spoken to the oldest daughter and power of attorney.  Reports were given. The ambulance had been called.  I told her so.

She then changed tactics and told me to let her feed him first.  He’d already had dinner.  She said not to call the ambulance until she said they were ready.  I told her if she wanted to get food she needed to go right away.  I couldn’t promise how long it would take for the ambulance to arrive.  She hung around the station for 30 minutes or so (in various conversations) before finally going downstairs.  She then took almost an hour to come back up with food.

And her father was gone.

She came back to the station holding the tray.  I explained that she’d been gone an hour, and that the ambulance could not wait for her.  She said again that I was supposed to wait for her.  I explained again that we had already discussed that he was going that night.  His doctors were ready, and her sister and power of attorney knew he was returning.  She dropped eye contact and began her conversations again.  I was about to turn away when she suddenly looked back at me and said that she knew I had tried to explain things as best as I could to her.

I asked her if she needed me to call a ride for her.  She said no.  She said the voices were bothering her.  I asked her if they were hurting her.  She said they wanted to but that she was stronger.  I asked her if she saw anyone for help or if she took any medicine to help keep the voices away.  She said that she did before, but she didn’t like how the medicine made her feel.

Then, just as suddenly, she broke eye contact and went to the empty room with the food – mumbling the whole way.

I had a  particularly challenging shift this last week.  So much so that I can now answer that always present question “Have you experienced an ethical dilemma?” on those pesky nursing surveys with a strong “Yes.”

I cared for an end-stage patient who had battled cancer for almost 20 years and unfortunately suffered from a recent stroke that left him aphasic.  He is a DNR and on comfort measures.  My problem?  The family’s idea of comfort.The family refused anything except Vicodin for pain.  They didn’t want him too sedated.  Fine, but their only apparent option was to leave him restless and visibly in pain?

The patient only had some semblance of peace when the family left and/or slept.  Every other time they were hovering around, picking at his nose, demanding q2h oral care, questioning the position of a leg, moving him,etc.

I consulted our palliative care nurse.  She is an excellent resource and passionate about her work with families and patients.  Even she came out of that room shaking her head.  They were in complete denial.  Specifically one daughter who took control every time she arrived.  Any bit of progress in patient care and in the wife’s processing of the situation got set back. She even went so far as to get PT/OT consults and CPT ordered.  The terminal congestion had already been explained.  Yet she wanted more.  When the doctor suggested cutting off the IV fluids as he was already receiving continuous NGT feedings and getting wetter and more edematous – she refused.  The wife let her completely take over.

I really felt for this wife.  Whenever we were finally alone, she and I were able to talk.  We spoke about the IV fluids and feedings.  We went over the signs of pain in a person unable to speak.  I explained that when those signs persisted after the pain pill was administered, it was appropriate to try a stronger medicine.  I reassured her that we would start out with smaller doses and increase them up to the point that they kept him comfortable.  She said to me at one point, “They keep telling me that it’s my decision, but how I am supposed to decide?”

That was the kicker.  The burden of decision was too much for her.   He had always come through before.  This time was different, and she was unprepared for it.

****

This situation broke my heart and motivated me to look at advance directives to share with my family this Christmas. I don’t anticipate such a situation with my family as we are practical and reasonable to a fault.  However, you never know. There are so many possible outcomes that may leave your family unsure of your wishes.  Aging With Dignity has a wonderful, easy-to-understand document called “Five Wishes.”  It meets the legal requirements in 42 states.  If you live in one of the states that does not recognize it, it can still be helpful and kept along with your legal directive.

The important thing is that your wishes are made known and that burden is lifted from your loved ones.  They can be at peace knowing that it is your decision, and they are simply helping you carry out your last wishes.

Work

I have another new nurse working with me.  She’s got a wonderful dry wit, and she’s very quick to learn. Maria and I are so happy to have her working with us. I love the older nurses, but my station is in dire need of new blood.

I had a patient with bilateral nephrostomy tubes for the first time.

My nursing director stopped me in the hall to tell me she wanted to speak to me later about management opportunities.  Hmmm…..

Life

I’m still working out what I’ll be making tomorrow for Thanksgiving.

Ever since I bought my house, my family has come to me for the holidays.  We didn’t have many traditions when I was growing up, so I’m trying to change that for us now.   First change was getting a live tree last year.  This year I might have everyone help decorate it Thanksgiving afternoon.  Next change:  more holiday photos.

I need to go pick out a Christmas tree today.

Love

Just kidding…

I have a hard time doing it.

Lately I’ve gotten worse, and this is particularly bad timing as administration is looking over every cost with a magnifying glass.

I know that the majority of my problem is that I do too much.  I’ll take care of anything that crosses my path, including meeting other patient’s needs – big or small.  This wouldn’t be a problem if everyone did this.  Because they don’t, I find myself running all shift long and wondering just how the other nurses are able to leave at 7:08 on the dot while I end the shift exhausted and still needing to finish charting.  I realized that I’m part of the reason everyone else is able to do so.  Not completely, I’m sure.  But it can only help them to have me running in the halls so they can stay caught up with charting.  I don’t believe any of them are actively using me.  I believe I’m allowing myself to be used.

I cut some time off by using the lounge computer to finish charting after giving report.  If I stay in the station I’ll keep answering the phone and doing random tasks just because nobody is in the station.  This helped, but it’s not enough.  I need to better manage my own time and tasks.  Somehow over the last year I’ve taken on more than my share.

Our nurse director recently brought up her wish to have everyone charting in patient’s rooms as they do their morning assessments.  (We already use rolling laptops for medication administration.) Other nurses were rolling their eyes, but this caught my attention.  If I’m in my room charting, this guarantees that it gets done and keeps me away from all the extras that keep me late shift after shift.  We carry voceras, so I can always be reached for my patient’s needs and physicians.

This weekend will be my first attempt to do so.  I do realize that what I plan to do to better manage my time is to actually hide myself instead of just saying no.

Baby steps, people.

My Happiness Project

1. Set a bedtime.
2. Make my bed every morning.
3. Always be reading something.
4. Move more.
5. Toss and organize.
6. Give proofs of love.
7. Leave the past.
8. Fight right.
9. Don't expect praise or appreciation.
10. Kiss more, hug more, touch more.
11. Aim higher.
12. Find some fun.
13. Ask for help.
14. Smile.
15. Realize it's possible.
16. Don't compare;be inspired.
17. Focus on what I have.
18. Beware of drift.
19. Take a chance.
20. Listen.
21. Be mindful.
22. Cultivate gratitude.
23. Spend out.
24. Do good, feel good.
25. Show up.
26. Have the courage to be imperfect.
27. Find joy in the ordinary.
28. Work smart.
29. Enjoy now.
30. Talk to strangers.
31. Go outside.
32. Start where I am.
33. Show up on time.
34. See art everyday.
35. Love with abandon.
36. Be colorful.
37. Dress the part.
38. Revel in accomplishments.
39. Learn something new.
40. Fear less.
41. Take pictures.
42. Speak with integrity.
43. Don't be critical about small things.
44. Manage my pain.
45. Surround myself with creative people.
46. Practice, practice, practice.
47. Don't force it.
48. Deal with something once.
49. Trust my instincts.
50. Avoid gossip.
51. Choose to see the best in people.
52. Take time to be silly.
53. Throw my own party.
54. Be a mentor.
55. Lean into my fears.
56. Find the others.
57. Do the unexpected.
58. Don't break the chain.
59. Do things others aren't.
60. Slow down.
61. Be cool with not being cool.
62. Be kinder than necessary and more generous than reasonable.
63. Pretend I'm good at it.
64. Keep in touch.
65. Row my own canoe.
66. Do what only you can do.
67. If it doesn't work out, find something that does.
68. Dream bigger.
69. Notice what's right.
70. Stop talking. Start doing.
71. When in doubt, choose laughter.
72. Don't let the perfect be the enemy of the good.
73. Respect everyone.
74. Be early.
75. Delete the unnecessary.

Three Simple Rules

1. If you do not GO after what you want, you will never have it.
2. If you do not ASK, the answer will always be no.
3. If you do not MOVE forward, you will always be in the same place.

All I Need

1. Someone to love.
2. Something to do.
3. Something to hope for.

What I’m Reading

Blood Meridian
by Cormac McCarthy
Their Eyes Were Watching God
by Zora Neale Hurston

U.S. States I’ve Visited

Alaska
Arizona
Arkansas
Colorado
Georgia
Florida
Louisiana
Maryland
New Mexico
North Carolina
Ohio
Oklahoma
Pennsylvania
Texas
Utah
Virgina

Countries I’ve Visited

Mexico
Colombia
Thailand
Vietnam
Bermuda (British territory)

I write about…