RE:Connect

The 3rd of Every Month

The 3rd of every month has come again and this day is quickly becoming my least favorite to work.What is the significance of the 3rd you may ask? This is the day when all the new residents start in my unit. Usually the only clinical experience the residents have thus far is working on the floors, not actual ICU experience. Every new nurse is warned of this day during orientation. Because, it is a day when you have to be extra careful and completely on your game. Every order that comes through must be triple checked and questioned and it is best to be in the patients room if the resident enters for any reason. These precautions may seem a bit much, but they are completely necessary. As we say in the South, "bless their hearts." "Bless their hearts" because even though the residents mean well, they really have no clue what is going on at this point.

An example of why nurses should always be extra cautious when working with new residents is an experience I had last night at work. I was caring for a 7 day old coarctation of the aorta repair. The patient's post-op course had been uncomplicated at this point. The patient was extubated earlier that morning, but it was noted that he was having some mild subcostal retractions. When I entered the patients room to complete my full assessment, the patient was severely retracting, using accessory muscles to breath, nasal flaring, etc. I immediately notified the resident. He said just to increase his oxygen. When some time had passed and the patient was still working very hard to breathe, I again notified the resident. He ordered a stat chest x-ray and an ABG. The patient's ABG revealed respiratory acidosis and the resident said out loud to me, the nurse, "Hmmm, this is a tricky one." It took everything in me to keep my patience and this is only the beginning of the story. We started the patient on Vapotherm and the resident did not think we needed to obtain another ABG. He said he wanted to simply manage the patient clinically. I looked at the resident and said "clinically the patient looks like crap."

Throughout the night the patient was transitioned to Nasal CPAP and then back to Vapotherm. Multiple times I had to go over his head and talk directly to the Attending to get anything done for my patient. Later I asked the resident if we were going to move to the next step because the patient was not clinically better. He said that he thought we should leave the patient alone and let day shift decide what they wanted to do with their patient. I had to walk away from the resident. He asked if I was okay with this and I turned around and said that I "absolutely was not okay with not doing anything for my patient." I explained to him that we have tried different interventions that are not improving the status of the patient and that he will only compensate for so long and that I wasn't in the mood to have to emergently intubate the patient during shift change. Now I know that was quite blunt, but it actually got the resident's attention. I was the only one advocating for this patient. I am at the patients bedside all night long and I may not know what is wrong but I sure know when something is not right or normal with my patient. It is that gut instinct that tells you that something has to be done. The patient was stable when I left this morning but had quite the eventful day.

The patient had a repeat echocardiogram that revealed mitral valve stenosis, mitral valve regurgitation and severe pulmonary hypertension. The patient is still on Vapotherm and is breathing more comfortably but is still having mild retractions. They believe that the patients coarc masked all the signs and symptoms of the stenosis, regurgitation and pulmonary hypertension. Usually to treat pulmonary hypertension, we give our patients sildenafil or Viagra. Well, apparently sildenafil can mess with stenosis and regurgitation and vice versa, the medications used to treat the stenosis and regurgitation can mess with the pulmonary hypertension. So the team is weighing the pros and cons of repairing the mitral valve and is supposed to form a plan tomorrow. I of all people understand how scary it is to start working in an ICU and feel stupid all the time, but the problem lies when people put off intervening for the patient because they don't know what to do. I will be very interested to find out the outcome of the patient.

A Great Decision

So far I am enjoying my decision to focus on Cardiac. I think I picked the best time to make this switch because all of my colleagues are having to garb up in isolation gear to care for the multiple cases of H1N1 in our unit. Since I have switched to Cardiac, I have had the opportunity to care for some very sick kids. I am challenged every time I come to work and I actually feel excited when I come in for my shift. I think this was the best decision for myself. It is nice because I feel like the charge nurses have really supported my decision to focus on cardiac because they have been giving me challenging assignments that I would expect a more experienced nurse to get, not me! They obviously have confidence in my abilities and that is what I am trying to remind myself when things get tough.

Focus Areas

Can you believe that we are already into October? I sure can not! It feels like just yesterday that I graduated nursing school and began the PNR program. Now I am considered an "experienced nurse." How crazy is that! 2009 has brought about many life changes for me. From graduation, to getting my first "big girl job," to living on my own. I can honestly say it has been amazing and I can not wait for what is yet to come! Right now at work I am continuing to adjust to night shift. I go through phases of really enjoying it to completely hating it. But, I just keep reminding myself that I am making more money and am having the opportunity to care for sicker patients than I would have on day shift. I just had my 6 month evaluation with my supervisor and I am just still in shock about how much time flies! I think my weeks go by faster having only 3 day work weeks.

In the PICU, we have to pick an area of focus, either cardiac or medical. You can still float into the different areas but the nurses generally work in which ever focus area they choose. I am now having to make that decision of what to focus on. I enjoy working in both areas for many different reasons. You never know what kind of patients you will get while working in the medical area and it is great experience. From trauma patients, to oncology patients, the medical focus area offers a variety of patient diagnoses to become familiar with. I have a lot to learn and understand about cardiac patients and all the different congenital anomalies, but I love caring for them because they are always busy. Cardiac is very specialized but it challenges me in many different ways.

There are pros and cons to each area of focus. Does anyone have any suggestions? I know that no matter what I decide to focus on, I will continue to learn something new everyday. I just want to be challenged and enjoy caring for my patients. There always seems to be some sort of decision that has to be made. Maybe that is just adulthood!

Taking Care of Yourself

Something I have been learning how to deal with lately is how to find time to care for myself and my body. My crazy schedule thus far has been switching back and forth between and day shift and night shift. I have just recently transitioned to working just night shift now. I will work nights until there is a day shift opening. The wait for day shift is around two years. Usually I sleep until around 3 pm and I wake up a cook a good dinner for myself. Then I pack a lunch of cereal, fruit, yogurt and sometimes a peanut butter sandwich. I eat "lunch" around 2 am. Usually when I get off work in the morning I am too tired and too nauseated to eat, so I go straight to bed around 9 am. Then I do the whole thing over again. So I really only get two meals during the day. My body has definitely seen the consequences of this lifestyle. I have lost a little bit of weight and am lacking in energy most days. I know I would feel better if I was eating more meals and exercising more than just taking my dog on a walk . I just can not fathom how I could muster up the energy to go to the gym or go running, when my body is already so tired. I try to make nutritious dinners before I go to work, but it just does not seem to be enough. I am wondering if anyone out there has some good advice on taking care of myself while having to work nights.

Stories and Struggles of Nursing

One very neat thing about writing this blog is that no matter what specialty you work in, we can all relate to each others stories and struggles of nursing. This week I admitted a chronic patient who had been treated for the last 22 years for osteopetrosis. This disorder is quite rare and is where the bones harden and become more dense causing them to be very brittle. The patient required a bone marrow transplant at age 10 and was transfused for the rest of his life. The patient was admitted to the PICU for altered mental status after going to the OR to have a left hip wound debrided. The patient had been on multiple broad spectrum antibiotics for weeks and was not responding to treatment. After the patient was admitted to my unit, his left hip wound would not stop bleeding. The site bled copiously for 12 hours straight. It was as if it was my mission to make the bleeding stop and believe me I was ecstatic when it finally stopped!

The second day I cared for the patient was much more difficult than the first. I saw a change in him mentally. He was deteriorating before my eyes yet he could still carry on a conversation. He asked me "why do all the doctors talk over me and not to me." That same day our entire PICU team and every other team involved in his care met to have a care conference to discuss the plan for the patient. After an hour and half, I finally understood this patient. This patient had an extensive social history with his aunt being his durable power of attorney. The main point of this care conference was that there was nothing more the team could do for this patient. He had a lethal infection that was not responding to treatment, severe ascites impeding his ability to breathe, he was in liver and kidney failure and was on his way to getting intubated which he made clear he did not want. This patient taught me a lot about myself. He showed me that I truly am a nurse who cares, because I was not going to sit by and have the patient's needs and requests go unnoticed. I made it a point to have someone watch my patient so I could attend the care conference to advocate for his needs. I made it a point to do everything in my power to help the patient mentally, physically and emotionally. I never stopped trying to make the patient comfortable. He passed away the next morning. I am sort of glad I was not at work because I think I would have lost it. I know I will never forget his sweet spirit. I am just relieved he is no longer in pain. I don't think it will ever get easier to lose patients you have cared for, you just have to believe that you are doing your best to make the last days of their life a little easier.

A Statement a Professional Nurse Should Never Make

Recently a very close friend told me about an experience her father had while being treated in a chemotherapy unit.  Her father was receiving a drug that we consider at our institution to be moderately to highly emetogenic depending on the dose, and if given where we work he would have received both premedications and PRN antiemetics.  Apparently the institution where he is being treated does not have the same antiemetic guidelines.  They only gave him a prescription for Ativan to be taken PRN.  My friend questioned the practice and asked her father to ask the nurse if this was in fact correct or if it was an error of omission.  When asked, the nurse stated “I don’t know I just do what the doctor tells me to do”. Obviously this was very upsetting to my friends’ father but even more embarrassing to my friend and I as a colleague of ours made a statement that goes against everything we’ve been working so hard to accomplish our entire profession.  We are smart intelligent professional nurses.  Yes we carry out doctors’ orders but not without critically thinking to make sure they are safe for the patient.  We use our knowledge learned, our experiences gained and mostly importantly we do so while being compassionate and caring.  Don’t ever think that as a nurse you should do otherwise, and if you do you’re certainly shouldn’t be considered one of us.
Let me know your thoughts???

More Than Just a Job

At work, I have been trying to become more involved. I want to be the kind of nurse who is proactive. Proactive in advancing my skills and knowledge base. Proactive in the community. Proactive in my own professional development. I do not simply want to go to work everyday, complete my tasks for the day and be done. I have found nursing to be a career that has many options within it to be more than just a job. This past week I signed up to be a "superuser." Our nursing educators asked the staff if some nurses would be interested in going to a training class to learn how to use the new Alaris IV pumps and come back and teach other nurses on the unit how to use them. This was completely out of my comfort zone, but with the encouragement of a friend, I signed up to be a "superuser." The experience was sort of neat because after completing the training I felt like I was really helping out my unit. It was very weird teaching other more experienced nurses how to use something, but nonetheless it was a very rewarding experience. At the end of the month, I will be participating in the annual Heart Walk. I want to encourage everyone to find ways to become more involved at your jobs and in the community. I know we are all tired and want to rest on our days off, but nurses are in a position to really make a difference in others' lives and we should never forget that!

See One, Do One, Teach One.

See one, do one, teach one. That seems to be the recurring theme in the nursing profession. Last week, I was receiving report from the night shift nurse, when I was approached by a PNR (pediatric nurse resident, a member of the summer 2009 cohort). She asked my name, and said that I would be her preceptor for the day. I thought to myself, "surely this must be a mistake!" Do these people seriously think I know how to precept someone when I have only been on my own for about 6 weeks? Well, the charge nurses thought it was completely appropriate. I was very nervous the whole day, because I did not want the PNR to ask questions that I did not know the answers for. However, I surprised myself, because I really do know more than I give myself credit for. I found myself sort of enjoying the teaching/precepting role. It takes a great deal of patience, but I think in a year or two that I could be a really great preceptor.

Ambulatory Oncology Clinics

Oncology nurses work in a variety of settings in too many roles/positions to name. The August edition of ONS Connect includes an article on ambulatory oncology clinics, which is the area of oncology where I work. Ambulatory out-patient clinic jobs are often seen as desirable to many nurses because of the set hours Monday to Friday, no weekends, no holidays and less overtime than ward nursing. What often isn't considered is that this type of nursing isn't for every nurse. It takes a special skill set to perform in these positions effectively, one that often isn't assessed for during the interview process, and is rarely taught or "upgraded" once on the job.

I love my job as a clinic nurse in the lymphoma/CLL clinic but it did takes some time to get used to the new hours. I miss having days off during the week to run errands and get stuff done while the "regular folk" are busy at work. It took some time to adjust to getting all my work done by the end of the day. As a ward nurse there was always another shift of nurses coming on to tie up any loose ends or take care of an unstable/critical patient. Time management is a make or break skill for an outpatient nurse. Lack of organization and poor time management can bury a nurse before their day even begins. In my 6 years in this position I have never received an inservie or training on time management or organization. I think that these would be more benefical for me than the same old inservice that is given year after year. Another necessary skill is the ability to recognize a crisis and adapt asap. Well honed assessment skills and quick thinking will serve a clinic nurse well in her day to day work. 

At our center, I am lucky to have an on-site chemotherapy treatment room that is open 364 days a year (we close for Christmas but have a nurse -on call for urgent treatment), 12 hours a day during the week and 8 hours a day on weekends and holidays. Nurses are hired to work in either the clinic setting or in the treatment room. We don't cross over, each area is seen as a specialty area. The Chemo Unit is the area where patients receive chemotherapy but also blood products, hydration, and have PICC lines inserted. To have access to such an area makes a clinic nurse's job easier because we don't have the hassle of organizing treatment in different hospitals with staff we have never met or who don't know our patients. 

I've often heard (unfulfilled) clinic nurses say that they feel like glorified secretaries, pushing papers all day long. I've never understood this comment. Yes, outpatient nursing is different from the wards. We may not wear scrubs but we're still nurses. On the ward, the focus is on illness while in the clinic we can focus on living well in the face of illness. I encourage nursing administrators and those in charge of hiring for ambulatory areas to make a conscious effort when interviewing nurses to not only make sure the candidate is right for the job but also that the job is the right one for the candidate.

Improving Patient Education Utilizing the "Teach Back" Method

Recently an outside consultant completed a team training session with my staff with the goals focusing on improving patient care and safety by increasing communication.  He discussed a rather simple method of assessing the understanding of information taught to patients by using a technique called "Teach Back".  Teach Back simply means that after the physician or nurse teaches or explains information to the patient the clinician would then ask the patient "Explain to me how you are going to explain what I just said or taught you to do to your family member?"  This allows the patient in their own words to explain or demonstrate the actual procedure of what they just learned.  It also allows the clinician to assess the patients' understanding of the information provided.  This simple open-ended question is much better than asking a closed ended question such as "Do you understand?" which most often the patient usually responds with a "yes" even when they have no clue about what just occurred.

One example the consultant provided of when teach back would have been very beneficial to the patient was in the case of the newly diagnosed diabetic.  The ER nurse noticed that the patient had several admissions to the ER over the last couple weeks with uncontrollable blood sugars.  It appears that he was admitted and discharged with instructions on diet, exercise and a glucometer and sliding scale for insulin administration.  Upon her assessment the nurse asked the patient about his diet and he stated that he had modified it as directed and was not happy eating the bland foods and was sad to give up his sweets.  He also told her about his exercise regimine that his wife insisted he adhere to.  The nurse inquired about his routine for checking his blood sugar and asked him to demonstrate which he did very well. He was also able to show her how to effectively use the sliding scale.  The nurse then asked him to demonstrate how he injected the insulin.  The patient stated "I inject it just like I was instructed" then he proceeded to take an orange from his bag.  He wiped the orange with an alcohol pad and injected the insulin into the orange then peeled it and was about to eat it.  The nurse looked on in shock, she said "What are you doing?" the patient said "It's what I been doing every day, four times a day since I last left here and I'm sick of eating these oranges".  YIkes!!!!!!!!!!!!  At last the source of the uncontrolable high blood sugars is revealed.  How often do we use props to teach patients how to perform self care procedures at home and assume that they should know that it's just a "prop"?

Next time you complete a teaching ask the patient to do the "Teach Back".  Do you have any other stories about patient education experiences gone wrong?  If so please share, examples like the one above help us all to learn for the future.