Nursing (RN) Challenges

Miscellaneous and Personal Stuff I Must Share
41

I would like to comment on the above. IMHO, the MOST important thing for the nurse calling me in the middle of the night is to tell whether the patient is sick or not. I tell my students and residents that this is the only thing they really need to learn during residency (that, and if you have ANY doubt about whether the patient needs to be seen right away, get up and see them).

My personal least favorite call is “the patient is confused and agitated-can I have something to calm him down?” If I don’t know the nurse, this is one I always always see. This could be anything; I’ve seen it range from an acute heart attack, to a blocked catheter with urinary retention, to an acute drop in sodium from the Cardiologist keeping a little old lady NPO and giving her loads of D5W during a cath.

I’d love it if all nurse were as complete as you are. Sorry to vent, but my hospital has been hiring a lot of temps, and having to deal with things like not being called for a BP of 80/55 in a patient with sepsis makes me mad.

Now that the rant is over, I would make sure that the patient with asthma and acute onset of pleuritic pain hasn’t actually had a PE or a pneumothorax. Coughing up “yucky stuff” to a patient can mean blood, so it always helps to press for an actual color.

The Hgb/Hct of 8/34 is internally inconsistent and I would repeat it as I would expect closer to 8/24 or 11/34.

The patient with chest pain and fever is going to need blood cultures. I don’t know if you can do them at your hospital or if you need an order.

42

I agree. A lot of people like to medicate symptoms and nt find out causes.

Agreed. A sputum was sent, so an observation note of the sputum could be assumed.

:eek: Holy crap–that is a typo and I didn’t catch it! Sorry. 8/24.

RNs can draw BC off of central lines, but we use phlebotomy for the peripheral sticks.

43

Just to add to the diagnosis question from WhyNot: We were taught what diagnoses matched what combinations of lab values in Med Tech school to put them in context, but we were cautioned, warned even, that we could not make a diagnosis to anyone about anyone, ever. That said, what we discuss here is from experience, training and book knowledge, used as an internal quality control mechanism. When I worked in a clinical lab and was reviewing some whacked-out lab values prior to releasing them, I’d look at the diagnosis as well and ask myself: does this make sense, or is the instrument not running right?

Vlad/Igor

44

Ok, time for the last scenario, because my RL is catching up with me!

I guess I’m a glutton for punishment. Here goes scenario the third. Same deal.
Same unit, same ratio, same staffing. AND some of the same pts (much like RL), but this is the next day(now day 4), early evening. Updates in different color font.

NOTE: not all of these things happened at the same time (although they could and have)
#2 85 year old black male. Sundowns. In for CHF, exacerbated by his noncompliance with his diet and meds. He did indeed flip into a rapid A fib at 1 pm yesterday. He was digitalized and the monitor now shows a controlled A fib. Other VS stable. As the evening draws in, he starts to complain of strange lights and things “looking funny.” His dig level was high, but doc ordered no Digibind because his renal function is ok. He is in SR. VSS. He says he’s not making it out of Cecil Adam’s Memorial, though. His monitor shows runs of bigeminy. His ankles are now 2+ edema, up from trace edema yesterday. EKG showed Afib this morning. He puts his call light on and c/o’s of “I’m about to throw up.” He proceeds to do, all over you. He is cold, clammy and starting to lose consciousness. BP is dropping–now 85/57 (from 122/78). HR=133; at glance, it looks like ST w/ PVCs. RR=20.

#4 74 y/o Hispanic male in for unstable angina. Speaks no English; has family at bedside. Pt is convinced his “dolor” is from indigestion. Interepreter got him to understand that he needs to take his pills. He continues to c/o of dolor. He is unable to rate it on a pain scale. He points to his chest and his abdomen, equally. He has spiked a fever of 102. He has + BS x 4 quads; abd soft. Still c/o dolor to abd and chest. VSS, except for temp and light ST. His light is on as well. He c/o’s of severe abdominal pain–pointing now to his below his belly button. He is rocking back and forth in bed, grimacing. BP is elevated, temp is now 100.5, ST with a pulse of 129. He is breathing about 28bpm, in shallow gasps.

New #1 This is 46 year old black woman admitted 2 hours ago for exacerbation of asthma. She is alert, cooperative. VSS. Her nebs are ordered q 4 and prn. (neb is albuterol). She states she has been coughing up some “yucky stuff”.
She feels much better with the O2 on. She has provided a sputum specimen. She puts her light on, c/o of a sharp pain to her right chest upon inspiration.Pt states she feels “much better” and needs to get back to her job. She asks you to hand her her purse from the bedside cabinet. In the process, a crack pipe falls onto the floor.

New pt #3. A 76 year old white man, hx of ETOH abuse, admitted from ER with acute upper GI bleed. He was scoped in the ED and is now on an Octreotide drip at the standard concentration and dosage. His Hgb and Hct are now 8/24. He is awake, alert, and wants dinner, despite being NPO. His other hx is unremarkable, as is his physical assessment. He does admit to smoking (cigarettes). He has no family.Doc thinks he looks good after 2 units of PRBCs and is prepared to transfer him for one more night on GMF before d/c. His Octreotide drip is discontinued and he was allowed to eat a clear liquid lunch. He seems anxious today, more so than yesterday, and keeps putting the call light on for trivial reasons.

OK-Questions:

Who is your number one priority? What is your number one priority? To whom can you delegate, if needed?

#2 Mr Sundowner: what is going on with this pt? What will you tell the doctor? What should be on the chart already concerning this pt? When will you call the doctor?

#4 pt: what is the most likely cause of his symptoms? What should you assess prior to calling the MD? Should you call the MD? What orders do you need from him or her?

#1 asthma lady: What do you do in this case? What teaching will you perform? What focus should you have for her?*

#3 GI Bleed–what is up with him and that damned light? Why is he calling for stuff like “move my water pitcher” and “I need a different pillow”? What should you look for?

  • I feel really bad about making my nice single mom a crackhead–but I didn’t want to write up another scenario. Scratch that–I do want to, I have no time!
45

Questions just because I feel like it:

You are at the nurses station. 3 things happen at once–what do you do?

  1. Nursing supervisor is on line one.

  2. Bed control is on line 2.

  3. Dr. Smith is on line 3, answering your page.

which call do you take first. I have told you all you need to know. These questions have nothing to do with the above scenarios.

46

Piss easy. Every-one knows that you Don’t Answer The Phone. Get some-one else to take a message, then when they relay it you, make sure you have your hands full before you say, “Oh dear, so busybusy! Could you deal with that, pulease?”. Don’t forget to smile nicely.

47

Answer line 3 first. If you paged Dr. Smith, then it’s because there’s something going on that he needs to know about. Also, he’ll hang up if you make him wait for very long.

Then answer line 1. The nursing supervisor is probably calling to tell you that your unit has just had 3 call-ins for the next shift and she needs you to work late, or else that your most obnoxious patient has made a complaint about you. Best to get it over with. :stuck_out_tongue:

Bed control can wait til last. If they hang up you can call them back; they aren’t going anywhere.

48

Nope. Nightingale got it dead right. Plus, if nursing supervisor pitches a hissy about why you didn’t pick up right away, you’ve got “I was on the phone with Dr Smith” in your hip pocket. Nursing sups tend to think that we eat bonbons or similar all day. And Dr Smith WILL hang up if you don’t answer soon–not out of malice (one hopes) but because s/he’s probably fielding 4 calls him or herself.

The hands were full, so, so busy only works when you’re in a pt’s room. Of course, now they gave us wireless phones. When asked why I don’t answer–I always say “pt confidentiality–I was in a room.”

No takers on the last scenario? Oh, well. I’ll check back later.

49

I am the nursing supervisor.

50

Thanks for doing these, it’s really cool of you! I’d like to play, but I’ve been swamped. You know how you mentioned nursing pharmacology? I’m taking finals in…well, I can’t remember how little time I have left to study. And I’m starting to burst at the seams with nursing knowledge that I have stacked up in my brain, ready for exams. So I’ll come back in a week or so and check out all the answers and stuff. I’m afraid I won’t do very well, but hey–it’ll be really educational for next quarter’s Med/Surg clinicals!

51

Is that supposed to change my answer? IMO, nsg sups have a strange time mentality–they forget how long it takes to actually accomplish anything. Telling me that I must get that pt up from ED is all well and good–but you’ve forgotten that the GMF needs to take my pt transfer before I can accept another one. (in my hospital, nsg sup still does some of this, so bed control and nsg sup often tag team the calls, thereby calling me from the bedside twice as much–and delaying the work!).

If you are calling to see if I’ll work over, the answer is no. It will always be no because our shifts are 12 hours. I learned long ago that nursing will suck you as dry as you let it. The work does not end; will not end. I have to look after me first, then everyone else. Looking out for my needs means setting limits on my stressors. We could get into mandatory overtime (a thing I have been blessed in my working life never to have been faced with) and the damage it has done to nursing, but that’s another thread…

52

It was a j/k. Never fear, I never paid much heed to them when I did work in acute care.

I do work in nursing management but over two largeish aged care facilities. Acute care nursing bores me witless though I can quite see how some nurses would say the same about aged care nursing. Plus, there’s a a stigma to aged care nursing, usually reinforced by nurses themselves - sometimes nurses within the field too. I’m going off on a tangent here, but it’s linked to the horizontal violence talked about in the other thread. Some-one touched on it possibly being related to the task-orientated days of yore. I think there’s a lot in that, some nurses just don’t get nursing which doesn’t involve technology and complex procedures and see it a less valuable. I’ve even heard the word “deskilled” used in reference to aged care nurses. Which is a shame, because aged care nursing is a complex field of nursing which requires high levels of nursing skills. The only other place I have ever found the same level of autonomy was when I was the only RN in a small bush hospital, but, hey, I wasn’t going to live in Wolf Creek the rest of my life.

53

“Deskilled”? That is terrible! There is no way I could do LT care–I don’t have the patience (and it must be said) the compassion or kindness for it. I admire those nurses who can, just like I admire peds or neonate ICU nurses–the first case of child abuse and I’d go spare.

This is all part and parcel about how nursing does not support its own. :frowning:

(I wondered if your nus sup thing was a joke. And then I decided to just treat it as a straight remark, on the off chance I could maybe wake up a sup or two!). :wink:

I have no time or energy to look back and update this thread tonight. Maybe tomorrow night.