The Nurse’s Famous Last Words: “But the Doctor Said it Was Okay..”

The Nurse’s Famous Last Words: “But the Doctor Said it Was Okay..”


One of my BFFs is a rapid response nurse (I know, coolest job ever). Whenever a patient is going downhill or looks not-so-hot, she gets a call. Many times, the call could and should have occurred hours before. However, what she is told most frequently is “but the doctor said it was okay”.

Notify MD, please

Notify the MD if __________ is a very common order. We notify for many things, and many times they don’t intervene.  And honestly, many times an intervention isn’t necessary. However, there are times in which interventions are necessary and it’s our job to convince them of such.

The doctors round once a day and we’re there with the patient for 12 hours. When things are subtly changing, we notice. Maybe at the beginning, signs and symptoms are a bit vague.. but we know something is up. Some doctors wait until things are glaringly wrong to intervene, which puts the patient at risk if you’re not advocating appropriately.

Take sepsis, for example. Someone can be in early sepsis, and no one notices until they’re in septic shock. However, if you catch it early and treat appropriately, you can literally save their life. The early symptoms however, can be quite vague.. especially if they were admitted for something else and it’s not on anyone’s radar.

Patient scenario

Let’s say they were admitted for a broken hip with surgical repair and are hanging out on your med-surg unit. It’s post-op day 2. Their O2 sat is 92% on room air and their heart rate is 110. Concerned?   Nope! Next patient, please..

So, their labs are back and you’re awesome and remember to look at them promptly. Their white count went from 9,000 yesterday to 13,000 today. They were 92% on room air but now they’re 88%, so you throw 2L nasal cannula on them and they come back up to 94%. Ok great.. my PRN interventions are working so I don’t need to call the doctor.. right?

It’s now 1300

You go in for some meds and notice their respiratory rate went from 16-22 to about 28-32, heart rate is 115, and O2 sat is now 90% on your 2L.  You increase to 4L and we’re back at 94%. They’re just working harder to breathe, it seems. They’re a little sleepier now. But they didn’t sleep too well, so maybe they’re just tired. Concerned? A little..  Ok, I’ll page the doctor and just FYI them.  I know they don’t want to do anything and I’m already behind on my meds.

“But they looked fine when I saw them at 0530 this morning!” says the doctor.

“Yes, that was almost 8 hours ago. He doesn’t look so hot. I don’t know what it is, but something is off,” as you tell him the changes in the patient’s assessment.

“Ok, I’ll put some orders in,” he says, and hangs up.

PHEW! He knows, he’s addressing it.. next patient please!

You check the computer for orders.. Duo nebs q4hs and two sets of blood cultures.   GREAT! Respiratory therapy does the nebs and phlebotomy will get the cultures. Time for some lunch.

You’re walking back from lunch. Your tech comes to find you.. his blood pressure is 78/42. WHAT! How can this be?!

Updated assessment

He’s stuperous; you can’t get him to open his eyes without a sternal rub. He’s now 87% on your 4L nasal cannula. He’s burning up.. temp of 101.9 F. His respiratory rate is 34. Heart rate 120. Recheck blood pressure, 76/40, MAP of 40.

Is he stable?

No, he’s not.

Is he perfusing his organ appropriately?

Absolutely not.

Paging the MD again

It’s 1500,  and the doctor calls back after what seems like an eternity, but is only 5 minutes. He puts in an order for a liter bolus, PRN Tylenol, and some antibiotics. And that’s it. You’re not happy. You decide to call rapid response.

“He’s probably septic,” says your rapid response nurse when she gets there and looks at him.. they run a lactate, hang another bolus, and put him on a non-rebreather. Blood pressure is now 95/60, HR 110, temp still elevated at 101.5 F, O2 sat 98% on a non-rebreather.

His lactate is 5 (normal should be 2 or less). He’s working really hard now to breathe. The rapid response nurse thinks he needs to be intubated she’s going to call the doctor for you.  Now.

Intubated!? What! How does she know that? She just got here and the doctor knows about everything except the non-rebreather and low blood pressure.. you think to yourself. It’s her funeral, he sounded frustrated I was bothering him in the first place.

You overhear her on the phone with him. “He’s working his butt off to breathe, his lungs sound coarse, he’s febrile, tachycardic, on a non-rebreather to maintain a sat in the 90’s, hypotensive, and now his lactate is 5. I think he needs to move to the ICU and get intubated,” says your rapid response nurse to the doctor on the phone.

As she hangs up, she notices that his sats are dropping. On his non-rebreather at full blast.. 92%.. 88%.. 82%.. 75%.. “call a code, get the code cart, he needs to be intubated NOW.”

WHAT. IS. HAPPENING.

OMG WHAT IS GOING ON I AM FREAAAAAKING OUT RIGHT NOW! (Internal struggle as you run out of the room for the crash cart..)

The ICU doc shows up, intubates him, and moves him to the unit where they give him 5L of fluid, put in a central line, and start him on Levophed, Vasopressin, and a bunch of antibiotics.

You give report to the nurse taking over. You start to walk back to your floor.. what. just. happened.

Ok, this is what really happened

He was in early sepsis when you first got report. When you got his labs back, you should have pushed to pan-culture him (two sets of blood cultures, urine culture, and sputum culture) and start some empiric (broad-spectrum because we don’t know what’s causing this) antibiotics. You should have called the rapid response nurse at 1300. He needed some fluid earlier. He needed closer monitoring earlier.

“BUT THE DOCTOR KNEW!” says the nurse.

“BUT WHY DIDN’T YOU QUESTION HIM!” says the lawyer in the courtroom six years later. Or your manager. Or the patient’s wife. Or the ICU physician.

I know, I know. It sucks that you’re expected to be aware of these subtle things.  You’ll get better at it.

And I know what you’re thinking:  you’re not a doctor and didn’t go to school for that, it’s the physician’s job to handle this.

However, you are an educated and knowledgable nurse that knows when something is wrong.  And it’s your job to push back and advocate when you know something is not right.

You’re not just the messenger to the doctor when things go wrong.  Messengers don’t have to do anything when they receive a reply they don’t like. They just do what they’re told.

You’re not a messenger. You’re an advocate. You’re a nurse. Push back.

This messenger attitude is very dangerous. Do not get caught into it. Don’t assume that because the doctor knows, everything is fine and you can go about your day. People die because of this.

If you’re scared, not sure, or don’t know what to do.. ask your lead nurse, charge nurse, rapid response nurse, call an ICU nurse, or your manager… just someone, and get another set of eyes on them.

Strengthen your case, and call again.

Everyone would rather you call when you’re not sure and have it be nothing than have you not call them and all of a sudden there was a code blue that could have been prevented.

Just because you called the doctor and they know doesn’t mean you’re good to go. Remember your critical thinking skills – step back and look at the entire clinical picture and ask yourself..

  • Are they stable?
  • Are they decompensating?
  • Does this feel right?

Doing so can literally save someone’s life.  And your license.

Important points

The diagnostics of sepsis continue to evolve. As of January 2016, a new consensus was made regarding how this is done. Here’s the updated way to diagnosis sepsis:

Quote directly from this study, originally published in the Journal of American Medicine:

  • Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
  • Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection.

    • The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction.
    • ASOFA score ≥2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection. Even patients presenting with modest dysfunction can deteriorate further, emphasizing the seriousness of this condition and the need for prompt and appropriate intervention, if not already being instituted.
  • In lay terms, sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.
  • Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with qSOFA, ie, alteration in mental status, systolic blood pressure ≥100 mm Hg, or respiratory rate ≥22/min.
  • Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
  • Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and having a serum lactate level >2 mmol/L (18mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%

Learn more

Sitting Down for Your Patient

I went to NTI in Denver, Colorado this last week.  For those of you that don’t know, it’s an annual national conference for critical care nurses.  And it’s awesome.

I went to a lot of sessions.  Some on brain death, some on vasoactive drips, on sepsis, and hyponatremia.. but the ones that hit me the hardest were the ones about end of life conversations and palliative care.  Those were the tough sessions.

It made me realize something.  We’re the nurse.  We’re running the show.  We’re in charge.  And for those traumatic situations that we see every day, we have our Nurse Face on.  Our tough-as-nails so we can live to fight another nursey day face.  And because it happens so frequently, you sort of have to do that as a survival tactic. Between constantly juggling our time management so that we can get everything done and not wanting to emotionally go there with the patient/their loved ones, we get sort of stuck.  Stuck at the bedside.

So there we stand.  At the patient’s bedside.  We’re busy working on drips, turns, assessments, and documentation.  But we can get lost in that.  Standing at the bedside is not the only place our patient needs us.  Sometimes, they need us sitting down next to them, listening.  Sometimes, they need us sitting down right next to their loved one, supporting them when the patient cannot.  Sometimes, that’s all they want.

As I was pondering this “sit down to stand up for your patient” concept, I was flipping through my Twitter feed.  Mark Reid, MD (@medicalaxioms) tweeted this:

“You know who comes in your house and never takes a seat? Cops. Don’t act like a cop in the patient’s room. Unless you are a cop.”

What perfect nuresy timing, doc!

How intimidating it must be for the patient and/or their loved ones to have someone towering over them, asking them questions about their history and not what they want the future to be like, and not really paying attention.  All the while, cutting them off because w’re thinking about the next 43 things we have to do.

Good nurses + doctors are empathetic and walk through this journey of life with their patients + their families.  We all know life is not perfect, but do we actually believe it?  Or do we try to get through life, striving for it to be perfect, healthy, and fine even when it’s unrealistic?  Even when our patients are knocking on death’s door and no one has told them yet?

We do a disservice to them by not asking them their goals of care.  We cannot just assume everyone’s goal is for their health is to just get “fixed” by all of our modern medicine and technological advancements and go back to whatever they were doing before they came in.  Maybe they don’t want that.  Maybe they’re tired and just need someone to tell them that it’s okay to stop.

We all want to optimize our journey.  However, everyone’s optimal life journey looks different.  The 19-year-old with a terminal heart condition is going to have a very different optimal life than the 35 -year-old triathlete.. and theirs will look different to the 89-year-old with COPD living alone with four hospital admissions already this year.  Everyone’s goals are going to be different and we need to know this so we can not only support them appropriately, but also so we can just plain do what they want us to.  But we have to ask first.  Before they’ve been in the hospital for days, weeks, or even months.

I also think it is our duty as honest health care professionals to be realistic with our patients and their families, even if they are in denial.  We need to be their graceful and supportive reality check.  And for them to be able to hear about the reality of the situation in front of them, they need to trust us and feel a connection with us.  We can (sometimes even quickly) establish this relationship by being empathetic.  Not by trying to fix things or make them immediately feel better, but just by connecting with them.

For those of you that don’t fully understand the difference between sympathy and empathy, check out this 2:45 minute video that explains it the simplest yet most helpful way.  It really helped me differentiate between the two because I didn’t understand it before.

When patients and their loved ones know and believe that you empathize with them and are being truthful, that will enable them to make sound decisions for themselves and their loved ones, even in the midst of chaos.

And as stressed medical providers, isn’t that’s all we want?  To know that we’re doing the right thing?  We all know what the right thing is – it’s a mix between what the patient wants but it’s also what we truly believe is right.  And if we’ve built a trusting relationship with them and their loved ones and we have no doubt we are honoring their decision (that was made because they knew all of the facts and felt supported), it typically will align with what we believe is right as well.

If from the moment we meet our patient, we empathize, connect, and listen to them while gracefully explaining the reality of what’s going on – and immediately identify and agree on realistic goals, we will avoid doing a lot of unnecessary things.  We can all rest assured that we are all fighting the same fight, working together towards the same goal.

This will avoid moral distress for the nursing staff and medical team because we know we’re doing the right thing.  And not to play the money card, but we and our patients can avoid paying for a bunch of things they didn’t really need or want in the first place.

Truthfully, we can all benefit from this.  And I think it is our duty at health care professionals and human beings to provide it every single time.

Have you ever had a situation that could have been avoided by some goals and support from day one?  Are you a palliative care pro and have some insight?  Please, comment and share below!  I’d love to hear your story!

Nursing Time Management Scenarios

Nursing Time Management Scenarios

Something that is essential in your development as an efficient and safe care provider is appropriate time management.  Below are some sticky situations and the safest and most efficient way to address them.

Q:  You’re assessing your new admission.  She’s crying in pain.  Her blood pressure is 162/38.  She needs an IV.  There are pended and held orders in her electronic chart and her only pain med is 2 mg IV morphine.  There’s a phone call for you from pharmacy about your other patient.   All of your coworkers are busy.  GO!

A:  While you’re in the room, release tumblr_m7abge6Pwf1r089y6your pended and held orders.  Tell her you’ll BRB.  Answer your pharmacy phone call in the nurse’s station and while you’re on the phone with them, say something like.. “So, my new admit, Mrs. Smith, just had a bunch of med orders come through.  She’s crying in pain.  Can you verify her morphine for me ASAP so I can give it right away?  Thanks, you’re the awesomest pharmacist I know!”  Grab stuff to start her IV.  Grab your morphine.  Start the IV.  While you’re starting the IV, distract her by asking some of your admission questions.  Give the morphine.  Enter the answers to your admission questions.  Recheck her blood pressure.  It’s now 132/48 because her pain is now a 2/10 instead of an 8/10.  WOO HOO!

Q:  Your patient is scheduled for a pacemaker placement in 2 hours.  You have to infuse 2 more units of FFP (they’ve already received 2 units) and recheck an INR before surgery.  They are now requiring 5L NC and their O2 sat is 87-tumblr_mbp1k3OmI41ra0fpao1_50089%.  You were awesome and have already assessed them and know their lungs are wet and they were clear 3 hours ago.  Your other patient has to pee.  A doctor is rounding on another one of your patients and has questions for you.  Other than freak out, what do you do?

A:  Grab a non-rebreather, crank the O2 up to 15L and put that on them.  Page respiratory.  Page the doctor.  Go back and recheck his sats (now 92% and breathing easier).  While you’re waiting for them to call you back, quickly talk to the rounding doctor.  When the doctor calls you back, let them know what’s up and “suggest” some lasix now and between your next dose of FFP.  Touch base with your respiratory therapist.  While grabbing your lasix, delegate the peeing patient to your CNA.  Give the lasix.  While you’re looking for/filling out your next blood product request form, talk to the family member on the phone.  Send for your next unit of FFP.  Infuse it slower and chart what just happened in the room.

Q:  Your fresh post-op patient just rolled on the floor.  Your CNA took their pressure and came to tell you that it’s 72/40, he’s really sleepy, and super pale.  Your other patient is eating their dinner and needs 19 units of insulin.  tumblr_m4cb06eIC11r98u24Another one of your patients is in the bathroom and just hit the call bell.  Your charge nurse just told you that you’re getting another patient.  GO!

A:  Ask the CNA that took the pressure to go get the other one out of the bathroom.  On the way to the room, ask your nurse that’s charting to give the insulin.  Go assess your patient.  Take a manual blood pressure.  Trendelenberg him.  Check his estimated blood loss from surgery and his hemoglobin.  (It dropped from 10.4 preoperatively to 6.9 and his EBL was only 150 ml).  STAT page the doctor.  While you’re waiting for the response, tell your charge nurse what’s going on and ask if someone else can take this admit and you get the next one.  Recheck a blood pressure, reassess, and get ready to send him back to the OR!

Disclaimer – please make sure you ALWAYS follow your hospital’s policies and procedures.  That will always supersede anything you read on this blog.  

Nursing Drip Basics

I’m going to do a few posts on various drips that are geared towards newer nurses.  Here are my 11 points of enlightenment when working with drips!

1.  When you get an order to start a drip, that becomes your priority.  Yes, I know Mr. Roberson in bed 28 really wants his suppository but he will have to wait.

2.  Collect necessary baseline labs, like, now.  For example, if you’re about to start a heparin drip you typically need a baseline PTT or Anti-Xa.

3.  If you don’t know exactly how to titrate/manage the drip, print the policy.  That will tell you everything.  Including weaning parameters.  If they’re at 5 mg/hr of Cardene and they’re well below their blood pressure limit – wean it off!  Always, always be looking to wean as soon as it is clinically appropriate.

4.  Have everything you need before you start your drip.  If they want a 10 mg bolus of Cardizem before you start your drip, make sure you have both the bolus and the drip bag in your hands.  You do not want to push the med and then wait for the bag to come up from pharmacy.  Or if you are hanging an Amiodarone drip, make sure you have your bolus bag AND your second bag ready.  Your bolus bag only takes 10 minutes and that goes by very, very quickly.  Have everything FIRST.

5.  Know when you need to call with concerns/questions.  For example, if they’ve been on a Cardizem drip for an hour and a half, are maxed out, and they are in afib with a heart rate of  140 – you need to call.  It’s not working.  Conversely, if they’ve been on a Cardizem drip for 2 days and there’s no orders for PO or talk of converting to PO – call and ask about the plan if it’s not written in a note.  They may round a 1300 and ask why they weren’t notified that there aren’t any orders for PO Cardizem and why they are STILL on the drip and no one told them (cough-becauseyourcolleaguedidntorderthem-cough).

6.  Don’t forget your critical thinking skills!  Remember when giving other meds what the drip is for.  If they are on a drip to INCREASE their blood pressure, do not give their scheduled antihypertensives. You’ll have to talk to the doctor about the plan because they’re still ordered (maybe a MAR hold until the drip is no longer needed or maybe they just need to be discontinued all together.)  Just make sure you think before you medicate – don’t get on autopilot!

7.  Check IV compatibility when you’re hanging antibiotics or other IVPB meds.  Surprisingly, many drips are compatible with a lot of things.  Utilize your IV lines and ports appropriately.

8.  Label your lines clearly near the first Y-port.  You’ll always know what is what very quickly!

9.  Chart all of your titrations in real time.  Otherwise, things get very confusing.

10.  Make sure your pump is programmed correctly (with the correct concentration!), make sure your order is written correctly, and if it is a weight based drug make sure the weight programmed in the pump is current/correct and coincides with your last charted weight.  If they’ve been on Propofol for a 4 days, been NPO, and had multiple doses of Lasix and diarrhea, I bet their weight has changed since the drip was started.

11.  If you are starting a vasoactive/vesicant drip – YOU NEED A CENTRAL LINE.  Do not allow vesicant drugs to infuse through a peripheral IV very long.  It’s typically okay to start them in a PIV just to get the drug in them, but this needs to be transitioned to a central line ASAP.  If you have an order for a PRN Levophed drip that you start in a PIV and don’t alert the doctor (“hey I just wanted you to know that Mr. Smith now needs Levo at 5 to maintain his BP limits and he only has two peripherals”), that is a big problem and it would be entirely your fault.  If it infiltrates it can cause necrosis.

Does anyone have any helpful hints for newbies?  Or any learning experiences?

Holistic Nursing Care

Thank you for your blog, and the words you use to instruct and encourage new nurses. I love reading what you have to say, and I have already used your advice when paging a physician during night shift! Definitely helped me prepare and keep my confidence. My question is this: how do you balance your physical, emotional, and spiritual care for patients? This has been on my mind a lot lately, and I’m frustrated at my apparent inability and lack of time to provide good, holistic care.  

– thered-gisterednurse via Tumblr

I think finding the right way to holistically care for your patients is to first identify their needs. And you can do that within the first 15 minutes of being around them.

Sometimes, patients have very good support systems, are emotionally secure, spiritually satisfied, and just really need their physical/medical needs to be attended to. These patients honestly need you less.. and that’s okay. That’s everyone’s idea situation when they go into the hospital, but I’m sure you’re well aware that many people are not so blessed.

Attention and time

I can tell which patients need a lot of emotional support. I can just feel that they need more attention and time. With these patients, just sitting in there, listening to them talk or just even being physically in the room is way more important to them than getting their meds given on time. When I identify this need, I’ll chart in the room with them. We don’t have to talk, I just want them to know I want to spend time around them. I ask them about their family, spouse, life, home, or even just simple stuff like the weather. These patients just want someone to want to be around them. I linger in the room as long as possible (but being careful that I’m not neglecting other patients). I save more time for them. I take extra time explaining things.

These patients also benefit from physical reassurance/touch as well. A hand on the back when they start telling you something and get tearful. Sometimes I’ll reassuringly hold their hand when they get emotional or are having a hard time talking. These patients really need your patience.

Encouragement

Little things are victories (finally pooping, standing at the side of the bed for the first time, keeping all of their pills down, sitting in the chair for 15 minutes today instead of the 5 minutes yesterday, eating half of their meal, etc.) I make a big obnoxious deal about these things because it really means a lot to them to have someone encouraging them. These are the patients that put on their call light just to tell you that they finally pooped and feel so much better. Someone consistently encouraging them makes them feel like they can do anything.

Emotional and spiritual support

You kind of have to feel around to identify their spiritual needs. Some people are very outright about their spiritual life and identity and some people don’t acknowledge that part of their life. It usually takes a little longer into the relationship to understand their spiritual needs if they don’t just outright tell you. This can be very, very personal so some don’t feel comfortable sharing it with you until they know they can trust you and you won’t judge them. And some never will, and that’s okay too. I’ve had a few share with me their personal beliefs without me asking first (it’s very important to let them tell you this stuff, not to pry it out of them!) and if I shared the same beliefs and they expressed a need for prayer and didn’t feel comfortable with our chaplain, I prayed for and with them. It’s quite an amazing experience.

So, in short.. I believe the key to properly supporting patients holistically is first appropriately identifying their needs (physical, emotional, spiritual) and filling in the gaps. Be able to interact with someone and see that they just need someone to listen to them. Or maybe they just need encouragement. Or maybe they need some prayer. Or maybe they need to just know you won’t/don’t judge them. Or maybe they just need to know and feel that they are important to you.

Honestly though, if you’re asking this question.. I know you’ve got to be a good nurse. Clearly, it’s about more than documenting correctly, giving meds, and doing procedures perfectly. You’re off to a fantastic start and I am sure your patients are very thankful for you. Thank you for what you do.

Working With “Difficult” Patients

Working With “Difficult” Patients

working with difficult patients
This question may be addressed in school, however, I wanted to ask since practice is so much different than textbook theory. Have you ever had to deal with difficult patients? Examples would be non compliance or worse. I read another nurse’s post including examples of things like biting, scratching, and spitting. I understand the potential is there but how common is that really? And how do you handle this?

– A questions submitted from an anonymous person from Tumblr

I’ve been pushed, screamed at, cursed at, and some old lady tried to body-bump me across the room (with a chest tube – ha!).  It’s just part of the job, and something I used to dread but now I don’t care.  There are different tactics for different kinds of difficult too.

Let me clarify the word “difficult” – many patients are confused due to their disease process.  They don’t know what they’re doing, most of the time.  It’s important to give people the benefit of the doubt, but have some clear boundaries for behavior with realistic expectations.

Know which battles to fight.  For example, if my super irritated detoxing patient is flipping out about all his meds.. I’m not going to spend 20 minutes convincing him to take a Colace.  It’s not happening and I don’t care at all about that Colace now.  I’m going to crush those blood pressure pills and Ativan and throw it in some applesauce and try to get him to take that one bite for me.  And if I think it’s going to be a problem or am concerned for my safety, I’ll call my buds in security to stand right next to me to make sure he takes them.

It’ll be a power struggle, again, just know which battles to fight.  Don’t get into a power struggle for the benefit for your ego.  Nurses that get the most bent out of shape by these patients usually have quite a bit of an ego/control thing and flip out when the patient doesn’t do as they’re told.  Getting mad about this is worthless; it’ll just stress you out more and make it more difficult to care for them and your other patients.

Here are some different approaches:

Grouchy/grumpy/mad about doing anything:  Befriend them, joke with them, figure out something they like and bring it up over and over again.  Be on their side.  And then when you need them to do something, present the task as a favor.

Belligerent/combative:  Restraints, security, and haldol are your best friend.  When they curse at you, “you will not speak to me like that” is a good thing to constantly say.  Minimal options; “this is what’s going to happen..” and tell them how things are going to go.  I love my security guards with these patients!

Demeaning:  I spend as little time at the bedside as possible and explain things in a matter-of-fact way.  I’m here to help, not get verbally abused, so my touchy-feely nursey side goes away for these patients.  And make sure I am in there when the doctor rounds.  A lot of times we’re “just nurses” to these patients, so I make sure to go in with the doctor so they know I mean business.  Again, “you will not speak to me like that” is another go-to phrase of mine.  And usually, when you say that (and if they just needed someone to be assertive back), they’ll feel like a jerk for acting like that and be super nice for the next 4 hours.

Way too talkative/avoiding doing things:  Talk, but know when to stop them and say “let’s get down to business” (to defeat… the huns!)   And then you can start singing Mulan to them.  I always blame the doctors with these patients and say something like: “the doctor insists you get out of bed three times today, no excuses.  Let’s get the first one out of the way now.”  Again, minimal options and redirect conversation to the task at hand.

As far as safety is concerned, I’ve never felt unsafe.  Security gets to my unit quickly, I can tie a restraint faster than I can wipe a butt, and can draw haldol up even faster.

Anyone have any more tips related to dealing with difficult patients?  Anyone have another kind of difficult patient and a specific way of handling them?

FUN 10.05 Patients with Communication Difficulties

Anatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyDifficult Patient (Medmaster Series)Difficult Patient (Medmaster Series)Care of the Difficult Patient: A Nurse's GuideCare of the Difficult Patient: A Nurse’s Guide

 

Central Line Basics for Bedside Nurses

A central line a catheter placed in a large vein in the neck, chest, or groin.  Check out the Wikipedia definition for some good pics and different types of central lines.  Typically, patients who need these are in a critical care environment, but when they get out to the floor, they still will have their line.  They can have anywhere from 1-3 lumens.  You can use them for blood draws, which is phenomenal for the patient and staff, and administer multiple medications simultaneously.

The main complications are a collapsed lung (pneumothorax) , a central line infection (CLASBI), and thrombus formation.

Patient can also have what is called a midline, which is a much shorter catheter that’s inserted in the arm.  Midlines can be inserted by a specially-trained nurse or PA.  It’s basically a big IV, but you care for them and remove them the same way as a central line.  However, certain meds (TPN or vesicant vasoactive drugs) cannot be given through a midline.

NURSEY RESPONSIBILITIES.

You need to make sure the dressing is intact.  They are changed every 7 days unless it’s compromised.  If it’s falling off, your patient is at risk for infection.  So, make sure you check and chart the status of the dressing.   When you get report and hear they have a central line, check to see if the dressing is due to be changed.  Now, you don’t want to go changing the dressing every time the antibiotic patch is slightly saturated.  Every time you remove the dressing, you’re exposing that site; which increases your risk for infection.  Check your hospital’s policies and procedures – that will tell you when it is appropriate to change the dressing before it is due.

Another responsibility you have is proper removal.. and if you learn one single thing from my posts, learn this:  never, ever remove a central line with a patient sitting up.  They MUST be lying flat or they can get an air embolism, code, and die before you know it.  And it would be your fault.  Check out this short article about how important this is.  Patients have died from this, as their nurse is removing their central line right before discharge.  Do not make this mistake.  I don’t care what your preceptor says or how they say it’s always been done on your floor.  If you want to protect you and your patient, you will do this!

Make sure the caps are tight.  If one pops off and goes unnoticed, you’ll have a bed full of blood.

Maintain patency of the line.  This means it is to be flushed a regular intervals with saline and typically a heparin flush as well (if clinically appropriate for your patient).   If a port is very difficult to flush or all lumens are completely occluded, call the doctor.  They may give you an order for a tPA/altplase flush to break up the occlusion, if appropriate, so that you can begin to use it again.

How to Keep Calm & Prioritize When Things Go Nuts

Many times in your nursey career, your seemingly awesome shift will turn crazy in a moment.  The mark of a good nurse is staying calm in the midst of chaos.

This is when your prioritization skills need to be on point.  You should think, “what is the most important and time sensitive thing at this specific moment?”  There are many things that can seem like emergencies that need to be done RIGHT NOW, but should actually be moved further down the list due to more pressing issues.

For example, when a nurse gets an order to transfuse blood, one may think that they need to drop everything and go do that immediately because blood = new and scary.  However, think about the reason they’re getting blood.  Is it because of acute blood loss or symptomatic anemia?  Or are they chronically anemic and their H/H has slowly dropped over the last few days and now we’re finally transfusing because it’s barely below normal?  Acute situations means you do need to drop everything.  Chronic, proactive situations/orders means you can get a few important things done first.  If you get an order for a unit of PRBC’s for a chronically anemic and asymptomatic patient and it’s mid-med pass and you’ve got 2 patients left with insulin due with their trays in front of them, I’d finish those two meds really quick before ordering your blood.

Calm delegation is the second step in keeping calming during a crazy storm.  After you identify what needs to be done, identify what you can delegate safely.  And when you go delegate these things, convey to the person you’re delegating to that it is time sensitive.  You may be so calm that they have no idea you’re internally freaking out.

During all of this, it is important to have the mentality that you can handle anything.  Even if you think you can’t.. that totally does not matter.  What’s important is that you convey to your patients and coworkers that no matter what happens, you have got this.  Confidence, confidence, confidence.  It goes such a long way in the midst of chaos.

So, let’s review with an example..

You are giving meds to your second patient.  He starts to puke.  You look into your computer chart and see an order for 2 units PRBC’s on your first patient.  You see you have an order for Zofran on your puking patient.  On your way to go get Zofran from the Pyxis, a family member calls and wants an update on your third patient.  A doctor is rounding and starts asking questions about your 4th patient.  And while the doctor is asking questions, your 5th patient is on their call bell, having to go to the bathroom, and wants a pain pill for a mild headache.  OH!  And the family member of your 6th patient says they are really, really lethargic and breathing really weird all of a sudden.

Now that you’re SOB from reading that, in what order do you do everything?

First, take a deep nursey breath.

Second, put your Nurse Face on because you can handle this.

Talk to the doctor whilst walking to the Pyxis and get Zofran.

Have whoever answered the phone with the family member take a message – you’ll call in 30 minutes.

Delegate to the nurse who just discharged 3 patients, is all caught up, and is flipping through her phone in the nurse’s station, to give the Zofran you just pulled.  Tell her the patient is currently puking.

Delegate to your tech checking her email to get a set of vitals on your 6th patient, and make sure to tell that tech that this needs to be done like, now, because the patient is having changes.  When she’s done, tell her to take your 5th patient to the bathroom.  Have her tell the 5th patient you’ll be there in 10 minutes with a pain pill.

Go check on your 6th patient who just got a fresh set of vitals.  Call the doc, if needed. While you’re waiting for the doc, fill out your blood request form, and grab the pain pill out of the Pyxis.  Wait to send the blood request down until you hear from the doc about your 6th patient before sending it down.  You want to make sure there aren’t any STAT orders you need to complete because once you send for the blood.. it’s on it’s way, and you’ll only have 30 minutes to hang it (and you have to be in the room with them for the first 15 minutes).

If everything is good with your 6th patient, send down your blood request form and while they’re working on sending the blood, go give your pain pill.  (Bonus!  You know they have 3 other meds due in 15 minutes so you snag those as well.)  If your blood isn’t here by the time you get done with that, call the family member back and check to see if the Zofran worked on your second patient.

BOOM.  You’ve put out 6 fires.  And it’s only been 28 minutes.

Nurses: Protect Your Back!

After you land your first nursey job, you’ll sit through a long orientation.  You’ll have just come back from lunch in a food coma, and will barely be paying attention to what they’re saying.  And that’s when they talk to you about how important ergonomics are.  They don’t want you to hurt your back or neck while working; and you’ll think to yourself “I’m young (maybe), healthy, smart, etc. I won’t hurt my back!  Is this almost over?” 

But wait!  Stop!

You foolish, foolish nurse!

Let me paint a nursey picture for you..

(note to self, I need to see how we can get the word “nursey” added to the dictionary..)

You’re running up and down the halls, frantically passing meds, doing turns, helping coworkers, and you go check on your 376 lb patient that’s here for cellulitis.  He doesn’t look so hot.  You grab a blood pressure, and it’s 60/40.  His face and hands are blue.  You pop the O2 prop on his finger and his sat is 72%.  You barely feel his pulse.

As you reach for the ambu bag and connect it to the O2 and crank it all the way up, you scream for help.

“CODE BLUE, ROOM 361!”  They run to call the code overhead, someone else runs to get the code cart, and you’re in the room alone.

He’s 376 lbs; his chest and head weigh more than you do.  He’s slumped down in the bed.  You pull the CPR level to get him flat, and use the sheet to pull him up because you have to do your jaw thrust to get that BVM on and sealed and that oxygen down into his lungs.

And then you feel a pop and surge of pain in your lower back and straight down your legs.

But you don’t care right now because your adrenaline is rushing and he’s literally dying in your hands.

The second you get that mask on, your tech shows up.  You tell her to get on his chest and start compressions while we wait for the troops to arrive.

You heard his ribs crack, she’s pushing hard and fast enough, so you tell your tech, “Hey you’re pretty good at CPR!” while you’re bagging him.  She says, “Thanks, I’d high-five you if I could!”  And you think to yourself, “Ok, she’s awesome.”

The troops arrive.  Respiratory takes over for you, and you explain your patient’s story to the MD as they intubate him, get his pressure back up, and quickly take him to the ICU because he’s probably septic.

You roll with them to the unit, give that nurse report, and start to walk back to your floor.

Just like that.  It’s over.  It’s only been 14 minutes.

And then you remember.  OMG MY BACK.

Your back.  Your back.  Your precious, precious back.

The above situation happened to a friend that can never, ever work at the bedside again.  She herniated and ruptured a few discs and has had surgery twice.  She was only 29 years old when it happened.

Just like that, her bedside nursing career was done.  She had only been at the bedside for six years.  And she was darn good at it.

Thankfully, she was in grad school, and after her back surgery, she was able to get a job at the same (awesome) hospital and transitioned into a non-bedside role.

So, please, new nurses out there. . please, please protect your back.  It is so valuable, precious, and fragile.

Use proper ergonomics.  So when you’re about to turn, lift, pull up, etc., your patient ..

  • Make sure the bed is at an appropriate height – “Yes, Mr. Patient, I’ll make you wait 45 seconds to give you your IV pain meds because I’m not bending over your bed for 2 minutes while I push this Dilaudid ever so slowly.”
  • If you have the time to use a lift, use it – ESPECIALLY for the bigger bariatric patients.  Don’t even attempt to lift them.  If they are really, really large.. double check the weight limit of your lift.
  • When you do lift your patient, stick your butt out and use those legs.  Your butt and legs should look like you’re doing a squat.  You’ll look ridiculous, but you need to lift with your legs.

Below, Peter Griffin explains exactly how to not lift your patients..

I also have had friends have an injury/accident happen outside of work that kept them from working at the bedside as well.  We have a high-stress job with a weight limit.  So if you break your hand, your shoulder, your back, etc… you cannot work at the bedside.  You won’t be allowed to go to work.  And you’re screwed.

My recommendation is to get disability insurance.  This is especially important if you’re like the rest of us, and have a mortgage and other bills to worry about, where if you went a few weeks without a paycheck, it would be devastating.

It’s usually a pretty cheap policy that many employers offer.  Sign up for it when you sign up for your benefits.  Yes, even if you’re 23 years old and healthy.  Yes, even if you work out all the time.

I HIGHLY RECOMMEND THIS GUYS.

I have another friend who sustained a shoulder injury while skiing, was out for 8 months, and lost her bedside nursing job.  She had to transition to an office setting until she was completely cleared.  Then she had to re-apply.  And she went months without a paycheck, had student and car loans, and was stressed to the max.

SRSLY GUYS, PROTECT YOUR BACK. 

No one will protect it for you.

Others will try to rush you to get something done really quick because they have 700 other things to do as well.  You need to say, “Hold up, let me change the height of the bed before we turn,” and they’ll look at you like, “OMG HURRY UP.” And you can just sit there, loving your back with a smile on your face while you’re pushing that button to adjust the height.

You have to take responsibility and time to care for it.   You wouldn’t want those terrible years at nursing school to go to waste when you hurt your back after only two years of nursing.  So you’re in debt, not working your dream job that just slipped through your fingers because you didn’t take the time to protect it.  And when you got into a situation that couldn’t be helped (coding someone like above), you didn’t have a back-up (ha!) plan.

Are there any benefits-savy people out there?  Anyone have any more detailed recommendations on how nurses can financially protect themselves from this?

Any nurses out there who did hurt their backs and have some advice for us?

How to Clean a Poopy Patient

How to Clean a Poopy Patient

 

So you’ve  gone through CNA training and while you’re awesome at cleaning theoretical poop on a mannequin, you are terrified of your first poopy patient experience.  You don’t even know what step 1 is.  Well, you are in luck my nursey friend!  Here are some basics on getting your patient squeaky clean after a code brown. 

Gather supplies

First, take a look at the patient. Are we talking a full bed change? Do you need the fitted sheet and a new gown or just a new disposable pad? This is especially important if the patient is in an isolation room. You don’t want to take in a bunch of unnecessary supplies because they pile up quickly. Grab a coworker.

How to begin

Basically what will happen is the patient will roll on one side while one of you cleans/rolls sheets, and then they will roll to the other side to finish. Sometimes, it’s much easier for a patient to roll to one side the the other (in particular stroke patients who have hemiparesis). If the patient is verbal, ask them which way they prefer. The first time they roll to their side will take the longest

Each person stands on either side of the bed, roughly at the patient’s hip.  Let’s say you’re going to be the first person to clean. Roll the patient away from you and have your coworker stabilize and hold them on their side. You can have them bend the leg closest to you 90 degrees, turn their hip towards your coworker and pick up their shoulder, turning them on their side.

Tip: if the patient is able, have the hang on to the side rail

Another tip: if the patient is pretty dirty, wait to turn them. Sometimes feces can sneak through to the front, especially it patients have diarrhea. If the is the case, clean the front first before turning. If there is a lot, you can push it down to their back side in between their legs and place a towel or more clean wipes on top of it to prevent it from getting dirty again while the patient rolls. Cleaning the front first is helpful because it’s hard to do that with a patient on their side. If the patient is able, you can also “frog leg” them, which exposes more, thus enabling you to clean better.

Make sure your coworker is good, stable and has a good grip and then get to work.

Get your clean on

First, use your wipes to clean all excrement off of their skin. Feel free to put your dirty wipes on the dirty pad because you’re going to throw it away anyway. (Don’t do this if you’re using washcloths though!) Clean. Clean. Clean. Once their skin is clean, you’ve got to make sure it won’t touch the dirty pad or linen as they turn. You also must roll all of the dirty linen up under them like you’re rolling up up a piece of paper to send a spitball flying at someone. If the pad isn’t too dirty, you can roll it so the dirty is completely covered up and the only thing touching their skin is the back of the pad. However, this may not be possible due to the amount of feces or where it is. If so, grab a towel to place in between their clean skin and the pad, then roll it up.

If you need to change the entire bed linen, fitted sheet and all, roll this up as well at this time.

Roll this up and push it as far as possible under the patient, while they are still on their side.

Put on your clean linen

Now grab your clean fitted sheet and pop it on the corners of your side. Push the clean sheet as far as possible under the patient. Then get your draw sheet, disposable pad, and/or brief (sometimes referred to as a diaper) and place it on the patient halfway, and pull it up in between their legs.

From your side, you should see: the patient’s clean backside, the sheet attached to the two corners on your side of the bed, the sheet halfway covering the bed and flatted out, and a disposable pad, rolled up and under the patient.

Turning the patient

Now, it’s time to turn the patient and have your coworker finish up. Tell the patient they’re going to roll over a big bump, and slowly roll them towards you.

Your coworker’s turn

Now, you will hold the patient in a comfortable position on their side. Your coworker will pull out all of the dirty linen carefully as to not dirty the new linen. They will clean any additional skin that is still dirty. Then, they will pull through all of the clean linen, attached the sheet corners to the bed and flatten out the pad. Then the patient can be laid on their back.

Final adjustments

Once the patient is flat on their back, then change their gown. (If it was visibly soiled in the beginning, you’d want to remove it earlier and wait to put the new one on until they’re all squeaky clean.)  They will naturally have sunk down into the bed and will need to be boosted up.  Boost the patient, ask if they want just a sheet over them or also a blanket, place pillows where they would like, and spray some deodorizer if necessary.

Some people feel bad spraying deodorizer, but let’s be honest – the patient knows they had a bowel movement, knows you just cleaned it up, and spraying a little room deodorizer isn’t going to be what makes them upset or feel bad. They typically appreciate it.  And, they probably don’t want to smell it either themselves. This is especially helpful if you had to ask guests to step out, and you know they’ll be back into the room. Do what you can to make it seem like you didn’t just do what you did. This may include taking out the trash as well.

Before you leave, make sure they’ve got their call light nearby, bed alarm back on, and all necessities within arm’s reach.

Tips to prevent injury

Patients can make unpredictable movements, or you can be in an uncomfortable position, or they can be quite heavy. It is CRUCIAL that you take the necessary steps to prevent injury.  I know multiple nurses who can no longer work at the bedside due to an injury sustained at the bedside.

Adjust the patient’s bed so it’s at a comfortable height for you, ensuring you’re not bending over the entire time and straining your back.

When lifting/moving, patients, use proper ergonomics – lift with legs and not your back and all that jazz.

If you have lifts or assistive devices – USE THEM.

Remember, injury is never worth it. Protect your back and your health. If you get injured while caring for a patient, don’t try to stick it out.  Go to Employee Health and get it taken care of as soon as possible. Don’t be a hero!

Read more

Need more tips for nursing school or your first year as a nurse?

Read about my first code brown, my first code blue, and more in my book published by the American Nurses Association, Anatomy of a Super Nurse: The Ultimate Guide to Becoming Nursey! Click below to purchase on Amazon.

Patient Teaching for Common/Non-Scary Meds

There are a few meds that almost all patients in the hospital are on.  Below is a list of a few of them (and common doses) and what I tell my patient when they asks, “Why the hell are you giving me that!?  I don’t take that at home!”

Colace 100 mg PO BID:  “This is a stool softener.  When you’re in bed, not moving around as much and taking pain meds, your bowels naturally slow down.  We don’t want you to get all blocked up and get what’s called an ileus because that is a major complication that will increase your stay here in the hospital with me!  We can easily avoid that by taking this med.  Colace just makes it easier to go, it’s not going to make you go like a laxative does.  If you get loose stool, we’ll hold a few doses.”

Pepcid 20 mg PO BID:  “When your body goes through stress [insert reason for hospitalization here], your stomach naturally secretes more acid.  This can put you at risk for getting a stress ulcer, which is painful and not a good thing.  We give you this medication to prevent that.  It’s not a permanent med, but for now, it’s important you take it.”

Heparin 5000 units SUBCUT q8hrs:  “This is a little shot that goes in your belly.  It’s really, really important because you’re at high risk for developing a blood clot.  We want to prevent that, so we give you this med.  It thins your blood enough to significantly decrease your risk for developing a clot but not thin enough to put you at a high risk for bleeding.  We don’t want you to get a blood clot because it can move and go into your lungs or your brain and cause a stroke.”

Insulin for the non-diabetic patient:  “When your body undergoes stress or trauma, your blood sugar naturally rises.  Medications can also cause this (steroids are a typical culprit) and usually the medication is extremely important, so we just need to keep your elevated blood sugar at bay with some insulin.  It’s not a permanent thing, but we need to check it at regular intervals and treat it if it’s too high.  If your blood sugar is above 200, your wounds and body cannot heal, so it’s extremely important to treat.”

Norco (hydrocodone/acetaminophen) 5/325 1-2 tabs q4-6hrs:  “This is a pain medication that’s a step up from just plain Tylenol.  We need to stay on top of your pain and not let it get out of control because it’s a lot easier to keep it at bay by taking this before it’s terrible than to wait until it’s unbearable and then this effective med won’t cut it.  Let’s start with 1 pill and see how you feel.”  

Note to nurse.. remember, this medication has Tylenol in it.  So, if they have a fever, you may be masking it.  And if they’re getting 2 pills q6hrs, that’s 2.6 grams on Tylenol in 24 hours.  And let’s say they get a fever and you forget Tylenol is in them (or some other nurse does), then they are REALLY getting a ton of Tylenol.  So with Norco, make sure you stay aware of how much Tylenol they’re getting… especially if they have liver issues already.  That is a big, big nursey deal.

What other meds do you frequently use and how do you simply explain them to patients?

Why Is My Stroke Patient NPO?

Why Is My Stroke Patient NPO?

When a patient has a stroke, something that is frequently compromised is the ability to swallow food, liquids, and even saliva safely.  Therefore, if your patient is coming from the ED with a stroke diagnosis, the MD will usually place an order for them to be NPO until a swallow evaluation can be completed.

Sometimes nurses can complete a prelim evaluation, but typically speech therapy comes by to assess the patient and give specific recommendations.  However if the patient is admitted at 0230, they’re going to be NPO until speech comes around … probably not until later in the morning.  (They usually come in at 0800, see all their new consults and go see them in the order they came in..)

This means Mee-Maw won’t eat until then.  And this also means the family is mad at you because you’re starving Mee-Maw.

A stroke is sudden and scary.  Families are usually pretty shaken up.  They feel helpless and that’s terrifying.  They want to be able to control SOMETHING.  And the easiest thing to control is food.  All these doctors, nurses, therapists all are dictating everything now but darnit, Mee-Maw will have her favorite snack, darn it!

The best way to explain this is coming from the “it’s for her safety” viewpoint.

“I know you think she is dying for a honey bun right now, but it’s really important that we make sure she can swallow safely.  Many times after a stroke, a person’s ability to swallow safely is impaired.  We don’t want her to get pneumonia.  You wind pipe and food pipe are right next to each other.  So if she cannot safely swallow, it will go into her lungs.  She’ll get what we call aspiration pneumonia, and choke on it.  And sometimes she food and fluids can go into her lungs and she doesn’t even cough and that’s called silent aspiration.  The speech therapist will do a thorough exam to make sure it’s safe and make recommendations.  That’s why it is vital that she does not eat and dangerous if she does.”

The chain of events typically looks like this.. the nurse does a preliminary screening.  Then speech therapy will check them out (usually the next day, depending on the time the consult was placed).  They will make a recommendation of the thickness of liquids and consistency food or for further, closer evaluation (barium swallow exam, for example).. etc.    If they are still not safe to swallow, the next step is a feeding tube.

The feeding tube goes through the nose and sucks to be put in.  It’s pretty painful/uncomfortable for the patient and rough for the family to see, but once it’s in, it’s in.

Families always ask “how about food in their IV?” (TPN), but that’s not at all a good choice.  It’s crazy expensive, you need a central line, and then all meds have to be IV.  There’s also many studies out there that show how bad TPN is compared to tube feeding.  Furthermore, if nothing goes down into their gut for a long time, you face some serious complications that can easily be avoided by just using tube feeding. So, for very good reason, TPN is rarely used in the case of impaired swallowing.

The typical feeding tube is a Dobhoff tube (DHT) through a nostril.  Sometimes MD’s will order NG’s as well, but Dobhoff’s are smaller and more comfortable for the patient.   I always have family step out when I insert them because it’s rough.  Families hate them, but it’s honestly the best thing for them at that point.  Once it’s inserted and placement is confirmed with an x-ray, we can begin tube feedings and administering meds through the tube.

If it is predicted that the patient will not be able to regain their swallowing ability in a few weeks, an MD will order for a PEG tube to be placed.  It basically a tube straight to the stomach via a hole in the abdomen to feed through and can stay permanently, if needed.  With this tube in the stomach, we can take the tube out of their nose and it’s much more comfortable, safe, and easy to keep clean.

Depending on your facility, patients either go to the OR for this or it’s done at the bedside by a GI doctor.

I hope this helped put a few pieces together of the process!  In my experience, families had many questions about food and how good old Mee-Maw will get her supper.. once I saw this process in action, it all made it easier to explain it to the family!

 

Dealing With Difficult Families

Dealing With Difficult Families

You know it's bad when the first thing the nurse says in report is that the patient is fine but the family....  Let's talk about difficult families.

They didn’t tell you about that in nursing school, did they!?  Nobody warned you!  I know, I know, no one warned me either. You know it’s bad when the first thing the nurse says in report is that the patient is fine but the family is freaking nuts and she needs a beer STAT. Difficult families.

Sometimes they seriously are nuts.  Sometimes they are freaked out because their loved one is sick.  Sometimes they’re jerks.  Sometimes they were a nurse/tech 20 years ago so they act like everything you’re doing is stupid.  Whatever the reason, it makes caring for the patient much more difficult.

First of all, when you hear that in report.. consciously step up your patience game.  You’ll need more patience with this today than a normal situation.  Don’t get pissed about it and dread it every time you have to go in the room, just accept that they kind of suck but don’t let it ruin your day.  Also, all of your interactions are going to have to intentional today.  You’re going to have to try harder with them than other patients + families because they need it.  Every time you walk in that room, walk in with confidence, having intentional conversations.

Uuuhhh what the heck is an intentional conversation, Nurse Eye Roll.. that sounds ridiculous…

Below is how I systematically and intentionally deal with this situation.  It was a little difficult at first, but now it’s like clockwork and I don’t think about it anymore.

I always go in the room and introduce myself to my patient first.  Everything is about them.  Family or no family, this person still needs your care and they should be the center of everything you do.

I tell them who I am, what’s going on today (scans, tests, transfer/discharge, labs, plan of care basics).  During this time, I’m speaking directly to the patient and occasionally look at whomever else is there.  When I’m done with that, I ask the patient, “so who is this (handsome or lovely) person you’ve got here with you today!?”  I always shake their hand and introduce myself to them after I’ve spoke with the patient directly.  It sets a professional tone.

Hopefully, that defuses them.  Maybe they hated the nurse last night and the doctor was short with them yesterday.  Maybe no one has really explained what’s going on to them and they feel completely out of the loop.  There’s a million reasons people are rude/overbearing/mean/condescending/etc.

You want them to feel safe and like their loved one is being taken care of.  Making your presence and authority known initially tends to make them feel better about leaving their loved one in your care.  You want them to trust you.  The more they trust you, the more they’ll let you do your job.

When you have that initial conversation at the beginning of your shift, let them know what the deal is for the day.  What we’re doing, what our plan is, when you can loosely predict the doctor will be around, etc.  (Use “we” terms, because you’re on the patient’s team, getting things done for them.)  Any plans/structure/routine that you can provide is reassuring to people.  Predictability is something that reassures scared family members; remember that as you’re interacting with them.  Even if you think you’re being redundant, go over the plan again.  You are in charge and it enhances your professionalism and authority.  It also makes them feel safe and taken care of during a scary and helpless time.  Their loved one is in your nursey hands and that probably scares them because they have no idea who you are and if you know what the heck you’re doing.

I try to keep things light as much as possible because patients enjoy that.  Typically, they’re in the hospital for something sad/serious/scary, so if you can make them laugh or talk about something not illness related, they light up.  If they see their loved one is in a good mood, that tends to rub off their grouchiness.

Have you noticed that families are typically more stressed than the patients themselves?  I get it; I would much rather be sick myself than see my husband in a hospital bed.  I’m nauseated thinking about it.   However, that doesn’t excuse behavior.

So I give families a little room to push my buttons, but just a little.  When someone is getting rude or demeaning.. Professional Nurse Eye Roll comes out.  My Nurse Face is on, and my matter-of-fact tone is out.

I have on multiple occasions told patients and families that have called me names, said I was stupid, didn’t know what I was doing, etc. something along the lines of :

It is not appropriate to speak to me that way.  I am your nurse, here to care for you, not to to be spoken to in that manner.  I’ll come back when you’re ready to talk.

Most times, the person feels bad right away and stumbles over their words to apologize.  It’s never about me, it’s about the situation and how they deal with whatever is happening to them.  I just remind myself that and then stand up for myself when they cross my Nurse Face line.

Know that line in your head.  Know when your Nurse Face needs to come out.  That line is different for every nurse.  The more aware of that line you are, the more control you have and the less frustrated/mad you’ll get when someone gets crazy.

I know nurses that get super offended every time someone is kind of rude.  They get stressed easily and it’s not worth it.  Just remember people are crazy, people get mean, whatever.  Give it very little power in your heart and mind.

Now these “it just got real” conversations never happen at the end of your shift.  They’re always 2 hours in when you have 10 more hours to deal with them.  Maintain your professionalism when you have additional interactions throughout the day.

An occasional joke goes a long way.  Don’t shun that person the rest of the day, it just creates more stress for you and makes caring for the patient more difficult.  Hook your patient up with some ice cream or a warm blanket or something.  If they know you’re still going to take care of their loved one, they usually chill out eventually.

I feel like I could talk about this forever, so consider this Part I of my two part series about dealing with rough families!

And check out my post on difficult patients.

Anatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyAnatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyDifficult People: Foolpoof Methods - Dealing with Difficult People, Mean People, and Workplace Bullying (Difficult People at Work, Passive Aggressive, ... Dealing with Difficult People, Negativity)Difficult People: Foolpoof Methods – Dealing with Difficult People, Mean People, and Workplace Bullying (Difficult People at Work, Passive Aggressive, … Dealing with Difficult People, Negativity)

 

Nursing Blood Pressure Management in Stroke Patients

Nursing Blood Pressure Management in Stroke Patients

Nursing Blood Pressure Management in Stroke Patients

Did you notice I love talking about strokes?  I wanted to expand a little more on my previous post about them.

Blood Pressure Management in Stroke Patients: Tips for Nurses

Stroke patients are not like every other patient. There is special consideration that must be given for various aspects of nursing care, specifically in terms of blood pressure management.

Let’s discuss the crucial aspects of blood pressure management in stroke patients, specifically as it relates to tips for nurses.

Cerebral collateral circulation

Do you remember in your cardiac unit when they talked about collateral circulation?  When a blockage is slowly formed, your body forms little blood vessels over time to get around it.  It’s your body’s way of making up for the lack of blood flow being caused by the blockage.

This is why when younger people who have heart attacks, they actually have a higher mortality rate because their hearts haven’t had years to build up that collateral circulation.

Interesting, right?

The same is true for your brain! When an infarction occurs, your brain reroutes the blood flow around the blockage. This is called cerebral collateral circulation.  However, to actually force blood to go through these smaller vessels around a blockage, higher pressure is needed. This is why you may see some higher blood pressure limits in ischemic stroke patients, especially ones in neurocritical care.

Essentially, you’re pushing up the blood pressure to force blood flow through those smaller vessels to perfuse the brain tissue past that area of infarction (which, statistically speaking is most likely due to a blood clot).

Then the penumbra (the area around the ischemia that has cells that are still viable) still has a chance! The theory is that if you raise the blood pressure above normal, then blood gets to those highly vulnerable areas and therefore enables that tissues to survive.

This is why you may see neuro changes in your ischemic stroke patient whose blood pressure drops.  They may have a normal 120/80 pressure, but it’s not high enough to perfuse all those areas of the brain now so they start acting different.

Typically, it’s a change in their mood/behavior/level of consciousness.  Maybe they’re more difficult to wake up, they’re really upset and agitated for no reason but have been super nice all night, and they’re saying some things that just don’t make sense. Any of that behavior should be a red flag for you.

Remember, neuro changes are subtle, if you’re waiting for pupillary changes or for them to become obtunded, you’re going to be too late and may have allow irreparable damage.

So, yes, this is a call the doctor right now because they need Neosynephrine or some medicine in the ICU that keeps their blood pressure up for a little while.

While it’s not an OMG THEY’RE DYING moment, but you need to drop everything else you’re doing and address it now.

Hemorrhagic conversion of an ischemic stroke

Let’s say you just got a report on your ischemic stroke patient that is coming up and you actually had time to pull up their CT scan.  So you pull up the scan and there’s the spot in their brain.

That’s their stroke.  That’s the area of ischemia.  So naturally, you think, “We need to prevent them from having another stroke so let’s thin their blood NOW!”

While I appreciate your enthusiasm, let’s pause for a moment.

If you do that too soon to a large ischemic stroke, you risk that area turning into a hemorrhage. That is a major complication and presents quite an issue for someone how needed their blood thinned but now has a bleed.

We must to wait until the neurologist says it’s okay to thin their blood to do so. This varies widely depending on the situation. My caution and tip to you as a bedside nurse is to be aware of any meds they are getting that could thin their blood and ensure they are safe.

For example, your neurologist may have ordered the patient to get a daily 325 mg aspirin (per the stroke order set) and the hospitalist may have put them on 5,000 units subcutaneous heparin injections q8hrs (per the DVT prophylaxis order set). One may not realize what the other has done, and it can easily be overlooked. For many patients, this isn’t a big deal. But, if we’ve got a patient with a very large ischemic stroke with high blood pressures, this could be enough to convert into a major bleed.

It’s better to be safe and clarify with the attending that they are Chances are that they do, but you’ll look like a rock star to that neurologist if you double check it with them.

See also:

 

Nursing Priorities for Post-Op Patients

Nursing Priorities for Post-Op Patients

Nursing Priorities for Post-Op Patients

You are rocking through your shift, feeling awesome because you kind of know what you’re doing now, and your charge nurse comes up to you to say you are getting a patient from the PACU.  As soon as she finishes that sentence, the phone rings.

They’re calling report.

CRAP!  I’ve never taken care of a fresh post-op!  BAAHHH!

Nursing Priorities for Post-Op Patients

Ok calm down, crazy nurse, this is no big deal.  You’ve got this!  Let’s talk about your nursing priorities for post-op patients.

Get everything together

Look at their labs, know their orders, grab everything you’ll need before they roll on the floor.  Be confident when you tell the family to scram while you settle and assess them.  While the family is gone, ask the patient who they want to be their go-to person/emergency contact.  It can get kind of dicey if you ask them in front of others.  Go get the family from the waiting room, and on the way back, go over your unit rules/contact info/plan of care.  Drop them off at the door and go sit down and chart that beautiful assessment you just did.

Pain control

Make sure you have orders for pain meds, oral and IV.

And Zofran.  (pain + pain meds + empty stomach = pukes)

Once they have kept some crackers/clear liquids down, get some oral pain meds in them.  If they’re in terrible pain, I give them a dose of IV pain meds at the same time as PO, so by the time the IV wears off, the PO is kicking in.

Side note, if it takes a sternal rub to wake them up, get the PCA out of their hand and grab some Narcan.  Buckle up, because they’re about to be pissed because you just instantly took all of their pain meds away you mean, mean nurse.

Incisions

Typically, the surgeon removes the first post-op dressing when they round the next day or whenever they deem appropriate.  Chances are if there is drainage they’ll only want you to reinforce the dressing, not tear it down and place a new one.  Just assume this unless told otherwise.

When the PACU nurse brings the patient up, look at the dressing together and make sure it looks the same.  If there is drainage on the dressing, outline it with a Sharpie.  Time/date/initial it as well so you know how much is draining.

Poops & Pukes

Remember to advance their diet slowly.  Clear liquids until they start passing gas is a good rule of thumb.  You want those bowels to start perculatin’ ASAP, so as soon as they’re allowed to get out of bed.. they need to get up!  Also, pain meds slow the bowels down.  They need the stool softeners, even if they say they don’t.  Encourage and educate them on the importance.  If a patient stays in bed, takes a bunch of pain meds, and eats a cheeseburger first… they will throw up, be in more pain, and then get an ischemic bowel.  And it’s all your fault!  Just kidding.. well, only if you documented appropriately…

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Nursing Priorities for Ischemic Stroke Patients – From a Neuro Nurse

Nursing Priorities for Ischemic Stroke Patients – From a Neuro Nurse

Nursing Priorities for Ischemic Stroke Patients

Alas, stroke patients.. my one true nursey love.

I love my stroke patients.  They have a special place in my heart.

Nursing Priorities for Stroke Patients

So, you just got the report from the ED and your patient who just had a large ischemic stroke is on their way up to you.  The ED nurse said their neuro exam was good so transport is bringing them up now.  (Good.. what does that mean!?)

Blood pressure monitoring is essential!

One of your main priorities with an ischemic stroke patient is their blood pressure.  Typically, the physician will order their blood pressure to be higher than normal.  (Why would I ever want my new patient’s blood pressure to be 190/85!?)

When someone has had an ischemic stroke (NOT a hemorrhagic stroke), a lack of blood flow caused by a blood clot (or something else) has caused some of their brain to begin to die.  Unless we increase their pressure to promote collateral circulation, the surrounding area will be forever lost as well.  Sometimes they have to go to intensive care to get frequent neuro checks and vasoactive drips to keep it high enough to preserve that part of their brain.  We want to prevent the stroke from getting worse.

Therefore, it is essential you know your blood pressure parameters!

So, what does this mean for you, bedside floor nurse?

  1. If they have scheduled blood pressure medications (typically home meds), clarify that with the doctor.  Get some holding parameters or see if they just want to discontinue them for the time being.  Some will indicate they want “permissive hypertension” but don’t specify a limit.  Again, make sure you know your limit!
  2. Communicate with your CNA’s that we want higher pressures and to notify you if it’s too low as well as if it’s too high.
  3. Make sure you have an aspirin ordered!  You don’t want them to have another stroke!  And if they can’t swallow or you think they will not pass their dysphagia screen, ask for an aspirin suppository.
  4. Make sure they have some VTE/DVT prevention ordered.  SCD’s, subcutaneous heparin, whatever it is.. they really need some prevention!  And that can fall back on you, the wonderful nurse, if you didn’t catch that.
  5. Make sure they’ve had a swallow/dysphagia screen before you give them oral intake.  A common problem with stroke patients is swallowing.  The epiglottis, which is that flap that goes over your trachea and esophagus, can be compromised.  This means they can get aspiration pneumonia quite easily (“down the wrong pipe”).  If their swallowing is impaired, they may be silently aspirating as well (getting food + fluids + pills into their lungs without coughing).  If there is the slightest indication they’re having problems, get a speech evaluation and make them NPO until they’re seen.  It’s a big deal.

I’ve had many patients who thought they were fine to get really upset with me when I made them NPO.. then speech came around and said they were aspirating and needed a modified diet.  No matter how well you explain it, some patients will still be upset with you.  However, their safety is our priority.

Systematic and routine neuro exams

And last, but most importantly.. stay on top of your neuro exams!  Every time you go into the room is essentially a neuro check.  If something is changing in their brain, the level of consciousness/mental status is usually the first thing to change.  So if they’re suddenly really sleepy and difficult to wake up, changes could be occurring.  If your patient needs a sternal rub to wake up and they haven’t been this sleepy, call the doctor immediately.

If you think you’re not going to get worried until a pupillary or vital sign change occurs, think again.  Those are LATE signs of neurological damage.  So doing your neuro checks, as ordered, is essential.  Level of consciousness, orientation, vocal quality, ability to follow commands/response to pain, grips/drifts/dorsi + plantar flexion, and pupillary changes, are all things you’re looking at to make sure they’re still doing okay.  Do this the same way, every time.  Be systematic and routine. This is how you will detect change.

Enjoy some neuro for me!  I love it!

Disclaimer: this is informational only, always follow your hospital’s policies and procedures.  

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