Caring from the heart is nursing

Yesterday I wrote about a frustrating moment I had. A reader said that nursing is caring from the heart. I agree with that.

Since going to the ICU,
most of my patients can’t talk to me.
But one was A/O x3, could speak, though didn’t seem normal quite yet.

He was what I called “call-bell happy.”
Too hot, too cold, not comfortable–
it can all happen in a matter of 10 minutes.

1st night- “can I have a sleeping pill?” “Ice, ice, ice” “blankets on, blankets off”

2nd night- slept throughout the night but I’d catch him when he woke up and waved at me to come over. “hurts, hurts, hurts” “your bum?” He nods. I turned him to the other side and boom! He was fast asleep again.

3rd night- he looked like a new man!! Ahh the wonders of a good night rest.

He waved me over to fix him up at change of shift. He proceeded, “thank you. I knew that the moment I looked at you that you’re caring from the heart. You have made a big difference for me.”

I was a little bit shocked that he spoke so normally. We continued to talk and he spoke about another hospital. I asked him about his experience there. His eyes lit up and said, “You should be working there! There’s where you belong. You see that everyone collaborates and works so seamlessly as teams.”

I was taken back a little bit because I felt my unit had members who worked well as teams too. Does that mean he implied that here was worse than there?

He continued, “Leave your information. I’m friends with the head doctor there. I’ll get you a job there. I will. Include your specialty.” And he repeated this several times before he went to sleep.

Unfortunately, he was a step down patient and a critical care patient needed to get transferred into his room. So he left. And a new patient went into his place.

I never did leave my information because I felt that it was a little unprofessional but also, would he really remember? He still has to go to rehab to recover and it would be odd to have my information amongst his personal belongings. I’m not sure if I would’ve gone- I kinda like where I am now. Plus I’m just starting here!!

Another patient- I also had her for 2 nights with a couple days off in between. On the 3rd night she just came back from a procedure. She saw me and reached out for me. The PACU nurse said, “aww she really likes you!” I squeezed the patient’s hand and she squeezed back.

I think that says everything.

When the human condition is in conflict with itself

Wow, I just read grrm.livejournal.com blog and it reminded me of how I used to write. Just as myself and not another “list” or really thought out piece. So here’s my start to get back to journaling.

I came across another article about stories– the only stories worth reading are the ones when the human condition is in conflict with itself. You have a set of ideals and yet you’re torn with how you feel.

For example, last night a patient was complaining of pain and her nurse gave her pain medication. 15 minutes later, she’s asking for help. Her nurse is across the room and she saw me sitting at nurse’s station. I knew that her nurse had already attended to her so I ignored her (wow that sounds bad but I was busy catching up!!). After she called 3 more times I walk over and ask her, “what’s the problem?”

“Why didn’t you come over right away?” She probed.
“Your nurse just spoke to you. What’s going on?”
“I’m in pain!”
“Did you tell your nurse?”
“Yes. He gave me pain medications.”
I overheard him say that he gave the pain meds 15 minutes ago. “Ok, then you have to let it kick in.”
“Yes but it hurts!!!”
“Ok but you still have to wait for it to kick in!” I thought to myself, why made her think that complaining to me would make any difference?

I felt sympathetic for her because face it, who likes to be in pain? But I felt the issue was already addressed and that’s nothing left for me to do. Is that wrong? Did I lose my patience?

She ended up falling asleep.

As a nurse, I feel compassion and empathy but there’s only so much to go around. I pour it all on my patients and any patient that has a 3 alarm star going off… Or I’ll help out another nurse “boost” a patient up in the bed. But that’s about it.

SBAR: How to Give a Good Handoff Report

SBAR

Probably one of the most nerve wrecking things that you have to do as a new nurse is to give a good report to the next oncoming nurse, the charge nurse, the nurse who covers you on break, the doctors, and the ancillary staff. You want to give the right amount of information that is pertinent to each person.

While I was in school, I thought it was a little silly to repeat the information that the instructor just gave me and I thought that I was doing it all wrong. But honestly, it’s good to just repeat the information out loud so you know what’s going on.

SBAR is really comprehensive and is great for the oncoming nurse. Here are the elements.

S : Situation – State Name, Unit, Patient, Problem

B : Background – Admission Diagnosis, Pertinent history, Current treatments

A : Assessment – Current VS, Physical assessment, Test results

R : Request – Needs MD/MLP evaluation, Further testing, Transfer to higher level of care

For example…

S: This is Jane Doe, 78 year old female under Dr. So-And-So. A/O x 3 but forgetful. No allergies, No isolation, full code.

B: She came in with pneumonia. Her past medical history includes COPD and diabetes. She came in yesterday (blah blah blah)…

A: (Vital signs) Her vital signs are stable. Afebrile. No pain.
(Activity) She can get out of bed to chair with 1 assist.
(IVs) She has 2 peripheral IVs in the right AC from two days ago. No drips but gets IV antibiotics.
(Skin) Her skin is intact. Palpable pulses.
(Lungs) She’s on 2 L nasal cannula sating 95%. Lungs diminished bilaterally.
(GI) Active bowel sounds. Regular diet. Last bowel movement was today.
(GU) Voids. Good urine output.
(Glucometer) No fingerstick.
(Labs) She needs a CBC and BMP in the morning.

Current labs Her WBC is elevated.

R: I recommend ID (infectious disease) consult on her.

—-

For a doctor or PA/NP who already knows the patient, you can do a shortened SBAR by stating name, the situation, the pertinent assessment (change in vital signs, mental status, respiratory, GI, GU, lab work), vital signs and your recommendation. For more information, the IHI (Institute for Healthcare Improvement) has the following documents that may be helpful.
SBAR Guidelines Kaiser Permanente
SBAR Worksheet Kaiser Permanente

For a doctor or PA/NP who is new to the patient, do the above but with pertinent past medical history and trending labs if possible.

For the charge nurse, you give report twice. Once in the beginning of the shift and one closer to the end. In the beginning, say the situation, any drips, and the plan for the patient. And if you anticipate that you’ll need help from her, this is a good time to speak up. For the second report, state what has changed since you started your shift (any new labs, tests performed, drips, assessment) and the plan for the patient.

For the nurse covering your break, state the situation, code status (Full code vs DNR etc), mental status, activity, diet, drips, and any abnormal vital signs that has stabilized or anything else to look out for.

For the ancillary staff,  state the situation, code status (Full code vs DNR etc), mental status, activity, diet, and any other additional things that they can do (fingerstick, lab work, turn patients, last wash, incontinence).

I hoped that helps!

I wish I knew that before

2013 was the best year of my life.
Independence rang true – new apartment, new car,
new nursing career from the nursing home, to tele and ortho, to ICU.
(wow, I sound like a typical millenniallook at the table below)

My family and friends started new careers too,
life is getting sweeter.

The stats were an all-time high,
Getting emails and comments all the time,
About NYU Nursing
Advising and inspiring future nurses.
To me, there’s no greater praise.

Last year’s theme was ‘New Nurse Blog.’
But now I’m no longer a fresh fresh nurse.
I’ve got one year under my belt!

For 2014 I’m changing it to
I wish I knew that before.’
“I” can be me, a friend, or you.
Health, Food, Money and Rights are my passions

So here it goes!

—-

This table is from a Medscape Nurses article about how to manage a 4 generation gap nursing workforce. You can sign up for a free account to read the article.

Generation What They Want Strategies
Traditionalists Less demanding schedules (part-time; shorter shifts)
Reduced stress or workload
A job well done
Use a personal touch
Provide traditional rewards
Use as mentors
Offer less physically demanding positions
Boomers Recognition for experience and excellence
Positive work environment
Good pay and benefits
Continuing education
Give public recognition
Find opportunities to share expertise (precept, mentor)
Promote “gradual retirement”
Xers Career advancement
Shared governance
Autonomy and independence
Work/life balance
Provide opportunities for skill development and leadership
Involve in decision-making
Avoid micromanaging
Millennials Meaningful work;
Stimulation, engagement, involvement; multitasking
Skill development
Socializing and networking
Impatient for promotion
“Move up or out”
Encourage teamwork
Offer a supportive work environment
Begin leadership development early
Provide feedback
Provide access to social networks; build on technology strengths
Develop skill base

Critical Care Orientation

Hi future critical care nurses,

Here were the topics that we covered in my critical care orientation. While the instructor said that this class is not to provoke anxiety, some of the topics made me a little nervous, but I guess that’s normal for anyone doing something for the first time.

Day 1

  • Compensation Mechanisms
  • Pharmacology

Day 2

  • Arctic Sun (Hypothermia therapy)
  • Hemodynamics I – Arterial lines, CVP
  • Intra-arterial thrombolytics

Day 3

  • Hemodynamics II – PA Catheters (Swan Ganz)
  • Hemodynamic Scenarios

Day 4

  • Glycemic Control
  • DKA/HHS
  • Insulin Infusion with Delta
  • Neuromuscular Blockage
  • IABP
  • TPA for MI
  • Temporary Pacing

Day 5

  • Phillips Monitoring
  • Acute Renal Failure
  • Peritoneal Dialysis
  • DIEP

Day 6

  • Mechanical Ventilation
  • Oxygenation
  • ABG Analysis

Day 7

  • Shock States
  • Sepsis

Day 8

  • ACLS Part 1 (BLS + videos)

Day 9

  • Intra-abdominal Pressure (IAP) Monitoring
  • Pulmonary Vein Isolation (PVI)
  • Crash Cart – Defib, Cardioversion, Pacing
  • EPIC Code narrator/critical care flowsheet

Day 10

  • Neuro RRT/tPA
  • Neuro Assessment
  • Neurosurgery
  • Intracranial (ICP) Monitoring

Day 11

  • Exams (Core and Pharmacology)
  • PACU Day – recovery from anesthesia

Day 12

  • ACLS Part 2 (Respiratory, Tachy, Brady algorithms; Test “Megacode”)

At least now I have some background information!

Anyway, happy holidays! Can’t wait to start.

Med-Surg to ICU Interview Questions

I’m so excited to announce that I was recently accepted into the MICU (medical intensive care unit) at my hospital! Critical care class starts in 2 days and I just finished my last shift on the telemetry med-surg and orthopedic unit!! I loved my team there– the people are truly incredible. The CCPs, PCAs, management, my fellow night nurses and day nurses made my time there truly amazing. It felt like a great teamwork every night, making sure essential things get done and always going above and beyond. 🙂

One year ago, I started at a nursing home for a month. 11 months ago, I started at the hospital on the telemetry unit. My hospital is having some of our ICU nurses go to another hospital in the system to build up their units so this great opportunity came up for me to go work in the ICU.

Fortunately, the interview was a “formality” but it’s no excuse not to prepare! With nearly a year of experience under my belt, it was much easier to come up with experiences showing my leadership. And remember, people relate to specific STORIES more than generalities! Here is a list of questions the nurse manager asked me.

  1. May I see your resume? (Asks questions on the resume especially regarding additional schooling aka your future plans and previous experience)
  2. What made you interested in coming to the ICU?
  3. How has your experience prepared you?
  4. What kind of drips have you used?
  5. Have you called a RRT or a neuro RRT or code before? What happened? What was that like?
  6. Describe a busy night for you.
  7. If you have several things going on, how do you deal with that? (Delegation and priority- give specific examples where this came in handy!))
  8. How do you keep your ancillary staff accountable? Do you always or only sometimes have huddles? Do you meet up with them again? How do you make sure they do what you asked them to?
  9. What do you do when you’re unsure of something?
  10. What is a strength you have? A weakness?
  11. What have you heard about this unit?
  12. Do you have any questions for me? (The answer is always yes and you ask questions!! Such as the type of patients, the ratio, the professional nursing organization, scheduling, etc)

I hope this helps! If you have heard of additional questions, I’d be happy to add in more to get a more comprehensive list. And happy thanksgiving to everyone!! I have a lot to be thankful for, including the readers who have given me positive feedback through emails, comments, and likes. 🙂 so thank you!!!

Help by voting please! Affordable senior care depends on you!

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