How to care for the dying

CARES: How to Care for the Dying

Within the first four months of working as a new bedside nurse, I’ve encountered two patients who were actively dying. I wasn’t sure what to do. After coming across this article from Medscape though (btw you need a free login to read this article), I finally understand what the palliative care nurse practitioners were doing.

The City of Hope came up with a tool called CARES to help the nurse take care of those who are dying.

C stands for comfort. You aim to alleviate pain and suffering for the patient. Additional testing and blood draws should be questioned, as the aim is to comfort, not treat.

C: Comfort

A stands for airway. We used a scopolamine patch placed behind the ear. It’s used to help stop secretions from building up. While oxygen and oral secretion will not necessarily help, it may be comforting for the patient to have those things.

How to care for the dying

A: Airway

R stands for restlessness or delirium. It occurs in 25-85% of actively dying patients. It could be due to uncontrolled pain, a distended bladder, or it could be that the patient feels that there are unresolved issues with the family. Playing familiar music and providing a non-stimulating environment will help.

How to care for the dying

R: Restlessness or Delirium

E stands of emotional and spiritual support. Don’t underestimate a listening ear and providing clear and open communication. Whatever can be done to promote a comfortable and peaceful death should be considered.

How to Care for the Dying

E: Emotional and Spiritual Support

S stands for self-care. The nurse is often stressed and may need to debrief too.

CARES: How to Care for the Dying

S: Self Care

List of New Graduate Nursing Residency — RNDeer

If you’re interested in a list of new graduate nursing residencies throughout the USA, you have to check out RNDeer.com.

As you may know, nursing students are having a difficult time finding a new grad position, even though this “nursing shortage” is upon us. RNDeer has complied a list with over 600 hospitals and skilled nursing facilities that have nursing residencies and accept new nursing graduates. It includes the most up-to-date program links, HR phone numbers, and blurbs about the hospitals and other programs.

For me personally, the most frustrating part about finding a position is organizing the list of places you’re interested in, and then meeting those deadlines! Since hospitals are not like schools, they have varying deadlines from month to month, year to year. Then, you have to fill out a similar form asking similar questions for each and every location.

Just as doctors get “Matched” on Match Day every March by applying to several hospitals at the same time, RNDeer also hopes to do same for nurses. They will unveil a common application. So far, they’ve received positive feedback from nursing students and hospitals alike.

In the meantime, check out their list of new graduate nurse residency programs. They are open to feedback and suggestions to better serve you. Check out why over 6000 people have already liked them on Facebook. Be sure to also follow them on Twitter.

And good luck with your job search!

Skills Day at the Hospital

Yesterday, we had our first Skills Day! It’s been 5 months since I started working at the hospital. Basically, we got paid to learn more. Sweet!

In the morning, we had discussions about medication errors.
After lunch, we learned how to put IV’s in.

Medication Errors
We watched a video about Josie King, who was a young child who died due to medication errors at Johns Hopkins. Her mother was angered, and instead of retaliation, she was determined to decrease the number of deaths caused by medication errors. She created the Josie King Foundation.

Medication errors do not occur due to one person. Rather, it is caused by a system error. It’s caused by miscommunication among the healthcare providers (prescribers, dispensers, and administers), not listening to the patient’s or family’s concern especially relating to change in mental status, and more.

It’s important to report potential and actual medication errors so that a ‘root cause analysis’ can be conducted to understand and fix the problem.

IV Insertion
When new graduates are just starting off, they are not to do IV’s at my hospital. This is to allow them to focus on nursing assessments, giving medications, and coordinating care. When an IV has to change (every 72 hours), they often ask the assistant nurse manager, charge, or another experienced nurse.

It is a very technical skill with specific steps.
1. Assess: Ask the patient what other providers have said about their veins and where they have previously put it in. Look at the arm. It’s always better to start from the hand and move up the arm. Those needing short term therapy can start higher on the arm.
2. Preparation: Prep the saline flush and IIA. Tie the tourniquet on (left on for 90 seconds or less!). Find a vein that is soft and palpable. Clean the site with chlorhexidine. Prep the needle. Use left hand to pull down on vein so that it doesn’t roll.
3. Insertion and Dressing: Use right hand to hold needle. Insert until flashback is seen. Use right index finger to advance hub. Place gauze underneath hub. Get IIA ready. Retract needle and connect IIA. Pull back on syringe to make sure it’s in the vein. If blood is seen, then flush the line. Disconnect the saline flush. Dress the IV site.

Ok, I think I’m ready!!

First Day Shift as a night nurse

Today was my first day doing a day shift. They were short during the day and over on nights so the manager asked if I wanted to do the day shift. I wanted to see what it was like so I agreed. Here are some differences:

    Insulin 3 times for those with diabetes – the timing for sugars is crucial during the day. You do the fingerstick around when they order meals and you give insulin humalog after the plate is in front of them. It’s not too hard when only one patient has DM but not as easy when you have more. I mostly crossed my fingers that their sugars are below 169 (typically).
    Admission/Discharge/Procedures — today my day wasn’t too bad because I didn’t have any of these happening except one cardiac procedure. But when there are many of these, I can imagine that the day is much more hectic.
    More resources more readily — more doctors, PAs, PT, RTs, more help from PCAs… It makes life much easier to get things done. You still have to think– tell the doctor or the PA? But at night, you nearly always consult the PA first. Doctors make more orders during the day so you have a better idea of what’s going on with the patient.
    Not worried about sleep — you don’t have to think about waking someone up. You can just proceed with whatever you have to do because they are supposed to be awake.

Free Scrub Giveaway — and Happy Nurses Week!!

Thank you “Life With Jess” readers for making this blog popular! And Happy Nurses Week!!!

A couple weeks ago, Uniformed Scrubs asked if I would like to give my readers a sneak preview of the Enzyme Washed V-Neck Grosgrain Ribbon Top nurse scrubs by Dickies. It will be available in about a month or so. I said yes!

dickies 84790 missy fit

I like it because:

  1. Mobility – I can swing my arms 360 degrees, twist and turn at ease.
  2. Soft fabric – It is so soft to touch and so smooth on my skin.
  3. Deep pockets – I don’t lose my essentials when I lean over or bend down.
  4. Feminine – It cinches in the back to create a feminine shape.

Unfortunately I wasn’t provided with the color that I wear at my hospital. Fortunately for my readers, I will be giving this one away for free! As long as you don’t mind that I’ve tried it on twice after I showered and you want royal blue in XS, it’s yours! I’ll even pay for shipping. 🙂

I want to give it away because 1) I want quality scrubs put to good use, and 2) in NYC, space is essential! Please write in the comments section on why you should win. The contest will end on Memorial Day – Monday, May 27, 2013. I will announce the winner shortly after that. Good luck!

If you’re interested in purchasing one of these Dickies Scrub Set, use the coupon code “trueblue” at uniformedscrubs.com for 15% off until July 31st, 2013.

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Life After Orientation

I just attended my first Life After Orientation. It’s an hour of talking to the nurse educator and the VP of Nursing. It’s probably better to go with a list of things to talk about next time but here were a few topics.

  • Delegation to the ancillary staff, especially regarding fingersticks, stat EKGs, answering call bells
  • Handout off to the next nurse – IV rounds with both nurses and bedside handoff; making sure there’s enough fluids in the bag for the next few hours and the patient is medicated for pain prior to report (if necessary)
  • Breaks – before going on break, do a quick round to make sure everyone is ok. Then tell the 2 nurses next to you on the unit, the charge nurse and ancillary staff you’re on break. It’s a good way to recharge and eat!!

Hospitals talk about patient satisfaction scores all the time now because it’s one of the major factors for reimbursement. I have to say that I’m proud of the unit I’m on because it just went from the lowest to the highest scores in the hospital. We aim to have nearly every score above 90%.

Ok that’s it for now.

Mental preparation is key

The New Nurse basics: Introduce self. Discuss the goal for the day. Address concerns.

1. Introduce self
Patients and co-workers will work with you better when they know who to contact. Memorizing their names will be golden.

2. Discuss the goal for the day
Mental preparation is key. Patients will be ready for the next step. Co-workers can plan their time.

3. Address concerns

    Water? Bathroom?
    If time allows, address it yourself. If not, delegate to ancillary staff.
    Pain? Medications? Sleeping or breathing issue? Family questions?
    Try to solve concerns on your own. If there is any doubt, ask the charge nurse or nurse educator. If necessary, escalate the concern to the appropriate person.

Nursing: Medical Vs Lay Language Barrier

“He is going to draw your blood.”

“I don’t understand.”

2 minutes later… After my PCA already drew the patient’s blood, I thought about a different way to word it.

“He took your blood.”

“Oh!!”

When someone doesn’t understand something, it doesn’t mean he is confused. And it doesn’t mean you repeat the same thing over and over. Or try to pass it off as something that she won’t understand. It means that you have to use different wording to get your message across. And the wording should be in a way an average person would know.

Sometimes it’s difficult to switch from “speaking medical” to “speaking with patients”. But I feel that a fine balance between the two is essential to being a great nurse.

Write down the list of Qs you have for the MD

Last night, I had a patient who had several questions that I couldn’t answer and the house PA couldn’t answer. I asked her to write down her questions so that she was ready to address everything and so that she wouldn’t forget.

Her doctor came just as I was about to leave, and she thanked me for having that suggestion.


As for pain, it’s best to stay on top of the pain and not let it get out of control. Sometimes it’s better to go with something stronger. And narcotics aren’t addictive if you take it for pain at the hospital. It just becomes addictive if you start taking it all the time.


My second night alone went well. Had my first direct admission. Thankfully, he had all of his medications with him and his previous medication list was given by another hospital. That helped! Then I had two more transfers. The charge nurse spread them apart so that made it so much easier to handle. And they already received their night time medications so I only had to assess them (and of course write a note). I have to be so thankful for the PCA and CCP for helping!

The nurse educator was also helpful! It was another set of hands and eyes for me because I know that the charge nurse also had a lot on her plate with admissions!


What I’ll take away from tonight: Always try to help the others when I’m free. Ask questions and ask for help when I don’t know something.