Tag Archives: nursing

My First ICU patient who passed away

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He officially passed away this morning
while I was on break. DNR status.

Yesterday his son asked for my thoughts.
“I think he’ll make it tonight.”
Even though he was slowly deteriorating,
Maxed out on oxygen and 3 drips to keep up his blood pressure.
On fentanyl to make him comfortable.
He made it.

I returned last night.
It was a different story.

“Jessica, how’s he doing?” His son asked.
The generic “he’s fine” is off limits. It was time for the truth.

“Last night his respiratory rate was 9 or 10. Now it’s 15-18.
Often when people are nearing the end of life,
it goes from slow to faster and back to slow again.”

“But his heart rate looks ok. It’s 85.”

“Yes that’s true.
But his blood pressure is slowing decreasing.
His heart is still trying to compensate.”
He cocked his head. I tried again.
“His heart is trying to get enough blood to his body
but it’s not working. It will eventually give up.”

Optimism in his voice,
“But wouldn’t the heart rate slowly taper off?
I thought he would live a couple more days.”

“No, his heart can suddenly stop because it’s giving up.
I’m not sure if he will make it through the morning.
His drips cause his blood vessels to constrict.
That explains why his hands are cold
and the oxygen probe to not read well.”

After midnight, his HR was suddenly dropped to 42. RR was 9. SpO2 77%.
“Can you give us an update, doc?”

“Well I’m not a doctor.”

“It’s ok. We’ve promoted you. Just give it to us straight.”

I started to tear up a little bit.
It wasn’t easy for me to tell them what I thought:
He’s on his way out.

They told me that they’ve shed their tears already
and were waiting this.
“Thank you for taking great care of him.
You should be proud of you and your coworkers.
Tremendous sense of purpose and goal and comradery.”

His blood pressures stop reading.
Apnea alarm sounds.
That probably should’ve been my cue.
I still felt a carotid pulse.
I checked my drips.
Gave report and went on break.

I came back from break and looked at the monitor.
His was black.
“Your patient expired.”
Icy cold hospital terminology.

I debriefed with the experienced nurse covering for me.
What could I do better next time?
1. Listen for his heartbeat, not only feel for pulse.
2. Consider the BiPAP machine delivering breaths for him.
What’s the rate set at and what is his RR now?

In the final progress note
Include: heart rhythm- PEA,
who pronounced time of death,
which doctors notified of death.
Family at bedside or contacted.

In the end,
This family was ready to accept their father’s fate.
The son shared his friend’s voicemail message:
“How did they prepare the chicken?
They told him he was going to die.”
We chuckled.
Humor can start the healing process.

After I gave report,
I said bye to the family
And they all gave me a hug
And thanked me again.

I drove home
Half crying
Trying to drown the feeling
By turning up the radio.

I showered, ate, and wrote this down
So that I don’t forget.

Med-Surg to ICU Interview Questions

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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!!!

My patients blew kisses to me

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blowing kisses

 

And for that, I’m super happy. :)

It could be because I gave them what they asked for quickly.

It could also mean that I remember the small things that they like and repeatedly deliver it. For example, a patient likes his blankets straightened out so I’ll make sure to straighten it every time he calls. Or if someone likes their ice and water separately. Or wants a straw or not. Or the door closed. Or making sure they are getting pain medication at the appropriate time.

Or even more importantly, if they tell me about an abnormal sign or some problems, I act accordingly (speaking to other nurses, the charge nurse, the PA, etc) and resolve the issue.

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I do think that it does start top down — the right management attitude, the appropriate beds clustered together so that the nurse taking care of the 6-7 patients isn’t too overwhelmed, the support received from management, other nursing staff, pharmacy, environmental, transport and the doctors (especially when they are thorough with their explanations with the patients and their families)… it all comes down to teamwork and everyone doing their part!! :)

Top 10 Things You Should Know About Nurses

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According to a patient in the hospital, these are the top 10 things patients should know about nurses. I thought that this did a good job of summarizing what nurses do at the hospital from the patient’s point of view.

1. You have been placed in the hospital for nursing care.

2. The provider of that care is an educated individual who unselfishly dedicates themselves to your health and well-being. And even though you may not like being told what things are good for you and what are not, the nurse telling you does so to give you a chance to redeem your health and well-being.

3. That provider is proud to be a nurse.

4. That nurse does more than you know. She plans your care around your medical condition, emotional state, abilities to do for yourself (sorry, [nurse], I think you said “self care” in your rant), that nurse provides support to you and your family, she/he is the link between you and the doctor, [and] the everything in the facility.

5. That nurse does your bedside care, she knows what medicine you need when, and how to give it. She knows what all the tubes and stuff are and what they are used for and what to look at them for.

6. That nurse can hang an IV or hold your hand and reassure you.

7. That nurse watches over you and reads monitors and knows when [you’re] sleeping and when [you’re] awake and pulls strings to get you that cup of tea at 3 a.m.

8. That nurse is your lifeline, she can call a whole team of professionals together with her calm voice and make them work their [butts] off for your life with the flash of her/his eyes.

9. That nurse will wish you luck and give you all the instructions you need when you leave her competent care even if you were the biggest pain in the ass she ever met.

10. The nurse is why you are in the hospital and why you will go onward, be it home, perpetual care, or the morgue, she will insure that you do so with your dignity and rights intact. Why? Because it is what a nurse does.

What is Nursing?

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I was browsing the net and stumbled upon the website called the Truth About Nursing. The purpose is to teach the difference between the mass portrayal of nursing (especially through TV shows) and what nursing really is. Their definition and their description of what nurses do everyday is pretty good and accurate.

What is Nursing?

Nurses save and improve lives as front line members of the health care delivery team. They independently assess and monitor patients, and taking a holistic approach, determine what patients need to attain and preserve their health. Nurses then provide care and, if needed, alert other health care professionals to assist. For instance, emergency department nurses triage all incoming patients, deciding which are the sickest and in what order they require the attention of other health care professionals. Thus, nurses coordinate care delivery by physicians, nurse practitioners, social workers, physical therapists and others. Nurses assess whether care is successful. If not, they create a different plan of action.

One of the most important roles of the nurse is to be a patient advocate–to protect the interests of patients when the patients themselves cannot because of illness or inadequate health knowledge.

Nurses are patient educators, responsible for explaining procedures and treatments. For instance, nurses teach patients and their families how to eat in a healthier way, take medicines, change wound dressings, and use health care equipment.

Nurses empower patients, guiding them toward healthy behaviors and support them in time of need. When patients are able, nurses encourage and teach them how to care for themselves. Nurses provide physical care only when patients cannot do so for themselves.

As patients near the end of their lives, nurses provide dignity in death by advocating for sufficient pain medication and the opportunity to die at home to allow them to spend meaningful time with family members in their final days.

Hospital nurses are responsible for discharge planning, deciding together with other health professionals when patients can go home, and helping patients adapt to their conditions and work toward full recovery.

Nurses, especially those working in community settings, work to prevent illness through education and community programs designed to decrease transmittable illnesses, violence, obesity and tobacco use, and provide maternal-child education–to prevent some of the leading health problems of our time.

Some nurses are independent scholars whose work is at the forefront of health care research. Many nurses obtain Master’s and Ph.D. degrees in nursing, then work as scholars, educators, health policy makers, managers, advanced practitioners such as Clinical Nurse Specialists or Nurse Practitioners, or sit on Boards of Directors.

First Code – CPR or hospice care for terminal illness?

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20130717-231231.jpg

This 90 something year old man was repeating, “I want to die” a couple days before. With stage 4 cancer (meaning, it spread from the source location), he should’ve been DNR (Do Not Resuscitate). But since he started to lose his mind (he couldn’t answer the 3 questions: name, location, and time), his family members began to make decisions for him (as a Heath Care Proxy). His family was in such denial that it was time for him to pass away. They believed he didn’t need morphine to ease his pain and should remain in full code in case his heart rhythm converted to v fib or v tach (at this point, you do CPR).

Throughout the night, he kept moaning. But his family would only allow him to take Tylenol. Which honestly isn’t enough if you have overgrown cells invading essential organs. And these organs allow you to breathe and circulate blood throughout your body.

After I had given out my morning meds and taken out a foley, I saw a nurse run. The next thing I heard was “999 on 1 West”. I saw 2 nurses with the crash cart wheel past me heading to a room in the next district over. When I saw them wheel the cart into that room, I knew it was him. The nurse there was already doing CPR compressions and someone else got the ambu bag ready. Though it felt like 5 minutes, about 30 seconds later, 2 critical care PAs, 3 critical care nurses, 2 MDs, respiratory therapist, nurse educator, patient care assistants, and all the nurses on the unit were there. The PAs took over the compressions. The pads were slapped on.

The EKG monitor was still on, so I watched it go in and out of v fib and v tach. Nurses made the call out to the attending and the family to tell them to come in immediately. My nurse manager told me to go the next unit over to get the Line Cart. I learned fast that’s the cart with the equipment to do a central line. Inserting a central line would allow them to bolus (or “quickly give”) fluid directly to his heart to increase blood pressure. Without a properly beating heart, the body won’t have circulating blood.

When I came back, I saw that he was also bleeding out from his rectum and abdomen. Cracked ribs and his tap sites from before may be the cause. Regardless, I primed the normal saline line to attach it to blood that we would give to him.

More epinephrine was needed. More flushes. The nurse educator asked if I knew any of the nurses in the room so she can document everything that’s happening in the room. I gave some names and then let the nurse who was taking care of him take over.

After the defibrillator delivered the shock, I heard that sound. That sound was an asystole sound. A solid beeeeeeeeeep. I looked at the EKG monitor and saw a solid line. He was gone. He got his wish.

This happened in 17 minutes.

20130717-231534.jpg

If only he had been DNR and was comforted, he would’ve died more peacefully. He wouldn’t have bled, have cracked ribs, have something tied to keep his tongue down in case of intubation. He died suffering from pain and misery. It could’ve been in peace in his sleep.

Family members may feel guilty if they decide to make their loved ones a DNR. They may feel that they aren’t doing the right thing and that they should do everything possible to save them. But in terminal cases, the focus should switch from treatment to comfort. This increases the quality of someone’s end-of-life care.

In my mind, when I die, I would want to die in my sleep. Peacefully. No pain. Just as living is a part of life, death is too. And we should pass with dignity.

Education Day 2: Communication and Delegation

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Today was our second “Education” Day. The first Education Day that happened one month ago covered medication errors and IV insertion. Today, we talked about communication, delegation and the electronic health record.

Communication among the nurses, patients, doctors, and ancillary staff are crucial for good patient outcomes. We communicate to convey  messages to other people. What do you think is the most important part about communication? Take a guess first!

  • Words
  • Body Language (facial expressions, hand gestures)
  • Paralinguistic (the tone; the way that the words are said)

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*

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It’s body language, which accounts of 55%. Words account for 7% and paralinguistic accounts for 38%. Body language shows your attitude and shows how you feel.

There are different ways to give and receive information. Even though we spend 7-12 years of our education on learning how to write and read, we spend less than 1-2 years of formal education on how to speak and listen. This is almost counterintuitive, considering that over half of our communication depends on LISTENING to each other.

We broke out into 4 groups and discussed about traits of good listeners vs bad listeners.

Good Listeners:

  • Eye contact
  • Gives feedback
  • Not rushed

Bad Listeners:

  • Interrupts
  • Has a reply or rebuttal before letting the other person finish speaking

Etc, etc, it can go on and on. To show that we care,

  1. Look at the patient in the eye (not at the WOW all the time; let the patient know you’ll ask a series of questions on the WOW so they know you’re not purposely trying to not give eye contact)
  2. Sit down next to the patient to show that you’re not rushed
  3. When they are concerned about something, ask them for more details (especially regarding pain!)

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As for delegation, it is something that new nurses struggle with. The most important takeaway messages I got was:

  • Be specific
    • Example: Take that patient for a walk vs
    • Take that patient for a walk for 80 feet. 1 assist with a walker and oxygen is needed at all times. It’s the first time the patient is getting up so take a pulse ox before and after he goes for the walk. When that’s completed, please tell me what happened.
  • Vital signs and I/O
    • “Please tell me any abnormal vital signs that you see. And for these specific patients (congestive heart failure, post-open heart patients, renal), please document intake and output.”
  • Change priorities as needed
    • Some ancillary staff may think that cleaning equipment or doing the bedtime bundle or whatever it is that they are doing is more important than a patient’s change in condition. Sometimes when you say, “please go do a fingerstick stat” or a “EKG stat” or something else that’s more urgent (such as compromised patient safety aka a patient getting out of bed without supervision especially if they want to use the bathroom or go for a walk but forget or don’t want to call you!), the PCA takes their time to do what you asked them to do.
    • It may help to say: “That isn’t important right now. Right now, it’s more important for you to take a set of vitals on this patient.”
  • If there is an isolated problem (they don’t know or just forgot), it is important to address it right away in private (never in front of the patient!!). Sandwich a compliment, criticism, and compliment. If it is a continuous problem (due to attitude or laziness), then still address it but also bring it up to management.
  • Give feedback. Everyone is valued and needed on the unit. Using their name and saying thanks goes a long way.

 

Donating Stool Isn’t That Weird Anymore

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The first time I came across donating poop from one to another was at my hospital. At first I was a little grossed out but then it made sense— all that healthy bacteria one person could have
— and then transplanting it over to someone who lacks the bacteria (especially those with ulcerative colitis) can work wonders. It helps restore a healthy digestive tract!

Read what a New York Times opinionator did to help save her friend by donating her fecal matter.

How to care for the dying

CARES: How to Care for the Dying

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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

First Day Shift as a night nurse

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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.