11.29.2008

thanks and no-thanks

Getting in four days in a row has been fun. I barely noticed when thanksgiving came and went.

Three days on the floor, two on rehab and one on long-term, and one day as supervisor.

I'm picking things up fast. After just a few weeks, all of a sudden people are asking -me- where to find forms and documents, people who've been working there way longer than I have.

The forms and documents thing has been a thorn in my side from day one. We have four drawers that have all the documents I need. Infection control reports, care plans (ugh), incident reports, lab slips, you name it. Working an admission is made more difficult than necessary by this filing system, especially when I have to break my chain of thought for 15 minutes to hunt for a piece of paper. The actual admission itself only takes me an hour or two, the rest of the time (which may be several hours) is spent trying to figure out where all of the relevant pieces of paper are and where I need to put them later (even though the HUC preloads the chart with all of the most important documents).

I'm starting to have a lot of fun with the lab orders. Now that I've gotten the hang of the labs, a whole galaxy of diagnostic possibilities is unfolding. This week I ordered some thyroid studies, basic blood-work and cancer-specific antigen tests. I mapped out all the diagnostic studies I wanted done for the next week and filed the lab slips in the appropriate sections of a voluminous three-ring binder.

I'm continuing to look critically at some of the medication orders. Some things slip through that shouldn't, in my opinion. One resident gets 3.9g of acetaminophen -scheduled- throughout the day, and still has an as-needed order for 650mg of acetaminophen. If anyone looked at that and said "hey, let's give him the PRN tylenol", they would have administered a potentially fatal overdose. Next time I'm in, me and my magical "discontinue" highlighter are goin' on a rampage. What's even more subtle and easy to miss is the combination opioid/non-opioid analgesics, some people forget which ones have tylenol and which ones have aspirin, a potentially serious mix-up.

I'm starting to take the broader view of what's going on here, and spending time in the trenches (on the floor) is directly responsible for that.

Now I'm starting to have to mitigate some of the personality conflicts on the unit, particularly among the CNAs. Managing people is tough! I'm relieved that some of the people I've asked to do labor intensive things still have a good enough rapport with me to come to -me- with their problems and not the other nurse supervisors. The reasons for this tend to revolve around fear of retribution, or even just being identified by the other CNAs as someone who "reports" things to the nurse supervisors.

I'm trying to sort out in my head how to handle these intraprofessional conflicts. It's tricky. I try to purchase all the capital I can by answering call-bells, helping with toileting and repositioning, and I think this is paying off with some people. So much goes on behind my back, however, it's difficult to know how to address some of these concerns without making it obvious who told me about them.

I have to keep up on the disciplinary process, though. If I get too lassez-faire, my shifts will be an anything-goes environments for the aides, and there's already too much of that, in my opinion. Weights don't get collected when they should, intake and output is guesstimated more than I would like, and some people have a nasty habit of forgetting to attach a tab or pad alarm to our fall-prone residents. I don't want to alienate these people I rely so heavily on, but I'm responsible for the kind of work they do.

I prefer to handle most things with a private word and a gentle reminder, but it's clear I'm going to have to leave a cogent paper-trail, for the sake of my license.

I saw my first Marinol pill today. The resident taking it didn't even know what it was or where it came from! The pills are cute. They are spherical, light green, and roll around pleasantly in the blister-packs.

11.25.2008

where's the care?

48 pound disabled woman dies and launches an investigation of over 1000 new jersey group homes for developmentally disabled adults. Link. Discussion here. This is what people are saying.

Where's the nursing care? The care of adults with developmentally disabled adults has gradually been shifted over to Unlicensed Support Personell.

I worked in one of these homes. Not in NJ but still. In general I thought the clients started receiving better care once private companies bought up all of the group homes that our state was hemmorhaging. The home I worked in was one of these recently-privately-owned group homes. From what I saw, it seemed to me that the clients got better care in these privately run group homes, and for labor that was literally half as expensive.

You can't get away from, however, the fact that we were taking on the daily responsibility for things like getting the clients fed and washed and even administering medications(many states, in case you did not know, allow unlicensed personnell to administer medications after taking a short class, but only if it's for care of the developmentally disabled), all for 10USD an hour in one of the richest states of the country.

The nursing care I saw my clients receive? One monthly checkup by a company RN.

That means that somewhere, someone was responsible for keeping track of this person's weight, and initiating actions based on the information he or she has collected.

Was this person an RN, in this case?

I'd like to think not, but there's the distinct possibility someone may find themselves up before NJ's state board of nursing or department of public health or whatever they got goin on down there.

My first impulse, having worked for one of these companies, would be to -go over the documentation-.

Who is managing these people's care? If it's not someone trained and licensed to manage care, you might run into problems.

Oh, wait, here it is, from the article:

The Division of Developmental Disabilities caseworker responsible for keeping tabs on the woman has been suspended, the home's license has been revoked and state workers are checking on the well-being of all 1,255 residents of similar homes, the officials said.


"The ... caseworker responsible for keeping tabs on the woman". Read that carefully.

After nursing school I looked back on that work I did at the group home with a new appreciation of how dangerous what we were doing actually was. None of us had any ability to interperet vital signs, and could only do automatic BPs if the RN (who had..i dunno..20 homes assigned to her?) called us and told us to. Knowledge of the drugs we were administering was very low. All we were concerned about was giving it on time, 'lest we point-out of our med cert cards. Adverse reactions and side effects were only screened for vary rarely, and not by us.

Even saying all of this, they got much better care than they would have in an institutional setting.

What I'm saying is that this is the concequence of privatizing the health care delivery system -too much-. If you've escaped entirely from the grasp of the system that licenses and certifies what you're doing, the very mistakes they're there to prevent will start cropping up.

Once you've made the decision that some people are, depending on their diagnoses, only worthy of having a caseworker "keep tabs" on them, what's next?

Hey, what we're doing could be really profitable if we try to make as much money as we can doing it!

A human being will recognize that someone is wasting away to death. A corporate entity will not. We've all benefited somehow from the Limit to Liability, but ultimately we are not valued by it as much as increasing shareholder return.

The larger concern here is how to provide adaquate nursing care to this population. Any ideas? Really the only thing to do is join up. Your Team is down over two million votes (projected nursing shortage in..i dunno, less than a decade from now), and the margin is growing all the time.

Now, think about this group-home business being transferred over to eldercare. When I worked in a group-home, getting nursing home patients out into four-person group homes in a suburb somewhere seemed like a great idea. Now I'm not so sure. Nursing would be edged out once again, "supervising" maybe 80 clients in 20 homes.

The emphasis now seems to be put on either high technology or volume of patients. Would it be different if there were more nurses? Maybe, I don't know. I know the shortage of masters degree nurses is a big factor, since the pool of people availible (nevermind willing) to teach is small. There's no shortage of pre-nursing students.

Is the rarity of our profession part of some other entities higher purpose? Is someone making a buck off the nursing shortage? Think about it.

Sedation

Now that I'm starting to get a handle on how the workflow in our facility is structured, I'm starting to look at things with more of a critical eye.

One thing I wrote down in my little black moleskin to check up on later is records of narcotic use.

Pain control is something that my education taught me to take very seriously. It's a tricky subject. All we really have to go on most of the time is the patient's own reporting of pain. What level of pain they're experiencing, what level of pain is bearable, what level of pain interferes with physical therapy and the recovery process.

Too little analgesia, and you risk increases in stress hormones (most notably cortisol), non-compliance with physical therapy regimen, and general overall grouchiness. Too -much- analgesia and you'll find that the orders for PRN vicodin or percoset or whatever are no longer adequate to control pain. Now you've got tolerance problems, along with the constipation and apathy that typically accompanies high levels of opioid analgesia.

Since we chart everything by hand, there are no helpful reminders to let the floor nurse know when their patient is coming dangerously close to that 4 gram/day barrier that tylenol presents us with (which is mixed together in many of the combination opiate/non-opiate analgesics (like vicodin, which may contain half a gram of tylenol per pill).

I've started to look through these records very carefully, prompted by an encounter with one of my residents. I was called to her bedside by an aide who noticed that her blood pressure was much lower than usual, somewhere around 80/40. Considering all the factors that might be in play, a few things came up. Diuretic use. Anti-hypertension medication. Lack of ambulation outside of therapy. Then there was the opiate use.

I looked through her as-needed-medication records and found that nearly -everyone- who had administered PRN pain medication to her had been giving her the maximum dose, meant for severe pain. The resident's pain was never recorded any higher than 3/10.

I sat down with the resident after her family had stepped outside and had a talk with them. This is never an easy discussion to have with someone, but once you notice that they're in danger of spending way more time in a facility than they have to, you have to say -something-.

I started off talking about the resident's blood pressure, and what we were planning on doing about it. When I started to talk about pain coverage, she started to get noticeably anxious, wringing her hands and making all of those familiar anxiety body movements. I -knew- she was being overmedicated for pain. I didn't need any more info from her to determine that. I know amputation sites can be painful, but after the site is well-healed and benign, 'round the clock administration of the maximum amount of PRN pain medication should not be necessary.

Following the advice of a good friend of mine (who's a retired psych nurse), I was completely matter-of-fact about everything and used a lot of open-ended questions. I found that the resident would overstate their pain because they were afraid of the pain increasing later. This was a good find, since it gave me a platform from which to launch into some much-needed teaching about the effects of pain medication (both desired and adverse), and how we could work together to keep her blood pressure within normal limits and get her out of here and back in her home in a timely fashion.

Next time I come in to work, I expect to see more initials in the 1-gtt field instead of all of them being in the 2-gtt field. More importantly, however, since I'm in a supervisory role, I have to make sure the rest of the team is on the same page. I documented some of my concerns and made sure the oncoming shift was aware of what we had discussed, I guess I'll see when I'm in next if that was enough.

PRN pain medication can truly be an insidious thing. Speaking with the spouse of one of the residents, they related to me how they were once in a skilled nursing facility for some kind of joint issue. In their pleasant, understated, european way, they said "after just a few days, I was quite looking forward to those pills".

Indeed.

This is an area where I think my education has served me well, by imprinting on me the importance of frequent and detailed pain assessments. It's been difficult to fold in everything I've learned during my training in a medical/surgical setting into long-term/rehab, mostly because there's just so much going on! I thought med/surg was a busy environment, but when you have 17-37 patients at a time instead of 4 or 5, it's not always easy to see where you should be spending all your time.

With that kind of patient load, I can see how it would be easy to gloss over the critical thinking aspect of pro-re-nata pain medication administration, especially when the director of nursing is telling me things like I have to "encourage the LPNs to think critically".

On the rehab side, requests for pain medications are frequent, and pose a challenge to getting all of the tasks done on time. On the long-term care side, pain assessments are even more challenging due to the altered thought processes of the residents.

On either side, I end up staying late. Maybe part of it is being new, maybe part of it is having been educated more recently, but when one of the aides (or nurses) tells me someone is requesting pain medication, my training dictates that I need to go in there and do a pain assessment before pouring medications for anyone.

I see where the experienced nurses are increasing their time-efficiency by cutting out certain steps and playing around with the ordering of tasks, I just don't always agree with where or how they do that. Of course, I'm learning a lot from them about what I -can- cut out and what I -can- do to use my time more efficiently, I just have to remember to think carefully and remember my training.

As much as I felt that the lectures in nursing school were mostly useless (mainly just reiterating what we were responsible for in the reading already), the lessons I've learned from my clinical instructors will end up making a big difference. Even things that took me a while to master (or maybe especially those things) like IV medication administration and aseptic technique...I came out of the program feeling like I was marginal at best at some of those skills, but now that I've entered the workforce I realize..hey, I CAN do this! In fact, I can do it well enough to be in the position of reminding and teaching -other- people how to do it!

I'm still loving my co-workers. I made the mistake of letting slip what bar I hang out at. Now I'm forever looking over my shoulder, expecting to see the Director of Nursing and the Minimum-Data-Set Nurse walk in. Hah.

11.23.2008

the grind

Now that my coworkers have figured out that I'll volunteer for every and any open shift there is, I'm putting tons of hours in. Now, in addition to a couple of days a week acting as supervisor, I'll be running one of the two sides of the facility (one is predominantly long-term care, the other predominantly rehab) a couple days a week. I've shadowed on both sides, following the LPNs as they do their treatments and pass out meds. Now, I've done one day on my own on each side, and I'll probably do more of this next week (I'm working all the way through thanksgiving!).

I got compliments from our director about an admission I ran and an incident report I wrote up. Yay!

One of the pool nurses (who is actually an MSN!) asked me an interesting question. "Which side do you think is more difficult?" she asked. She always takes the long-term care side, which is generally thought by most of the nurses to be the easier side, since there are usually less dressing changes and more chronic patients.

At this point I was nearing the end of a shift on the rehab side, which is thought to be more difficult because there are more treatments and frequent requests for as-needed pain medications.

I told her I thought the long-term care side was more difficult to complete on time, because I'm more apt to spend more time at the bedside on that side, leaving less time for my tasks. This answer seemed to suprise her somewhat, until I mentioned that of that time at the bedside, I spent most of -that- reorienting confused people.

I qualified that by saying that I've really only done one day on my own on each side, and I'm still learning how to organize myself. BOTH of those days had me walking out of the building 45 minutes after the end of my shift, with a verbal report to the oncoming shift being the last thing I do before I leave. There's a voice recorder to record report, but by the end of the night I've left so much paperwork to do I never get out on time.

The paperwork, whether you're supervising or one of the floor nurses, is staggering.

I say this mostly because if I were to bring along on my two carts (meds and treatments) all of the 3-ring binders I need to chart in, they would be sliding off each other and falling off the carts. There are simply too many of them. There's a huge binder for medication kardexes, another one for treatment kardexes, a controlled substance disposition log, a binder containing the nurses notes and assessment flowsheets for everyone on the side for the last three days, and then my 3-page printout for my notes that I write for myself throughout the day (most of which also has to be documented elsewhere in the other binders).

It's true what they say, I spend more of my time wrangling these binders and writing things down in them than I do actually caring for patients. I actually get more time at the bedside as a supervisor than as a floor nurse!

So, I'm getting quicker at it as I continue to fold in organizational tips from the floor nurses, It'll probably take a while to settle in on the scheme that works well for me. I have a feeling that the optimal scheme for me would involve..you know..one of those computer thingies.

11.19.2008

Gravity

I'm slowly getting the hang of admissions. There's a LOT of paperwork, and I've had three different RNs walk me through the process. Eventually, I got to do one more or less "by myself", meaning the HUC still assembled the chart for me and prefilled a few of the name and date fields.

I think my learning process requires me, to a certain extent, to make mistakes when I do something on my own and then think -back- to what other people have shown me to avoid those mistakes in the future.

Next time, I'm going to remember to do all the paperwork I can as early as possible instead of leaving it for after my assessment. My admission assessment is taking way too long, unfortunately, the RN who's opinion I've come to weigh the most heavily told me I should be in and out of there in 20 minutes. By the time I've gone over every signature form with them, asked them all the questions, oriented them to the facility, completed a head-to-toe assessment, personally treated every wound I found and give a quick backrub, over an HOUR has gone by. There's definately some friction here between my administrative responsibilities as the charge RN and my desire to spend time at the bedside. I'll figure it out, I just need to do a bunch more admissions.

This post has been moved to "SNiF-Confidential", an invitation-only blog. Now accepting regular or guest contributors!


My notebook continues to expand in volume, with dedicated summary pages to therapy consults and lab values. A few angrily scribbled comments in red like "neglect risk", "watch closely", and "supervise care" pepper the pages. I've even started some entries for individual employees. I'm starting to realize I'm not responsible for just the just-under-fourty census of residents, I have 7 other people I have to assess and diagnose right along with them (2 LPNs, 5CNAs).

In my short time at this facility, I've already roped some of my friends into coming to visit and help out. One friend is a credentialed expressive therapist (mainly music), another one does reiki and tarot. The recreational therapist said she could probably get them money for their services. Another friend of mine is a medically retired psych nurse who's going to come in and do pet therapy with her two dogs and her caregiver. Another two friends are going to volunteer just to hang out and keep my residents company (under the strict understanding that they can't help out with toileting, hygiene, mobility, etc). Volunteer resources are so important, so where do they come from?

They come from people who are helped by the activity just as much as the people they're volunteering for.

I like the idea of drawing so many of my friends into what I'm doing, it's something I try to do with any of my interests, mainly Aikido and Go, but this is the only endeavor in which I've become rapidly successful in involving so many of my friends.

Well, so far anyway, we'll see what happens.

11.18.2008

Optogenetics

via Neurophilosophy

Optogenetics is a recently developed technique based on microbial proteins called channelrhodopsins (ChRs), which render neurons sensitive to light when inserted into them, thus enabling researchers to manipulate the activity of the cells using laser pulses.

Although still very new - the first ChR protein was isolated from a species of green algae in 2002 - optogenetics has already proven to be extremely powerful - it can be used to switch neurons on or off in an extremely precise manner and so to control simple behaviours in small organisms such as the nematode worm.

Earlier this year, ChR was used to restore vision to blind mice lacking the light-sensitive photoreceptor cells in the retina. And now researchers from Case Western Reserve University in Cleveland, Ohio have used the technique to restore motor function in rats paralysed by spinal cord injuries.

11.16.2008

Two admissions, two emergencies.

Another 12-hour shift. I'm gradually running more and more of the show. The RN supervisor working with me today stepped back and let me make a lot of my own decisions, and spent a bit of her day in the chartroom putting together in-service teaching modules for the other nurses. It was a busy day, even with the other RN supervisor helping me out with paperwork and prompting me occasionally to start or focus on certain projects.

At breakfast-time, the fire alarms went off. A little red light flashed angrily on the supervisor's panel. I imagine the panel made a sound, too, but it couldn't be heard over the deafening wail of the fire klaxons.

It was quite a sound, it seemed to cover a very wide frequency range, and caused interference patterns with the other alarms that were simply staggering.

The bright side of this was that I got to learn what we do when the alarm goes off. Clear the hallways, close all the doors, account for all the residents, etc. I helped the Lead CNA sweep the rooms and reassure the residents. The funny scottish one was on again today, I love working with her.

It took about 10-12 minutes for a uniformed firefighter to enter our facility, and he spent another 5-10 minutes puzzling over our supervisor's panel trying to figure out how to get the alarm to stop. Even after the fire klaxons went silent, all the egress alarms were still going off, and it took another 20 minutes or so for them to figure out how to turn -those- off.

As it turned out, someone had just burned some toast. Fortunately the fire alarm debacle didn't disrupt our plans too much, I grabbed the treatment kardex on the rehab side and used the treatments as an excuse to check up on the residents and examine them more thoroughly.

I had two admissions today, which was a good way to get faster with them. One was an easy knee arthroplasty. While I was giving her the head-to-toe admission workup, one of the CNAs walked in with the CNA admission packet. When I told her I was doing their admission, they said "hey, great!" and walked out of the room, leaving behind the CNA admission packet. Somehow she got the impression I was going to fill out her 5-page admission packet after I was done with my 20-page packet of documents. She sauntered in later and did her work, since I was "slow". Funny.

The second admission was for a head laceration secondary to a fall without loss of consciousness. The night shift called an ambulance for her after she triggered the emergency alarm in her apartment in our retirement community. It took even longer because she carefully read each document I handed her to sign (which is good). Each document triggered a lengthy rambling conversation (which was also good but time consuming).

We sent a resident out by ambulance with a blood pressure of 200+/100+, irregular heart rhythm (my money was on 2nd degree mobitz II block but no one did an EKG and our machine is broken) and unresponsiveness. Oh, and he was satting 82%. This person is one of our long-termers, dementia, ETOH, behavior problems. He continued to drink heavily as an elder. Now, less than 20 years away from his centennial, transient ischemic attacks of the brain had left him unable to do much of anything but eat, soil himself, and call out for help throughout the night.

At the emergency room, they simply diagnosed him with cellulitis (which he had developed in an extremity he as given a flu shot in) and sent him right back with a nonsensical antibiotic order (Keflex IV? Umm, no). They treated him extremely conservatively because of his DNR status. Once his vitals stabilized they just shipped him right back to us, no EKG or anything. The ED physician even went so far as to say that there was no point in doing anything else because the resident's a DNR. We disagreed with this, obviously, since he seemed to have treatable medical issues.

Once he came back we contacted the MD on call for us for orders. He was pretty pissed about the quick turnaround the patient experienced (they were only out of our facility for a few hours) and rattled off some orders, including an antibiotic that isn't cleared renally, which I dutifully jotted down. I placed a foley catheter (with a Coude tip to make it past his hypertrophic prostate), made him as comfortable as I could, and turned my attention to the rest of the unit.

I had spent a lot of time with this resident in the past. His room is right near the nurse's station, and he would constantly cry out at night. Most of the rest of the staff, used to his constant cries for attention, tended to tune him out. Being on orientation, I found myself with a lot of extra time to meet patient requests, so I spent a lot of time sitting on the floor next to his bed, reassuring him.

His conversations would always start with "Help! Help! Nurse! Help me please!". I'd sit down next to him and figure out what he wanted. Sometimes it was help using the urinal, sometimes it was a mouthfull of water, sometimes it was ice cream or an extra blanket. Occasionally he would say things like

"I need...I need you to be my friend. I need your friendship".

I'd reassure him by telling him he's my friend, then he would say

"No, no, you don't understand. I need your friendship 24 hours a day!".

No matter how often I explained to him that he's safe and that we're taking care of him, he would always plead with me to stay, saying he was afraid of falling out of bed and hurting himself (his bed is lowered with mats on the floor). Eventually I would excuse myself, promising to return in a set amount of time (this is what I use a chronometer for, among other things).

After he got started on PRN risperdal (an anti-psychotic), his sentences would get a little longer. The last words to me before I found him obtunded and crashing the next day were

"I need you...to help me...get out of bed...so I can dig a hole in the ground"

"There's no holes to dig here, Captain, you're in the rest home."

"I...understand that."

"What do you need to dig a hole for, Captain?" (We all call him captain, not sure why)

"I'm...not sure"

And so it would go. The director of Nursing stopped in briefly after the fire alarm incident, and she counseled me to give the Captain (in the event he appeared to have passed) a good 20 minutes before pronouncing him Dead. Apparently he went pulseless for a good 20 minutes in one of the common areas a couple weeks back. One of the LPNs gave him a light sternal massage and he went right back to Baseline. Wild.

After my shift I sat and pondered over my small, lineless moleskin notebook where I jot down notes about the residents for me to follow up on during the next shift. I brainstorm some consults and interventions for one elderly patient with a new ileostomy who's being discharged this week and still isn't changing her appliance independently. An elderly Japanese man just started eating in the common area, but I have some psychosocial concerns with him, he always eats alone. One of my favorites, a former professor of mechanical engineering with advanced dementia (tries to dissassemble everything in sight unless I give him blocks to play with or towels to fold) might have caught C-diff and I had to leave the collection of a stool sample for the next shift because I didn't get one.

Writing these notes are cathartic, because after I'm done, I don't -have- to think about it until my next shift, but if something comes to me I can always just jot it down.

On the first page is a quote from a Chuck Palahniuk novel. "Losing all hope is freedom". It appeared in the magickal notebook my intuitive/tarot/reiki friend was showing me after she got back from the Omega Institute. I copied it into my own notebook out of...I dunno...a sense of connection with her maybe? She cares for her elderly grandparents at home, we share a lot of the same interests, and she resembles someone who was very dear to me, so I tend to value her input, which tends to be wildly synchronistic at times.

Two hours after my shift, I wrote one last entry under the heading "Captain".

"Death may be imminent."

And under that,

"Wait 20 minutes before prounouncing death."

Then I ordered a beer.

abounds

I have less than 5 hours to sleep before my next 12-hour post at the nursing home.

For the first time in my life, I actually have something interesting enough to write notes about. On my way to the coffee shop tonight, I grabbed an ancient, small, untouched moleskin notebook. I bought it intending it to use it for notes and things during nursing school, but nothing I heard or saw there really inspired me to write any of it down (except for my blogging, that is).

Now that I'm responsible for so many people, ideas come to me when I'm off the clock, so now I have a notebook to write them all down. I just write entries on the lineless paper about the residents, identified by either room number or initials. Remember to get an Albumin on this resident. Follow up with dietician about this other patient I just discovered a pressure ulcer on. Councel this other patient about their diet choices and changes in diabetes medication.

After I leave all sorts of interventions and consults blossom in my mind, so now I'm writing them down.

Along with those, I'm jotting down things to talk to the Director of Nursing about.

While walking through one of the halls of my unit, I overheard one of the agency LPNs raising her voice to a resident. I leaned against the wall outside the door and sighed as I listened to this nurse yell at one of my residents.

She was crying because she thought the resident called her ugly. She told him that she had been in and out of this room 15 times already this shift, and if he could remember anything for more than 5 minutes he'd realize that. Now, this is a somewhat demanding patient, but he's on the long-term care side so there's plenty of extra time to help people out.

I took her aside as she left the room and asked her what was up. She tearfully explained to me that she hadn't had much sleep and couldn't handle the abuse from the residents. I told her that I didn't care if he called her a fat bitch, these residents have dementia and memory loss. They can give us all the shit they want. I immediately wanted to send her home. It was towards the end of the shift, I could easily have finished her meds and treatments on my own. I consulted with the other RN on duty, and she suggested we give her a moment to cool down and finish her work, while we took over the patient she hollered at.

I see the wisdom in giving someone an opprotunity to cool out, but there was really no excuse for what I overheard. She gave tearful excuses about being overworked and not having enough sleep, but I had no sympathy. So you're saying you're practicing while impaired? That's not much better.

Even worse, I found that she administered two 5/500mg vicodin to a resident who already had 4000mg of tylenol that day. Now, the first 1000mg was given at 00:30, so it was borderline, but this guy was in liver failure, and this LPN administered what was technically his FIFTH GRAM of acetaminophen for the day, and the max dosage is four grams because of the potential of liver damage. For a resident like this I'd be wary of even getting up to that fourth. I started filling out the med error report and paged the doctor (who never called back, as usual), but the RN shadowing me said that the first dose was close to midnight so it's not a big deal.

Things are going to run a lot differently when I'm off orientation, that's for damn sure.

The emergency calls from the independant living apartments are a constant source of amusement for me. This is what happened when I answered a call this same night, 10 minutes after I should have clocked out.

"This is PM at the health center, what's going on?"

"I can't poop! I've been sitting here for hours and nothing's coming out."

"Well, unfortuantely I can't bring you a laxative or anything like that, we can only respond to emergencies."

"What about an enema? You don't have to give it to me, just leave it with me."

"I can't do that either, sir, our supplies are for our patients, and you aren't one of our patients."

"Oh, I see..." He started to trail off, obviously frustrated.

"Lemme ask you this," my customer-service-mode was kicking in: "how long has it been since your last bowel movement?"

"Oh, about a day or so, I guess."

"Well sir, I wouldn't be worried about that until three days have gone by. Going three days between bowel movements is perfectly normal. Call Mrs. X at the visiting nurses station if you haven't gone after three days, ok?

"Ok, thanks, sorry to bother you."

Now, I was half-hoping there was something serious going on, like chest pain or a fall-with-fracture, but when I hung up that phone I felt a warm relief knowing that there really was no emergency, that everyone was really OK, and they didn't really need me at all.

I had plenty of other people to worry about.

11.12.2008

The bid'ness

I visited the nursing home this morning to attend a corporate orientation. There were three food servers, two CNAs and another RN in attendance. Most of the speakers were familiar faces, the Executive Director, Associate Director, Director of Nursing, Director of HR, and Director of Accounting. I had met all of these people except Accounting already.

I walked into the room late because I thought I was supposed to be in the HR director's office. Once I settled in I recognized the familiar corporate orientation routine, discussions about safety, abuse/neglect, parking, paychecks, etc.

The Director of Nursing (my immediate supervisor) only got two sentences into her presentation when the Unit Coordinator (Imagine a super-secretary with the ability to move mountains) stuck her head in the room and told the Director of Nursing that she needed her -now-.

Those of us attending the meeting looked around uncertainly, a couple of us made jokes, and then the Director of Nursing's head poked into the room.

"PM, you better come along for this, this will be a good one for you to see."

I lept out of my seat and followed the DoN through the Executive Director's office and into the hallways of the residences. Questions and answers were breathlessly exchanged as we hurried down the hall. Was this an emergency call? No, not exactly. Do we need the emergency bag? No, that won't be necessary. The DoN's voice lowered and our pace quickened, I wasn't able to understand her more detailed explanation because she was speaking in that "confidentiality voice" we're all familiar with.

As we rounded a corner we saw the Executive Director running full-speed-ahead to catch up with us, and we started running too. Elderly residents smiled and waved at us as we flew past them, and we waved back and made jokes about a fictitious employee exercise program.

We finally arrived at one of the residences, where security and the facilities manager were waiting for us. A resident had recently died, they were discovered during some kind of routine check that they do. There was nothing left to do but call the police. I didn't even get to see the body. Apparently since the residents are not our patients until they check into the skilled nursing facility on-site, we don't pronounce death or provide post-mortem care.

The Executive Director delegated the responsibility of notifying the family members to the DoN, and we walked back to the health center at a more leisurely pace, while she explained to me the procedures involved and what would come next.

I returned to the conference room where the other employees were listening to the Director of Accounting talk about shift differentials. The other RN in the room looked at me quizzically from across the table. I grabbed a pen from one of the CNAs and drew a big down-arrow on the back of my orientation packet and showed it to her. She nodded, recognizing the nursing shorthand for "dead".

In addition to attending the scene of a Resident Demise, tonight I will be "In Charge", for reals. I'll have the keys to both LPNs med and treatment carts, and a large circular desk filled with trees worth of paperwork to preside over. The DoN and HUC (Health Unit Coordinator) leave an hour or two into the shift. Thankfully, the Minimum-Data-Set Nurse will be there if I get too overwhelmed.

11.11.2008

A meeting

After being canceled on a couple of times, I finally had a sit-down with my boss about the pedi case. Flu season keeps everyone busy, it seems.

I was nervous going in, even though I had told myself that even being fired instead of switching assignments wouldn't be as bad as continuing to work on this case.

The boss, thankfully, is a pleasant guy. He's personally cared for my client in the past, and when I told him all the issues I was having, he nodded sympathetically and told me that that's more or less what the last thirty nurses said also.

Wait a minute, THIRTY?

The boss confirmed what I had suspected about receiving the case because of my gender, figuring that there would be less personality conflicts and I'd be less likely to strew makeup and feminine hygiene products all over their bathroom.

I tagged along as long as I did because I assumed that once the chart arrived I'd have doctors orders to back up the things I'm doing. Administering the lactulose via g-tube was a major thing. I'm not the one mixing it, the mom is, but I'm the one administering it. When she mentioned offhand that she had changed the dose, red flags started popping up everywhere.

Besides that, though, there was just too much about the situation that screamed at me to get out of it. The mom had no faith in what I was doing, when I assessed a new bruise I found (a common occurrence for this kid), she yelled at me for "pushing" on it when I was just lightly feeling it for warmth! She'd criticize me for being in a "rush", and then when we're late for the school van, guess who's fault that suddenly became!

I went over all of this with the boss, and he said he'd have to confer with higher-ups to see if this case is worth the liability risk. He told me he'd call me tomorrow and tell me what they've determined, and for now to plan on showing up for my next shift. I'm seriously considering refusing.

I offered a compromise, everything runs pretty smoothly at school, so I offered to work the hours in the school and just hand-off the kid afterward. I wanted to offer some kind of concession, but really that's just going to postpone the inevitable. During my meeting with the boss I actually used the words "time bomb".

I have a lot of sympathy for the family, they take really good care of the kid and work hard and lose sleep to keep everything going, but there's just too much stress, and too little communication. I suggested that if someone was going to be successful on this case, it's going to be someone with the experience and education to provide nursing care for the mother and boyfriend as well as the child. The problem is that a nurse with that kind of experience and education (probably a BSN, although I hate to say it) is unlikely to work for what a job like that pays.

My enthusiasm for the charge nurse position at the nursing home is still on the upswing, though. There's a lot to learn, but I have a lot of extra shifts scheduled to figure it out. I'm actually working two 7a-7p shifts this weekend!

11.08.2008

Fun on the floor

I didn't even notice when it was time to leave at the end of my 12 hour shift at the nursing home. Lots of fun. I got to order X-rays for a couple residents, helped put together all the admission paperwork and actually writing the orders I was following earlier in the week while I was learning the treatment and med cart with the LPNs.

I switched sides of the health-center today, and helped cover the side with more long term care, while the half I was on earlier in the week was mostly rehab. The director of nursing picked a clever method for integrating me into the unit, starting me out where things are the most slammed, and then introducing subtler and more complicated elements.

The amount of paper work is staggering. I could think of dozens of ways to speed this up with computers, but the in-house designed system hasn't gotten to us yet (if one exists at all).

It's a lot of writing by hand, something I've always been averse to and not any good at. I can't write in cursive, at all. It's messy at times, and I make a lot of mistakes, but I think as sloppy as it is it's still more readable than that cursive garbage. I'm forever having to ask people what written words mean. I almost mistook an entry in the Kardex for a completely different drug! No pyxis, no automation, no double-checks.

I'm thankful for the OCD-ness my clinical instructors strived to inspire in us, It saves my butt on a daily basis from near-misses and mindfulness.

It reminds me of something my aikido sensei said about meditation. At first it's challenging because sitting that way can be really painful at first, maybe for a long time. Then, when the pain is gone, the problem becomes staying awake.

Same on the unit, I think. At first the challenge is getting everything done, then the next challenge is doing it every time even when you've gotten good enough at it for it to be routine.

I witnessed some interesting things during my time there so far, but maybe two much to fold into a single post, I'll just sprinkle vignettes throughout.

11.07.2008

Blue Team Wins!

(via dissidentvoice.org)

Fox News: Guess who’s here? The Independent party candidate, Ralph Nader. This is his second run for the Presidency since he played spoiler in the close 2000 contest. This year he was on the ballot in 45 states plus D.C. This year he was polling about 1-percent. Ralph, you spoke to Fox News Radio’s Houston affiliate today, and said this:

Ralph Nader: To put it very simply, he is our first African American president; or he will be. And we wish him well. But his choice, basically, is whether he’s going to be Uncle Sam for the people of this country, or Uncle Tom for the giant corporations.

Fox News: Really. Ralph Nader — What was that?

Nader: It’s very simple. He has gone along with corporate power from the moment he entered politics in the State Senate — Voted for the Wall Street Bailout — Supports expanding military budget that is desired by the military industrial complex, and doesn’t really have a tax reform thing for the ordinary fellow in this country — Opposes single-payer full Medicare for all, because the giant HMOs AETNA and SIGNA do — Doesn’t have a living wage — He’s supposed to be respectful of the poor — hardly mentions them in his speech — It’s all the middle class — He doesn’t have a comprehensive program…

(Interrupted by Fox)

Fox News: … and you utter the words “Uncle Tom”? Are you kidding me?

Nader: Yeah… that’s the question he’s gotta face.

(Interrupted by Fox)

Fox News: He didn’t have to face it until it came out of your mouth! I mean, I just wonder if you don’t realize that you had a number of supporters out there. You were running a percentage this year, you were reduced to irrelevant, and I just wonder now if that’s what you want your legacy to be — the man who, on the night that the first African American President in the history of this nation was elected, you ask if he’s going to be Uncle Sam or Uncle Tom.

Nader: Yeah, of course. He’s turned his back on a hundred-million poor people in this country — African Americans and Latinos and poor whites, and we’re gonna hold them to a higher standard. It’s just not an unprecedented career move, ya know, in the White House. We expect more of Barack Obama…

(Interrupted by Fox)

Fox News: You were reduced to complete irrelevance here. You weren’t able to play spoiler. Will you run again?

Nader: Look, I don’t like bullies like you. I can’t see you. You can pull the plug on me. I’m lookin’ at a dark camera…

(Interrupted by Fox)

Fox News: You said “Uncle Tom.” I didn’t say it, sir. With respect, I did not say it…

Nader: I said that’s the question HE has to answer. He can become a great President, or he can become a toady for the corporate powers that have brought both parties to their knees against working people in this country, and have allowed our country to be hijacked by global corporations who have no allegiance to this country other than to ship its jobs and industries to fascist and communist dictators abroad who know how to keep their workers in their place. This is reality here. This is not show business. It’s not celebrity politics. There are people suffering in this country, and we expect a great Presidency from Barack Obama, and we’re gonna try to hold his feet to the fire…

(Interrupted by Fox)

Fox News: I just wonder if, in hindsight, you wish you’d used a phrase other than Uncle Tom?

Nader: Not — at all. Do you know what the historic….

(Interrupted by Fox)

Fox News: Fair enough. Thanks very much. We’ll have a response from our panel in just a moment.”

Nader: Thank you…




I know some of you out there think that people who didn't vote don't have a right to participate in the dialog. That reveals a dangerous amount of absolutism. If you want to really address the problems that are going on right now, you won't find the solutions in a ballot box. Private Power holds no elections, and has no obligation other than shareholder return.

The Red Team and The Blue team are both fronts for the same thing. The transfer of public funds to private businesses and other entities. It's a great system they've worked out, but it isn't OUR system.

The ratings were great, though. So great hardly anybody's talking about the US's attacks on Syria and Pakistan and refusal to comment. Nobody's talking about how what's left of the Bush administration is scrambling around to change as much as possible in the amount of time they have left. Everybody is too busy celebrating and basking in the warm glowing warming glow of knowing that Their Guy won. Well, not -everybody-, but so many people, you know? The majority of them. Those PR types know what they're doing.

Now, I tend to take the extreme view that even engaging in that purely symbolic participatory act of voting is to contribute to this system of exploitation, so I don't do it personally. A more moderate view might be that the act is pointless, but inspires individual people so it's beneficial in that sense, so good for them.

Of course, the belief that one of those groups of people has no right to talk to them pulls back the curtain and reveals itself for what it is: another layer of the "us vs. them" gambit that news corporations, military contractors, fast-food chains, even the election process itself (limited to it's two candidates) foist on people to keep them distracted from the fact that less exploitative systems exist, and are in fact preferable to the people who have to endure them.

11.06.2008

watch

I'm having a hell of a time finding a professional chronometer. I want to be able to quickly and easily start multiple countdown timers, preferably with messages to go along with them.

Doing a quick internet search of what passes for "professional nursing watches" was immediately frustrating and infuriating. Apperantly this is what passes for the watch of a nursing professional nowadays:



A quick search for "medical watches" turned up a bunch of beeping or vibrating watches to remind people to take their meds. All well and good, but they're meant for daily consistent reminders, so that's not good.

I want to be able to set a 10 minute reminder to go back and take someone off their breathing treatment, for example. Set up an hourly alarm to remember to come back at regular intervals to complete different steps of a complex sequence of care (like gtube care, meds and feeding for example). Set up another 1 hour alarm to remind me to check on the effectiveness of a pain med. People seem to usually try to do this all in their head, but when that happens a lot of things get missed.

I'll have to get back to looking, feel free to share any watches you think fit the bill.

EDIT: WHOA. Check this one out.

orienting

Almost made it through the week! I did three 4-hour shifts at the nursing home, and I got to work with a lot of different RNs and LPNs in the process. Everyone is friendly and has quirky senses of humor. From what I've been told, the plan's been to give me some practice with the med and treatment carts just to be able to fill in when things get slammed.

The next orientation shift this weekend is a full 12 hours, and I'll be spending more of my time learning the administrative side of things and doing admissions. I've seen RNs get so hung up on those they don't administer any meds or treatments, something that doesn't exactly ingratiate you with the LPNs. I think part of the reason I'm going to work out well here is that I'd -rather- be spending my time doing direct patient care, so I'll figure out efficient ways to get all of the administrative work done and still help out on the floor.

I called up and asked for another shift of orientation at the nursing home next week, I figure, hey, I have a day off from the pedi job during the week, might as well pick up another shift there while I can for orientation.

More job offers have been coming in, one of them is very tempting. 24 hours, paid for 36 hours. All at once (or maybe over a weekend?). Weekly. At something probably closer to $30 an hour than $25. At another nursing home closer to home.

The facility I'm working at now is thinking of getting Nintendo Wiis and Wii Fits for the residents. Why not?

11.05.2008

Busy week

Phew, I'm on my last day of working 8-4 doing pedi homecare and orienting 5-9 at the nursing home. As exhausting as this schedule has been, I think I might ask to do the same thing next week, after my 12-hour orientation shift on the shift I'll be working there.

I love the nursing home so far! Everyone's been super friendly and helpful. I think I've made a good impression so far. Despite the fact that I've been out of the med/surg environment for a while (the longest period of time since I started), a lot of it came flowing back once I got on the floor. I've been assigned to follow a different LPN each orientation day to get a hang of their routine for medication passes and treatments.

I got to do my first intra-dermal injection (a PPD test)! I was a little nervous I'd mess it up, never having done one before, and I had a hard time visualizing the bevel of the needle since I'm stuck wearing old-prescription contacts until I find my misplaced glasses. I slid the needle in to the skin of a patient's arm and was rewarded by a perfect bleb containing the PPD. I also got to administer some g-tube medications, gave some insulin, passed a bunch of meds, did some dressing changes, and I had a blast doing it. The LPNs couldn't help but crack up when they saw how enthusiastic I was about getting to do a dressing change.

Working the floor has been going well so far, despite the fact that they still use paper charting (ugh!), the books and forms remind me a bit of my year in the group home for adults with autism. I'm still getting the hang of the workflow, but there are even bigger challenges coming up at this job.

See, I'm being hired as the -charge nurse-. As I explained before, I have a feeling that this is more to fulfill the facility's medicare requirement to have an RN on shift by hiring someone who won't mess up the experienced LPNs system. I got a taste of what kinds of things I'll be doing as charge, as I had to manage a constant influx of information from the CNAs, requests from residents and family members, and a census that included a lot of confused, forgetful people on a variety of medications.

I've discovered that once I'm off orientation I'll be able to write orders for PRNs (like anti-emetics and anti-diarrheals), X-rays and even Labs! It'll be a while before I can really exercise this ability efficiently, but the thought of being able to order Albumins, 'lytes, U/As, tox screens, etc is really exciting to me for some reason.

I think I've made a good impression on the LPNs so far. We all realize I have a lot to learn, but doing little things like asking to see the sliding scale when one of them hands me a syringe of insulin to administer shows them, at least, that I'm aware of what I'm doing, even if I'm doing it a bit slowly at first.

It looks like getting the job done on the floor in a timely fashion requires a lot of things that I would have considered cutting corners after my training in med/surg. There's "too much to do" to dot all the i's and cross all the t's the way I've been taught it's supposed to work. Even still, I'm holding on to those imperatives my clinical faculty imparted to me. Even though I didn't always get it right while I was in school, I managed to carry a lot of their stern reminders and warnings with me (which I guess was the point).

I'm definately going to have to bring a notebook with me to jot down notes on all of the requests people make. I'll probably have to get another one of those multi-color pens as well, from the looks of it.

I got approached by an MBA who works for one of the big dialysis companies, he wants me to email him my resume and references and get me hooked up at a dialysis clinic near where I live. I'm seriously considering it, since the Pedi homecare job is starting to look like more stress than it's worth. Not from the patient, mind you, I think I'm doing great with the kid's care, it's the -mom-. When I told this to the LPNs at the nursing home they all nodded knowingly. They said it was the parents that kept them out of Pedi, not the patients. We'll see what happens.

11.02.2008

Trends (concept map)

I noticed a recent drop-off in my number of visitors-per-day. Curious as to the reason, I started to poke around in Google Trends a bit today.



As you can see, google searches for concept map peak around the beginning of the fall semester, and then drop off around..well, now. Since most of my incoming traffic is searches for concept maps (and links from my concept map on google images), I suppose this isn't all that surprising.

This lends further evidence to my theory that concept mapping has no relevance outside the realm of educators who are out of their depth and struggling to come up with busywork.

It's also interesting to compare side by side the trends analysis of "concept map" and "nursing education". Notice something?



Also, searches for "yawngasm" were too few to show up in trends. Go me! Heh.