12.27.2008

The no-sleep over

I recently got an opportunity to get oriented on the 11-7 shift at my facility. There's only one RN who's willing to cover other people's shifts, and she claims she's too old to work five days a week, so I figured I'd let her show me the ropes so I could help her cover the other night RN's vacations and leaves of absence.

For the first 5 hours or so, I felt more like a clerical worker than a nurse. Well, more so than usual anyway. We calibrated the glucometers, checked the emergency equipment, recorded the temperatures in the refrigerators, and then audited each of the residents charts to make sure the orders were noted in the treatment and medication kardexes.

This shift was on..what did they call it...flip night? A third RN got all of the new kardexes ready for the new month, which involved another painstaking layer of audits and double-checks. We spotted some anomalies in the orders and flagged them for the next shift to hash out with the house doctor and the pharmacy.

The med pass for 6AM looked daunting, but I didn't have many treatments to do (mostly lower extremity vascular assessments and pulse oximetry) and I had flagged all the MAR cards ahead of time, so I figured I could make short work of it. I medicated a couple of people for pain throughout the night, re-tucked-in one of our dementia patients a few times, and got ready to bang out the medications, which were all scheduled to be administered right before the end of my shift.

Once the residents all started waking up, of course, was when the problems started.

*****

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

12.22.2008

A fancy party

The x-mas party was a blast. I took along a friend of mine who's a CNA to introduce her to the DNS and 1st shift lead CNA, but she ended up running into old friends among my coworkers. Go figure. I had a couple of nice heart-to-hearts with people I've gotten to know from work, and I'm going to have a sit-down over coffee with one of them who's been there a while to get the "whole scoop" on the place. Looking forward to it = very yes! I'm excited about the prospect of working with friends of mine. Two of my friends have even decided to go either take the CNA test or challenge it to come along for the ride!

I only took a couple pictures at the party because I was so occupied.





There were some hushed conversations with a lot of hand-and-arm holding involving some of the people who had been there longest, concerning our hospice patient who was doing well last we heard.

I came back to the facility the next morning for another 12-hour shift. The overnight shift reported to me that our hospice patient died while we were at the party.

The overnight shift also told me that the CNA I wrote up was working last night and cussed out the 2nd shift lead CNA so loudly that they could hear it from the nurse's station. Seeing that she was on the schedule again for today and the LPN she cussed out was also working with me, I called up our DNS and told her what was reported to me, explaining that I wouldn't be comfortable with her coming in.

I took her off the schedule, but had no way of informing her of this, since the phone number she gave us doesn't work. I got her -mother's- number from one of the other nurses (apparently that CNA has family connections with one or more of the RNs) and told her to pass along to her daughter that she wasn't on the schedule for today. The CNA later called to say she wouldn't be "returning back", which my sleep-deprived brain couldn't process.

"What?"

"I won't be returning back."

"What does that mean?"

"I won't be returning."

"Oh, ok, thanks for calling." *click*

I called the scheduler while she was at her second job to let her know not to schedule her for any more shifts. I also explained what happened to the LPN who got yelled at by the CNA.

I called the temp agency and had someone else fill in. We could have gotten away with having three aides normally, but all of the residents had to be weighed during this day and the previous, and hardly any had been completed. The 1st shift lead CNA warned me about this at the party, so I was sure to look out for it.

I talked to one of the CNAs about the hospice patient, it was her first post-mortum care experience and she described cheyne-stokes respirations without knowing what they were, so we had a little chat about it standing out in the snow in front of the facility.

That particular CNA was working with a new-hire, fresh out of CNA school. The next shift, while doing rounds, discovered stool on the linen pad of one of our residents, so I called her up after she left. I really just told her that this was found on her side, and asked her to help me remind the new guy about all the things he's supposed to do. No write-up, just a friendly reminder.

Apparently, this CNA then started texting the CNA who had just quit, and -she- started texting her sister (who was on-shift, found the stool in the first place, and still had a job) to try to figure out who "ratted her out". Ironically, the chain of text messages lead straight to the person who found it and reported it to me in the first place, the sister of the CNA who was just fired/quit.

This CNA and the 2nd shift lead CNA -then- brought the text messages to my attention. What I told them was exactly what I told the CNA who was working with the new guy. I can't remember exactly how the conversation went down, but essentially it boils down to "so-and-so isn't working here any more, I just want to give you the heads up that if you talk to her about what goes on at work you're breaking the law."

It sounded like she got the point, hopefully she isn't too stressed out about it.

I'll be working all through the holidays this week, a bunch of 3-11 shifts out on the floor. I'd honestly rather be supervising but I can't go too long without doing some shifts on the floor, there are still things I need to figure out regarding how to balance the brutal grind of med-passes with individualized holistic care.

Maybe if I had some volunteers.....are you listening guys?

12.19.2008

The wandering engineer, an unusual dinner, a blizzard and a Hospice consult.

When I returned to work this week I had been off for a few days. I like having 3 or 4 days off a week, even if that means the shifts I do work are all crammed together.

I delayed my usual preparations for the frenetic grind of working the Floor to sit down with our DoN. I brought up the whole behavior plan thing, only to find out that our parent company is preparing the framework to do more or less exactly what I had proposed.

She then told me that the Captain had left us. His behavior had escalated (much as you would imagine the behaviors of a 90+ retired naval captain escalating while being henpecked by burnt-out CNAs) and he was sent out to a specialized behavior setting. Although I was glad he didn't end up in the mental hospital; I was quietly, invisibly seething with rage at the two CNAs who saw fit to gang up on him when there were no RNs about. I later calmed myself by checking the permanent schedule to verify that certain changes had taken place.

The DoN said that they were holding his room, and that he wouldn't be able to return until the behavior plan was in place, the CNAs were properly trained and understood the implications of the behavior plan, and one of our RNs had visited him in his new milieu to verify that his aggression had decreased.

His repetitive, non-functional calls for help and borderline personality grated on all of us, but I was disappointed to find him gone. I felt as though we had failed him as caregivers and supervisors. The captain didn't require specialized care, just caregivers that reacted to his behaviors consistently. Basic dementia care. I'm told things will be different when we open the locked unit early next year.

The DoN asked me casually if I wanted to trade my evening shift on the floor the next day for a day shift as supervisor. The facility needs an RN in the building every shift, and on days it's usually the DoN. She hadn't been able to get a day off in a while, so she proposed that I leave early that night (at 9 instead of 11) and pick up the day shift the next day.

I readily agreed, since this would mean I'd be working side-by-side with the LPN who acts as charge on Day shift, a person who practically runs the facility single-handed. I'm definately going to learn as much from her as I can!

*****

The next day I walked back on the unit bleary-eyed from 4 hours of sleep and surprised the third-shifters, since they had received a taped report from me the night before. Some of the support staff thought I had stayed all through the night!

I had a re-admission to work on, one of our rehab patients came back after being sent out for a Volvulus of the Splenic Flexure.

I figured I could make short work of the admission, so I helped out one of the LPNs with dressing changes between steps.

Before too long, it started snowing. It started snowing a LOT. Traffic accidents. One resident's relatives who flew in on a private jet got stuck in traffic and had to stay at a motel instead. The dietary staff all left early, leaving us with no one to wash dishes or prepare food. To their credit, they set us up with a cold-cut buffet and disposable tableware (it's bad enough I have to do clerical work, I am NOT doing dishes).

Worst of all, we were missing some CNAs. The lead CNA (the Scottish woman I write about so fondly) stayed far beyond the end of her shift to keep the CNA headcount nice and legal (we need at least 3, 4-6 is preferable). Two CNAs couldn't make it at all, despite the fact that the DoN had left a message up for a week saying that CNAs could clock in early to beat the snowstorm and that missing their shift due to the snow would count as an unexcused absence. One aide called asking if the DoN's husband could come pick them up, so I transfered them to the scheduler's line. Unfortunately, the phone numbers they gave us to get back to them didn't work, so they were SOL there.

The second aide called (the one who mouthed off to one of the LPNs behind the nurse's station) asking more or less the same thing, I told her the same thing I told the first one and asked if she'd like me to transfer her to the scheduler's office.

"It don't matter.." she said.

"Oh. Well, in that case, I have other things to do." *click*

Back to work.

With the dietary staff gone, we decided to move most of the residents who usually eat in the dining room (mostly the long-termers) into the lounge/library area and set up the cold cuts there.

With only three aides on the floor instead of the usual 5 we would have for the census we had, I abandoned my rapidly mounting paperwork to help out. I ended up being of limited usefulness, not having much practice with the long-termer's individual quirks and anxieties about transfers. I managed to transport two by wheelchair to the lounge in the same time the other three had transferred 10 or so. The Lead CNA occupied some of the dementia and psych disorder residents by making up songs to sing to them, one or two would make up verses and sing them back to her. It was heartwarming.

The scheduler and the HUC helped feed the long-termers (many of them need to be supervised while eating or fed by hand) while I transcribed orders and put out fires on the rehab side.

Throughout all of this, the wandering engineer was wandering. He used to be a professor, and his wife lives on the independent living side of the campus. For a while he was on a tab alarm (which sets off a horrendous siren if the person attached to it gets out of their chair), because he was considered a fall risk. After it was apparent that he was pretty steady on his feet, we got rid of the tab alarm. The problem then became that he would wander around everywhere. Urinary retention, supra-pubic cystostomy and pretty heavy dementia, by the way.

Our unit isn't a locked unit, but some residents have "wander-guards" strapped to their wrists. If they get too close to one of the exits, the door will lock and an alarm will sound. The wandering engineer tripped the alarm many times that evening, mostly because someone had set up a table with cookies and cider right next to the front entrance.

He was always restless, but now he could wander about as he pleased. This was an overwhelmingly positive development, but not without it's drawbacks. His agitation increases somewhat when his wife leaves to go back to their apartment, a regrettable but unavoidable fact of his care. Most troublesomely, he never remembers which room is his (or even that he has a room here) and he tends to randomly walk into the rooms of other residents.

His speech is disorganized and full of indefinite articles. He's always talking about "it" and "then" and "there" in a way that makes it clear he's trying to articulate something very important to him, but when asked what he's talking about he just gets confused. He's always trying to disassemble some things and testing the structural integrity of other things (I heard civil engineering was his specialty).

We aren't supposed to have favorites, but I can't help having a certain fondness for the wandering engineer. Part of this may be because I used to be an engineer myself, another part may be that I tend to get the most attached to the residents that require the most attention to ensure their safety.

After dinner was finished and the room was cleared out, I peaked in to find that the door out on to the snow-covered patio was wide open. I went immediately into elopement mode, figuring the wandering engineer had wandered out into the snow.

He was on the other side of the room, trying to figure out how to take the electric wheelchair apart, shivering from the snowy wind.

*****

This week I also found that our chemo patient had returned. She was still refusing all of her medications. She was in immense pain, having quit her voluminous medication list cold-turkey. Hospice had rejected her once, when I heard this in the administrative report (kind of like the nurses morning report but with the heads of all the departments, including the charge nurse and top admins) my jaw practically dropped.

"How...how could she not get on hospice?" I was struck stupid by the information.

"They have criteria." was the nonchalant reply.

On my time hospice was called again, and this time she was accepted as a hospice patient. The Lead CNA (the same Scottish woman who had stayed past her shift) asked me to come help make her more comfortable.

I ended up just running errands for her after helping her reposition the patient. I fetched some ultra-absorbent pads for the bed so she could get rid of the incontinence briefs. She was refusing oral care in addition to the meds, and wouldn't let anyone do anything but change her. Watching the CNA care for her reminded me (as I'm reminded every shift) how much I still have to learn about this job. She had me bring some ginger-ale, she whetted the oral-care swabs with them and moistened the patient's mouth, talking to her soothingly, confidently.

We stood out in the blizzard afterwards smoking cigarettes, and she told me she cared for her mother as she died from multiple sclerosis. She only brought it up when I mentioned a friend of mine with MS who wanted to come in to volunteer.

"Not many people understand MS." She said thoughtfully. "Me mum sounded like she was drunk all the time, she ne'er touched a drink in her life."

"She was diagnosed when she was young and died in her 70s." She continued in her thick Edinburgh accent. "She ne'er even had a pressure ulcer when she died. Ne'er spent a day in the hospital. I took good care of 'er."

In stark contrast to her usual sing-song cheeriness, she sounded almost mournful.

The cherry of her cigarette glinted in her eyes. She looked fierce and proud.

*****

Halfway through the shift one of the other RN supervisors called me up and asked me to switch shifts with her. This means I don't have to work on the day of the Christmas party (at the swanky resort casino nearby), but I WILL have to work 7AM on the day AFTER the Christmas party. Oh well, I never get much sleep before a 7-7 anyway.

Plus, this means I get to supervise again instead of taking the floor.

I drove home through the blizzard, just as I've driven through every other blizzard that's hit this part of the country since I could drive. I'm at home in the snow.

One of the residents is leaving soon. She's sad because the home she raised her children in is being sold, and she's moving to a different facility soon. She had been sitting in her room all day, so while we were getting everyone up for dinner I brought her to the bay windows in the lobby, where we watched the snow together in silence.

12.15.2008

The Hard Line

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

12.09.2008

Week after week.

The gas station near my house is playing the theme song from "charlie brown" as part of it's christmas music rotation. Weird.

My work schedule is getting compressed into three days. I enjoy having a four day weekend every week, with the baylor shift on saturday it's turning out to be 36 hours or so a week. Too bad I'm still technically part-time! Hopefully that won't last much past February.

Having all this extra time in my schedule again has me thinking about hitting up the agency for more positions. Most of their offerings seem to be pedi homecare, but they supposedly do SNF placements too, that might be a good way to see the other SNFs in my area and get a good idea of how they work (my DoN suggests this would be a good way to appreciate how "good we have it" in our facility).

The largest benefit of this schedule, however, is still having time for Aikido in the evenings. I can't go four days a week anymore like I was, but being able to go at least twice is still nice. Last night, after the sensei descended the steps from his loft residence into the dojo, loud southern rock music started booming through the floorboards underneath the tatami mats. He arranged himself on his zafu and we sat zazen, music booming through the dojo the whole time. It didn't stop, even when zazen ended and we started training. He explained later that the music was for his plants in the basement, to help them survive the winter I suppose.

Friday is an employee meeting. According to the flier I got with my last paycheck, the iron chef secret ingredient of this meeting is Ginger. I hope they won't expect me to cook anything, but if they do I have two fine pinch-cookers to act as my stunt-double (I tend to burn most of the foods I cook in search of that "flavorful sear").

We also have an employee christmas party later this month, at one of our local resort casinos. I liked the idea of lounging at the bar with my new compatriots, but it looks like they rented out a ballroom or something like that for the event. Should be interesting, anyway. Everyone seems like fun to hang out with, and there's something uniquely useful about the experience of hanging out with your superiors and subordinates outside of work for some drinks...and some important conversations.

I feel like I'm learning a lot from everyone, but sometimes I'm learning conflicting things. This makes things very frustrating sometimes. For example, while I was processing a couple of admissions, I remembered what the night nurses told me about filling out duplicate kardexes so we'd be all set when the next month clicked over. When I started doing this, the day nurses told me that I wasn't supposed to do that. When I related this to the night nurses, they were extremely upset. I'm still in the "hey, I'm new here, sorry" stage, but that doesn't seem like it will last for very long.

One thing I'm pretty excited about is the opportunity to learn Reiki from one of the other RN supervisors. She practices a 10 minute treatment, which she says you normally aren't supposed to do for the young or elderly, but she "asked the universe to let it work", and she gives 10 minute treatments to our elderly Alzheimer's patients. Dementia is her specialty, you see.

I'm supposed to replace her when she leaves our floor to head-up the new memory unit next-door in February, our floor will then convert to mostly rehab. I'm considering following her when she leaves.

After only a few weeks at this facility, suddenly I'm the one telling people where to find a form. My position as the most recently-educated RN comes in handy, too. One RN showed me the lab results for one of our residents with metastatic cancer, she was concerned about the high white blood-cell count. Elevated WBCs might indicate an infection. I glanced at the differential count and then went back to organizing my treatment kardex.

"Maybe it's the neupogen we're giving them." I murmured, barely audible. I was on the floor that day, and had dozens of small emergencies and crises to sort out.

"Oh, right. Thanks."

Another time one of the new CNAs showed me the blood pressure he obtained for one of my craniotomy patients. 60/30, pulse 52...hmm...not good. I summoned the more experienced charge nurse and we got more detailed assessment data, but no interventions were proposed except to pass the info along and arrange for the antihypertensive dose to be lowered or changed to extended-release, and to write a new treatment order to obtain the BP manually before administering antihypertensives.

The charge nurse was puzzling over this out-loud, and I suggested off-hand as I was zipping by the nurse's station (I get a lot of exercise while I'm on the floor) that we obtain a head CT, thinking back to my lessons on the compensatory mechanisms that interrelate blood pressure and intra-cranial pressure.

"Hey, good idea! Thanks!"

I'm spending a lot of time with the lab and drug references, refreshing and applying my RN training. One of the silver linings of having an ungodly amount of paperwork to do is that this affords me some time to browse through a reference (what's another 5 minutes when you're half an hour behind?) and look something up. I think I'll bring my hefty med/surg and pharmacology texts with me this week, write my name on them and just leave them there. Too bad my nursing fundamentals textbook is unrecoverable!

My desire to see computers used in this setting is rising inexorably. As many problems as electronic charting has, the alternative system wastes too much of our time and introduces too many vectors for serious errors. There's no reason why I should have to be hunting down pieces of paper carried by the aides to copy down vitals and I&Os. There's no reason we should have to be highlighting which values we expect the CNAs to record for us. If we had computers-on-wheels, inputting vitals and I&Os can be a shared responsibility, only would have to be recorded somewhere once (and not in 3 different binders) and would be instantly available by everyone.

This would make our house MD's life easier, too. Apollo, Asclepius, Hygieia, and Panacea bless the guy, his willingness to call me back when I page him at 10PM often makes the difference between agony and relative comfort for one of my residents. I'm glad my training included how to organize yourself to ask for and receive telephone orders from an MD, even though our facility lets me write a lot of TOs on my own.

Imagine, though, if our house MD had electronic access to all of our charting and assessment data in real-time? It's easy to do, really. He could even transmit orders electronically, without even tying up our phone.

The biggest obstacle, I'm told, is getting the aides to use computerized charting. This is an obstacle I'm ready to meet head-on. The solution, I think, is one-on-one training. Forget all this sitting in a room and trying to show 20 people how to use it at the same time, it doesn't work for math class and it doesn't work for a reading/critical thinking exercise like using a new piece of software.

There may, of course, be larger obstacles I'm not aware of. Our DoN told me when I was hired that a computerized charting solution is in the works, but that our parent corporation was waiting to see other products field-tested by other facilities before implementing their own solution.

No, I don't want to be a Nurse Informaticist, damnit! I just want to practice in the 21st century.

This blog is coming up on a bit of a defining event. I've added one of my coworkers (who also goes to the same nursing school I graduated from) to my facebook contacts, and there's a link from my profile to this blog.

In terms of the law, I'm not concerned. The 18 forbidden identifiers don't appear here (although there is some gray area that has me thinking I should comb through older entries just in case), but the fact that I'm writing about work where someone from work can read it suddenly makes things much more complicated.

12.02.2008

what i've been up to

With one day left of my four-day weekend, I thought I'd show ya what I've been up to, in case you were curious.

This is about 25 minutes, and mostly consists of some hot guitar-on-kaosspad action.

I'm the one in the scrubs.