“Do you have any allergies?”

How often do you ask your patients about their allergies? Better yet, do you clarify and ask about medication and any other allergies?

We get in the habit of trusting our doctors who order the meds and the pharmacy that verifies the meds. However, we may need to get into the habit of asking about food, medication, and “any other” allergies on admission.

When doing the admission database I used to always ask whether the patient was allergic to any medications. That’s all I figured I needed to know… until a patient was negatively affected.

Way back when I was a Med-Surg nurse there was a patient that needed a CT scan. No big deal, he tolerated the scan fine but his kidneys, however, did not. We started noticing his BUN and creatinine creeping up, his urine output decreasing, all for no apparent reason. He just didn’t look as good as he should. He said he has had a CT scan before and never had any trouble. He had no known allergies. He was not a renal patient. It didn’t make sense! One of our nurses happened to be in the room giving him a saline bolus to see if we could get his urine output to pick back up. He was questioned about his previous CT scans again and this time he mentions that one time they “put something in his IV “and it “made him sick and put him in the hospital” but “that was years ago.”

Oh really?

Well, guess who had a CT scan with IV contrast… Mind you, he said he had no allergies. Turns out because of his education level he only considered medications to be the pills he took at home so the IV contrast allergy didn’t register with him. I don’t think he even understood that his reaction was an actual allergy.  He didn’t really know what IV contrast was and since we only asked about meds, he didn’t see a reason to mention it.

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Looks like we found our problem guys.

Needless to say, that changed how I asked about allergies. I try to keep my patient’s education level in mind when asking questions. I want to make sure they understand what I am asking them. It is my job to keep them safe. As the nurse, we are often the last safety check before something reaches the patient. We block all the foolishness from getting to our patients because we are awesome.

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Charge

I’m a charge nurse on my unit. I actually wasn’t comfortable taking on that role but my coworkers thought I would do well so I said ok.

Some days I regret that decision.

Don’t get me wrong, I do enjoy having new responsibilities. I like seeing nursing from a different perspective. I rather enjoy the decision making that is left in my hands.

I do not enjoy the stupidity that I encounter. For instance, our OR and ER are fully aware that because of the way EPIC is set up, we need an admission order placed by the physician so that bed center can place the patient on our bed board. If the patient is not on our bed board then we cannot pull them onto our unit list and thus we cannot get into their chart once they arrive to our unit. If we can’t get into their chart then we can’t see their orders. If we can’t see their orders then we can’t carry them out. They know this. It never fails, however, the doc will call us to tell us they need a bed but not put in the order. Once they arrive to the unit, they want to look at us crazy because we can’t start carrying out their orders and draw admission labs. It is now to the point that if the admission order isn’t in then we just don’t take report. Why? Why do we have to go through this!

I also do not enjoy the micromanaging. There is a list that charge nurses have to carry out each night. I have to check and see if everyone’s admission database is done, whether each patient has an up to date blood band, whether each patient has ICU and blood consent, whether each patient with restraints has an up to date restraint order, and whether or not each patient has a daily weight. Because heaven forbid we hold nurses accountable for their patients! I understand some of the list. I know when I have patients I rarely check the admission database. There are typically too many other things taking place for me to worry about that at 0034 in the morning. Consents though? As the nurse, I should be checking those. I feel like it’s micromanaging. More importantly, how are nurses going to form the habit of checking for consents and active blood bands if I am always doing it for them? It is my least favorite thing to do and everyone knows it.

Overall, I am still glad that I decided to become a charge nurse. I have a greater understanding of why assignments are the way they are sometimes. I understand how difficult it is to decide who is getting the next admission. I understand the frustration involved with moving patients out just to make room to get patients in. I realize now that the reason I am just learning of the admit I am getting, because ER is on the phone to give me report, is because the charge nurse is just learning of the admission as well. Things that I used to take as a personal strike against me no longer bother me. I realize the charge nurse doesn’t have the time to spiteful. It’s too damn busy for all of that. Being in charge has given me a whole new perspective.

Gory Glory

I’ll admit it, I like the gory stuff that nursing involves. We recently had a crush injury admitted to our unit and when they took down the bandage I was all up in there! I wasn’t the only one. My coworkers were all up in it too.

The gory things never really bothered me. I have always been great at doing wound care. The bad wounds were the ones I really got into. I think that is why I really wanted to get into a trauma ICU at a true trauma center. I wanted to play in that fun stuff. Blood is just a part of the job. If there is blood coming out of the body I just need to replace. I can do that. Foot falling off? No problem. Blood spurting everywhere? Let me apply some pressure. Ribs cracking while I do chest compressions? Well, that just means I am doing a good job.

And then there’s mucus…

I HATE MUCUS. Nothing turns my stomach like the sound of a trach that needs to be suctioned. I don’t know why it bothers me so much. But that’s not the worst of it. When there are mucus bubbles popping up around the trach… Grossed_out

Before I go into suction I definitely have to take a moment to get myself together.

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Helpful hint

So you’ve put in an naso/oro- gastric tube. Great! Did you verify placement? If so, how? Did you immediately get gastric contents back when you aspirated? Did you listen and confirm placement in the stomach? Did you use the CO2 detector that some institutions have?

I ask because I ran into a situation in which an OG tube was placed in the ER before my patient was sent to me. Helpful. Thanks. Except it wasn’t helpful at all. My new admission’s abdomen was quite distended despite the OG tube. I connected the tube to wall suction and got nothing out. I changed the canister and tubing just to make sure it wasn’t something wrong on that end. Nothing. I listened and couldn’t quite say with 100% certainty that I heard it in the stomach. Hmm… Not sure I want to use this…

And then he vomited. A lot. And kept vomiting while I held the yankauer in his mouth to keep him from aspirating.

Nope, that OG wasn’t in.

So, I took it out and decided to try my luck at placing an NG instead of an OG. As soon as the tube hit 60 cm in depth contents start pouring out. No need to auscultate that! Hooked it to suction and in about five minutes I got a full liter of contents out of him. Oh look, his abdomen isn’t as distended now…

I say all of that to say this: verify placement! However you choose to do so, make sure you KNOW that the NG or OG is in the stomach and not curled up in the back of the throat. Have someone verify it behind you if you aren’t sure. If all else fails, take it out. I would rather you send me a patient without a tube than send me a patient with a misplaced tube.

Forever alone

Sometimes I feel “forever alone” when I am around non-nursing people. As a nurse I get to be a part of something amazing. I’ll always be proud I am a nurse. I don’t feel like my profession makes me better than anyone else. I do feel like my profession changed me.

I have seen death first hand.

I have had to hold back tears while a family kisses their 16 year old goodbye. I have watched a person suffer in the ICU because the family guilted them into remainding a full code, and endure multiple surgeries that ultimately wouldn’t fix anything, until they finally passed away in that bed. I have watched families lose hope as the transplanted organ fails. I have had to comfort patients after a devastating diagnosis.

I have had my ass handed to me at work.

I have worked 12 straight hours without being able to eat or even stop to pee. I have dealt with physical and emotional abuse at the hands of patients and their loved ones. I have been talked down to by medical professionals that feel they are above me thanks to a difference in degrees.

I hold it all in when I’m with family and non nursing friends. When people say my job is “easy” since I work nights and everyone is asleep, I just laugh. When people are certain I’m “paid” because nurses make “so much money”, I just stare blankly. I listen to people complain about their jobs intently while they dismiss my complaints because I knew nursing was hard.

It can make you feel alone.

It’s not all family members and not all non-nursing friends but enough to make me not talk about my job unless I am talking to a select few. It’s why the nursing community is so INVALUABLE to me. We can swap stories about the worst of the worst. We can laugh about some seriously dark sh*t with no judgment! We understand each other. The nursing community keeps me from feeling “forever alone”. Sometimes we are all we’ve got 😁!

Good morning to you too 😒

Hi management, how are you? It’s nice to see you all bright eyed and bushy tailed. You’re coming off of a full nights sleep. You have quite a bit of energy huh? Sure you do. 

I don’t.

I just finished 12 hours of getting my ass handed to me. I’ve done two CT trips tonight. I got a sh*t show from the OR. I got yelled at by a doc for labs not sent from the previous shift. I finally ate this morning at 5 am and that was at the desk. 

You would know this if you came in and asked me how the night was instead of complaining about the cup at the desk without a lid. No, I haven’t read the email you sent because I haven’t had the time. Yes, the EKG machine is sitting outside a room. You know what else is outside that room? The code cart. It’s been that kind of night… But you wouldn’t know that because instead of inquiring about your staff you came in with complaints.

Maybe, just maybe you could say “good morning” first. Maybe you could take 10 extra seconds to get a feel for the unit and how the night was. Maybe you can look at what we accomplished instead of what we missed. Maybe you could manage to come in with a little positivity… Maybe….

Alarm fatigue 

I am legitimately over it. We have new GE monitors and they beep for EVERYTHING! Apnea is a triple beep but an arrhythmia isn’t. It doesn’t read the respiratory leads well so everyone is either tachypneic or breathing 6 breaths a minute.   There is something beeping every minute it seems. It’s getting to the point that we are starting to ignore the alarms because there are so many of them. 

This is what they mean when they refer to “alarm fatigue”

Story time no. 8

I decided to actually check my work mail box. Amongst the numerous papers that I’ve totally ignored I found lots of little shout outs and even a few gift cards from patients and coworkers.

I don’t think people realize just how much little things like this mean. It makes us feel appreciated. It makes me feel appreciated. It shows me that I’m doing something right…

Dear medical student…

Dear med student,

Hi. I’m the nurse that had been taking care of this patient for the last 12 hours. I am the nurse that charted every med given or not given over this shift. I’m the nurse that verified all those vital signs. I’m the nurse that put in that progress note last night. I drew the labs this morning. Yes, I know my patient.

You do not. That’s ok.

While I do not mind you asking me about my assessment, I will not do your assessment for you. You need to check the pupils. You need to check a neuro status. You need to check the lab results. You need to look over the vital signs. You need to look at the meds. You need to know this patient so that you can give your information during rounds.

Walk in. Introduce yourself to the patient and I, the nurse. Put on your gloves and get hands on. Ask questions, we don’t mind. We nurses understand that you are still trying to get your footing. We were there at one time as well.

Understand that ultimately, you still have to assess your patient yourself. Take these moments to build your communication and assessment skills. Each moment of patient contact is a potential moment for learning. Get all up in there!

DNR vs Comfort Care

I have heard DNR and comfort care used interchangeably, especially by doctors. One is not the other!

DNR: Do not resuscitate. It is exactly what it says, you do not try life-saving measures in the event of a code situation. This does not imply that you stop caring for a patient. DNR does not mean “do not treat”! You will continue to provide patient care. You will hang medications for their blood pressure if it is dangerously low. You will more than likely continue to draw labs as well. You will still treat this patient pretty much like any other unless the patient, or their medical POA (power of attorney), tells you otherwise. One thing you must be aware of is whether or not the patient has exceptions to their DNR. Some may say that in the event of a code they want code medications but no chest compressions or intubation. Some people may say meds and intubation are fine but no chest compressions. I have even seen meds and compressions but no intubation (which leaves you wondering but hey, it’s what they want.)

Comfort Care: This is what most people think a DNR is. Just keep them comfortable until they pass on their own. At this point, you are no longer going to escalate care. In fact, you will more than likely begin to scale back dramatically the amount of care you provide. Typically the only medications you will give will be pain medications like morphine and maybe a few breathing treatments to help ease their work of breathing. For the most part, you are there as support for the family if needed, and to assure that your patient dies with dignity.

Please, for the sake of your patient, understand the difference. If you need to clarify with the patient or POA then do so. You don’t want to wait until the patient is near death to try and figure out what the patient actually wants.