Self-care and nursing

You are a nurse. Your job is to take care of everyone else. When do you take care of you? As nurses, we are so conditioned to take care of others that we may feel guilty focusing on ourselves. That’s not fair to you.

At some point, you run out of steam. If you keep giving and giving but receiving nothing in return, you will become empty. An empty nurse is a dangerous nurse. An empty nurse can barely take care of themselves much less anyone else.

An empty nurse lacks empathy. An empty nurse stops caring. An empty nurse has nothing left of themselves to give.

THIS IS WHY SELF-CARE IS SO IMPORTANT! You cannot take care of others if you aren’t taking care of yourself. You have to practice self-care. You need to take moments to do things that you like to do. Like to shop? There is a lovely flea market on Saturday, go check it out. Like to cook? Well, whip it up chef! Like to sleep? You enjoy that nap like you’re still in kindergarten. Do whatever it is that makes you happy. You have to. You are just as important as anyone else. Your sanity matters. Imagine how much better you will feel. Imagine how much happier you will be. Imagine how much energy you will have to be the best nurse you can be. You are worth the time.

giphy

 

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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.

The end isn’t always the end

I learned a lesson not too long ago. The end is not always the end. I got to see this first hand more than once.

A few months ago we had a trauma, pedestrian-vs-motor vehicle, that came to our unit with severe head trauma. The patient had a head bleed along with swelling. The CT scans did not look good. The MRI didn’t look any better. The patient and family were refugees from a war torn country, they spoke little English. The team began having “the talk” with his family. You know that talk, the one where they are pushing for the DNR because the patient is not expected to have any quality of life. Yeah, that talk.

The family would have none of it. We managed to stabilize the patient. They got the standard trach/peg combo. The doctors continued to speak with the family about the quality of life and the family continued to hold out hope. The patient ultimately managed to be transferred out of the hospital into a long term care facility. We were pretty much under the impression that they would just waste away in a nursing home, with no improvement in neuro status.

The patient came back to visit us, along with the family. The patient still has noticeable deficits but was able to fully communicate and even thanked us for our care. We had given up but they didn’t.

dont give up

More recently, our unit had a very sick vascular patient that coded during their surgery. The OR team got them back and immediately brought them to our unit (STICU). They coded again, the second code was worked for an extended period of time and then the team called it. They died. And then they decided death wasn’t really for them and their heart started beating again… spontaneously… after the code was called… while the team were having a moment of silence for the patient.

The medical team spoke with the family and let them know that even though the heart is beating, the patient has been “down” for an extended period of time and neurologically there is probably nothing there. The family decides it’s in the patient’s best interest to make the patient a DNR. The family begins saying their goodbyes and leave in expectation that the patient would probably code again within the next few days. Everyone is pretty much preparing for this patient’s end of life…

gointothelight

Except the patient…

That night, they opened their eyes to painful stimuli. Then it turned into opening eyes to name but no purposeful movement by the next day. By the third day or so they just woke the fuck up and tried to self extubate! All of us were pretty much like:

heart attack

They were completely alert, oriented, and by the end of the shift able to write questions on a piece of paper. Needless to say we were all kinds of confused, surprised, and impressed. We ended up nicknaming the patient “Lazarus”. Are we going to Hell? Yes. We are all well aware. I have a time share there.

The patient had a rough course. They were intubated, extubated, and reintubated multiple times before finally being trached and pegged. However, as I am typing this they are alive and are being prepped for long term acute care out on the floor. That’s right, the patient that we basically pronounced dead is instead going to LTACH soon.

These moments have taught me that it is not over until the patient decides it’s over. It has also taught me that maybe I shouldn’t give up so easily. My miracle patients are showing me there are still some things that we in medicine don’t understand. We don’t know it all. I am glad for that.