The Dog Ate My Care Plan…

Just a mom/wife/nursing student extraordinaire trying to make it in the big bad city…

Archive for June, 2010

DNR: Do-Not-Resuscitate or Disregard-Nana’s-Requests?

Posted by isntshelovlei on June 20, 2010

Yesterday when we arrived on the floor my patient coded. Actually she wasn’t my patient anymore, I’d had her the last clinical weekend. As she was not documented as a DNR/DNI in her chart, when she coded they of course brought her back. Her husband arrives, goes into her room, and began longingly stroking her (empty) bed…he had already begun to grieve as he thought she was gone. The staff finally did convey to him (there was a language barrier) that his wife was indeed alive and had been transferred to the ICU. Once he (and the family) saw her and the condition she was in, they-were-livid. Though she was breathing on her own, she was in otherwise poor condition. The family blamed the hospital/staff for “doing this to her.” Though the family clearly did not want her to be suffering like that, as far as her chart was concerned, she was a full code. Even though the family would have wanted them to have let her go, they never put that in writing. Interestingly enough, advance directives are supposed to be part of the standard admission process (at least at this facility), so I wonder if the language barrier also came into play (and by the way, where the hell are the “language lines” and interpreters?!?).

Sidenote: I’ve noticed that the code status is often listed in the chart as “Unable to Ascertain.” What exactly does that mean? That you couldn’t understand the patient? Or that you didn’t ask? Now while that explanation might fly with my elderly patient who only spoke Korean (though again where are the supports for our non-English-speaking patients?), or even in an emergency admission, why that same explanation was also in the chart of my 20-year-old patient who walked into the hospital in for an elective surgery—with her mother in tow—is just beyond my comprehension.

In any event, this whole situation is a glaring example of why it is so important to have living wills/advance directives “just in case…” 

Or is it?

This incident, of course stemmed a full discussion about DNR/DNIs, living wills, advance directives, and the like. According to our clinical instructor, even if I have signed all of the proper paperwork stating that I do not want to be resuscitated/intubated/etc., once I am “out” and no longer able to advocate for myself, my family can just come in and overrule me (so-to-speak) and tell the hospital, “No, do everything you can to save her.” If that’s true, then what is the point of these documents??? The way I see it, when I’m “out” is when I actually NEED the DNR to make my wishes known since I am unable to communicate them myself.  But if my documented wishes can just be overturned by my family (or health care surrogate, etc.), someone please explain to me what is the point of formally documenting them? I thought the patient always has the right to refuse a treatment, a medication, or whatever, and I saw the DNR order as a way for a patient to execute that right to refuse even when they are unable to express it themselves.

These types of situations usually bring up talk of the Terri Schiavo case. Mom and Pop wanted this…Hubby wanted that. But what about what Terri wanted? After all it was her life, her body. Shouldn’t she get a say so? Unfortunately, Terri Schiavo did not have an advanced directive so we’ll never really know for sure what she truly would have wanted. I wonder had she documented her wishes, and did not want to be kept alive in that state, would the 15-year battle have still ensued between her parents and her husband? Or would her own wishes have been honored from the beginning?

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When In Doubt, Wear Gloves

Posted by isntshelovlei on June 19, 2010

Just when should you wear gloves? Usually the rule of thumb is to always wear gloves when there is a risk of coming into contact with blood, body fluids, or mucous membranes, and if either you or the patient has areas of broken skin.

So I had a patient this weekend—I nicknamed him Mr. Independent. He had a BKA (amongst a host of other things), and didn’t want anyone helping him do anything because he was damn well capable of doing it himself (a nice change from what one of my instructors describes as the patients with the “alligator arms”). So his primary nurse asked him to at least call one of us when he planned to transfer. He of course informed us (once more) that he had already been trained to transfer and had been doing so successfully (by himself) for over six months now. But he agreed to call. So when he did, I came in and of course I didn’t think that going from point A to point B would involve coming into contact with any body fluids. But one too swift move from Mr. Independent and all I saw was red. Blood running down his arm..in the spokes of his wheelchair…on the floor. He had pulled out his frickin’ IV. I silently panicked because I immediately thought “I’m not wearing gloves!!” but I kept it pretty calm, cool, and collected on the outside. I think I automatically switched into Mom-mode. I remember once my daughter decided to jump off the top bunk bed and my son screaming “MOOOOOOMMMM! She’s BLEEEE-DING!!!!” So I’ve seen my fair share of bumps, bruises, and blood. I calmly told Mr. Independent, “I need you to STAY right there and I will be right back.” I knew gloves were right outside the room, so I popped out, grabbed a pair, just so happened to spot his nurse in the hall, waved her in, and popped back in (now gloved) to put pressure on his IV site all in about 15 seconds. Move over Carl Lewis…

So while I don’t plan to wear gloves 24/7 when I’m in the hospital, I now definitely keep a pair in my pocket—along with all of those other what-every-nurse-should-carry-in-their-pockets items…like alcohol pads!

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There Are No Words…

Posted by isntshelovlei on June 6, 2010

*RANT ALERT*

I’m sorry but I had to do it. Nothing pisses me off bothers me more than so-called health care “professionals” leaving patients to lay in their own piss and shit urine and feces. I came in today and one of my patients was literally laying in just that—liquid shit feces at that. I’ll give them that she was admitted to the unit sometime during the night. But you cannot tell me that no one noticed the odor that was not only limited to the patient’s room, but was now starting to creep down the hallway. Just how many people had been in and out of that room in the last few hours and just left her that way?—the night shift RN, the day shift RN, the PCAs (don’t even get me started on them), the phlebotomist (who we all know is notorious for waking up the patients at the ass crack of dawn to draw blood)… So don’t tell me that no one noticed this poor woman laying there, writhing in a sea of body fluids. I felt absolutely horrible for her. To make matters worse, she didn’t speak  any English, only Korean. AND HER CALL BELL WAS ACROSS THE ROOM!! How the hell was she supposed to call for help?—especially since she was neatly tucked in a far corner away from the nursing station. She was using the only method of communicating she had available—moaning—and still people continued to walk on by.

So I grabbed one of my fellow Supa Dupa SN’s and we went to work on getting her cleaned up. I should’ve grabbed one of the lazy ass PCAs (who see nursing students and believe that we’re here solely to do all of their work), but I wanted it done right—and without the attitude. Just yesterday, one of the PCAs came into a patient’s room to change his linens but he was on the phone. He asked her if she could wait a few minutes until he finished his call. Her response was: “Okay, but I ain’t guaranteeing that I’m coming back!” Now what type of shit is that to say to a patient?!? These people are sick. They have end-stage kidney and liver disease, multiple transplant rejections, terminal cancer… The least you can do is keep them clean and comfortable. It’s not like you’re doing anything since I’M doing YOUR vitals, YOUR accu-cheks, YOUR a.m. care, and whatever else needs to be done while YOUR ass is hiding in the clean linen closet on your cell phone.

But that’s a story for another day.

So we got my patient cleaned up, put a fresh gown on her, and changed her linens. We talked soothingly (and apologetically) to her as we worked, even though we knew she wasn’t able to understand what we were saying. I just hoped that maybe our tone of voice, facial expressions, something, would convey to her that we cared. Guess it’s just the NURSE in me…

What are you supposed to do in these types of situations? I know this happens often enough—but it shouldn’t. The majority of students (and clinical instructors as well) are scared hesitant to make waves since we’re technically “guests” at these hospitals. But shouldn’t ensuring a certain standard of patient care supercede all of the damn politics? Am I being oversensitive/overreacting? 

What if it was YOUR mother/father/loved one?

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Eye of the Tiger

Posted by isntshelovlei on June 4, 2010

I know. I’ve totally neglected my blogging duties. Sorry but LIFE happens sometimes. Family drama, stuff with the kids, job gets crazy…and then you add nursing school on top of all of that. A lot of people ask me how I do it. How do I work full-time, have three children (four if you count my husband), go to nursing school, get A’s, volunteer in a NICU (among other places) and not 302 myself?!? Honestly, I can’t answer that question. I don’t know. It is what it is and I gotta do what I gotta do.

But trust and believe, nursing school will definitely weed out the shoulda-coulda-woulda’s. If you’re not here because you truly want to be, you’re probably not going to make it. If you think nursing school is “easy” because “it’s not like it’s med school or something,” prepare for a very rude awakening. I’ll try not to laugh when you run screaming from the building as if your hair was on fire. People who are in it for the so-called bottomless pit of job security—do not even get me started. If you’re lazy, unmotivated, or just have tail-between-your-legs tendencies you are eventually going to tap out. If you can’t take the heat, nursing school is definitely one kitchen you want to stay out of. Nursing school is NO JOKE. Add kids, jobs, and LIFE to that—and you’d better be prepared for some blood, sweat, and tears.

But it CAN be done.

I don’t sleep much—maybe 5-6 hours a night tops. I know that’s bad. But hey, once I’m a nurse I won’t be able to pee that often either—maybe qshift—if that. Sacrifices. Such is life. I’m always eating on the go so I make sure I have a stash of stuff like Special K bars and Garden Salsa SunChips (loving those right now) in my bag to keep me away from the fast food drive thrus. I’m a Starbucks addict—though now that I’m taking pharm I know that it’s probably more like psychologically dependent. I have to be very organized—keeping track of my schedule, the kids’ schedules, lectures, clinicals, due dates, and scheduling study time is a lot of work. I live in a world of post-it notes and color-coded everything. But above all, I try not to forget to take a little time out for myself and for my family. My son commented one day that it seemed like he hadn’t seen me for 3 days. I do get in late after those painfully long lectures; and I do creep out of the house at the crack of dawn to go to clinicals—so his words did have a ring of truth to them. We are all making sacrifices. So everytime I start to retreat under my little alienated rock I think of this little story which helps bring things back into perspective. It’s weird, but I miss my kids/husband/family even though they’re right there. The nursing school grind will sometimes make you feel like a visitor in your own home. But everyone keeps telling me—”It’ll all be worth it.” Gawd, I hope so!!

So I’m going through a rough patch right now, but I’ll be okay. “Pain is temporary. It may last a minute, or an hour, or a day, or a year, but eventually it will subside and something else will take its place. If I quit, however, it lasts forever.” ~ Lance Armstrong

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