Things I've seen
The patient is on bedrest. The theme is to keep the groin area immobile and straight, and don't increase interabdominal pressure (that is, don't pull up with the abdominal muscles). Once there was a resident who told the patient to lean forward so she can listen to the patient's lungs. The patient thought that she shouldn't do it, but naturally, she obeyed the resident. Surely the resident knew what she was doing, right?
Ak! No!
Fortunately for this patient, she did not rebleed. Stupid resident.
I've seen people decide they need to roll over on their sides and curl up for a nap. No.
I've seen people in tobacco and alcohol withdrawal who can't lie still. Earlier in the day they swear it's not a problem, and they won't need a nicotine patch. Yeah.
No one likes to use a urinal or bedpan, but there's no getting up to the bathroom while on bedrest. I've seen a few patients rebleed after trying to use the urinal (men). They don't ask for help, and then raise up their heads to see what their doing, and pop! Hey, nurse? There's blood on my hands. (yeh, and everywhere else.)
The women aren't so bad, but they can't attempt to use the bedpan by themselves. We place them on the bedpan. Sometimes they pee all over the bed. This doesn't really bother me, though, because using a bedpan is hard and sometimes it's not positioned well, and women have lots of flesh in the way.
I try really hard not to embarrass people about this issue. It *IS* embarrassing, and we force these folks to be in a situation where they cannot take care of themselves. I just wish people would ask for assistance rather than try, if they aren't sure. I don't want to force myself on them, either.
It does bother me a little when a patient has to poop during bedrest.
The Easy Afternoon
On an easy afternoon, I can finish up my paper work. If that's all done, then I can goof off some, like check my home email, surf the net, do ancillary tasks like chart audits, peer reviews, restock supplies, etc. I cannot count on this time being available though; as a result, more often than not, I don't have any paperwork to do - I rushed through it earlier! I really wish I could partition my work out throughout the day so that I can do a quality job and not feel so hurried. It's unwise to do so, - getting the paperwork done, even if it's hurried and sloppy is better than not getting it done at all.
The late afternoon is when the early cases get off bedrest. Some people go home. In this case we complete their discharge paperwork, discharge teaching, and send them on their way.
Wait. Did you reach the logical conclusion? Some people come in and leave in the same day. We've done an entire admission and discharge on these people. This is why I use the term "shitload" for the amount of paperwork. I have created an entire chart full of paper for them. Some people come and go in as short as 3-4 hours!!!!!! That's one reason why you can't put off your paperwork. By the time you realize the patient is going done, you should have had it all done already.
The other reason you can't put off paperwork is that an easy afternoon can turn into a difficult afternoon without any notice.
The Difficult Afternoon
An afternoon is difficult when the labs are working late into the afternoon and/or everyone, it seems, gets complications. Other factors include: lots of patients, high-maintenance patients or family members, and a number of patients getting changed to inpatient status and moved off the unit.
We also have fewer staff in the afternoon - several nurses and cardio techs do not work the 12 hour shifts and leave at 1630. Sometimes we get stuck waiting on only one cardio tech who remains through the end of shift to do sheath pulls because they pile up and back up. It sucks for the cardio tech because they go from holding pressure for 20 minutes straight to another, to another. It's physically difficult.
Sometimes management pressures us to get patients off the unit before shift change - usually it's a staffing issue. A patient has been changed to inpatient status, and we need to move them to an inpatient unit, because we don't have enough nurses on night shift to allow that patient to stay in our unit.
When I am this rushed, I am most vulnerable to errors. Thanks to my guardian angel, I have not made many errors, and those I have made have not been dangerous for the patients. I have just pissed off my team members.
Example
On one recent afternoon, I was trying to get a patient's sheath pulled and moved upstairs before night shift. The patient had an ACT of 186 when he returned, and 2 hours had passed waiting for a cardiotech to do the sheath pull. It looks like the stars were aligning to have this all happen; the cardiotech became available, and if we starte right away, I'd be able to do the sheath pull, give 1 hour recovery, then get him upstairs. Bam, we started the line pull. I had not rechecked the ACT before we pulled because on average, a patient goes down 50 seconds every hour after the stop of the blood thinner. This means that even if the patient had terrible kidney function (which he did not) he should have been within range.
So when the 20 minutes of pressure was done, the patient was still bleeding!!!! Why? This made no sense???!!!
Well, it turns out, the patient's ACT was over 300 upon return to the unit. I was given an erroneous report. Due to other stuff that happened that afternoon, I had received report second hand, and somewhere between the cath lab nurse and the nurse that took report and me, the number had changed.
The patient was not harmed, but we had to hold about 30 minutes of pressure. It slowed everyone down. I felt bad...usually I'm very conservative with having numbers to back up my clinical decisions.
Indeed, I was rushing. I learned from this experience.
Shift Change
At shift change we give report to the night nurse. Hopefully all of the paperwork has been done for the patient staying over night. In most cases it is. I hate leaving a "mess" for the night nurse.
Mostly our team is pretty good about messes. They usually know that if the paperwork isn't completely done, then there is a good reason for it (because in the vast majority of instances, the paperwork is done to completion!). Every once in a while someone has an attitude about it. I hate that, but I get the hell over it.
Our night shift nurses are good. They come in on time, get report, and take right over. No one has called me after shift to ask questions. (That happened once on my previous job - that stressed me out all night.)
Going Home
When I have given all of my reports, I pick up my stuff from my work station (if any) and log off the computer. I take off my Vocera, check for medications in my pockets, and leave the unit. First I go to the breakroom to pick up my lunch bag, sections of the paper I would like to keep, or any other things I'd stashed in my mailbox cubby. I clock out, then go in the locker room to un-gear for the the day. I empty my pockets. I hope I don't find any medications in my pockets becuase then I have to go back on the unit and return them. Don't want to be walking off the unit with a pocket full of Valium or Morphine! That's a quick way to get fired.
I bundle up if it's cold out (like yesterday - sheesh, 32 degrees!!!) and walk to the car. It takes about 7 minutes. Then drive home. I listen to NPR on the ride home. Usually I'm hear the last half of "The World." That's fun - I get to hear the "Geo-Quiz." Mostly I'm driving home between 1920-2000. Sometimes earlier, sometimes later.
At Home
When I come home, I want to be cared for. I want my dinner ready (or in the works) and I want to sit. I usually don't get this luxury. Sometimes I do, and I love it when it happens.
I go upstairs and change clothes. If I was mindful at work and drank my water, I usually have to pee (this is important, because I just don't drink when I'm working and that's not healthy). If I'm motivated, I'll wash my face for bed and take off my eye makeup before coming back downstairs. Then I eat. On the days I work, my husband is responsible for making meals, and about 90% of the time a meal is in the near future. My husband is not the most inspired cook. On a good day, I get hamburger helper, chicken helper, or a Zatarains mix. On an average day, I get spaghetti with sauce, sometimes with a can of mushrooms mixed in or some ground burger (fake beef) mixed in. Sometimes it's leftovers. I almost never get vegetables or sides with these dishes (such things are unnecessary, I suppose).
I don't complain about the food. After 10 years of marriage I have learned that this kind of griping is pointless.
However, I still hope. It feels so nice to come home to a fresh meal. Occasionally I am surprised! Occasionally there is the thrill of fresh take-out!
Dinner and After
We eat dinner sitting at either end of the sofa watching Tivo of all the shows he likes. I enjoy them too, but I can live without them. Apparently, my sitting next to him quietly is very nurturing to him. If I want to talk, or if I want to sit at the kitchen table, he seems out of sorts.
We watch Jeopardy, The Daily Show (up until the writers strike), Grey's Anatomy, Pushing Daisies, Private Practice, Heroes (ooh, we actually watch THAT one live...), Reaper, Torchwood, or Graham Norton.
I ask him how his day is, and he says, "Not bad," or "I had a day." What did you do today? "Work." Anything interesting? "No." Oh.
He may ask how my day was. I'll say "Excellent." This is because if I say anything negative about my day, in his mind, I don't like my job and I'll be looking for another soon. This is not true: in fact, I like my job very much (see more about this in the next post). But, like many men, situations are either black or white. So, I'll whitewash to avoid accusations. I try not to talk too much about my day, either. Most of my issues are either mundane or disgusting. There are HIPAA issues to be considered. Or I get sucked into complaining about something....danger, danger!
...now you know why I am writing this series.
I tend to eat too much when I get off work. I am hungry, since I don't get a dinner break at work (I get a lunch break most days). But I crave the comforting feelings I get from food after a hard day. Since dinner isn't ready when I get home, I eat something that is easily grabbable and keep on eating until dinner. This is not good.
I try to do a few chores before bed, and often I'll work a few rows on a knitting project. I give attention to the pets. If I'm lucky, I'll remember to empty out my lunch bag from the workday (to get it ready for tomorrow), and I'll remember to plug in my cell phone. Sometimes, if the day was really busy, I curl up on the couch and doze off.
At 2130, I'm off to bed.
Coming next time: The workday: An Editorial.
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