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patient

If I could only have half of the faith… angels in disguise

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50 y/o female with multiple myeloma and leukemia presents to the ER for a fever… a medical emergency in one receiving chemotherapy due to myelosuppression.

She has been in and out of hospitals to receive chemo and then be readmitted for the side effects of cancer.

I walk into the room and she is diffusing essential oils, she is riding around the hall and her room in her wheelchair, she is cracking jokes, she is laughing, and has the biggest smile on her face, and she asks about everyone’s personal lives when they walk into the room. I have never met someone with as much hope, faith, joy, and someone who as closely resembles Jesus as this precious woman.

She told me that Jesus will put angels in your path and I was one of hers. I can say that Jesus put her as my angel during my past three, challenging shifts.

Covid has brought a much higher acuity census to the caseload and this week has been stressful, challenging, and draining.

Her joy and optimism brought the just needed light into my week. I fortunately was able to sit with her for quite some time as I administered blood transfusions.

The highlight of my entire nursing career thus far was when she asked to go to the main lobby to play the grand piano. I was able to wheel her down in her wheelchair with her IV pole, mask, and lots of hand sanitizer to go sit and play her joyful noise. I couldn’t help but become teary eyed.

Even through everything that she was facing, she continued to minister to others and bring such joy into their lives. If I have half of the faith of this Godly woman, I will be okay.

It is a reminder that even on the toughest days; take a deep breath and trust that God has your back.

Until next shift,

Shania

What is Magnet?

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According to the American Nurses Credentialing Center, there are currently 523 hospitals out of 6,146 hospitals in the USA that have achieved Magnet recognition.

The ANCC originally developed the Magnet Recognition Program after noticing a nursing shortage and the need to obtain and retain nurses. Magnet status is the highest of honors for a healthcare facility, however only 8.5% of US hospitals have achieved this status.

The ANCC developed “14 Forces of Magnetism” and later the “5 Magnet Components” that each Magnet hospital must represent:

  1. Transformational leadership- nurses leading nurses in guiding the organization where it needs to go, not just where it wants to go.
  2. Structural Empowerment- Nurses creating an environment conducive to the mission, vision, and values of the organization.
  3. Exemplary Professional Practice- Nurses working interprofessionally to practice the highest quality of care.
  4. New Knowledge, Innovations, and Improvements- Nurses having an attitude of continuous learning and research.
  5. Empirical Outcomes- Structures are in place to ensure the best outcomes; nurses can view the difference their work has made.

Magnet hospitals are shown to have greater patient and employee satisfaction, a higher quality of care, higher retention rates, higher salaries, and the optimal professionalism.

The “Pathway to Excellence” typically takes about 7-10 years and is validating with a site visit.

https://www.nursingworld.org/organizational-programs/magnet/application-process/

Until next shift,

Shania

Things nursing school does not teach you

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Even after the 2-4 years of intense studying that is required to become a registered nurse, it takes about a year working full-time to feel comfortable in the new leadership position. There is anywhere between 6-12 weeks of orientation with an experienced preceptor, as well as facility-required courses and classes. Nursing school teaches the disease process and basic assessment techniques, but does not prepare the student for the actual nursing role. Below is a brief list of things nursing school does not teach…

  1. Nurses have autonomy. Nurses see the patients 12 hours/day while doctors view the patient for at most 30 minutes. Nurses are in charge of reporting assessment changes, communicating critical lab values, ordering interventions per nursing protocols, among many other things. Textbooks ensure a doctor’s order for everything, when in reality nurses often drive these orders.
  2. Nurses do not provide “total care.” In many clinical rotations that I have had, we were assigned one patient and required to complete the assessments, baths, vital signs, and administer all medications. These patient encounters were unrealistic compared with the actual routine of a bedside nurse. Yes, it is in the scope of practice to perform all of these things, however, there is not enough time in the shift to perform all of these interventions for all 5-6 patients. It is extremely important to delegate to nursing assistants and to assist them when able.
  3. The Davis Drug book is not your best friend. It is much easier and acceptable to use online drug resources such as Micromedex or Medscape. Many MARs actually have reference information for drug administration directly on the administration wizard.
  4. You will not chart in real time. It is okay to back-time assessments. It is impossible to chart as you complete nursing tasks while ensuring all patients are cared for in a timely manner.
  5. Over 50% of a shift is behind a computer. This was the biggest challenge for me when transitioning from a CNA to an RN. It is frustrating to have so little hands-on time with the patients, while spending a lot of time reviewing orders, charting, on the phone, etc.
  6. You do not always have to “call” the doctor. Many facilities have a direct messaging system to relay non-emergent information, rather than calling the doctor for every request.
  7. Find out what advancement opportunities a facility offers. Anything from tuition reimbursement, mentorship programs, and certification incentives…
  8. You have to be creative. This applies to many things such as finding new ways to use nursing supplies, working with only two hands, convincing the confused patient to stay in the bed, or communicating effectively with difficult families. One of the funnier moments of creativity was one a nurse used a syringe of normal saline to stop a “seizure” a patient was apparently having. She said this injection of “Normasaline” will stop the seizure, and miraculously it worked!
  9. The burden of health care is real. Every shift, there will be a patient who is medically cleared for discharge, however is waiting on insurance approval to go to rehab or a skilled nursing facility. A patient is noncompliant with medications because they cannot afford them.
  10. Use free time wisely. Any extra time should be spent helping out other nurses, researching disease processes, updating report cards, or studying for continuing education. That extra study time will be appreciated during the busy shifts when you are trying to find enough time to pee.
  11. Having a patient leave AMA (against medical advice) is probably for your benefit. Don’t take it to heart.
  12. Even the best, most experienced nurse will get yelled at by a patient, family member, or doctor. It is okay.
  13. Always remain humble and ask questions.. just because you learned how to do something one way, does not mean that it is the best way.

Until next shift,

Shania

How to choose a great facility

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A variety of sources reveal that on average 1 in 5 nurses leave their first job within the first year of nursing. And some of these people leave nursing altogether. How do you know what facility is right for you? How do you know what facility is “good”? Below I reveal my top few green flags for a nursing facility (based on my own experience).

  1. Friendly work environment- Nurses helping nurses, interdisciplinary communication, etc.
  2. Open communication- Management will not hold any information from staff.. this can come in direct communication, emails, posters, etc. Also, have the ability to speak to leaders when a problem/idea arises
  3. Resources- Can you always find/have what you need to perform nursing duties?
  4. Culture of professional development/learning- Ask about tuition reimbursement, certifications, raises, committee involvement, etc.
  5. Benefits
  6. Ability to transfer specialties
  7. Ratios- Med-Surg averages 1 nurse to 5-6 patients
  8. High patient satisfaction ratings- Medicare.gov posts hospital survey statistics
  9. Nursing recognition- How do they represent/honor the so-called “heroes”? Nursing awards, posters, gifts, spotlights, etc.
  10. How do they prevent burnout?
  11. Scheduling- do you have any say? PTO? Overtime

Until next shift,

Shania

Sample Patients in Medical-Surgical Nursing

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**Identifying patient information has been altered to protect patient confidentiality

Patient 1: 68 y/o male with spinal stenosis and resulting functional paraplegia presents to the ER with abdominal dissension, nausea, vomiting, and diarrhea. Pt was found to have a small bowel obstruction. GI order NGT to low-intermittent wall suction (LIWS) for decompression. The patient also has a history of vascular dementia and delusional disorder. He frequently asks for food, water, and repeatedly states that nursing is starving him. Fortunately, pt eventually had several BMs and will get an abdominal X-ray to assess for small bowel obstruction resolve and hopefully NGT removal.

Patient 2: 75 y/o female is brought in with family c/o AMS. Lab work reveals a UTI and acute renal failure. Both BUN and Cr are critical and does not decrease for several days. CT abdomen reveals possible myeloma. Family does not yet know this and nursing must not reveal these results until oncology confirms.

Patient 3: 50 y/o male comes to the ER with abdominal distention, nausea, vomiting, constipation, and failed paracentesis outpatient. GI attempts EGD and colonoscopy, however pt unable to tolerate Golytely and/or enemas. Imaging reveals a colonic volvulus (twisting of the intestine)- a medical emergency. NGT placed for decompression, as patient continues to vomit. Surgery consulted brings pt for immediate colectomy with ostomy placement. Unfortunately was this patient’s h/o CKD and CHF, pt will likely be transferred to CCU post surgery. Family care during this surgery is crucial as they wait to hear how the pt recovers.

Patient 4: 30 y/o female comes to ER with c/o uncontrollable abdominal pain and ascites. Pain management is the main goal for nursing. Balancing IV pain medication for breakthrough with PO medication along with treating the side effects of nausea and pruritus is the challenge. **Patients with liver failure/cirrhosis are difficult cases as all lab work is often abnormal.. critically low H/H, elevated clotting factors, and elevated LFTs must be monitored.

Patient 5: 75 y/o male presents with abdominal pain, N/V/D. Pt is diagnosed with diverticulitis and will be treated with IVF, bowel rest (NPO), and finally diet advancement as pt tolerates.

**All of these cases are in a single shift. Some days are much easier than others and vice versa. Prioritization is key in these situations.. “Who will die first?” Remember the ABCs and include pain as top priorities. Leave charting for later, and keep all patients informed of rounding times, to limit call lights.

Med-Surg is also funny in the sense that you haven’t performed a nursing skill in a while or a certain skill increases anxiety, and the next shift you will have to perform it. This shift was that for me. I was always nervous around NGTs because they are easy to come out, some are hooked up to suction and others are not, placement must be checked frequently (ph), and patients are always anxious to pull them out. After this recent shift, I am comfortable with them!

Until next shift,

Shania

It’s called Chorea

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A man in his 70s with a history of diabetes mellitus and myasthenia gravis presents with severe, involuntary movements of both upper and lower extremities coupled with uncontrollable nausea, vomiting, and diarrhea. It looked like this man was having a never-ending grand-mal seizure while remaining conscious and not foaming from the mouth. He was brought into the ED after sustaining multiple falls while at home, and was treated with increased doses of Mestinon which caused the vomiting and diarrhea.. we tried to fix the movements, while causing fluid volume deficits.

Myasthenia gravis is a neuromuscular disorder that results in easy fatiguability of muscles, whereas this man was having excitability of all muscles. The neurologist coined these involuntary movements as chorea and attempted to treat with Olanzapine (antipsychotic), Keppra (antiseizure), and pyridostigmine/Mestinon (anti-myasthenia gravis) medications. The MD thought the chorea could potentially be caused by hyperglycemia (I have never heard of this as a cause), which was also a problem during this admission.

I do not know what the ultimate cause of the choreic movements was, but after sleep and medication therapy, the patient was discharged from the hospital with vastly reduced movements and was working with physical therapy the next day.

Until next shift,

Shania

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615-856-8181
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