Waterpark capital of the WORLD …

Here in Middle America, we get hammered by Momma Nature pretty regularly. Tornadoes, earthquakes, 101.1″ of snow, months of rain, years of drought, straight-line winds; we take it all in stride. Two weeks ago we went on our annual Mother’s Day camping and fishing trip – and had to hole up in the truck when it started to snow, sleet, and hail. Two weeks later and it’s only 49° here Saturday morning of Memorial Day weekend. Whatever the weather, we cope – that’s what we do – we’re Cheese Heads.

But weather can do weird things to peoples’ heads. A few years ago (the year of the 101.1″ snow, I believe) our local tourist destination – Wisconsin Dells, the Waterpark Capital of the World – had its season basically wiped out. Lake Delton, the 267-acre centerpiece, decided to go walkabout. One spring storm too many and the half-billion gallons of water within its boundaries breached a county highway and headed south. The lake was gone, and with it thousands of jobs and several hundred million tourist dollars. The lake bed was mud, the fish were flopping, and the locals were dealing. Well, some of them were dealing – and at least a few had lost their minds.

Guess what you shouldn’t do on a semi-dry lake bed? Jet ski. Yep, Good ol’ Jakey (a 19-yo male who came to be known affectionately as the Lake Delton Dunderhead on the Orthopedic Surgery unit) decided it would be fun to “mud ski” on the Lake Formerly Known as Delton. Found a “puddle.” Dragged his jet ski into it. Hit the gas. Hit a rock. Hit his head. Hit the OR about noon that same day. Hit Ortho about 1800 that night. His turned out to be a long summer in a body cast.

No nurse, nowhere, no how, has ever said, “I thought I’d seen it all,” and meant it.

We’ll make a fortune …

I’m bending down to retie the shoe of one of my residents after breakfast. As I do so, she starts stroking my hair.

“Nurse Dux, you have such beautiful hair!”

“Thanks, Ella, that’s nice of you to say so.”

“It’s so soft … it’s very shiny … Oh! … We could sell it!”

o.O

Pissant …

SOB 22-yo male patient is on Facebook bragging about manipulating the nurses on the unit into giving him drugs. “I’m so fucking good at making them think I’m in pain.” He threw his toast at a CNA this morning because it, “Wasn’t fit to feed a fucking dog.”

He leaves his phone on and logged in to Facebook when he goes to sleep at night …

Speaking of allergies …

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As I reviewed the PMH of a new admit to my facility, I saw that her MAR listed allergies to penicillin, sulfasalazine, and epinephrine. Epinephrine? Really? Yes, that is what it said – and for the epi (aka adrenalin), the sign/symptom of her allergic reaction was listed as “tachycardia.”

She should hope so! And I hope that she doesn’t code — “I’m so sorry, we couldn’t save your daughter when she went into cardiac arrest. Her chart said that she was allergic to epinephrine, and we didn’t want to take the chance she would have a reaction to it if we gave it to her. Please accept our condolences.”

I get this all the time. “I’m allergic to Tylenol – it upsets my stomach.” “I can’t take vitamins – I’m allergic to them and they make me constipated.” “I’m allergic to hydrocodone, it makes me throw up.” Why is it that people aren’t educated by their doctors that a side effect is not the same as an allergy. Your tummy gets upset? Deal. Antibiotics give you diarrhea? This too shall pass. You have my sympathy – some side effects can be wicked uncomfortable – but that doesn’t mean you are allergic to that medication, dumbass. Any doctor or other PCP who includes an item in a patient’s allergy list that isn’t something that person is actually allergic to is doing their patient a disservice. They are potentially denying them pain control, comfort, and therapeutic options during times when they may need them most.

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Probed by aliens …

I had arrived early for my day shift to cover the emergency exit of another RN. One of my assigned patients was Dotty, a late PM shift admit, a 93-yo who fell at her home in a retirement community and broke her hip. She was scheduled for the OR sometime that day, but even unfixed she wasn’t in too much discomfort. I had looked over her PMH and saw that she was a relatively healthy woman for her age, was somewhat HOH, and was only beginning to exhibit some very mild cognitive deficits.

I was in her room about 0545 quietly changing an IV bag before she awoke, when the door opened and three medical residents came in. One of them greeted her by her first name, asked how she was doing (“I’m FINE!”), and then proceeded to tell her that they would be sending her for an MRI and a bone scan, running a CBC, a Chem-10, and some other labs, and making a decision as to what surgery she would need before scheduling her for a possible THA or IM-nailing sometime during the day. They told her that she would be held NPO but that Nurse Dux would make sure she was comfortable while she waited.

The resident (a 5th year) asked her if she had any questions (“I’m FINE!”), then said he’d see her later after surgery and they all exited. All I could see of her as they left was a pair of enormous eyeballs peeking over the blanket. Since she was now wide awake, I asked her how she was feeling and told her I would be taking her vitals. I was completely startled by her next comment.

“Did you see them too?”

“The residents? Yes, Dotty, I was right here next to you.”

“No, the ALIENS! They were right here in this room! Did you see them?”

Needless to say, I was startled. Believing I might be witnessing hallucinations and the onset of delirium, I asked her, “Dotty, are you telling me you you’re seeing things?”

She looked right at me. “You must have seen them! There were three of them. They were really tall, really green, and they were speaking some space language I couldn’t understand. Will they be back? You won’t let them probe me, will you?”

Resisting the urge to laugh out loud, I just smiled, and sat down at Dotty’s bedside. I held her hand while I explained what had just happened. The “tall green aliens” were three of our Orthopedic residents on their morning rounds. All three are over six-feet tall, and they were dressed in green surgical scrubs and hats. When they came into the room they didn’t turn on the light because the hall light illuminated her just fine—but left them backlit at the doorway. Scott, the 5th year BMOC, didn’t introduce himself or the others, and peppered her with rapid doc-speak – which she couldn’t understand at all.

They got no usable information from her, conveyed no understandable information to her, and had no idea that they had just frightened the bejesus out of this sweet elderly lady. They could have done many things differently – turning on the lights, introducing themselves, sitting down, making sure she had her hearing aids in and her glasses on, making sure she was awake and not in pain, and so on. But that’s not what medical residents are taught to do by attendings, and it would be years before they learned it on their own (the odds of them ever asking for guidance from an RN? slim to none …).

Dotty did settle down as I talked with her, but I sure didn’t fault her for her interpretation of the morning’s events. The pictures of those residents on the unit bulletin board now sport antenna and space helmets courtesy of this RN. I’ve been told that one of them thinks it’s disrespectful. Warms my cockles, it does.

Get me the alligator gun …

I’m in need of a bigger alligator gun. I am up to my ass in them, and they think they’re winning.

I’m providing nursing care for 42 residents in a two-building, 60-bed facility. They are all here because they failed placements at other facilities for behavioural reasons. Lots of LTC facilities have “memory units,” and take demented old Granny as long as she can pay. But as soon as she starts screaming at the wallpaper, eating off of everyone’s plate but hers, delivering poop presents to staff, peeing in the fireplace, and getting naked before arts and crafts, they send her packing.

That’s where a facility like this comes in. It’s set up to safely house and care for the soon-to-be-homeless schizo seniors, the demented dodderers, the hitters, the kickers, the spitters, and the screamers. The youngest residents are in their 40s, the oldest in their 90s. Some have as many as 12 failed placements before they end up in a facility like this.

I spent the day wheedling med orders out of distant docs. I was polite when I told one doc that her wound care order was [barbaric] and 50 years behind the times. I shoveled one resident into a cab three times, only to have her exit out the other side three times. I finally had to send for a cab with lockable doors. My staff is uneducated, and although some have potential, some need to find other jobs. I have conversations that involve invisible refrigerators (it was in her stomach), “purple sixteens,” the people in the television [off] who tell them to not take their pills, poisoned food (the “twelve-inch people” do it), and missing hair. One resident called the police on me today when I wouldn’t get her a pregnancy test (“Polly, you’re 81 and you yell ‘whoop! whoop!’ every time you poop. I’m not thinking the guys around here are lining up outside your door at night to do the granny-hop with you”).

My first week in the new job as DON – 60+ hours – I spent defending the facility against a Statement of Deficiency from the state that ran 76 pages (it arrived Monday afternoon, my first day). Six IJs (immediate jeopardy tags), and 21 other nursing citations – the state closed one of their  buildings to new admissions. I had no idea that on my first day as DON I would go from the frying pan into the fire. I had to write a policy manual for the facility from scratch, and provide the nursing care for 42 psychiatric and advanced dementia patients (four of whom I discovered had pressure ulcers; there would be more).

At the end of two weeks, I was fried. The weekend came, and I tried to crawl inside a scotch bottle and hide. It didn’t work, Monday still found me.

Thinking sideways …

There needs to be some way of adding creativity to the standard nursing curriculum. Evidence-based practice, rubrics, exams, and case studies abound in nursing school at all levels, and sometimes the process becomes the point, and the end becomes obscured. I believe that creative thinking should (must!) be encouraged in Registered Nurses both before and after graduation.

Creativity can be not only practice-expanding, it can also be fun. It’s easy to be too earnest and too serious about what we do. Inserting creativity into the structure of the classroom may not be easy, however. I would dread being given an assignment that “required” me to “be creative,” because my preferred style and type of creativity may not be yours. I would fear being judged on how I approached the assignment, and would try to make sure what I produced matched the rubric of the assignment – self-defeating, eh?

I use humour to communicate, and I find that humour is often lacking in my fellow nurses and nursing instructors. I once gave a group of nursing students I was precepting on a med-surg unit an assignment – they were each to write a limerick over the weekend that focused on any important lesson they  learned the previous week.

You’d be surprised at how many things you can rhyme with “bedpan.”

I get the, “But I’m not a creative person!” from some of my students, and I have to tell these folks that learning to be creative is a real thing. For some it comes naturally, others have to work at it, but everyone can do it.

Part of the secret is to find an avenue of creativity that you enjoy. I have one friend who sews stuffed toys. They are whimsical, colorful, and she gives them away to her own students and friends. They often reflect personal events or interests of the person she gifts them to. Another friend makes her own greeting cards, painting blanks and filling them with serious or silly thoughts. Many recipients frame them or keep them on their desks. I write and cartoon, and often translate my daily life as a nurse into humourous commentary on my blog – or into goofy pictures on my patient’s walls.

The very act of being creative changes the way you look at and process life. You think differently and act differently when you have an outlet for expressing yourself creatively. You start to look at the world not as a succession of problems and tasks, but as a collection of jumping-off points for creative expression. As with any other learning experience, your brain rewires itself, and then it learns to use these new neural pathways to solve old problems. New pathways that can be used to creatively move from Problem A to Solution B – pathways that might not have existed if you had never drawn that first cartoon on the whiteboard or written that first limerick – are the key reason reason to nurture your own and others’ creativity.

Think sideways.

Theory and Philosophy of Nursing …

My own philosophy of nursing is evolving, and the process of identifying, expanding on, and encoding its elements has been an important part of my development as a professional Registered Nurse. I have observed patterns during my years of practice that repeat in predictable ways – repeat not because of the inter-connectedness of ephemeral energy fields, but because the human mind has evolved to act and interact with its environment in structured, recognizable ways. I recognize in myself some of these patterns of action/interaction, and introspection has been an important part of my nursing theory development. But humans do not exist apart from their environment, and just as medicine, nursing, and other health-scientists debate the roles of nature and nurture, so must a nursing theory take the effects of all into account.

Environment. Every human being is born into an environment. The environment can be defined as everything that surrounds and affects that human, from other humans to the inanimate rocks on her path. Each element in the person’s environment has an effect on that person, and the effects of the elements are determined by external (it’s cold) factors, internal (I can cope with cold) factors, and distance (it’s cold outside but I’m not there) factors.

Health. In my evolving understanding of the interactions of humans with their environments, I have been able to define and detect patterns of human health and existence that make me more proficient at providing nursing care to those who come to me for care. In my theorizing I have found that everything from human anxiety to Maslow’s hierarchy has a place.

Nursing practice. I am taking control of my vision of nursing, in part by formalizing my own theories of nursing, from the grand to the practical. I may never reach the end of my explorations, and will certainly never be satisfied with “what is” or “what was” as long as there is a “how come?” left. While the answer may indeed turn out to be 42, I still need to know why. The process is more important to me than the product, and by continuing to write, I believe that I will establish a solid foundation for my future professional practice.

Nursing Theory as Worldview: To Be Determined …

It is difficult for me to choose a single grand nursing theory to wrap my practice around. After years of studying nursing theory, both as part of required coursework and as ongoing intellectual entertainment, I have yet to find a Nursing Grand Theory that comes close to fitting my own worldview. I have read the works of many of the Grand Dames of nursing theory, and from most I have gleaned useful concepts, ideas, and philosophies that have informed (and improved) my nursing practice. But I do not feel entirely comfortable with any one theory to the extent that I can base my entire practice on it. No one theory yet holds the answers for me.

While exploring, reading, and discussing nursing theory with fellow nursing students in the past, and in the present with a collegial group of nursing friends who are admitted theory geeks, I have been encouraged to analyze, encode, and verbalize my own views. To me, nursing theory is neither static nor immutable. Nursing theories, my own included, change, develop, and evolve, becoming (with luck and work) more useful, practical, and elegant as time passes.

A very good friend of mine is a nurse practitioner, nursing scholar and an unabashed Rogerian, and she believes that at the core I am one as well. She and I discuss pattern recognition whenever we get together, and that remains one area where I do feel that I recognize the intent and usefulness of Martha Rogers’ theorizing. I am unable, however, to buy into her many of her theoretical constructs, such as pandimensionality, unitary energy fields, and therapeutic touch. I place my faith in what I can see and feel, and my feet are firmly planted in three dimensions. A fourth all-encompassing dimension in which humans interact as energy-beings is one I can’t rationalize, and therefore I am unable to integrate that Rogers concept into my practice. In addition, while many nurses today have become expert in the use of physical therapeutic touch as a means to bond with and help their patients heal, Martha Rogers’ “laying on of the hands” to repattern a patient’s energy fields without touching that patient’s body is just too much of a stretch for this skeptic.

To be continued …

Not all it’s cracked up to be …

Being the Director of Nursing for a psych facility is not the cush job it first appears to be.

• 0625. Arrived at the facility. Met at the door by two NOC staff with their updates, complaints, and emergencies.
• Five eloping patients tried to leave over 100 times during the day shift.
• Four resident assistants reprimanded for leaving door alarms unarmed.
• One computer meltdown finally fixed after four days with no connection.
• One dying patient in pain and with sinking O2 sats assessed and comforted. Hospice notified but tells me “We’re pretty busy today, can you handle it?”
• Two crisis family meetings.
• Four missing syringes of morphine.
• Nine calls to the VA and hospice to order more morphine.
• One meeting with a parole officer, one meeting with an angry parolee.
• Five calls to MDs to adjust meds.
• One resident transported emergently to the ER for chest pain.
• One solid beating of the DON (me) by an angry bipolar who wanted to leave the back yard. One pair of broken glasses.
• One new exterior gate latch purchased and installed by the DON to prevent further back yard escapes.
• One trip to Shopko for toilet paper, butt wipes, and gloves.
• One extremely unsavoury coccyx wound repacking on a screaming resident.
• One hemorrhoid tucking for a resident who’s spitting on me.
• One call from and collaboration with an ER doc.
• Nearly 400 meds found in a closet from 2010 logged in and destroyed.
• Over 110 HIPAA act label violations found in a mailbox and remedied.
• Two missing psychotropic med scrips tracked down and original orders refaxed to pharmacies.
• Two wound care packages ordered.
• Two staff fights refereed, the staff’s July schedule approved, and three more staff schedule disagreements handled.
• Another 150 pages of protected patient information shredded.
• 26 residents rounded on twice.
• Multiple hugs administered.
• Office chairs cleaned of resident urine twice.
• Cellphone located in resident’s shoe.

1855 heading for home. Day 19 in a row without a day off. My cellphone rings before I even leave the driveway.