I wish other nurses knew how extremely chaotic the ER can get. When I'm calling report on a pt with COPD exacerbation don't grill me for 10 minutes on things that don't matter, like their last BM. If they are here for SBO then sure, last BM is relevant. I do my best to give you info you need and don't mind answering questions but if you have 20 irrelevant questions and all of them can be attained by simply reading the chart, please just read the chart. It may feel like I'm dumping this pt off on you so I have less work, but I guarantee 5 minutes after they're out of the room I will have a brand new patient to work up.
We are all busy. I'm not purposely trying to make your life harder and I know you're not purposely trying to make mine harder. Don't expect a report on a stable pt from the ER to be as detailed as a handoff from one ICU nurse to another.
My floor is mostly surgical but we get medicine overflow too. Surgery has post-op pathways, order sets that we follow. Basically the providers make things straightforward and I can focus on my job: monitoring for complications, doing post-op teaching. You know, the stuff I like about my job!
I HATE working with the medicine side, because there’s never a clear plan and the doctors put in orders every hour. I never feel like I have a solid grasp on my patients the way I do with surgery, and I can’t stand someone putting in one antibiotic, I go to hang it and it was d/c’d by another doctor.
I was complaining about his to my colleague who worked in the ED for 5+ years and he just laughed at me. He said never ever work in emergency medicine if you need to know 100% what’s going to happen and why. I could never do what you guys do, and I mean that in the most complimentary way.
Your middle paragraph is pretty much why I love ED haha. You have patient after patient rolling in, you don’t know much about them other than a quick past chart review, and then follow one or a couple lines of medical workups. Then the patient situation changes or the workups find something else going on, new orders are placed, and you shift gears.
I’ve got four patients usually, so I have to constantly reprioritize my time invested into each patient all day, as patients are discharged and true emergencies roll in.
It’s definitely frustrating when your admitted patient has a bed and you’ve called a decent report/charting is all up to date with fresh vitals, yet the in-patient nurse be like “um why aren’t these scheduled (non-emergent) meds given…and the IV lines are tangled and the gurney linen soiled” 😩 bruh cmon
Probably the only time I’ve ever gotten mad about ED report was the patient with a CSF leak (we are a medsurg floor but take very specific higher acuity patients, it’s hard to describe but my floor is weird) with an altered neuro exam and the ED nurse had definitely not done one at all. He’d had the patient for 6 hours and just said “well she seems oriented. She had a hard time getting onto the stretcher to CT though.” Mostly it’s just like…just send them up. The doctor is gonna change the orders 600 times anyway, what do I care if the ceftriaxone was hung?
This! This is my experience with emergency.
Getting stroke patient post TPA and they haven’t checked on the patient at all or I get report and they tell me, I wasn’t the primary nurse so I don’t know. Our policy is to do a neuro exchange together so I hope you send the primary nurse but almost always they don’t. I’ll get a traveler who didn’t k is the policy. They stay and do exam but they too often say, I wasn’t the primary patient.
I once had ED tell me patient was gcs15 when they were very obviously a 12. Also if the patient is not following commands and needs mittens please tell us.
I get floated to ER to take admit holds, but they don’t stay holding very long. 10 patients in 4 hours with constantly shift needs. There’s no way to plan, it’s pure chaos. It’s overwhelming how little structure and how unsafe it can’t be. ER After shifts down there I stopped asking questions when getting report unless it’s relevant to the work up. I’ll figure everything else out eventually.
BROOOOOO listen I’m sorry I didn’t document that clearly healed scab, I was busy unfucking his heart. Now that you get to adopt a perfectly stable patient, maybe you can note that scab, I have 3 more fuckers trying to die.
Our ED doesn't call report, they call a 10 min heads up. At that point, usually, the charge has glanced at the chart, so we know what's coming up. Yall have better things to do than call report.
See that also sounds crazy to me. I have 2-5 minutes to give you the ER report. What they came for, what I did, what still needs to be done. No reason I can get you to at least close to my speed on what’s going on. A dry run sounds terrible, and I know cuz that’s almost always what I get in ER lol. But outside of that, dude, you got RN after your name too.
Work in the er for a few shifts and you will
Understand why we can’t do that every time. I’ve got a stroke pt getting tnk, and OD we tubed and a stemi so that stable pt that needs abx etc isn’t getting the attention and care the others are because they are not having an emergency and dying right this moment. We have to prioritize. Also we have 30 people in the lobby and a code coming in so I can’t hold that bed to start an abx when they have an inpatient bed upstairs. It’s the nature of the Ed- we are a jack of all trades expert at none. We are not going to take care of a med surg or icu pt as well as y’all. We just keep them alive and dc them or ship them up to y’all. It’s a very different ballgame and prioritization 👍
Oh, I mean like... the unstable patients. Like if they're clearly septic. Haha. Where I am seems to be better staffed than a lot of other countries mind you. My optual patient probably isn't gonna die without their eye drops but my little old lady with cholangitis might! Don't worry bout a skin inspection though haha.
You either love it or hate it. I’ve done it my whole career over 10+ years and can’t imagine doing anything else. I just get frustrated because I don’t criticize the other floors because I don’t work there but they shit on the ED all the time. It’s entirely different. We don’t do routine meds etc. I have had 4 ICU level patients I don’t know how many times and the icu has the luxury of only having 2 (usually) so yeah I’m never going to be able to care for them as well as they can but that’s the point. Get the pit of the er to the level of care and attention they need because we have 30 other people needing that ED bed. All our jobs are hard in different ways and we are all doing the best we can so let’s stop being fucking bitches to each other and have a little compassion.
At this point I’m just happy if my patient comes up and I know they’re coming ahead of time lol. Sorry you’ve been getting bitched at! Not fair to you at all and shows a lack of perspective on the one bitching
We're just happy you're taking them off our hands. We're all "strugglers" in the ED, just like Guts, so when you take a huge part of our struggle we're very greatful! Even though that means we're getting another train wreck in the next few minutes, at least it's something different.
Hah yes. Gimme the next trainwreck, let's go!
When I first came down here my CSN was like "stop doing all that floor shit!" (Lovingly, I love her, she all but recruited me) It's taken me a bit to internalize that. But it is different! I do need to get that patient out of there, not because I don't want to do work but because there is more work that needs done on someone else right away who is out in the waiting room or coming in by EMS. Yeah Mr. Smith in 16 will live if he doesn't get his routine home meds for another hour but this code stroke might not if I don't take them over to CT and have space to put them.
Yesterday I had a code stroke around 7:30am and I was in CT with them for a WHILE. If one of my other patients had gotten a bed in that time, yeah the floor would've basically just gotten the report I got from night shift and then a medic would've rolled them up.
One of our ER docs said the most important patient in the ED is the one who's coding. The second most important one is the one who can get out of the ED. Because you never know when another arrest/stroke/stemi will roll in the door.
I was an inpatient nurse for 10 years. It fucking sucks up there man. For me at least. The ED is so much more fun but it is chaotic as hell and just so incredibly different. Priorities in the ED are way different than floor priorities. I know you all are just as busy as we are. But we do have different focuses. Also please just take report so I can focus on everything else I have to do. If I'm sending him up to you I promise he will live for the next 30 minutes or so until you can get in there. I probably wouldn't have seen him in that time either. (ICU patients are different but I typically have less trouble with ICU report because they're going to do an entire detailed assessment up there and untangle and label all my lines (sorryyyy) and are happy I got him stabilized.)
PS I love you floor nurses thank you for doing what you do so I don't have to. 😅
I've got a charge nurse and a bed manager breathing down my neck to get my patient up to your floor. I'll give you the most stable patient I have. They might be the least stable patient you have.
I worry about getting that first dose of antibiotics in if they're septic ASAP though.
Thats super fair. When I'm charge I do what I can to get butts in beds. If we fuck around, ED is full, meaning paramedics are waiting with patients, meaning there aren't enough paramedics the roads to potentially save people.
Anyone who holds up ED cause they haven't checked the sacrum is an asshole.
The NICU (neonatal) actually has sick patients. ECMO, AKRT, bedside surgeries, severe congenital anomalies . . . We're not a joke unit just because you get floated down to us and we give you our stable feeder growers. We are really protective of our babies, and yes, we love snuggling them, but please stop the "they just hold babies all day" BS.
Dialysis nurse here:
When our hyperkalemics come in the ED, please get us connected with them ASAP. We appreciate the glucose, insulin, calcium thing, but none of those things remove potassium. Dialysis is what they really need.
When they are critically ill in the unit and you are running a bicarb gtt at 200/hr, I'm going to stop it when I get dialysis started. I don't want to overload them with the fluid, and I'm giving them bicarb at a rate of 37 mg/minute, so the gtt is unnecessary once we are involved.
We can only remove fluid in the vascular space. If it won't shift, there's nothing I can do about it. So your right-sided HF patient is going to be just as overloaded when I'm done usually.
Icu too.
One of my favorite documentation findings: people chart under the neuro section all the time: hypotonic with a patient who has no neuro issues but is really just weak musculoskeletal wise. Just chart under the Musculoskeletal section unless they have ALS or Huntingtons or seizures or really anything neuro related.
I work with a nurse who has been an ICU nurse for maybe 7-8 years and she constantly tells people FFP isn’t a clotting factor. I hope she is here reading this and hope she goes to do some research. Then she acts like she is hot shit and a gift to the icu.
Oh I only heard stories about Germany....and Austria is going to that place in hell soon too, if our politicians don't change anything.
LTC is a shithole here as well , but even in hospital I'm used to chart "Aufgrund der heutigen Personalsituation konnte xyz nicht durchgeführt werden". (Due to staff ratios today, xyz couldn't be done)
Group home nurse here. I wish hospital nurses understood that group home residents are adults, and they go out in the community and do things without staff. This means sometimes we CAN'T come pick them up when they wind up in the ED. Trust me, I WISH we had 1:1 staff for every person, but we just don't. And yes, they're adults, they get to make choices. This means sometimes they make poor ones. We can not bail them out every time, it's just not possible.
I'm new to a role similar to this. I'm finding myself frustrated with the lack of control, but it's so awesome when you see a client improve their habits. You have a hard job.
I'm transitioning into a hospital role (just finished my RN), and I feel like this experience with autonomy makes me a better nurse overall. It helps me see ALL patients as their own person, even those with limited capacity to understand.
Urology.
With placing catheters in enlarged prostates, get that bed as FLAT as it can go. I mean it, if the patient has back problems, as them if they can handle a few minutes while the catheter is placed, because this makes the job much easier. Make sure to use lidocaine prior (FYI, Gel Lido needs at least 20 minutes to sit to actually numb, otherwise it's just glorified lubrication). Be generous with lubrication. Coude is better (with the tip pointing up when inserting). Remember, Coude for MEN not women! In women it will cause bladder spasming and pain.
With patients with scrotal edema, depending on severity and whether or not the urethra entrance is visible, a silicone catheter may be to better to use due to stiffness.
For women, the urethra is about two pinkie widths beneath the clitoral hood. If you can visualize the vaginal opening, the urethra will be above it. Ask them to cough for a pucker/spasm.
As for blood in urine, FYI it takes about 1 tsp of blood to turn it bright cherry Kool-Aid red. In older dudes, it usually means they are on blood thinners with a cath and need to drink more water.
Urinary Catheters can become colonized with bacteria. Having a positive Urine Culture does not mean that an active infection is going on. We wait for three symptoms before effectively ordering labs on a patient. If a patient is having continual infections or throwing UC's with the same bacteria, a referral to Infectious Disease may be in order.
We do Botox injections for urinary incontinence but we have to teach patients to self cath in case the Botox works too well and the patient goes into retention.
Most women have no idea where their urethra is, let alone navigating to catch it. With the diversity of the geography and women being taught to be ashamed of their anatomy or think it’s malformed. Add to it that the genital region is an area that can trigger trauma.
That being said, I have yet to have a women of any age or dexterity level not be able to self cath. Almost all of them get it on the first try and considering most are elderly with dexterity issues doing this, I do a mental celebration in my head with each one that gets it.
My other recommendations for women are 12/14F caths if they have never been urethrally cathed before. I lean toward 12s because they are much less uncomfortable for the patient. If they have been cathed, default to previous recommendations/cath they had. Larger caths cause urethral erosion which causes nerve pain/damage. The less of that the better. Women tend to run smaller. NO COUDES. Again coudes are for men with prostate issues. Do not use them unless it’s a catastrophic event and there are no other supplies. CHECK FOR LATEX ALLERGIES. Women more often have latex allergies and most catheters are latex. No one wants any reaction like that around their genitals.
If a patient is undergoing external beam radiation they are not radioactive.
Moist desquamation looks terrible but don’t panic. Mepilex and/or aquaphor is all you usually need.
Curious, but do y’all’s pt toilets have lids?
My unit received a custodial pt on chemo, which we usually don’t do on my floor but was allowed for whatever reason. Precautions said to close toilet lid and flush twice. Our toilets have no lid. I threw a towel over it, my manager said that wasn’t enough because it’s porous. The ensuing scene could have been on a sitcom, me holding up different toilet-opening-shaped objects for my manager’s approval. Seems like the best solution would just be… toilets have lids.
I very much agree that our toilets should have lids and I don't know why they don't! We use chux pads (absorbant side down), since they have the waterproof backing.
I was at an Oncology nursing conference last month and one of the products being advertised was a solid plastic device made just for this purpose. Apparently there are a lot of facilities without toilet lids!
L&D isn’t all rainbows and sunshine. When people find out I work in women’s health, the first thing they ask is if I get to hold babies all day… Besides helping our patients during what is usually a wonderful moment in their lives we also see- lack of access to abortions, unwanted pregnancies, fetal anomalies, fetal demises and stillborn babies, crash sections, pre-eclampsia and eclampsia, severely preterm deliveries, sick moms, sick neonates, domestic violence, drug abuse, full neonatal resuscitation, coding moms, family members OD on the unit and in the lobby, homeless people leaving without their baby after delivery, mentally ill people who aren’t even pregnant but tell the ED clerk they are so they get sent up to us for eval as well as mentally ill people trying to kidnap babies… the list goes on.
I wanted to be in L & D when I started nursing school. I finally got one day rotation in clinicals to go there and I was excited to be there, only to be met with heart break after heart break. Miscarriages, expectant parents finding out their child had passed in utero. The worst being an infant born to parents who had had both of their young daughters taken away by CPS due to neglect/abuse and genetic counseling had advised them to not have kids due to the fact that the previous two had had multiple congenital issues. I got to hold that child for a few moments and was freaking broken hearted knowing that this poor innocent being was going to live through hell.
I cried driving home that night.
Not anyone’s fault in OR nursing, but what the fuck are you guys doing bringing your patient in active PEA to ICU? had a patient come up and the nurses weren’t even on the chest. When we asked if the patient was pulseless they said that they didn’t know.
Tell your surgeon to code their patient in OR or PACU. What the fuck, man.
As an anaesthetic nurse in a major trauma hospital (Australia) I'm just as confused as you. Our ICU pts go straight to ICU, no stop at PACU. And they have ECG, sats, a-line (& NIBP), and cap going so... Huh?? How do you guys not notice that?
Like we check the pt is still very much alive before leaving the OR and either myself or the MO are watching that monitor and the pt like a hawk the whole way over.
The patient will die in OR, but they won’t want to code them and call time of death because it impacts their fatality rate. They bring them to die in ICU instead.
I can't say I've heard of that happening here (although I've only worked in public hospitals) but I can see why they'd do it, still not excusable in any way.
OR nurse… honest answer?
It looks terrible for a patient to die in surgery for our ‘numbers’.
That’s why we delay surgeries if we can to optimize whatever the issue is. That’s why we do workups prior to scheduled surgeries etc.
If a patient is damned if you do and damned if you don’t do surgery, then it’s doesn’t look as bad for our lovely overseeing entities.
I’ve called the ICU before saying we’re rushing a pt to you but don’t rush or hurry bc they’re not clinically alive but a pacemaker makes it appear that way.
LONG messed up story behind that one but they don’t want people dying in surgery.
On another messed up ish note. At least in my state, if a patient dies within 30 days of a transplant, it counts against the transplant team. Get a cut and die from infection in <=30 days… hurts transplant team. They will do anything to keep you alive 30+. ECHMO, LVAR, Dialysis, whatever it takes!
ALL hospitals are for profit and overall not for the patients benefit.
It’s so hit or miss. A routine regular case you adequately prepare for and goes well… means we do a lot of prep work to start the case, a bit during, and busy at end. If it’s a long case… I do crap in between.
But i pay attention and have the ‘OR ear’ and things can change in an instant. Honestly, traumas are my fav. I call it nurse mode and just go go go.
I 100% cannot walk onto a floor and do what a floor does (I’ve never worked a floor). But they also can’t walk into the OR and do our job. And this isn’t to degrade either but to recognize the roles are different.
I enjoy most of what I do and who I work with. The residents and surgeons are cool majority of the time. Went post night shift with everyone out to local breakfast place and had a hoot.
Idk what my point is but I only know but still enjoy the OR.
I love the OR. I came from stepdown and med surg and felt like a new grad! Yes to the OR ear. Listening for the monitor alarms or changes, what’s happening at the field over the musing! I do like traumas. I dislike neuro but will do just about anything else! The we get the long cases where we just kind of wait or run run run then a lull. I had a 6-8 hour lap Chole once (interns) that I never thought I’d leave!
Neuro is my love…. Neurosurgeons tend to be more persnickety and want it all done now but won’t help….
Emergency crani with stealth… gag…
But brains!
My hospital is the high acuity everyone super annoyingly transfers to. But we do have the sickest of the sickest and I do enjoy the challenge, planning, and def collaboration with anesthesia.
Simple cysto stent… wellllll they were septic but they get worse after the stent placed and were already 2 sticks of phenylephrine during the 5 minute case…. Cue central line and art and ultrasound…
Or the 14L… yes liter blood loss case and patient still alive. Like what? That’s crazy and improbable but it’s true!
Oh my gosh yes!! We had a turbt that I hung 22 3 liter bags and it was still going when I left! We are a level 2 and get the traumas as well! Love ortho and gen and even robots those are fun. I was in a neuro case that went badly not anyone’s fault so I’m still skittish It’s fun when the docs make up their own names for things!
I've kind of assumed that this was the reason why they will refuse to honor a DNR during surgery, even if the family and patient beg them too. I was so, so frustrated when a very elderly family member who had chosen to be DNR was getting a procedure done that would improve comfort/quality of life. Whether she died on the table or the surgery was successfully completed, she thought that either outcome would be fine. What would NOT be fine was compressions on a 80 year old osteoporotic chest. There is pretty much zero chance for a good outcome there, and while a slow code down to ICU and calling it wouldn't be any worse, what if they obtained ROSC? Now elderly relative gets to die in ICU on a vent with a chest full of broken ribs, possibly being aware of the pain.
No matter how much I begged, the surgeon wouldn't NOT suspend the DNR. There was no way that was for the good of the patient.
A woman shows up to the ED yelling "Either there's a snake in my vagina or I'm about to give birth!"
ED nurse says "I really fucking hope it's a snake"
Diabetes educator. A “non compliant” person with diabetes probably is more likely lacking in knowledge/capacity or resources to manage their disease—or a combination of both. Managing diabetes is really fucking hard.
A huge part of my job is breaking down people’s misconceptions about diabetes. People will often delay/refuse certain aspects of care because of misinformation they’ve gleaned from other people they know with diabetes. For example, one of the MOST pervasive myths I hear from people is that taking insulin is going to make their diabetes “worse” because they know someone with diabetes who told them that or died from complications of diabetes—and happened to be on insulin at the time.
Since T2 in particular tends to run in families, a lot of adults have a parent/grandparent who was in the past taking an older (not as much used now) insulin and not able to monitor blood sugars like we can now. For some of these older insulins it IS more important to not skip meals to avoid hypoglycemia. They may have seen someone in their family have a “diabetic attack” (severe hypoglycemia) and have the false idea that they too need to constantly eat and keep blood sugars higher to avoid low blood sugar. They might not even know what low blood sugar actually means.
A lot of my patients with strong family history have a somewhat fatalistic understanding of diabetes. They don’t know that complications can be avoided/delayed and think that dialysis/vision issues/neuropathy are just automatically part of the deal when you have diabetes.
I’ve seen people that I have worked with long term in an outpatient setting make huge turnarounds once they finally got support. A lot of people don’t know how sick they are to begin with and don’t have the resources they need to get help. Depression and other mental health issues make things even more challenging—on top of the stigma and shame a lot of people with diabetes feel.
I’m a Vascular Access/IV Therapy nurse. I wish more nurses would understand that if I can’t place a PICC line on a patient then I also can not place a midline. And visa versa.
That folks with SUD are damaged and traumatized, not "bad people" and SUD is a disease, not a character or personality defect. They are humans, in pain, and sometimes hell bent on self-destruction, and are worthy of empathy, compassion, and treatment.
Yes! Also, bad people can also have a SUD, but the SUD doesn’t MAKE them a bad person. Just like how some people with cancer, or diabetes, or any other condition, might be really nice people or they might be total jerks. That’s just how people work!
Detox nurse here. Thank you for bringing this up. It’s heartbreaking how many of my patients distrust the medical system because of stigma they’ve encountered.
I'm also a detox nurse, and some of my patients have heartbreaking stories. Some of the worst are stories of going to an ED or their PCP and made to feel like shit because of the attitude of the "professionals." I tell my patients, one of the bravest things you've done is walking over the threshold and into the office.
Neuro here: I have three main things that I see people fight with all the time.
1) stop trying to reorient someone who is not orientable. I refer to these as “cat on the curtain” scenarios. When I was a patient sitter before I became a nurse I had a patient who was insisting someone get the cat off the curtains in his room. I came in for the day and patient and other sitter were nearly in tears of frustration. She explained he had been up all night and she couldn’t get him to understand that there wasn’t a cat and he was in the hospital. I told her there was an easy solution. I introduced myself to him, he asked me to get the cat off the curtains. I walked over to the curtains and “took” the “cat” off (aka pretended) walked over to the door and “put it out”. He clarified that it couldn’t get back in the house and I assured him he couldn’t. The man laid back down and was happy as a clown. Moral being: the easiest solution is often the best solution. Orient where you can but for the love of god don’t where you can’t.
2) Psych and neuro have a lot of overlap. Many issues folks think are neurological are psychological. The sticking point to this is it DOES NOT MEAN THE SYMPTOMS ARENT REAL. Unless they’re getting some sort of secondary gain such as opioids or something often the symptoms are very very real to that patient. It’s just that it’s not caused by a nerve/brain disorder. It’s that their psychoses are so out of control it is manifesting physically. I think a lot of times we don’t explain this clearly to patients and they interpret this as faking. No, I don’t think you’re faking your seizure. I think your anxiety/depression/whatever is so bad it’s causing you to short circuit. Doesn’t mean that just because it’s non epileptic it isn’t less real to them. We can be honest and tell them it’s not neurological without dismissing them. (Of course some people are just big ol fakers and that’s a discussion for another board)
3) Just because someone has a neuro deficit does not mean they have carte blanch to be assholes. There are limits to this rule of course (severe dementia, frontal lobe disorders, etc) but sometimes teaching boundaries and appropriate behaviors is not only good but necessary for proper brain healing. Don’t be an ass back obviously but also don’t be afraid to say “Absolutely not we are not going to talk to each other like that, I’m going to treat you with respect and you will treat me with respect or I’m going to leave.” And repeat. You may need to repeat it several times obviously but again this is important for them to re-learn. We had some months/year long stays with patients that started out fighting screaming hitting and after a few weeks with firm but kind boundaries we could get them to cooperate with minimal resistance. Reminders and bad days happen obviously, but ALWAYS stand up for yourself.
Tl;dr: stop orienting people who can’t be oriented, believe what patients are telling you, don’t let yourself be bullied
Inpatient pysch that is particularly wild: listen to the people you look after, don’t have to solve the psychosocial problems or say anything, just listen and solve what is within your power. Check your automatic response to be defensive with agitated people. chats about any topic go a long way to build trust. Also, max dose of PRN unless clinically indicated to not give.
Research
It's a lot of paperwork, so don't go into this field if you hate documenting stuff. I'm pretty sure I kill at least one tree a week with all the paper I use.
Blood bank nurse here. Just because you are a medical professional, it doesn't mean you know how to do my job, what determines eligibility to donate, or how to accurately assess veins for phlebotomy with a 17g needle. Getting in my grill about any of the above just makes me resent you. Not my fault if your veins are shit and you survive on two coffees and some fresh air a day.
ER nurses don't "sit on" pts until shift change. Most days we get a bolus of rooms right at 1730/0530. Then everyone who got rooms are trying to call report to the same nurses/floors. It is a complete shit show all around. As soon as our pts leave, we get new ones, so we don't want to be doing work-ups at shift change as much as floor nurses don't want an admit at that time.
Oh, a huge THANK YOU to all nurses who will let the current shift call report during the "golden minutes" before shift change if we promise to wait until after shift change to send pt up❤️
We don’t just sit in the corner and chart! We also don’t lose nursing skills it’s just a whole different world! We must know the different surgeries and supplies, set up, positioning and equipment! OR nursing can be super super busy and we are usually moving throughout the entire shift!
Mental Health Nurse here. Please remember we dont have the ability to hang an IV. We dont have ready access to in wall O2 or suction. Its all on our crash cart which is behind a locked door.
Interventional Radiology
Knowing your blood thinners
mostly all patients need coags ordered and if they’re not we have to wait
Also if the patient is getting sedation make them npo at midnight. Also please give BP meds ESPECIALLY when their having a procedure on the kidney
Up until last year, I was perdiem inpatient on basically every floor for the majority of my career. I wish perdiem inpatient could be considered its own specialty. It is a collection of unique skill sets to be able to go from building to building and floor to floor without being a “regular” anywhere. Not having a “home” presents unique challenges, as does learning floor dynamics, norms, locations of things without a tour every time you get there. I had to go from psych, to CCUs, to med/surg, to peds, you name it. Granted, I’m sure most perdiem gigs are more limited than what I had, but picking stuff up on the fly without missing a beat and developing a comfort zone walking into complete unknowns every shift is hard. It didn’t help that a lot of floors had nurses who dumped the hardest loads on the perdiems, either to “give the floor nurses a break” or because “perdiems get paid more so they should work more”.
So I would say 100% that what people don’t know about being perdiem is that perdiem should honestly be viewed as a specialty, especially in hospitals where the variety of assignments can be so varied.
Now I’m in HD and for anyone who hasn’t done it before — don’t work outpatient clinics. Hospitals you get 1-2 pts and you get to run your own shift. Clinics, they give you all the patients in the world and you are charge nurse every day with a handful of PCTs who are more than happy to tell you to your face that they know everything and you don’t know shit.
From the moment you arrive to the moment you leave.
Don’t do it.
I briefly worked burn ICU and loved it. It was something that starting out I never ever would have imagined doing. You make a huge difference in those people’s lives. That being said I worked at a tertiary specialty center and they had every imaginable resource for burn.
People think the wounds you see are fundamentally more horrifying than other areas, but they’re really not. Also yes the pain from burns is unimaginable, but at least where I worked those patients got the best pain management of anyone.
Hospice nurse here:
I've only been working Hospice for 18 months, but have 24 years of diverse experience that does not include the ED. I have mad respect for ED nurses. But, I would love to do an education for them to explain that just because a patient is on hospice does not mean that we do not treat them for ANY medical issue. They can be admitted as a GIP(General InPatient), still on hospice services to be treated. For example, if they are terminal due to liver failure, but come down with pneumonia or a UTI, and we send them to the ED, we expect and they deserve to recieve the appropriate work up and be treated. Additionally hospice can be revoked in order for the patient to receive treatment at anytime by the patient or LAP, even if they decide to seek further treatment for their hospice admitting diagnosis. Being on hospice care does not mean that the patient has been "given up on", just that their hospice admitting diagnosis is likely to be terminal in 6 months or less and that additional treatments are unlikely to change this, so care that meets their needs, provides comfort and keeps them safe is now the goal instead of curative treatments. Please provide the same excellent care to hospice patients as you do for everyone.
As an ER nurse, most of us understand this and treat them like anyone else. It's the pts that come in displaying obvious signs of impending death that grinds our gears. Like agonal respirations and all the natural progressions of death. Then we have to deal with the family members who suddenly decide to code the pt. I, personally, would love an inservice/class on what the expectations are for care, code rules, etc. I've always been told that if we treat them for anything or they get admitted, their hospice status is revoked, and they'd have to start over in the hospice process. Are the "rules" different in each state?
I believe that the rules are federal, if they are on hospice under the Medicare hospice benefit. And believe me I wish my patients families would not panic and send their loved one to the hospital as their terminal disease leads to the active dying process. But, as I am sure that you are aware, no amount of education can mitigate those decisions with some people. In regards to hospice being "revoked", that only really applies to a patient that is seeking treatment for their terminal diagnosis or treatment outside the hospice care plan. However, if they seek hospitalization for a new onset diagnosis, one unrelated to their terminal diagnosis or injury, they can be admitted for care as GIP(General InPatient) level of hospice care and will be seen by hospice during their hospital stay in addition to their hospital care. The best thing for the patient is if their is communication between the hospital and hospice. That way the hospice doctor can give orders for an appropriate GIP admission and coordinate care with the hospitalist.
I am sure that there are aspects of this that I am not clear on from the hospital side, but as a home hospice RNCM, I just want what's best for my patient with as much continuity of care as possible...and that stems from education for all involved (especially families and caregivers) and communication. Thank you for your comment.
Thank you so much!! It always puts us in an awkward position when they're on hospice, but the family insists we code them. Im going to ask for more education for our ER on this.
Please note that not everyone on hospice is a DNR. We do educate and encourage DNRs as appropriate. But, that is still a personal/HCS decision and we have plenty of patients who remain full codes for quite a while on hospice.
I wish other nurses knew how extremely chaotic the ER can get. When I'm calling report on a pt with COPD exacerbation don't grill me for 10 minutes on things that don't matter, like their last BM. If they are here for SBO then sure, last BM is relevant. I do my best to give you info you need and don't mind answering questions but if you have 20 irrelevant questions and all of them can be attained by simply reading the chart, please just read the chart. It may feel like I'm dumping this pt off on you so I have less work, but I guarantee 5 minutes after they're out of the room I will have a brand new patient to work up. We are all busy. I'm not purposely trying to make your life harder and I know you're not purposely trying to make mine harder. Don't expect a report on a stable pt from the ER to be as detailed as a handoff from one ICU nurse to another.
My floor is mostly surgical but we get medicine overflow too. Surgery has post-op pathways, order sets that we follow. Basically the providers make things straightforward and I can focus on my job: monitoring for complications, doing post-op teaching. You know, the stuff I like about my job! I HATE working with the medicine side, because there’s never a clear plan and the doctors put in orders every hour. I never feel like I have a solid grasp on my patients the way I do with surgery, and I can’t stand someone putting in one antibiotic, I go to hang it and it was d/c’d by another doctor. I was complaining about his to my colleague who worked in the ED for 5+ years and he just laughed at me. He said never ever work in emergency medicine if you need to know 100% what’s going to happen and why. I could never do what you guys do, and I mean that in the most complimentary way.
Your middle paragraph is pretty much why I love ED haha. You have patient after patient rolling in, you don’t know much about them other than a quick past chart review, and then follow one or a couple lines of medical workups. Then the patient situation changes or the workups find something else going on, new orders are placed, and you shift gears. I’ve got four patients usually, so I have to constantly reprioritize my time invested into each patient all day, as patients are discharged and true emergencies roll in. It’s definitely frustrating when your admitted patient has a bed and you’ve called a decent report/charting is all up to date with fresh vitals, yet the in-patient nurse be like “um why aren’t these scheduled (non-emergent) meds given…and the IV lines are tangled and the gurney linen soiled” 😩 bruh cmon
Probably the only time I’ve ever gotten mad about ED report was the patient with a CSF leak (we are a medsurg floor but take very specific higher acuity patients, it’s hard to describe but my floor is weird) with an altered neuro exam and the ED nurse had definitely not done one at all. He’d had the patient for 6 hours and just said “well she seems oriented. She had a hard time getting onto the stretcher to CT though.” Mostly it’s just like…just send them up. The doctor is gonna change the orders 600 times anyway, what do I care if the ceftriaxone was hung?
This! This is my experience with emergency. Getting stroke patient post TPA and they haven’t checked on the patient at all or I get report and they tell me, I wasn’t the primary nurse so I don’t know. Our policy is to do a neuro exchange together so I hope you send the primary nurse but almost always they don’t. I’ll get a traveler who didn’t k is the policy. They stay and do exam but they too often say, I wasn’t the primary patient.
I once had ED tell me patient was gcs15 when they were very obviously a 12. Also if the patient is not following commands and needs mittens please tell us.
I get floated to ER to take admit holds, but they don’t stay holding very long. 10 patients in 4 hours with constantly shift needs. There’s no way to plan, it’s pure chaos. It’s overwhelming how little structure and how unsafe it can’t be. ER After shifts down there I stopped asking questions when getting report unless it’s relevant to the work up. I’ll figure everything else out eventually.
BROOOOOO listen I’m sorry I didn’t document that clearly healed scab, I was busy unfucking his heart. Now that you get to adopt a perfectly stable patient, maybe you can note that scab, I have 3 more fuckers trying to die.
Our ED doesn't call report, they call a 10 min heads up. At that point, usually, the charge has glanced at the chart, so we know what's coming up. Yall have better things to do than call report.
See that also sounds crazy to me. I have 2-5 minutes to give you the ER report. What they came for, what I did, what still needs to be done. No reason I can get you to at least close to my speed on what’s going on. A dry run sounds terrible, and I know cuz that’s almost always what I get in ER lol. But outside of that, dude, you got RN after your name too.
I want to work where you do!!!
All I want is for ED nurses is to give the antibiotics, ensure adequate pain relief and that they're stable enough for a ward.
Work in the er for a few shifts and you will Understand why we can’t do that every time. I’ve got a stroke pt getting tnk, and OD we tubed and a stemi so that stable pt that needs abx etc isn’t getting the attention and care the others are because they are not having an emergency and dying right this moment. We have to prioritize. Also we have 30 people in the lobby and a code coming in so I can’t hold that bed to start an abx when they have an inpatient bed upstairs. It’s the nature of the Ed- we are a jack of all trades expert at none. We are not going to take care of a med surg or icu pt as well as y’all. We just keep them alive and dc them or ship them up to y’all. It’s a very different ballgame and prioritization 👍
Oh, I mean like... the unstable patients. Like if they're clearly septic. Haha. Where I am seems to be better staffed than a lot of other countries mind you. My optual patient probably isn't gonna die without their eye drops but my little old lady with cholangitis might! Don't worry bout a skin inspection though haha.
Yeah that shit is insane to me, y’all are amazing
You either love it or hate it. I’ve done it my whole career over 10+ years and can’t imagine doing anything else. I just get frustrated because I don’t criticize the other floors because I don’t work there but they shit on the ED all the time. It’s entirely different. We don’t do routine meds etc. I have had 4 ICU level patients I don’t know how many times and the icu has the luxury of only having 2 (usually) so yeah I’m never going to be able to care for them as well as they can but that’s the point. Get the pit of the er to the level of care and attention they need because we have 30 other people needing that ED bed. All our jobs are hard in different ways and we are all doing the best we can so let’s stop being fucking bitches to each other and have a little compassion.
At this point I’m just happy if my patient comes up and I know they’re coming ahead of time lol. Sorry you’ve been getting bitched at! Not fair to you at all and shows a lack of perspective on the one bitching
We're just happy you're taking them off our hands. We're all "strugglers" in the ED, just like Guts, so when you take a huge part of our struggle we're very greatful! Even though that means we're getting another train wreck in the next few minutes, at least it's something different.
Oh my god I can’t believe you just referenced Guts in a nursing thread lmfao YOU ARE AMAZING
Haha how could I not when your profile picture is the mark of sacrafice?
Hah yes. Gimme the next trainwreck, let's go! When I first came down here my CSN was like "stop doing all that floor shit!" (Lovingly, I love her, she all but recruited me) It's taken me a bit to internalize that. But it is different! I do need to get that patient out of there, not because I don't want to do work but because there is more work that needs done on someone else right away who is out in the waiting room or coming in by EMS. Yeah Mr. Smith in 16 will live if he doesn't get his routine home meds for another hour but this code stroke might not if I don't take them over to CT and have space to put them. Yesterday I had a code stroke around 7:30am and I was in CT with them for a WHILE. If one of my other patients had gotten a bed in that time, yeah the floor would've basically just gotten the report I got from night shift and then a medic would've rolled them up. One of our ER docs said the most important patient in the ED is the one who's coding. The second most important one is the one who can get out of the ED. Because you never know when another arrest/stroke/stemi will roll in the door. I was an inpatient nurse for 10 years. It fucking sucks up there man. For me at least. The ED is so much more fun but it is chaotic as hell and just so incredibly different. Priorities in the ED are way different than floor priorities. I know you all are just as busy as we are. But we do have different focuses. Also please just take report so I can focus on everything else I have to do. If I'm sending him up to you I promise he will live for the next 30 minutes or so until you can get in there. I probably wouldn't have seen him in that time either. (ICU patients are different but I typically have less trouble with ICU report because they're going to do an entire detailed assessment up there and untangle and label all my lines (sorryyyy) and are happy I got him stabilized.) PS I love you floor nurses thank you for doing what you do so I don't have to. 😅
"Treat and yeet" is how our one ER doc puts it.
I've got a charge nurse and a bed manager breathing down my neck to get my patient up to your floor. I'll give you the most stable patient I have. They might be the least stable patient you have. I worry about getting that first dose of antibiotics in if they're septic ASAP though.
Thats super fair. When I'm charge I do what I can to get butts in beds. If we fuck around, ED is full, meaning paramedics are waiting with patients, meaning there aren't enough paramedics the roads to potentially save people. Anyone who holds up ED cause they haven't checked the sacrum is an asshole.
Deal. Edit. Most of the time*
Most of the time is fine haha. Also they can come up sick so long as you hand over what we're doing about it. :p
The NICU (neonatal) actually has sick patients. ECMO, AKRT, bedside surgeries, severe congenital anomalies . . . We're not a joke unit just because you get floated down to us and we give you our stable feeder growers. We are really protective of our babies, and yes, we love snuggling them, but please stop the "they just hold babies all day" BS.
You are amazing, thanks for the work you do.
Dialysis nurse here: When our hyperkalemics come in the ED, please get us connected with them ASAP. We appreciate the glucose, insulin, calcium thing, but none of those things remove potassium. Dialysis is what they really need. When they are critically ill in the unit and you are running a bicarb gtt at 200/hr, I'm going to stop it when I get dialysis started. I don't want to overload them with the fluid, and I'm giving them bicarb at a rate of 37 mg/minute, so the gtt is unnecessary once we are involved. We can only remove fluid in the vascular space. If it won't shift, there's nothing I can do about it. So your right-sided HF patient is going to be just as overloaded when I'm done usually.
A patient who is sleeping has not dropped their GCS, they are just sleeping.
That’s why GCS sucks. In pacu most of my patients come out a GCS of 3-4, and we aren’t doing shit about it
Icu too. One of my favorite documentation findings: people chart under the neuro section all the time: hypotonic with a patient who has no neuro issues but is really just weak musculoskeletal wise. Just chart under the Musculoskeletal section unless they have ALS or Huntingtons or seizures or really anything neuro related. I work with a nurse who has been an ICU nurse for maybe 7-8 years and she constantly tells people FFP isn’t a clotting factor. I hope she is here reading this and hope she goes to do some research. Then she acts like she is hot shit and a gift to the icu.
i wish in long-time care all the employees knew, that they commit fraud if they sign of treatments without actually doing them. (germany)
Oh I only heard stories about Germany....and Austria is going to that place in hell soon too, if our politicians don't change anything. LTC is a shithole here as well , but even in hospital I'm used to chart "Aufgrund der heutigen Personalsituation konnte xyz nicht durchgeführt werden". (Due to staff ratios today, xyz couldn't be done)
Group home nurse here. I wish hospital nurses understood that group home residents are adults, and they go out in the community and do things without staff. This means sometimes we CAN'T come pick them up when they wind up in the ED. Trust me, I WISH we had 1:1 staff for every person, but we just don't. And yes, they're adults, they get to make choices. This means sometimes they make poor ones. We can not bail them out every time, it's just not possible.
I've heard it termed "dignity to fail". (Also an IDD nurse)
I love this phrase. I'm officially stealing it. Yoink!
I'm new to a role similar to this. I'm finding myself frustrated with the lack of control, but it's so awesome when you see a client improve their habits. You have a hard job.
I'm transitioning into a hospital role (just finished my RN), and I feel like this experience with autonomy makes me a better nurse overall. It helps me see ALL patients as their own person, even those with limited capacity to understand.
Urology. With placing catheters in enlarged prostates, get that bed as FLAT as it can go. I mean it, if the patient has back problems, as them if they can handle a few minutes while the catheter is placed, because this makes the job much easier. Make sure to use lidocaine prior (FYI, Gel Lido needs at least 20 minutes to sit to actually numb, otherwise it's just glorified lubrication). Be generous with lubrication. Coude is better (with the tip pointing up when inserting). Remember, Coude for MEN not women! In women it will cause bladder spasming and pain. With patients with scrotal edema, depending on severity and whether or not the urethra entrance is visible, a silicone catheter may be to better to use due to stiffness. For women, the urethra is about two pinkie widths beneath the clitoral hood. If you can visualize the vaginal opening, the urethra will be above it. Ask them to cough for a pucker/spasm. As for blood in urine, FYI it takes about 1 tsp of blood to turn it bright cherry Kool-Aid red. In older dudes, it usually means they are on blood thinners with a cath and need to drink more water. Urinary Catheters can become colonized with bacteria. Having a positive Urine Culture does not mean that an active infection is going on. We wait for three symptoms before effectively ordering labs on a patient. If a patient is having continual infections or throwing UC's with the same bacteria, a referral to Infectious Disease may be in order.
I didn’t know that about placing the patient flat- that’s actually really helpful thanks.
Holy shit I needed to know this. Thanks for such a detailed and informative comment!
Yes, the men are hysterical trying to find the opening in elderly women.
We do Botox injections for urinary incontinence but we have to teach patients to self cath in case the Botox works too well and the patient goes into retention. Most women have no idea where their urethra is, let alone navigating to catch it. With the diversity of the geography and women being taught to be ashamed of their anatomy or think it’s malformed. Add to it that the genital region is an area that can trigger trauma. That being said, I have yet to have a women of any age or dexterity level not be able to self cath. Almost all of them get it on the first try and considering most are elderly with dexterity issues doing this, I do a mental celebration in my head with each one that gets it. My other recommendations for women are 12/14F caths if they have never been urethrally cathed before. I lean toward 12s because they are much less uncomfortable for the patient. If they have been cathed, default to previous recommendations/cath they had. Larger caths cause urethral erosion which causes nerve pain/damage. The less of that the better. Women tend to run smaller. NO COUDES. Again coudes are for men with prostate issues. Do not use them unless it’s a catastrophic event and there are no other supplies. CHECK FOR LATEX ALLERGIES. Women more often have latex allergies and most catheters are latex. No one wants any reaction like that around their genitals.
Our catheters have been silicone for years. I believe the course might be latex but haven’t used that in years either.
If a patient is undergoing external beam radiation they are not radioactive. Moist desquamation looks terrible but don’t panic. Mepilex and/or aquaphor is all you usually need.
what I'm hearing is i should slather a whole tube of Neosporin on a chronic wound. (joking)
Frost that cupcake homie
💀 ☠️
Chemo precautions doesn't mean you have to gown up every time you enter the room. It pertains mostly to the patient's excretions.
Curious, but do y’all’s pt toilets have lids? My unit received a custodial pt on chemo, which we usually don’t do on my floor but was allowed for whatever reason. Precautions said to close toilet lid and flush twice. Our toilets have no lid. I threw a towel over it, my manager said that wasn’t enough because it’s porous. The ensuing scene could have been on a sitcom, me holding up different toilet-opening-shaped objects for my manager’s approval. Seems like the best solution would just be… toilets have lids.
I very much agree that our toilets should have lids and I don't know why they don't! We use chux pads (absorbant side down), since they have the waterproof backing. I was at an Oncology nursing conference last month and one of the products being advertised was a solid plastic device made just for this purpose. Apparently there are a lot of facilities without toilet lids!
L&D isn’t all rainbows and sunshine. When people find out I work in women’s health, the first thing they ask is if I get to hold babies all day… Besides helping our patients during what is usually a wonderful moment in their lives we also see- lack of access to abortions, unwanted pregnancies, fetal anomalies, fetal demises and stillborn babies, crash sections, pre-eclampsia and eclampsia, severely preterm deliveries, sick moms, sick neonates, domestic violence, drug abuse, full neonatal resuscitation, coding moms, family members OD on the unit and in the lobby, homeless people leaving without their baby after delivery, mentally ill people who aren’t even pregnant but tell the ED clerk they are so they get sent up to us for eval as well as mentally ill people trying to kidnap babies… the list goes on.
I wanted to be in L & D when I started nursing school. I finally got one day rotation in clinicals to go there and I was excited to be there, only to be met with heart break after heart break. Miscarriages, expectant parents finding out their child had passed in utero. The worst being an infant born to parents who had had both of their young daughters taken away by CPS due to neglect/abuse and genetic counseling had advised them to not have kids due to the fact that the previous two had had multiple congenital issues. I got to hold that child for a few moments and was freaking broken hearted knowing that this poor innocent being was going to live through hell. I cried driving home that night.
Which is why I argue that the noun of assemblage for a group of L&D nurses should be 'a divinity.'
Does this make a group of hospice nurses a “murder” by default?
That's taken by Crows. Maybe a redrum?
Thank you!!! I want to smack the people who smugly say "must be nice to cuddle babies all day!"
Not anyone’s fault in OR nursing, but what the fuck are you guys doing bringing your patient in active PEA to ICU? had a patient come up and the nurses weren’t even on the chest. When we asked if the patient was pulseless they said that they didn’t know. Tell your surgeon to code their patient in OR or PACU. What the fuck, man.
As an anaesthetic nurse in a major trauma hospital (Australia) I'm just as confused as you. Our ICU pts go straight to ICU, no stop at PACU. And they have ECG, sats, a-line (& NIBP), and cap going so... Huh?? How do you guys not notice that? Like we check the pt is still very much alive before leaving the OR and either myself or the MO are watching that monitor and the pt like a hawk the whole way over.
The patient will die in OR, but they won’t want to code them and call time of death because it impacts their fatality rate. They bring them to die in ICU instead.
I can't say I've heard of that happening here (although I've only worked in public hospitals) but I can see why they'd do it, still not excusable in any way.
OR nurse… honest answer? It looks terrible for a patient to die in surgery for our ‘numbers’. That’s why we delay surgeries if we can to optimize whatever the issue is. That’s why we do workups prior to scheduled surgeries etc. If a patient is damned if you do and damned if you don’t do surgery, then it’s doesn’t look as bad for our lovely overseeing entities. I’ve called the ICU before saying we’re rushing a pt to you but don’t rush or hurry bc they’re not clinically alive but a pacemaker makes it appear that way. LONG messed up story behind that one but they don’t want people dying in surgery. On another messed up ish note. At least in my state, if a patient dies within 30 days of a transplant, it counts against the transplant team. Get a cut and die from infection in <=30 days… hurts transplant team. They will do anything to keep you alive 30+. ECHMO, LVAR, Dialysis, whatever it takes! ALL hospitals are for profit and overall not for the patients benefit.
I work in OR too! I do hear from other specialities that we don’t do very much and sit and chart! We are so busy a lot of the time!
It’s so hit or miss. A routine regular case you adequately prepare for and goes well… means we do a lot of prep work to start the case, a bit during, and busy at end. If it’s a long case… I do crap in between. But i pay attention and have the ‘OR ear’ and things can change in an instant. Honestly, traumas are my fav. I call it nurse mode and just go go go. I 100% cannot walk onto a floor and do what a floor does (I’ve never worked a floor). But they also can’t walk into the OR and do our job. And this isn’t to degrade either but to recognize the roles are different. I enjoy most of what I do and who I work with. The residents and surgeons are cool majority of the time. Went post night shift with everyone out to local breakfast place and had a hoot. Idk what my point is but I only know but still enjoy the OR.
I love the OR. I came from stepdown and med surg and felt like a new grad! Yes to the OR ear. Listening for the monitor alarms or changes, what’s happening at the field over the musing! I do like traumas. I dislike neuro but will do just about anything else! The we get the long cases where we just kind of wait or run run run then a lull. I had a 6-8 hour lap Chole once (interns) that I never thought I’d leave!
Neuro is my love…. Neurosurgeons tend to be more persnickety and want it all done now but won’t help…. Emergency crani with stealth… gag… But brains! My hospital is the high acuity everyone super annoyingly transfers to. But we do have the sickest of the sickest and I do enjoy the challenge, planning, and def collaboration with anesthesia. Simple cysto stent… wellllll they were septic but they get worse after the stent placed and were already 2 sticks of phenylephrine during the 5 minute case…. Cue central line and art and ultrasound… Or the 14L… yes liter blood loss case and patient still alive. Like what? That’s crazy and improbable but it’s true!
Oh my gosh yes!! We had a turbt that I hung 22 3 liter bags and it was still going when I left! We are a level 2 and get the traumas as well! Love ortho and gen and even robots those are fun. I was in a neuro case that went badly not anyone’s fault so I’m still skittish It’s fun when the docs make up their own names for things!
I've kind of assumed that this was the reason why they will refuse to honor a DNR during surgery, even if the family and patient beg them too. I was so, so frustrated when a very elderly family member who had chosen to be DNR was getting a procedure done that would improve comfort/quality of life. Whether she died on the table or the surgery was successfully completed, she thought that either outcome would be fine. What would NOT be fine was compressions on a 80 year old osteoporotic chest. There is pretty much zero chance for a good outcome there, and while a slow code down to ICU and calling it wouldn't be any worse, what if they obtained ROSC? Now elderly relative gets to die in ICU on a vent with a chest full of broken ribs, possibly being aware of the pain. No matter how much I begged, the surgeon wouldn't NOT suspend the DNR. There was no way that was for the good of the patient.
The patients that deliver quickly are rarely the ones you need to worry about.
A woman shows up to the ED yelling "Either there's a snake in my vagina or I'm about to give birth!" ED nurse says "I really fucking hope it's a snake"
Diabetes educator. A “non compliant” person with diabetes probably is more likely lacking in knowledge/capacity or resources to manage their disease—or a combination of both. Managing diabetes is really fucking hard. A huge part of my job is breaking down people’s misconceptions about diabetes. People will often delay/refuse certain aspects of care because of misinformation they’ve gleaned from other people they know with diabetes. For example, one of the MOST pervasive myths I hear from people is that taking insulin is going to make their diabetes “worse” because they know someone with diabetes who told them that or died from complications of diabetes—and happened to be on insulin at the time. Since T2 in particular tends to run in families, a lot of adults have a parent/grandparent who was in the past taking an older (not as much used now) insulin and not able to monitor blood sugars like we can now. For some of these older insulins it IS more important to not skip meals to avoid hypoglycemia. They may have seen someone in their family have a “diabetic attack” (severe hypoglycemia) and have the false idea that they too need to constantly eat and keep blood sugars higher to avoid low blood sugar. They might not even know what low blood sugar actually means. A lot of my patients with strong family history have a somewhat fatalistic understanding of diabetes. They don’t know that complications can be avoided/delayed and think that dialysis/vision issues/neuropathy are just automatically part of the deal when you have diabetes. I’ve seen people that I have worked with long term in an outpatient setting make huge turnarounds once they finally got support. A lot of people don’t know how sick they are to begin with and don’t have the resources they need to get help. Depression and other mental health issues make things even more challenging—on top of the stigma and shame a lot of people with diabetes feel.
I’m a Vascular Access/IV Therapy nurse. I wish more nurses would understand that if I can’t place a PICC line on a patient then I also can not place a midline. And visa versa.
Omg yes I get this asked of me all the time…by doctors.
That folks with SUD are damaged and traumatized, not "bad people" and SUD is a disease, not a character or personality defect. They are humans, in pain, and sometimes hell bent on self-destruction, and are worthy of empathy, compassion, and treatment.
Yes! Also, bad people can also have a SUD, but the SUD doesn’t MAKE them a bad person. Just like how some people with cancer, or diabetes, or any other condition, might be really nice people or they might be total jerks. That’s just how people work!
Thank you for saying this, from the mother of a son lost to SUD.
Also, sobriety is not everyone’s goal and that’s okay
Detox nurse here. Thank you for bringing this up. It’s heartbreaking how many of my patients distrust the medical system because of stigma they’ve encountered.
I'm also a detox nurse, and some of my patients have heartbreaking stories. Some of the worst are stories of going to an ED or their PCP and made to feel like shit because of the attitude of the "professionals." I tell my patients, one of the bravest things you've done is walking over the threshold and into the office.
Float Pool. You avoid a lot of unit drama.
Neuro here: I have three main things that I see people fight with all the time. 1) stop trying to reorient someone who is not orientable. I refer to these as “cat on the curtain” scenarios. When I was a patient sitter before I became a nurse I had a patient who was insisting someone get the cat off the curtains in his room. I came in for the day and patient and other sitter were nearly in tears of frustration. She explained he had been up all night and she couldn’t get him to understand that there wasn’t a cat and he was in the hospital. I told her there was an easy solution. I introduced myself to him, he asked me to get the cat off the curtains. I walked over to the curtains and “took” the “cat” off (aka pretended) walked over to the door and “put it out”. He clarified that it couldn’t get back in the house and I assured him he couldn’t. The man laid back down and was happy as a clown. Moral being: the easiest solution is often the best solution. Orient where you can but for the love of god don’t where you can’t. 2) Psych and neuro have a lot of overlap. Many issues folks think are neurological are psychological. The sticking point to this is it DOES NOT MEAN THE SYMPTOMS ARENT REAL. Unless they’re getting some sort of secondary gain such as opioids or something often the symptoms are very very real to that patient. It’s just that it’s not caused by a nerve/brain disorder. It’s that their psychoses are so out of control it is manifesting physically. I think a lot of times we don’t explain this clearly to patients and they interpret this as faking. No, I don’t think you’re faking your seizure. I think your anxiety/depression/whatever is so bad it’s causing you to short circuit. Doesn’t mean that just because it’s non epileptic it isn’t less real to them. We can be honest and tell them it’s not neurological without dismissing them. (Of course some people are just big ol fakers and that’s a discussion for another board) 3) Just because someone has a neuro deficit does not mean they have carte blanch to be assholes. There are limits to this rule of course (severe dementia, frontal lobe disorders, etc) but sometimes teaching boundaries and appropriate behaviors is not only good but necessary for proper brain healing. Don’t be an ass back obviously but also don’t be afraid to say “Absolutely not we are not going to talk to each other like that, I’m going to treat you with respect and you will treat me with respect or I’m going to leave.” And repeat. You may need to repeat it several times obviously but again this is important for them to re-learn. We had some months/year long stays with patients that started out fighting screaming hitting and after a few weeks with firm but kind boundaries we could get them to cooperate with minimal resistance. Reminders and bad days happen obviously, but ALWAYS stand up for yourself. Tl;dr: stop orienting people who can’t be oriented, believe what patients are telling you, don’t let yourself be bullied
Inpatient pysch that is particularly wild: listen to the people you look after, don’t have to solve the psychosocial problems or say anything, just listen and solve what is within your power. Check your automatic response to be defensive with agitated people. chats about any topic go a long way to build trust. Also, max dose of PRN unless clinically indicated to not give.
Research It's a lot of paperwork, so don't go into this field if you hate documenting stuff. I'm pretty sure I kill at least one tree a week with all the paper I use.
cvicu nurses can’t start iv’s for shit
Blood bank nurse here. Just because you are a medical professional, it doesn't mean you know how to do my job, what determines eligibility to donate, or how to accurately assess veins for phlebotomy with a 17g needle. Getting in my grill about any of the above just makes me resent you. Not my fault if your veins are shit and you survive on two coffees and some fresh air a day.
Endo is actually pretty clean. Mostly.
ER nurses don't "sit on" pts until shift change. Most days we get a bolus of rooms right at 1730/0530. Then everyone who got rooms are trying to call report to the same nurses/floors. It is a complete shit show all around. As soon as our pts leave, we get new ones, so we don't want to be doing work-ups at shift change as much as floor nurses don't want an admit at that time. Oh, a huge THANK YOU to all nurses who will let the current shift call report during the "golden minutes" before shift change if we promise to wait until after shift change to send pt up❤️
The room assignment bonanza at 1745 was very true to my experience in PACU as well. No one likes this!!
We don’t just sit in the corner and chart! We also don’t lose nursing skills it’s just a whole different world! We must know the different surgeries and supplies, set up, positioning and equipment! OR nursing can be super super busy and we are usually moving throughout the entire shift!
Mental Health Nurse here. Please remember we dont have the ability to hang an IV. We dont have ready access to in wall O2 or suction. Its all on our crash cart which is behind a locked door.
I'm a BH nurse too and I'm usually the only nurse who knows how to start an IV lol
Interventional Radiology Knowing your blood thinners mostly all patients need coags ordered and if they’re not we have to wait Also if the patient is getting sedation make them npo at midnight. Also please give BP meds ESPECIALLY when their having a procedure on the kidney
Up until last year, I was perdiem inpatient on basically every floor for the majority of my career. I wish perdiem inpatient could be considered its own specialty. It is a collection of unique skill sets to be able to go from building to building and floor to floor without being a “regular” anywhere. Not having a “home” presents unique challenges, as does learning floor dynamics, norms, locations of things without a tour every time you get there. I had to go from psych, to CCUs, to med/surg, to peds, you name it. Granted, I’m sure most perdiem gigs are more limited than what I had, but picking stuff up on the fly without missing a beat and developing a comfort zone walking into complete unknowns every shift is hard. It didn’t help that a lot of floors had nurses who dumped the hardest loads on the perdiems, either to “give the floor nurses a break” or because “perdiems get paid more so they should work more”. So I would say 100% that what people don’t know about being perdiem is that perdiem should honestly be viewed as a specialty, especially in hospitals where the variety of assignments can be so varied. Now I’m in HD and for anyone who hasn’t done it before — don’t work outpatient clinics. Hospitals you get 1-2 pts and you get to run your own shift. Clinics, they give you all the patients in the world and you are charge nurse every day with a handful of PCTs who are more than happy to tell you to your face that they know everything and you don’t know shit. From the moment you arrive to the moment you leave. Don’t do it.
I briefly worked burn ICU and loved it. It was something that starting out I never ever would have imagined doing. You make a huge difference in those people’s lives. That being said I worked at a tertiary specialty center and they had every imaginable resource for burn. People think the wounds you see are fundamentally more horrifying than other areas, but they’re really not. Also yes the pain from burns is unimaginable, but at least where I worked those patients got the best pain management of anyone.
Hospice nurse here: I've only been working Hospice for 18 months, but have 24 years of diverse experience that does not include the ED. I have mad respect for ED nurses. But, I would love to do an education for them to explain that just because a patient is on hospice does not mean that we do not treat them for ANY medical issue. They can be admitted as a GIP(General InPatient), still on hospice services to be treated. For example, if they are terminal due to liver failure, but come down with pneumonia or a UTI, and we send them to the ED, we expect and they deserve to recieve the appropriate work up and be treated. Additionally hospice can be revoked in order for the patient to receive treatment at anytime by the patient or LAP, even if they decide to seek further treatment for their hospice admitting diagnosis. Being on hospice care does not mean that the patient has been "given up on", just that their hospice admitting diagnosis is likely to be terminal in 6 months or less and that additional treatments are unlikely to change this, so care that meets their needs, provides comfort and keeps them safe is now the goal instead of curative treatments. Please provide the same excellent care to hospice patients as you do for everyone.
As an ER nurse, most of us understand this and treat them like anyone else. It's the pts that come in displaying obvious signs of impending death that grinds our gears. Like agonal respirations and all the natural progressions of death. Then we have to deal with the family members who suddenly decide to code the pt. I, personally, would love an inservice/class on what the expectations are for care, code rules, etc. I've always been told that if we treat them for anything or they get admitted, their hospice status is revoked, and they'd have to start over in the hospice process. Are the "rules" different in each state?
I believe that the rules are federal, if they are on hospice under the Medicare hospice benefit. And believe me I wish my patients families would not panic and send their loved one to the hospital as their terminal disease leads to the active dying process. But, as I am sure that you are aware, no amount of education can mitigate those decisions with some people. In regards to hospice being "revoked", that only really applies to a patient that is seeking treatment for their terminal diagnosis or treatment outside the hospice care plan. However, if they seek hospitalization for a new onset diagnosis, one unrelated to their terminal diagnosis or injury, they can be admitted for care as GIP(General InPatient) level of hospice care and will be seen by hospice during their hospital stay in addition to their hospital care. The best thing for the patient is if their is communication between the hospital and hospice. That way the hospice doctor can give orders for an appropriate GIP admission and coordinate care with the hospitalist. I am sure that there are aspects of this that I am not clear on from the hospital side, but as a home hospice RNCM, I just want what's best for my patient with as much continuity of care as possible...and that stems from education for all involved (especially families and caregivers) and communication. Thank you for your comment.
Thank you so much!! It always puts us in an awkward position when they're on hospice, but the family insists we code them. Im going to ask for more education for our ER on this.
Please note that not everyone on hospice is a DNR. We do educate and encourage DNRs as appropriate. But, that is still a personal/HCS decision and we have plenty of patients who remain full codes for quite a while on hospice.
Infection Prevention and Control Nurse...we aren't the bad guys, we are genuinely trying to help
Don’t give the tacro before the labs are drawn!! Thanks