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Below are the 20 most recent journal entries recorded in New Grad Nurses' LiveJournal:

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Tuesday, August 30th, 2011
8:45 pm
[nursewithaunit]
An interesting evening.

I’m a little pissed because I made a good catch this morning but should have picked it up earlier.

I came on last night at 2245, got report and started my tour.

The only interesting thing on report was a fellow who had crappy lung sounds. He was started on Levaquim 500mg PO BID x10 a few days ago. Well, this AM he had a chest x-ray done and it came back as likely CHF, plural effusion, etc. No order for furosemide, which I would have expected and right there is where I should have started to get suspicious.

Anyway, since he was on report for the ABX he had to have his temp checked at least once per shift.

I went and checked on him and he was fine. Report said he had some breathing issues earlier but when I checked on him he was breathing fine with 2Lpm of supplemental O2 via NC. No s/sx of cyanosis. No dyspnea, SOB, etc. Basically, he seemed fine.

So I didn’t check his O2 sat. I should have checked it as soon as I saw the CHF dx, but when I saw him and he had no distress…………..

So around 0545 I see him on med pass and he just seems ‘off’. You know what I mean. You can’t put your finger on it, but you –know- something is going on, your nursing Spidey-Sense starts tingling and you start paying very close attention to whats going on.

I corral my CNA’s and ask them if they notice anything different about the resident and they say that he just seems ‘off’.

Now the thing that I and I think everbody else hates about our job is that we get to spend so little time with our residents/patients. I have 40 residents and spend maybe 3 minutes with each one per night. That’s it.

I bang out the rest of med pass as fast as I safely can. Check my watch. 45 minutes until shift change. I grab my stethoscope, sphygmomanometer, O2 meter and thermometer and decide to go play with Mr. CHF for a little while.

I go in and start with a pulse ox reading. He’s combative, as he always is, but I have weight, age and size on him.

Pulse 95. Ok, not outrageous especially since he’s fighting me.

Pulse oximetry…..%79-80. What the?!?!?

Run the pulse ox again in case his fighting gave me a false reading.

Pulse ox holding on %80. All the while he is still getting O2 at 2Lpm via NC.

Check his lung sounds. Bilat crappy w/ expiratory gurgling. Nail beds have good capillary refill, but are a little dusky.

That’s enough for me.

Off to get the supervisor. I tell her what the skinny is and that I want to call the doc and get some Lasix going.

She comes up to the floor and calls one of the admin nurses. The res is the father of one of the admin RN’s. She tells the admin nurse that I called the supv regarding the res and that she should come and join us to see what has got me so concerned that I had to get the supv.

I suspect she thinks I was overreacting. We get there and examine the guy. She greenlights me to call the doc and get some meds rolling.

Note to students and new grads: When you have to call the doc to report a change of status you’re going to find that there are two types of docs. One type will take your report and then say “Do this, this and this and then call me if there’s any change”. These docs are easy because all you’re doing is acting like a stenographer. He dictates the order and your off to the races. The other kind of doc is the one who takes your report and then says “..uhhuh…ok..so what do –you- want to do?”

What do –I- want to do? I want to do whatever the freakin’ guy who went to med school wants to do!! Although in a way I suppose it is a vote of confidence that the doc is asking what the person who actually has “boots on the ground” wants to do. I suggested 40mg IM Lasix and a bump up on the O2. Doc went with 30mg Lasix IM and supplemental O2 at 3Lpm via NC.

Done. 45 minutes later he’s sat’ing around %90 and is visibly more comfortable. His daughter, on the other hand, was a bit of a trainwreck.

Was it a good catch for me. Yes although I should have picked it up as soon as I came on. As soon as I saw CHF on the report I should have gotten an O2 sat right off even though there was no distress at that time.

Other stuff:
The CXR was done that AM. On the 24hr report it stated that the MD was contacted to give the results to but there was no note showing that he ever called back. That’s why he had no furosemide order; doc had never called back. 1500-2300 should have seen on report that a call was out to the MD and had not been returned and then followed up.

Stuff happens.

Lesson I learned: CHF = get a pulse ox right at start of shift/tour.

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Spoke to the admissions folks at the local diploma mill.

My transcripts finally showed up. I have to go by Thursday morning, meet with an adviser and get classes picked.
Sunday, August 28th, 2011
7:40 pm
[nursewithaunit]
Monday, August 22nd, 2011
1:52 am
[nursewithaunit]
How very odd. I am sitting at the Nurses Station, it’s 0110 and I have my laptop out and have Internet access!!!!

There is an allowance made for the use of personal laptops presuming all other work is done and one is attentive for bells and alarms. So……here I am.

I’m doing nights now by myself. Last night was my last night of nights orientation, so tonight I am flying solo.

I’m on Unit 3 tonight. I wanted 4 because I am way more familiar with that, but…… I don’t have a ‘home’ yet. I’ll float between 3 and 4 but learned that the 4 night nurse is bailing out in a week. I’m goin to talk to the 4 Nurse Manager tomorrow and see if I can get her to have me as the permanent 4 night nurse. She was pretty happy with me during my day tours orientation and I did a week of nights there as well with no problems, so………

The job is not that different than it was at my last employer. Subtle procedural differences, but otherwise not so different.

I’m still waiting on my college transcripts to hit the local school so I can get registered for fall classes and start chipping away at RN.

It feel strange and yet comforting to be back on nights. I’ve been getting less sleep than last time but haven’t really been tired at work. Part of that is probably excitement/anxiety about being in a new place, but maybe a part of it is I am just pretty accustomed to nights.

Anyway, the new job continues as does the hunt for a better paying one.
Wednesday, August 10th, 2011
8:34 pm
[nursewithaunit]
I had my med pass audit yesterday. For those not familiar with the term, the med pass audit is when a person newly hired to facility is shadowed by the Staff Development/Training director who watches to make sure that the med pass is done the facility way.

It’s much like your drivers license road test and about as relevant. After you have successfully taken your drivers road test you will –never- drive with your hands at 10 and 2, adjust the mirrors as soon as you get in and use the rear view mirror to back up instead of throwing one arm over the passenger seat, craning your neck around and steering one-handed while you floor it in reverse.

Similarly you will never again place a med cup on the med cart and then stoop down to read the level while pouring with your hand protecting the label, completely lock the cart and close and secure the medex when you turn your back on the cart, or actually remove the relevant pages and take them into the room with as you check the ID on a patient you know by sight and name.

Anyway, I had my med pass audit and it seems to have gone well. Passing meds is one of those things that I don’t really have any problems with after a year of experience, but I still get a little anxious doing the audit.

The hardest part f the new gig is just matching faces with names. It’ll be much easier when I go to nights and everyone will be in their labeled rooms and beds and not on PT, LOA or at Activities.

Tomorrow I spend my day tour off the unit and will be shadowing the treatment nurse throughout the facility. While the floor nurses handle most of the treatments, anything staged (Stage1,2,3,4) gets handled by the Wound Rounds Nurse.

I actually enjoy wound care. I feel more ‘nursey’ when I have blood on my gloves; like I am accomplishing something.

So far days has been interesting. It had been a while since I had done days and I had forgotten how the pace sometimes get.

I’ll be starting nights this coming Sunday.

Nights tends to be -----generally----- more relaxed, although the last 2 hours (0500-0700) tends to be all go because you’re trying to hit the 0600 med pass and have it done before shift change AND have charting done on any little fires that the CNA’s discover when they’re waking people up. I –HATE—it when I see a CNA’s head pop out of a doorway and say “Hey, come look at this!”. As soon as they say that I know I just lost 30-45 minutes off my schedule.
Sunday, August 7th, 2011
7:41 pm
[nursewithaunit]
A couple administrative details first.

Very shortly I will stop posting in the NewGradNurses group because I will be hitting my one year anniversary of licensure and I think that after one year, you’re not really a new grad (although you are still dangerous!).

I will continue to post on my own LiveJournal page, as well as the Nursing and CynicalNurses group. I will also soon start again on the Nurse_Students and Student_Nurses because I will, hopefully, be starting school again this Fall to start chipping away at an ADN.

So, whats ben happening lately in the life of NurseWithAUnit?

When we last left our intrepid hero, he had just been fired for falling asleep on the job.

Well, I was out of work for 3 weeks before starting a new gig, which I found after less than 2 weeks searching.

Nurse_Students and Student_Nurses take note: The FIRST job you find takes much effort and time. The second one you find is usually easier because you have more experience, know what the DON/HR/Staff Development people want to hear (or as I say to them “Look, I’ll act like a $20 hooker; you tell me what you want to hear and I’ll try and say it like I mean it.”) and most importantly, you have some experience. Suck it up the first year; it’s gonna blow. Once you have that one year under your belt, maybe a couple continuing ed seminars/conferences/classes and now you become a lot more desirable.

Anyway, I landed at a LTC/Rehab joint about 15 minutes from my home. It’s much bigger: approx. 250 beds and spread over a 6 story building.

Right now I am supposed to do 2300-0700 shift. I’ll take 2 nights on Unit 3 and 2 nights on Unit 4 and one night a week they’ll find something for me. I’m not thrilled about that. I just wrapped a week on 3 and am in the midst of a week on 4. I would much rather get assigned to one floor so that I can learn it inside out and know all there is to know about my residents.

Since I have only worked one place before, this place is very illuminating. People always told me that you can go from facility to facility and the job is pretty much the same. Turns out they were right. Certainly there are little nuances and changes but the big stuff remains the same.

Some interesting differences:
New place (hereafter known as The Barn) has decent staffing. The CNA’s are mostly hard core. They are fairly well motivated and have good morale and I am seeing that that makes a HUGE difference. Also, The Barn uses the CNA’s right up the edge of their skillsets. Example: CNA’s obviously can do vital signs but at Site W they wanted them done by nurses only. The Barn has the CNA’s do vital signs as well as weights, skin checks and even enemas. On the other hand they have some restrictions on what LPN’s can do. At Site W if one of my residents said they were having trouble breathing I would go in and get a set of VS and check lung sounds. OK, I’ll give some PRN Albuterol. Do that, go back and check lung sounds. Not that much better. It’s 0200 and I’ll call the doc and ask for 2mg IM furosemide and can I get an order for a CXR in the morning? At The Barn they classify lung sounds as an assessment; that’s an RN gig. No PRN administrations without an RN assessment first. No calls to doc without clearing it through supv first. There is an annoying little loss of autonomy. I do notice however that the reality is very different than the ideal and –everyone- seems to understand that.

We can pass meds during meals, which is ---way--- cool for scheduling purposes!

They mandate which is fine with me because that means I always have full CNA staffing. If you’re mandated you get paid doubletime.

They provide you with one meal per shift. It’s usually nothing great, but once in a while they hit the target and have something edible.

They arguably have a dedicated treatment nurse, so the floor nurses don’t really do treatments except when the treatment nurse is late or out or if a dressing comes off during shower or the like.

On the downside the money sucks. On a 40 hour day tour, I take home slightly less than half of what I was taking home from Site W for a 56 hour night tour. Those differentials make all the difference!!!

I’m doing 3 weeks of day orientation then I’ll do a week of night orientation and then it’s all me all night all the time. It’s very strange to be on days again. It seems like once the breakfast and lunch med pass are done and some minimal charting finished it’s just sitting around playing grab ass until relieved.

Nights, in my limited experience, tends to be different. It is slow but it always ends on a frantic note because your biggest part of the shift, 0600 med pass, come dead last, right before shift change. On days the last hour is sitting at the nurses station watching the clock. On nights the last hour is the mad scramble to finish the pass and get the last note written before the 0700-1500 team comes in to get report.

Thus far things aren’t too bad. The staff seems mostly younger. Admin seems like a less offensive and malicious variety of weasel than at Site W, but that may change later.

The money really is a problem though. I am going to need either a raise or an assload of OT to be where I want to be. I suspect that if I find something else that pays signfigantly better (like the jail job I am looking at) I may have to think about moving jobs again.

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Went and took my reading and math placement tests for the local diploma mill community college.

I have most of the pre-requisites for the RN nursing program but it’s very competitive. The pre-req’s I am missing I’ll take first, see where I sit on the list and then while waiting take some of the classes that I have already done but not especially well and re-do those.

I figure if I can keep classes to between 0800 and 1200 I should be ok.
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This is my last full weekend off. Important tip to the Nurse_Students and Student_Nurses and NewGradNurses: find out if there is a weekend diferential -----BEFORE----- volunteering for permanent weekends. Learn from my mistakes!
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That’s about it. I catch day tours the rest of the wek. Tomorrow will be my last chance to fine tune my morning med pass skills and on Tuesday I’ll have a med pass audit with the Staff Development person. I’m nervous a bit, simply because there’s so much little crap that you have to remember to do that you will likely never do again.
Wednesday, July 13th, 2011
3:43 pm
[nursewithaunit]
Well, much like dating, if you lower your standards your odds of success increase.

I got a call back from the nursing home (Site B) that I interviewed at yesterday. They want me to start the process and my first day of work would be 25JUL11. A couple weeks of days orientation and then shift to nights.

I haven’t heard back from the jail job, although I did call my hook over there and asked her to find out what the skinny on my app is.

I suspect I am going to take the Site B job even though it’s a financial hit. Right off the top its $40 a week less based on hourly. Then it’s an $80 a week hit on the decreased night diff. Then it’s a $32 a week hit for the lack of a weekend diff. All together a 40 hour week would get me $150 less per week than what I was making before.

Sigh.

I think what I am going to do is work at this place but keep searching for something else and bail if something better comes along.
Tuesday, July 12th, 2011
1:29 pm
[nursewithaunit]
Job hunting continues.

I had an interview today with a 236 bed LTC/Rehab place just north of here.

I always knew the place I worked at paid a bit better than most but I hadn’t realized how much.

Old Place: New Place:
Hourly: $17.10 $16
Night diff: $2 $0.50
Charge nurse diff: $0.50 $0
Weekend diff: $2 $0

If I go to this new place I’ll be taking a pretty fair hit. There are a couple pluses, but nothing that puts extra money in my pocket.

Still waiting to hear from the county jail job and a couple others.
Tuesday, July 5th, 2011
10:19 pm
[nursewithaunit]
Well, not a great day.

I was supposed to work 2 8-hour shifts this weekend. Friday the scheduling coordinator called and asked if I could do 2 12-hour shifts instead. I said I would as long as I got to work my choice of units. They said ok.

I did the 2 12-hour shifts and was only on my choice unit for a quarter of that. For the Monday into Tuesday shift I was scheduled for 8 and they called me that afternoon and asked me to come in early, turning my 8 into a 10. Not a big deal.

Well circumstances conspired against my getting any real sleep and I went to work at 2100 on about 1.5 hours sleep.

I was so exhausted that at 0400 I fell asleep in the staff bathroom after taking a dump. Supervisor walked by, heard me snoring and sent me home. HR called a few hours later and said I’m out of a job.

Bummer.
Monday, June 20th, 2011
5:43 pm
[nursewithaunit]
Oh the weirdness that is my life.

Work frequently calls and asks me (and everyone else) if we can “..help the team..” by working a 12 tonight instead of an 8.

Now I don’t have a problem with that, particularly when its overtime. However I have a very specific view and that is thus:

If you call and beg me to come do a 12 instead of an 8 AND promise me that it will be on my favorite unit and the when I show up and punch in, switch me to my least favorite unit, you are being deceitful and violating the whole ‘team’ concept.

So a few days ago they called me and said “hey, since your on for an 8 Saturday night, could you give us 10 instead?”. I said sure, provided that I got be on my favorite unit for the extra two hours. Then I would go to my assigned unit. They said fine. So I went in Friday night and looked at the schedule and they had me down for my least favorite unit for all 10 hours! OK, fine. From now on I’ll do all my 8’s and the next time they ask I’ll say no.

Last night they called and asked mt to take the 10 and switch it to a 12. I said that I wouldn’t because What I was promised and was (not) delivered were two different. Also I was maxed at 56 hours.

Here’s how desperate they were for staff last night. The offered (AND DELIVERED) a 12 hour shift on my favorite unit AND they authorized me hours above the 56 hour limit. That’s unheard of. They were –desperate-!

I didn’t realize how desperate until I showed up. The night supervisor called out and they could not get ANYONE to come in to do a Saturday-into-Sunday 12 hour shift. No one. They finally anointed a 26 y/o LPN from Unit 3 and made her night supervisor!!!

Could it get more weird/desperate?

As a matter of fact, yes!

Why was the appointed RN supervisor absent?

According to the rumor circulating her adult son was home and had a c/o arm pain. He went and saw a neighbor who is a nurse as mom was not home. Alleged nurse took a pill of some type, presumably a pain med, crushed it and injected it into the arm. Adult son wakes up next morning with his arm looking like the Michelin Man. Compartment syndrome. Goes to hospital where arm is essentially filleted and he goes to ICU where he currently remains.

If this is anywhere near true, it’s very damned odd.

Anyway, the brevet 26 y/o night supervisor did pretty well. She’s an ex-army nurse so she’s got a good head on her shoulders. Also, yes, kinda cute. 
Friday, June 17th, 2011
9:01 am
[nursewithaunit]
Well I have been working the past week or so on Unit 3, the rehab unit.

It’s very different than Unit 1. On 3, the folks are in for rehab so they actually get to go home eventually. Also, their minds work. It’s very strange to go up to someone and say “Good Morning Mr. NAME” and have them respond with “Oh, hi! How are you today?” instead of the the word salad I get out of my occasionally barely verbal folks on Unit 1.

The Director of Nursing says that the reason that I was transferred was to allegedly make me a better rounded nurse who could pinch hit in any unit. Also, supposedly I would learn more. So far my duties don’t seem all that different than on Unit 1 with the exception of my lifes newest bane: Medicare Charting. Oy!

How much can you say about a resident who was asleep when I came on, asleep all shift and asleep when I went off? “Resident in bed with eyes closed breathing regular & even without difficulty. 0 s/sx of pain, discomfort or distress. Bed in lowermost position. Call device @ hand.” That’s about it. The occasional “Foley patent and draining XXX mL of COLOR OPACITY urine at this time” or “Nasal cannula in place delivering 4Lpm of supplemental 02”.

The other duties/tasks really aren’t that different than on Unit 1.

A couple of nice things about nights on 3 versus nights on 1; on 3 I am busier. While on the face of it that might not seem like such a good thing, I find that the busier I am the faster the night goes and I don’t get drowsy on shift. Another nice thing is THERE IS A OTHER NURSE WORKING WITH ME!!!! It’s not just me flying solo. And since there is another nice, I only have –half- the unit (20 people) instead of the whole unit (40 people).

Bad stuff: THERE IS ANOTHER NURSE WORKING WITH ME. Meaning I can’t play the radio, work at a more leisurely glacier-like pace, eat residents ice cream from the freezer or make what I call Nutrition Sandwiches (Rice Krispies, Sugar and soft Ice Cream slathered into sandwiches on large sugar cookies) out of stuff from the Nutrition/Snack Cart. Also, I had been using the graduated cylinders we have for urine measurements to make Frosted Flakes & Milk to eat during chart checks; can’t do that now.

Also, before on 1 the supervisors office was hell and gone from my unit. You practically needed a passport and a subway token to get from my place to the supervisors office. Now……..15 feet away.

So, it hasn’t been to bad. I work with good people for the most part. A few ok people and one or two folks whom the world would rotate quite nicely without. My environment is much classier. The nurses station is sheathed in oak (real stuff, not formica), theres carpeting and all the rooms have flat screen TV’s including the lounges. There is a better ice maker (important to me) and a seriously better stocked Clean Linen Supply and Medical Supply. The quality of CNA’s seems better.

In the morning I have my little cluster of little old ladies in wheelchairs who I practice appropriate jokes on. I’m toying with getting yellow painters tape and as a joke making little parking spots for them at the Nurses Station. They hang there to hear all the ‘gossip’ about the other residents.
Wednesday, June 8th, 2011
4:19 pm
[nursewithaunit]
There is a move afoot to transfer me from my beloved Unit/Wing 1 (Dementia) to the pimped out Hollywood unit Wing 3 (rehab).

Its not a question of if I go as much as when I go.

I showed up the other night and they threw me on 3. I don’t want to be on 3. I’d rather be with my demntia people. Not because I have any great love for them, but rather because I know all of them and their little quirks. I can look at someone and watch them for a couple of minutes and tell if they are off their normal or not; I know how they take their pills (crushed, in vanilla ice cream, call them Mom while they are taking them).

So I did a night tour on 3. It wasn’t as bad as I thought. I hate not knowing the patients. Also, there is an assload of medicaid charting and while my ‘regular’ charting is satisfactoty (actually, it’s pretty damn good), Medicaid charting has me totally lost. On the plus side, Wing 3 is a 2 nurse post (assuming the staffing shows up, a big risk these days), so instead of 40 patients I have 20.
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Another resident died on me the other day. Thats 3 in a month just for me and about 5 or 6 for the unit.

1900 shift change:
ME: OK, thanks for report. Get out of here. Run. Don’t look back.
OFFGOING: Good luck, see ya tomorrow.
(I grab some roxanol and head towards dying residents room)
ME: Shit! (thumping sternum) Wakey, wakey! (res name) are you in there? Fuck!
-Storming off to nurses station to get my stethescope-
CNA: Whats up?
ME: (res name) just checked out.
CNA: Are you sure?
ME: I will be in a couple of minutes. If she’s not dead, she’s very very calm.
CNA: Now way! We just did care on her 5 minutes ago and she was fine.
ME: Really? Well, what the hell did you do to her? (said jokingly)

Sure enough, she was off to the Eternal Care Unit. I went and rounded up a supervisor to make it official (I can’t pronounce as I’m just an LPN; need an RN for pronouncements).

Now I have over 200 syringes of rox and liquid Ativan to count every shift change. Sigh.

I let my next higher know that we –really- need to waste narcs. Lets see what happens.

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In totally shallow and silly news, I have switched to my new working togs. The problem I am having, and that hope all of you can help me with, is I can not find a mens white medical/dental tunic for sale from a US business. All the ones that I find on line have to be ordered from England.

I refuse to believe there is not a single place in the US that sells a white mens medical tunic of the type shown below:



I’m just looking for the classic working medical mans attire. You’d think the internet would be lousy with these things. Nope. Anyone able to help?
Saturday, June 4th, 2011
12:15 pm
[nursewithaunit]
Seriously? How much morpine?
Oh what a time we’ve been having.

I had one patient die on me the other day. We’d been giving him Rox q2 for a couple days and his end stage dementia combined with COPD and a few other underlying issues finally pushed him out the door. He went a little rough but it was relatively quick.

This is the second person to die on my watch. I guess now that my streak is broken, it doesn’t really matter; “The first one is expensive but all the rest are free.”

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I order the meds for my unit. The narcotics are ordered by the Unit Charge Nurse, a malicious condescending creature who has been pissing off a lot of people lately.

I did my count when I got off duty this morning. In –ONE—med locker for the A side of the wing (19 residents) I have 181 syringes of morphine!!!!!! One hundred eighty one. B side has 17. I have enough roxonal right now to send the entire facility resident population t the Eternal Care Unit. The pisser is that half of that rox is d/c’ed and just hasn’t been wasted yet. My Next Highers keep saying they will come and pick them up, but never do. My end of shifts are starting to look like a bad Sesame Street episode in a rough neighborhood as my relief counts aloud and tosses a narcotic filled syringe into a bag with each verbalized number.

One resident who just went on hospice and has –NO- PRN for rox and gets it on orders q6 has 120 syringes!

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Last night I came in and was waiting by the time clock to punch in. The night supervisor came in and said hello. She looked and sounded fine.

When the night supervisor got to the scheduling board she saw that instead of supervising only, she was to take the keys and have a unit (Wing 2). Now this is a supervisor who would rather receive a razor ribbon enema than “take keys”.

She went to the off going supervisor (coming of an 8) and said she had a sore throat and was going home and she left! The remaining supervisor had to a double and her sister who car pooled in with her was also stuck! About 2 hours later the sore throat supervisor showed up in a very quiet and humble mood and took keys and went to work, relieving the other supervisor and her sister. Appearantly the higher ups called her at home and explained the facts of life and the realities of future unemployment. A very embarrassing situation for all who were around.

I have a different view about work. If you don’t like your job, don’t show up. You can bitch and moan but the end result is that you can always leave if you don’t like it. Should work treat us better? Yes. Do we have a right to complain? Probably. Does work have an obligation to act on our complaints? No. It’s a free market system; if work gets really unbearable then they will lose staff and have to shut their doors. As much as employers should treat staff well, staff has the whip hand since they can always leave.

I need a job. I balance my need and desire for a job against the amount of stress, heartache and mind numbing hours work gives me. At the moment I come out ahead. For the moment.

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Walk into work the other night and step into The Octagon (as I call the nursing station). The 2 nurses I am relieving are very quiet.

ME: Whats up?
OTHER NURSE: There’s some big trouble going down. The state is going to have to come by!
ME: (sphincter tightening) Whats wrong?
OTHER NURSE: (name of resident) climbed out his room window and got outside!
ME: No shit?! When?
OTHER NURSE: This shift about 2 hours ago. I was doing med pass and heard someone pounding on the fire door. I looked through the window covering and saw it was (resident name). He wanted to come back in.
ME: No doubt he forgot where he parked and wanted us to call him a cab.
OTHER NURSE: This is serious and its not funny! The state is going to be here to investigate.
ME: It is funny, especially since it didn’t happen on my shift. Likewise it’s not serious since I’m not at fault here. No one is. The guys an elopement risk. The only reason he hasn’t broken out before is because his VCR was working and we gave him all the surplus tapes we were going to throw away when the facility switched to cable and DVD’s. I guess he finally finished watching them all.
OTHER NURSE: This isn’t funny! There going to be an investigation! The state is coming!
ME: And they’ll find it’s no ones fault, we did all we could and documented what we did. So lets count, give me the keys and before you leave, call maintainance and have them come by and nail his windows shut.

And that’s what they did!

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We are wicked shortstaffed on nurses at night. Now one is getting ready to on maternity leave and another just went on vacation.

They are starting to shuffle people around and I suspect that –very—shortly they are going to put me on Wing 3 which is the money making “Hollywood” (all pimped out) unit.

I can not begin to describe how badly I don’t want to go.

I’m comfortable right where I am. I would learn more on 3 for sure, but right now I need to just have some stability for a few months.

-=-=-=-=-=-=-=-=-=-=-=-=-==-=-=-=-=-=-=-=-=-

Oh yea, Evil New Slightly Hot Charge Nurse From Hell got written up yesterday. Facility regulations require that all the CNA have a gait belt on their person at all times (although they –almost- never actually use them). Most CNA’s wear it around their waist, under their scrub tops. The Evil New Slightly Hot Charge Nurse From Hell allegedly ‘patted down’ one of the CNA’s to make sure she had her gait belt with her. Big mistake. CNA went to HR and HR asked for a moment of ENSHCNFH’s time…..now!

Other issues have popped up as well. I don’t think she’ll be around for the Christmas party!
Saturday, May 21st, 2011
10:22 am
[nursewithaunit]
New things added to my list of duties:

Do walking rounds with the supervisor at the beginning of the shift. I am to insure (either through my own work or supervising the work of my CNA’s) that each room:
Has call bell within residents reach
Shoes are not on chairs (wheel or otherwise)
No dinner dishes or glasses left in room
Not have 8 different Styrofoam cups of water on the bedside table
Toilet contains clean water (has been flushed)
No laundry on floor
No tissues, papers, etc. on floor
Also, around 0200 I or the people I supervise are to go to the two dining rooms on the wing and put table clothes on all the dining tables and put out placemats and chairs according to the seating plan.

Sometimes I feel less like a nurse and more like a glorified concierge with narc keys.

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=

The fellow who dies on me the other day showed some odd behavior before he died. Normally a quiet fellow, the last 4 days before he checked out he became considerably more verbal and animated. He started yelling out at night, which was something he had never done before.

The woman who died the other die did the same thing. She was always very very quiet and non demonstrative. The 5-6 days before she died she would sit up and wave at me when I came in with meds, tried to self transfer (she had NEVER tried that before) and was more verbal and animated when in her wheelchair amongst other residents.

Is it typical to see non-typical behaviors in those who are about to ‘leave us’?
Thursday, May 19th, 2011
8:47 am
[nursewithaunit]
I'm really getting fed up with management where I work.

the big problem is that since I've never worked as an LPN anywhere else I don't know if its just my place that is screwed up or if its all places.

I'm thinking that just to screw with them I will ask for normal hours.

Right now I am scheduled 48 hours per week and then I pick up an extra 8 for a total of 56. i work every weekend and I work every holiday.

I'm wondering what they would say if I walked into scheduling and said "Gimme a 40 hour week, I want every other wekend off like everyone else and I want to be anm the alternating holiday schedule like everyone else too." They'd have to find someone to pick up my 2 extra 8 hour 200-0700's during the week and every other weekend they'd have to find someone for my weekend double 12's (1900-0700x2).

That would freak them out.

then again, it would be a big pay cut :(

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

In the past 10 days 3 people died on my unit. Anyone else eve just have a run of people checking out? Fortunately only one went on my shift, so although my streak is broken, I still have only ONE death on my watch.
Monday, May 16th, 2011
2:20 pm
[nursewithaunit]
Set the building on fire; do it now.
OK, back with a new hard drive after a wicked and annoying hard drive crash.

The worst part was losing all my applications and some of my un-backed up smut.

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-
Ever see that really classic movie poster for the movie PLATOON? The one with William Defoe on his knees about to die with his arms stretched up towards the heavens as if pleading?

You know, this one:
title or description

I would love for someone to re-stage this photo with the following changes:
Put William Defoe into scrubs w/ name tag, stethoscope, bulging pockets and coffee stains
Change the background of burning jungle to the employee entrance to the facility
Remove the VC w/ AK’s and replace them with supervisors w/ radios and administrators w/ clipboards.
Retitle it NIGHTSHIFT.

That’s how I feel after doing a double and making it out to the parking lot!

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

Work has been pulling some annoying crap.

They called me up on my day off and said they were short a nurse and would I come in for a half shift to help out. Having seen this movie before and knowing how it ends I asked “what unit will I be on?” Unit 1, I was told. Good, that’s my regular unit. ‘Will I be working alone?” No, there are two nurses on Unit 1 right now; when you show up we will float one to Unit 2 and you and the remaining nurse will cover unit one.

OK.

I show up. “Are you punched in yet?” Yup. “There’s been a change, you and the other nurse (who is a new grad/new hire) are going to do this shift as CNA’s.”

$#^%*&%&%$&%^*&^*&^!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Oh man was I pissed. Nothing against CNA’s. The only reason nurses in LTC still have their licenses is because of CNA’s , but I have been a CNA and don’t want to be one again! What really pisses me off was the duplicitous way that they waited until I showed up and punched in (point of no return) before they unloaded this on me.

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

Nights are pretty slow lately.

The higher ups have been reviewing surveillance tapes of the various wings and are now trying to micromanage the place. When we are between rounds and have completed our tasks and have nothing to do we are no longer allowed to read newspapers, books or do crossword puzzles. If we want something to read, we can read patient charts. Music is no longer permitted. Nightshift staff are not permitted to leave the unit for their meal break; they must consume their meal on the unit (this by the way is contrary to the memo we got 6 months ago saying that all breaks MUST be taken off the unit).

They tried to ding me the other day, saying that they reviewed video of me and I sat at the nurses station for our hours without getting up. My response was that the way my bladder has been lately, that’s impossible. They conceded I may have gotten up once or twice, but I spent 4 hours sitting there doing nothing. I asked what day they were referring to. They told me and I explained that I was sitting there for 4 hours because it was change over night and I was comparing every single medication entry in the NEW medex to the ones in the OLD medex and that because the camera only shows my from the shoulders up sitting behind a high nurses station counter, they could not see the medexes I was working on. Oh. OK, never mind.

Man I have got to get my feces cohesive and start getting back to school. RN can not come fast enough!

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

I’m still fantasizing about nailing the scheduling coordinator and administrator.


To a cross.


Doused in gasoline.


As a warning to the rest of the REMFS.

-=-=-=-=-=-==-=-=-=-=-=-=-=-=-=-=-=-=-=-=-==-

In doing my 24 hour chart checks I noticed that about a score of patients had gotten orders prescribing one alcoholic beverage QD PRN. What the f? It seems the Activitys people (of aspirated pretzel fame) decided that pretzels were not sufficiently dangerous on their own and decided to up the ante by having a ‘mocktail party’. That is to say a party where non-alcoholic cocktails would be served.

Seems reasonable.

Then someone decided that since everyone is over the age of 21 by several decades, why not use real booze?

(palm/face/contact!)

Let me make this clear. Someone decided it was a good idea, and management approved, the giving of alcoholic beverages to folks with assorted dementias.

Screw the residents, they should have whipped some up for the staff.

The absolute corker? As I read the orders for one patient, it said “Resident may have one alcoholic beverage QD PRN”. At the bottome of the page under Existing Dx, it listed this residents ailments as “dementia, hyperlipidemia, HTN, ETOH abuse, ……..etc”

ETOH abuse and you gave him a PRN for Jello shooters?

I am amazed that we always have enough rope for all the goats…..sigh……..
Saturday, May 7th, 2011
11:02 am
[nursewithaunit]
Jesus Take The Medex
This months medex change over was completed a couple of days ago.

Try to imagine taking a medex, dousing it in flaming surgical lubrican and then cramming it, still alight, into the mist distal part of your GI tract. I -wish- the changeover had been that enjoyable.

Swear to god I am going to start scheduling my off day around when changeove is being done.

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

My nine month streak of no one dying on my shift came to an end this morning.

I vame in to start may shift and had 3 people actively dying. One looked really bad and was undoubtedly going to go first while the other two were going to fight it out for second place.

Made my rounds and then checked on all the dying ones every 15 minutes all shift. 0330 I go on break, checking and making sure everything is good. Come back and my number two choice is gone.

First one I've had go on my shift.

Not a bad old guy. 86. Vet. Tarawa. Guadacanal. Not very communicative towards the end. Went in his sleep.

His family is 2000 miles away. I told them he went in his sleep and looked very peaceful, which is a lie, he looked like crap, but they'll never know and it made them feel better.

My other two active die'ers held on and were still holding when I left. One I suspect will hang on for a long while. The other one I would bet money on not making it through the weekend and probably not till tonight. We just started her roxanol and combined with 20 second apnea episodes and cheyne stokes, I don't see her sticking around for long.

It occurs to me that in 9 months I've only seen 3 people leave my unit alive. 2 went to another facility and one actually went home.

Thats thing with dementia LTC: no ones getting better and, realistically, no ones's going home. Not to their earthly one anyway.

It doesn't really phase me. I would have liked my guy to have had some roxanol to keep him more comfortable, but the family wanted him to according to God's schedule or some such.

Its hard for me to get upset or down about people on my unit dying. I've said it before: they're in a warm bed, there is a roof over their head, they have more meds (usually) than they'll ever need, they are surrounded by caring staff, etc. They're not lying on a medevac blanket getting dust blown on them as we wave in helicopters; they aren't pinned in a burning vehicle smelling their legs char as we try and hack the steering column out and extinguish the engine compartment.

There are a lot of crappy ways to go and I've been around for a few of them; checking out in a place like my unit is far away from being a bad way to go.

So do I get bothered by when my folks Go? No. Do I have compassion for them and their family? Absolutely. Happily though, it is very easy for me to disconnect emotionally and while some might find it a bad thing I think it makes the job a little easier.

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

Saw my first agency CNA at work today.

Appearantly the facility is so hated and despised by -all- the CNA's (and lets be honest, probably about half the nurses) that they can not get any CNA's to do overtime. Its gotten so bad that they now are getting agency CNA's.

CNA's had their hours cap raised to 64 per week. Nurses are still limited to 56 AND they will not bring in agency nurses. they would rather pull a jurse from a 2 nurse unit and have 2 units with one nurse each, than have each unit with 2 nurses one of whom is agency.

So..........my streak ends. It was a good run though; nine months without a death.

Back to work tonight at 2300 where I will hopefully catch up on some of the paperwork I didn't complete today/last night.
Sunday, May 1st, 2011
9:03 am
[nursewithaunit]
I can not begin to describe how hard last night was due to poor management and borderline criminal understaffing.

I have multiple fantasies. Some involve nursing. A few of those actually don't involve nurse uniforms, posey restraints, jello shooters and surgical lubricant.

My main fantasy right now: My unit, my shift picks up 4 new nurses and 8 new CNA's and they are ALL former Marines. Oh god would that be great. We'd be so well organized, self motivating, punctual and professional. On the downside we would probably be sending the occassional nurse-led 0300 raiding party into the staff lounge in Unit 3 but thats their fault for always having the better snack goodies and not mounting a guard.

As it is now most have the staff do the minimum needed to get to the end of shift and then they flee the building like its a crime scene. Whats really sad is these are not bad people (ok, some are). Most really -want- to a good job but are hamstrung by managerial fiefdoms, high school clique-ish nurses and a low level of morale due to management being very liberal about firing people.

Management gives us a lot conflicting orders. 6 months ago we got a memo that said under no circumstances were we to take our rest break (15 min.) or meal break (30 min.) on the unit. We were required to take our break off the units. Memo came down this week: all breaks are to be taken on the unit. Staff may not leave the unit for breaks.

So if I whine about this, what am I doing to fix it? Nothing. I still have the new nurse smell about me and freely admit that I am still learning a lot. If I had 6-7 years under my belt I might think about asking to fill the unit supervisor position that just opened up (my uni supervisor was fired for venting with foul language in her office).

What would make the place work better?
Give staffers permanent assignments. Stop floating CNA's and let them stay in one place so they can develop a rapport with the residents and their own systems for most efficently getting things done.

Assign nurses to specific units and shifts just like the CNA's for the same reason.

Try and keep people together long enough so they can develop a working relationship. I can't support and help my CNA's when they faces keep changing week to week and they are not going to have any desire to support me if they know that they are only going to be with me for 2 or 3 days.

Don't micromanage. Say what you want done, when you want it done and give some VERY broad directions how and then let us work the fine points. The most effective way to manage is to find a competent person, tell him what you want done, make the resources available to do the job and then get out of that persons way and only butt in if the f-ck up.

Use your freakin' brain!! Just because the supply chick has the weekend off does not mean that I don't need supplies on the weekend. Either overstock me on Friday or give me a key to Central Supply because by Sunday night my CNA's are swaddling residents in chucks and towels because we are out of adult incontinence garments.

Also since the laundry is closed on the weekend how about overstocking me on towels, chucks, linens AND HOYER PADS on Friday. You know the weekend is coming, it shows up every 5 days or so, so this really isn't a surprise.

Anyway, rough night and tonight will be just as rough with the added bonus of being a 12 hour goat rope.

I'm bringing the dog, whose got the pony?
Saturday, April 30th, 2011
9:17 am
[nursewithaunit]
You confuse discipline with foreplay.....
While looking at my pay stub yesterday I noticed that my nighttime differntial was listed as $2.50 instead of $2.00. So I asked my shift supervisor about it:

Me: Hey boss, I was loking at my pay stub and noticed my night shift diff is $2.50 instead of $2.00.
SUPV: Are you complaining?
Me: No, just wondering why the change.
SUPV: Let me see.............
Me: (give boss pay stub)
SUPV: Thats your Charge Nurse diff.
Me: My what?
SUPV: You get an extra fifty cents per hour at night for being the Charge Nurse.
Me: But I'm not the Charge Nurse, I'm a grunt.
SUPV: At night you're the only nurse on the unit, therefore you are the Charge Nurse. Also you are the Fire Response Nurse, Records Nurse, Med Pass Nurse, etc. You're in charge, making you Charge Nurse and getting you an extra half dollar per hour.
Me: Yea, now that I think about it, as the only nurse on the unit, I am the ranking staffer.
SUPV: Anything else?
Me: Still trying to wrap my around the "in charge" thing......do I get a badge?
SUPV: A what?
Me: A badge. Something that says "I'm in charge".
SUPV: (looking a bit askance) No.
Me: Do I get a sidearm?
SUPV: No.
Me: How about a saber?
SUPV: NO!
Me: Can I have anyone flogged?
SUPV: GET OUT!

So I can't have anyone flogged, which does kind of make being Charge Nurse pointless. Or is that just me?
Thursday, April 21st, 2011
8:17 pm
[nursewithaunit]
All the really interesting stuff seems to happen when I’m not around.

In some ways this is good and in others it’s not.

I’m a closeted adrenaline junkie; Marine Corps, firefighting, motorcycle, I like those moments of excitement. It’s how I’m wired.

I am unhappy when the interesting stuff goes down at work and I miss it because I want to be a part of that excitement, part of that out of the ordinary moment.

On the other hand, you have that out of the ordinary moment that goes awry, the heat starts coming down for it and everybody who was there gets to catch a little napalm. At times like that as the circular firing squad forms up, I’m grateful to have missed the excitement.

I’m doing my 1900-0700 shift. The Staff Development chick comes in at 0700 and sets up a Code Blue drill.

The shifts are changing and the call goes out. All the licensed people fly to the scene, commence to thumping & shocking and call it good.

Now the important thing here to remember is that the drill was done at shift change, so Nights AND Days were aware of it.

I have a nice fellow on my unit who has enough dysphagia that his diet recommendation is House Ground w/ Nectar Thick Liquids.

Right towards Days & Evening shift change (1500) he gets rolled into the Activities Room, which is staffed (not surprisingly) by Activities people.

Here we go..........

Due to chronic shortstaffing the resident is transported from the unit to Activities by a secretary. She rolls the resident in and hands him off to Activities.

Activities is having some sort of mini-party/festival and there is food. Whole, intact food.

The secretary asked the Activities folks if the resident could have a large soft pretzel, was told yes and gave it to the resident (according to the secretary, activities says she never asked).

At this point I should point out only Nurses and CNA’s are allowed to feed; NOT secretaries, activities, housekeeping, etc.

Resident starts to consume pretzel and then aspirates it. Choking resident is wheeled out of activities and headed back to unit when he becomes unresponsive.

Resident is a good sized man and all the immediate staff are older women or small younger women. They are unable to lift resident out of his chair and perform Heimlich Manuver although they try. Resident is placed on hallway floor and Code Blue is called over PA.

Now Day shift knew there was a Code Blue drill earlier in the day and they told oncoming Evening shift there had been one and likely would be another. The result was the rersponse to this Code Blue was, shall we say, lackluster.

Eventually enough panic creeped into the voice on the PA that people started responding. Crash cart rolls up and suction is hooked up to clear partially blocked airway. Suction is improperly assembled and will not create a vacuum. Airway manually cleared and O2 applied. Crash cart O2 tank is empty!

Eeventually working suction is obtained and airway cleared. A full O2 tank is obtained and supplemental O2 applied. Squad comes by and transports resident to local ICU where he is on a vent.

I come in at 1900 and hear about this Chinese Fire Drill. I think to myself that now is as good a time as any to go through -my- crash cart and see how it looks. Normally it gets checked once a day by the supplies person but then again so was the one that had empty O2 and bad suction. I threw away about half the stuff on the cart because it was past expiration, my IV kits were missing the IV fluids and assorted little odds and ends needed attention.

Thats the first interesting thing going on, the second is fingersticks.

The facility has handed down a new order that fingersticks on DM residents are to be done at 0630. Fine.

HOWEVER, insulin coverage for those fingersticks is not to be done until 15 minutes before meal, which is 0745 or so.

Thus when I stick my resident at 0630 and her BS is 350, I am to give her NO coverage. Instead I am to report my finding to the oncoming shift (0700-1500) and they will provide coverage before breakfast is served!!

Problems I have:

Aside from the obvious hyperglycemic ones for the residents........

The facility is asking me to sign that I took a BS reading but did not give coverage.
Then they are asking next shift to give coverage without checking for themselves what the BS is. Would -you- give someone their insulin without checking the BS for yourself?

I can just see some lawyer down the road asking in court :
“What did you do when my clients BS hit 375?”
“I wrote it on the 24 hour report”
“Why?”
“So the next shift could administer coverage.”
“And when would that be?”
“In about an hour” Ka-ching!!
Thursday, April 14th, 2011
10:40 am
[nursewithaunit]
In a post that really should be read by all nurses, sistrmoon (whose icon looks like my fantasy wife), has a link to an article about electronic tracking of staff. Go to the post for a link to the article.

Exerpt below:
When Sentara Princess Anne Hospital opens in August, it will feature a high-tech way to track who sees patients and how much time caregivers spend in their rooms.

Hospital staffers will be issued badges with tags that are scanned when they enter and leave a patient's room. Different tags will be assigned to different workers, and colored lights outside the room will indicate who is inside: say, blue for a physician or green for a nurse.

The information will be stored on a computer, so workers can better monitor the frequency and duration of the visits.

Stephen Porter, president of the Sentara Princess Anne campus in Virginia Beach, said this and other new technology at the hospital will help ensure that patients are getting enough attention. The system also will alert more hospital workers if a patient's call bell remains unanswered for a certain amount of time.

"It's not so much that we're trying to be Big Brother," Porter said. "We're going to be able to provide an environment that allows our staff to be at the bedside more."


Would this work with me and my fellow Nighshit Resistance/Darksiders?

Nope.

I know me. As soon as the supervisor hands me that badge I would velcro it to the housekeeping cart. As housekeeping makes their rounds, my records will show that I methodically visited every patients room and was in there for at least 5 minutes. In a dazzling display of efficency and patient safety awareness, I also checked each and every hallway bathroom, phone booth alcove and water fountain.

Thats what it would look like on the computer. The reality is that I am either asleep in the med room or in the lunch room fishing cookies packs out of the vending machines with a broken bed siderail.

Of course with my luck, I’ll either forget to remove it at end of shift or not realize that unit housekeeping phoned in sick that day. I’ll only find out when the supervisor asks why I spent 8 hours last night, according to tracker badge computer records, camped out in the janitors closet!
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