Last week, Wrongway Regional Medical Center (WRMC) had a Joint Commission survey. The surveyors found ligature points, being chairs, in the community room. A ligature point is defined as "A feature in an environment which could be used to support a noose or other strangulation device (especially, for the purpose of attempting to commit suicide)".
Joint Commission has ruled that patient care areas are to be “Without points where a cord, rope, bed sheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.”
The area of concern Joint Commission found was that the geriatric and child psych units community rooms were without doors. Therefore, it is believed that patients could unnoticeably enter the community room with noose made from a cord, rope, bed sheet or other fabric/material and attempt to commit self harm or suicide. Therefore, doors with locking devices need to be installed on the community rooms.
Fine. Sure. Okay. I guess, theoretically speaking, a suicidal patient could enter the community room unnoticed with a noose made out of a cord, rope, or bed sheet or other fabric/material, stand on a chair, throw it up over some ligature point and attempt to commit self harm or suicide. So doors need to be installed.
But what to do in the meantime?
WRMC administration has deemed that, until doors with locking devices can be installed, a specific staff member will act as a door, sitting in front of the community room doorway 24/7. This staff member will assure no suicidal patient will enter the community room with a noose made out of a cord, rope, bed sheet, or other fabric/material and attempt to commit self harm or suicide!
That staff member acting as a door will be allowed to do nothing else: No patient care, no 15 minute safety rounds, no charting, and of course no electronic devices of any sort, or reading material of any kind! The staff member is to just sit there and act like a door!
I kid you not!
The staff member assigned as a door will be relieved every 2 hours.
As I was sitting being a Door, I came up with an idea about a song for that musical called "Joint Commission Superstar".
Maybe I could do a little dance number to the tune of "Camp Town Races"?
Friday night had a patient who said she had experienced some dysuria in the evening and was currently, in the wee hours, experiencing anuria. I got a bladder scan of 366 mls and contacted the NP who gave me an order for a straight cath. The patient was to be followed up by the day NP. I passed on the information on in shift report. That evening, it was reported that the NP had followed the patient up, prescribed some meds. The off going nurse also mentioned that the patient had been bladder scanned and cathed x2 with the amounts given.
Later in the night, the patient again c/o anuria, so I checked the orders. My order for the straight cath was the last one entered. I thought of a line from the movies "Treasure of the Sierra Madre" and "Blazing Saddles".
Oh! And Joint Commission was in the building!
Do I hear a *DING!*?
Friday night, while sitting in the nurses station, I was working on finishing up two admissions. Bestica, the acting house supervisor, dropped a Staff Education form on top of one the admissions that I was working on and said, "You need to sign this and give it back to me". I picked up the form, tossed it to the side, and replied, "I'll sign it when I get a chance to review it". Bestica said, "Whatever. Joint Commission is going to be here Monday morning and we have to have it before then" and went on her way. I remembered the form Monday morning around 0400. Now, usually, these staff education forms contain information on procedures we all know well and the documentation and signing thereof is a mere formality. For example, like the procedure for performing an accucheck. This staff education form was on follow up assessments after administering a PRN. The information on the procedure was incorrect, noting the wrong icon to click on for administering a med! So I noted the error, drew a line through the "I understand and will follow this procedure so help me God", signed the form and faxed it to administration. This is a portion of the actual faxed form:
My supervisor, RoofElmo, was unexpectedly there at shift report later that morning, and implored me to sign a fresh staff education form. I refused on the basis that the procedure was incorrect for administering meds.
"But what they want you to focus on is the procedure for follow up assessments for PRNs" RoofElmo replied.
"If a portion is incorrect, the entire procedure is incorrect and I refuse to follow an incorrect procedure". About that time, Mandy the wonderful house supervisor showed up with a corrected staff education form and I agreed to sign it.
I wonder how many nurses signed the incorrect staff education form, not reviewing it, in the days before Joint Commission got there? *DING!*
A nurse I worked with a lot on the male adult psych unit over ten years ago, Dee Butcher RN, passed away. My work wife Eleanor and I got the news just last night. After we said our "Awwwwws", we began recalling memories. Dee was a great nurse and a very funny lady.
I recalled a conversation we as a group had in the lobby while waiting to clock in for our MN shift. One of the nurses said that a patient who had been discharged on the day shift was waiting in ER to be readmitted.
Dee said, "It doesn't surprise me because...
A patient incontinent of urine was transferred to the geriatric psych unit from another facility via ambulance stretcher and my work wife Eleanor immediately met the patient's hygienic needs. I was making rounds and noticed some liquid on the floor which was not easily seen due to the low lights in the hallway.
"Where did this liquid come from?" I asked Eleanor as I sprayed Dispatch and mopped up the spill with a towel."I think it was from the newly admitted patient because the trail leads all the way outside of the unit doors!"
:
A perfectly understandable error!
I received a shift report on the geriatric psych unit from a young know-it-all nurse and disagreed with her advisement:
Even we nurses use internet docs:
Didja ever notice how people will write "ect" when they mean "etc"?
Et cetera, abbreviated to etc. is a Latin expression used in English to mean "and other things", or "and so forth". Translated literally from Latin, et means 'and', while cetera means 'the rest'; thus the expression means 'and the rest (of such things)'.
Whereas "ect"...
Electroconvulsive Therapy (ECT), often referred to as shock treatment, is a psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders.
Big difference.
People often ask me, "Why did you get into nursing?"
Nurses attempt different types of interventions in order to make patients feel more comfortable.
Here's an example:
I graduated as an LPN in January 1984 and my first nursing job was at Mom & Pop Nursing Home where my great aunt resided. One night, she asked me for a pain pill for her headache. "But don't give me any of that Tylenol- that stuff doesn't do anything for me!" she said. Tylenol was all she had ordered for pain, so I gave it to her, referring to it by its generic name. This comic is the result of that intervention.
It is believed that nurses should only call off in the event of an emergency:
Here's some images copied and edited from one of my old journals:
Here's another situation from my time as an LPN student:
Here's another situation I experienced as an LPN student:
From the same journal, here's an edited entry of a situation that was truly a neat experience:
Little Brother drew this of me in 1984, depicting what he thought I looked like at work:
HA HA HA HA HA!
When I really looked like this!
I was in the third semester of the RN program in 1989 when my first wife and I divorced.
This is a cartoon inspired by a conversation from around that time:
I got my LPN and moved out for the fifth and final time from my parents' house when I was 26 years old. I lived with a girlfriend for three years, we got married, and then divorced three years after that.
When I knew I was to be divorced, I wondered to my little brother if he thought Mom & Dad would consider letting me move back in with them.
"No", he said, "Because then they'd have to get a divorce!"
I worked in the OR at Weed Rover Township Hospital in 1987. Back then we didn't use any type of anesthetic, so the patient was fully conscious through the entire procedure.
An extremely hard-of-hearing elderly patient was to undergo a colonoscopy. We were in a closed room, so I felt comfortable SPEAKING VERY LOUDLY!
I explained every portion of the procedure in minute detail. The patient would reply now and then with "uh huh" indicating understanding. FIRST, THE DOCTOR WILL SPREAD YOUR CHEEKS ! "uh huh" THEN THE DOCTOR WILL APPLY THE LUBRICANT! "uh huh" THEN THE DOCTOR WILL INSERT THE SCOPE! "uh huh". Through the entire explanation of the procedure.
Silently, the stone-faced Dr. ABC walked into the room and without a word, sat down, spread the patient's cheeks, applied lubricant, and readied the scope for insertion.
HERE IT COMES! I yelled.
Dr ABC lost it, laughing.
The neighbors called the Police on him. All he wanted to do was light firecrackers and throw them off his porch.
Dr. ABC. He had been a Viet Nam M*A*S*H surgeon. He was a rock climber and flew a one man plane. He used old fashioned techniques for surgeries and loved to improvise. He was stone-faced and spoke in a nasal voice.
I loved scrubbing in with him. He was my PCP back in the mid to late 1980's.
Sadly, he crashed his plane and died in 1990.
Here's to you, Dr. ABC!
Her's another comic inspired by Dr. ABC I drew for a thread on nurseswebsite titled "Wise One Liners":
I wanted to go back and work in OR sometime after I got my RN in 1990. I had enjoyed working as an LPN scrub nurse in 1986 and '87 at Weed Rover Township Hospital and got a position at St. Anomaly's Health Center. It wasn't an easy transition, starting new and getting to know the people, place and procedures. I didn't care for my "mentor" and the other nurses just didn't seem to like me but I wanted to give the job a chance. I worked at it for awhile, dealing with some pitfalls and stumbling blocks here and there.
I was to first scrub on a total abdominal hysterectomy with a doctor known as "The Nazi Surgeon", Dr. S. I was warned that Dr. S was very difficult with which to get along. Dr. S had his own personal instruments. Dr. S could be brutal.
I wanted to prove myself and I studied Dr. S's procedure card and got everything down to a "T". The surgery went well and at the end Dr.S said, "Good job!"
Dubious Victory. I tried working at St. Anomaly's for a couple of months but got tired of the constant negative feedback and left for another position.
Several years ago, while working on the adult female psych unit on the MN shift, a patient came to the nurses station because she was experiencing increased anxiety. I reassured her and probably gave her a PRN anti-anxiety.
This cartoon is based on her statement of "I feel like my mattress is going to swallow me up!":
When I began working in nursing some 35 years ago, abbreviations, primarily in Latin, were common. For example, if a doctor ordered a med to be give once daily, s/he would write "OD". Well, OD can also be the Latin abbreviation for "oculus dexter" which means "right eye", so sometimes the order was confusing.
Those in power changed all that so a situation like this would not occur:
One of the reasons I got into nursing was to meet chicks, and I am, may I say, quite revered at work. Even as an old nurse working on the geriatric psych unit, I am still something of a lady's man.
Some of the younger nurses have given me titles of respect like "The Geriatric Gigolo" or "The Don Juan of Dementia".
Women want me. As one of my coworkers said, "Yeah, Davey Do, women do want you. Most of them want you dead!"
I know she was only kidding, because a lot of my female coworkers will go out of their way to get may attention. They''ll do attention-seeking things like not speak to me, turn the other way as they approach me, ignore me or talk about me behind my back. Some will go so far- and this is really cute- when they see me, they'll go so far as to stick their finger in their mouth and feign heaving!
On the nurseswebsite, we were discussing the pain scale which rates a patient's level of pain and looks like this:
Allie Brosh, on her website "Hyperbole and a Half", some years ago came up with a great parody of the pain scale. Check it out- it's hilarious!
http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html
Anyway, I thought I'd come up with my own personal Pain Scale:
Before nurseswebsite banned me from submitting comics, a member requested a scale for nausea that was comparable to the pain scale.
Back in 1989, I was working a MN shift at Weed Rover Hospital on the chemical dependency unit. I was an LPN, going to school for my RN, and was called up to a medical unit in the morning to assess a young man for treatment.
I went into the room and saw a young man who had the head of the bed raised and was sitting on the upper part of it, clad only in pajama bottoms. I introduced myself, told him why I was there, and began asking him questions. All I remember him saying with big bug eyes was,"Dextromethorphan Hydrobromide Acid, man!" I thought "What's that?" and went to give my assessment results to the nurses.
Basically, I told them the patient needed to be assessed by a psychiatrist, be transferred to psych and stabilized before chemical dependency treatment would be beneficial. About that time, the young man's room mate came to the nurses station and informed us that the young man was acting weird and required attention.
I went into the patients' room and found the young man in the running shower, still clad in his pajama bottoms. As I stood there, the young man lunged at me saying, "Dextromethorphan Hydrobromide Acid, man!" The two of us went spinning into the hallway and went down to the floor, wrestled, I yelled out a code for security's assistance to the nurses, and got the young man into a hold from behind.
There, on his back, in beautiful dark blue Old English lettering were the words, "Dextromethorphan Hydrobromide Acid".
I thought, "Oh yeah- 'Dextromethorphan Hydrobromide'. That's cough syrup!"
I had a dream where I was with a psychotic patient who was a one on one, I felt sick and fell on the floor, and a code for patient behavior was called.
A doctor who came to the code said he'd give me something to make me feel better and I thought he was going to write me a script for some antibiotics. At first I was happy but became disappointed when he gave me his ink-stained business card with blurry directions to his office. I looked at him and saw that he was naked under his lab coat and thought, "This guy is Wrongway Regional Medical Center material".
A nurse on the nurseswebsite told of an incident where a patient was NPO for a surgery. A diploma student administered 30 ml of Milk of Magnesia (MOM) "in the butt" since the patient complained of constipation. The nurse envisioned a an MOM enema, and wondered aloud if whether the patient needed a tap water enema in order to wash out the MOM.
"Don't worry", the student said, "It was given intramuscular"!
WOW. MOM IM.
Gave the entire 30 ml. Caused a big abscess.
During a class while in the RN program, we were discussing DVTs 'and the Homan's sign. The instructor said if the foot is dorsiflexed and the patient experiences profound pain, this indicated a positive Homan's sign.
One student said, "So we know it's a positive Holman's sign if the patient loudly says,
'HO HO HO MAN!' "
We had a patient admitted last Spring to the geriatric psych unit who was a few years younger than the required age of 55. This patient needed to be on continuous O2 and the adult psych units aren't equipped for proving oxygen.
It seems this patient lit up a joint while wearing the O2 nasal cannula and suffered some
1st degree burns to their face.
Maybe this patient never saw those Stoney the Bear posters:
I know that I sleep better being clean shaved. Back in November of '04, I tried administering various meds to a restless geriatric psych patient suffering from insomnia to little avail and thought that maybe a shave would help.
This is an edited drawing from that time:
My wife B is a very competent caring nurse who works on a medical floor at Anomaly Memorial Hospital. She, too, is innovative in providing quality comfort measures for the patients she serves:
I would guesstimate that 99.99% of patients who are suicidal in the ER deny feeling so due to a typical admission intervention:
I'm going through old journals looking for this, that, and the other thing for inspiration when
I found this announcement from Cut Throat Community Counseling Center:
A nurse on the nurseswebsite wrote, " I was covering for another nurse who was on her lunch break, and a call light from one of her rooms came on. I was in a particularly good mood that evening and waltzed into the room with a cheerful "WassUP, homie?" And then I went around the curtain...and the patient was African-American. I was so embarrassed. It was stupid of me to use the vernacular anyway. He was OK with it though. " :
