Being a Nurse Family Member…

Most nurses know that the worst family members of patients are doctors, lawyers, and other nurses!  We know what to look for. We know what is standard operating procedure. We know what is correct technique. We know what the alarms and numbers mean. We know how things are supposed to be done…and we don’t want crap care for our families.  When my dad had surgery recently, I saw some things that I wasn’t happy about- but not close enough to see what was going on at the time, or had taken a break to go take care of my dog, so not there at all.  I’d hear when I got back to the hospital.

Dad returned from surgery to spend 24 hours in ICU for observation since the surgery was on his neck, with a lot of real estate in there that needed to be closely monitored. One of his blood vessels had to be cut in order to remove a mass, and then sutured shut, and it was critical that he be monitored for any signs of that vessel leaking.  It could be fatal- or life-altering- if it ‘blew’.  I had to wait until he got settled until I could see him in ICU- very understandable that they had to get him hooked up and an initial assessment done. Seems his nurse forgot about his family and close friend in the waiting room for nearly an hour and a half.  I finally asked if it was OK to see him, only to see his nurse sitting at the desk at the end of the hall. She said , “Oh, yeah, come on back”, as if we had just shown up.  We’d been in the hall when he was brought into the unit, and told they’d come and get us.  That nurse was there.

I initially stayed in the ICU room for only a few minutes, since dad was still sleeping most of the time, and the numbers on the monitor were stable.  I stepped out into the waiting room again with his friend, and we talked.  I needed to run home and give my dog her medicine, and then came back up to the hospital.  When I got there, dad’s IV fluids had been turned off. He hadn’t peed yet, and wasn’t taking enough fluids to compensate.  When he got some IV nausea meds (preventing vomiting was very important to protect that sutured blood vessel), he said it hurt.  There was no saline flush first- just straight to the nausea meds.  He was told that meds sometimes hurt (which is true- BUT, the site and patency of the site must be checked).  Basically, he was blown off. Then, after the medication, the saline flush was the bare minimum to maybe clear the extension tubing (5-6 inch tubing that makes it easier to reconnect IV antibiotics and give IV meds).  The nurses were ALL very nice. That wasn’t an issue. But youth and the inexperience that goes with it (simply because there isn’t the time yet to  gain the experience) aren’t always useful.  It’s not always because someone is ‘still out of it’ from anesthesia.  They still feel pain in IVs- and dad was plenty aware when the meds were given.  More than one nurse did this. When he got to a room (more on that later) the first thing the ‘old timer’ RN did was assess the IV site when he flinched a bit, and said that isn’t right; she changed the site, and dad had no more problems with the nausea meds or the antibiotics that had been leaking into his hand.

When dad was transferred to a room, I was again taking care of the dog’s meds (took me about an hour in the afternoon/early evening to do this) during the actual transfer. I knew he was going to a room, and was fine with that- he was ready.  He had been up in the chair and done well, and walked one time to the end of the ICU hall (about 6 rooms) and back. When I got back, and found his new room, I was told that the nurse loaded up his stuff to carry, his friend had carried some stuff, and dad was left to walk with no support (or WHEELCHAIR) to a room on another part of the same floor.  It was a considerable distance away from his ICU bed. It was the second time he walked at all, and a few hours after he’d even been out of bed at all.  His friend told him to hold on to her arm, at which time the nurse offered her arm- but if he had started to lose  his balance,  nobody (the NURSE) would have had any sort of grip on him. His elderly friend certainly wasn’t responsible for his safety.  I was mad when I heard that. He could walk when he got to the other room- NOT as a means to transfer him there. That is incredibly stupid from a safety standpoint.

Dad had eaten a bowl of soup a while before ‘tranferring’ himself to the new room.  That was the first food in 36 hours besides sips of diet soda.  Since his IV fluids had been axed before he was taking adequate fluids, he was ‘low’ on fluids. His heart rate was OK, and his blood pressure was actually a bit up for him (the dinging and gongs in ICU drove him nuts- he is VERY sensitive to auditory stim….gum chewers in the same area will actually drive his BP up to stroke level)…so I guess from looking at the numbers alone (and not the actual patient), he may have looked hemodynamically stable….but people still need fluids !!  Orthostatic changes don’t always happen in the first minute; he could have easily dropped his pressure en route to the new room from being ‘dry’.

The nurses on the regular ‘floor’ were outstanding.  Both of the ones he had were personable and very attentive to the things that may not seem ‘worth’ the time of an ICU nurse- but can make a huge difference in how care is perceived.  I’ve been an RN for nearly 28 years.  Granted, I’ve been on disability for 8.5 years- but during that time I’ve been IN the hospital a LOT.  I still know the routine procedures and when an IV needs to be assessed more closely.   IV meds aren’t given without a saline flush (and assessment of the IV itself) first.  I’ve spent time around monitors and floated to several types of ICU (including NICU).  That’s only part of the picture.  Someone can have great ‘numbers’ but still have things wrong!

Nurses must listen to the patient, and if a patient is complaining about an IV site hurting when anything is pushed into them, they need to be changed (or at least addressed in some way besides some lame ‘oh, some meds do that’ comment- without looking at it). Sure- meds can be pushed through just about anything…doesn’t mean the vein and IV are intact.  Many of the patients in that ICU were on vents and not communicative- maybe the nurses just got used to dealing with overt, objective issues. Maybe the transferring of someone who could walk seemed OK since most of their patients don’t walk at all.  That goes back to inexperience (and some lack of common sense of youth- and known policies re: transfers).

An elderly patient one day after major surgery with no supportive fluids, or consistent food intake is not a candidate for walking throughout the hospital to a new room, or ignored when they say the IV site hurts. 

There are many good young nurses- but ALL nurses (no matter how many decades they have worked) must always be open to learning.  The young ones need mentors during their first several years- especially in a critical care setting.  IV fluids need to run until the patient is taking in enough oral fluids to equal the rate of the IV, and at LEAST until they pee (providing there aren’t any issues with fluid overload or kidney function; my dad had neither of those).  As a patient myself, I saw why it’s no wonder these younger nurses aren’t doing the basics. As students, they weren’t allowed to do anything but follow an experienced (sometimes still relatively new) nurse during clinicals.  When I graduated, if we didn’t DO the skills, we didn’t graduate (never got to take boards). Period.  There is a huge gap between book knowledge and practical knowledge that is only getting worse.

All of the nurses dad had were so very kind and sweet. That wasn’t a problem at all… but some of the decision making reminded me of my very first semester of nursing school, with trying to get the basic skills learned.  Press Ganey will hear about this.  But this hospital’s ER satisfaction is a ratty %83 per the hospital’s own information anyway. That’s up from the %65 from a few years ago.  The floor and ICU numbers were better, but in ICU I wonder if it’s because their patients often can’t reply or respond to satisfaction surveys and their family members don’t know what is responsible care in specific situations. ?   With healthcare becoming a concierge (hotel-like) industry with these stupid surveys, the nurses focus on the sweet and kind, and less on the technical prowess needed with the sicker patients.  Dad was relatively easy for ICU standards- but he could communicate with them. And they didn’t listen.

Dementia Wins By A Landslide !

I worked in various nursing homes during the years I worked as an RN, starting in 1985.  I worked as a ‘floor’ nurse, charge nurse, supervisor, and administrative (desk) nurse.  Nursing homes really are quite delightful places to work, and while nursing home nurses are often looked down upon by hospital nurses (I’ve done that kind of nursing too), the skill set required is extensive.  They have to have a bit of knowledge about all medical specialties (except obstetrics, though one gentleman did scream that he was giving birth to a calf in an emergent situation…my guess is that most people in a 3-4 block area knew of his distress; his doc felt that Haldol was a good ‘post-partum’ drug… I don’t like Haldol for the elderly; it was designed for schizophrenics- but it did quiet him down).  There are the medical issues that put people in nursing homes to begin with, and then there are those folks with dementia who can be so totally heartbreaking to watch…or a source of some humor. If we didn’t chuckle, we’d weep.  The following are from some decades ago… some of the rules were a bit ‘different’ back then, though nobody ever did anything to make the situation worse.

One woman I remember was very distinguished in her outward appearance. She was always ‘put together’ in how she dressed and in her appropriate greetings of people she met in the halls, but had no clue about hygiene or changing her clothes regularly.  Usually the certified nursing assistants (CNAs) could get almost every resident into the shower without too much hassle, but this lady was persistent in her refusal.  Nursing home residents have the right to be sloppy…when they are coherent enough to know the risk/benefit of their decisions.  When a green cloud follows them, and people fall like dominoes in their wake, something has to be done.  That’s when the administrative nurses have to jump in and figure something out.

The first thing to do was notify the family and get their permission to bathe Mrs. Cloud, even if she refused. They were the legal guardians since she couldn’t make decisions, so that wasn’t hard- they were thankful we were looking out for her (they were also out of town, so couldn’t be ‘hands-on’). The next thing to do was to figure out a plan.  The assistant director of nurses (ADON) and I were the ones who somehow got blessed with this task assignment, and thought we had a pretty good idea of how to get the job done. We got Mrs. Cloud into her private room, and carried on some generic, though tangential conversations as we got her overcoat off, and then talked about getting her clothes washed (that was usually less threatening than actually talking about showers up front).  OY.  We got the coat. We were doing pretty well with the dress, but getting down to her slip, and undies, we noticed that she had about 4 pairs of caked-on pantyhose. Each of those pantyhose required getting Mrs. Cloud back on her bed, ‘scootching’ the hose down, and then removing them…. x 4. Between each ‘scootch’, she’d bolt up and try to run off, so we’d have to get her seated again, then lying back on the bed so we could continue ‘scootching’.   The ADON and I were sweating by the time that was over.  The slip, bra, and undies were a piece of cake after the pantyhose circus.

So, we get Mrs. Cloud into her shower- after all, if we’re going to clean her clothes, why not get a nice warm shower (sounded like a good line)… she wasn’t happy, but went for it. We had the towels and washcloths ready. But…. oops. I forgot the body wash.  The  poor ADON was left wrangling Mrs. Cloud in the shower as I sped out of the room to find body wash.  I found what we needed, and we finished the shower from hell with no casualties.  A few minutes later, I saw Mrs. Cloud in the hallway, all fresh and sans cloud-o-funk, and she greeted me as if she’d never seen me before- very polite with a superficial smile. She remembered nothing. Crickets.

I also worked ‘the floor’ at night for a while.  One night, another confused little lady was wandering in a sort of frenzy, and was visibly tired. She had a sleeping pill ordered, so I offered her one. She wouldn’t take it.  I opened up the capsule, and mixed it with a tablespoon of orange juice in a one ounce plastic ‘shot glass’ medicine cup. I offered her a little nightcap, and she was so happy to take it.  I had poured some plain orange juice to get rid of any funky taste in her mouth, and she looked at me- dead serious- and said “Oh, Honey- I can only have one”.  She traipsed off to bed and finally got some sleep.

Another night, I was doing my routine work on the 11-7 shift, and one of the CNAs comes flying up the hallway off  one of the ‘pods’ (a grouping of rooms), calling my name as if she’d just witnessed Jack the Ripper field dressing a dozen deer in the back room.   I immediately went racing down to meet her, and follow her to the room in ‘distress’.  I stopped cold when I saw the elderly gentleman (also confused as all get out) sitting completely naked, bolt upright in his bed, grinning from ear to ear with his sheets and blankets all over the place. He was ‘splashing’ the gel from his gel mattress (as much as someone can splash something with the consistency of applesauce).  He had managed to puncture the mattress (used to protect skin), and had that gunk all over the place. It was hysterical.  I didn’t want to laugh at him, but it was hard to maintain anybody’s dignity at that moment. He was having a ball !  We got him cleaned up, and my only comment to the CNA was the need to differentiate between something that is life-threatening and something that is an inconvenience, but essentially harmless.  We didn’t need blood curdling screams in the middle of the night for a little  gunk on the floor (well, OK, it was a lot of gunk).

We also had a  hoarder.  The facility towels and washcloths, junk- didn’t matter. And she was possessive.  Anybody who went to clear out the stuff for laundry to rewash had to have someone else ‘stand lookout’, or the poor ‘lone’ retriever would be yelled at for a good 3-5 mintues, until the hoarder forgot why she was mad. One afternoon, one of the activity aides found a family of mice (mama and babies….LOTS of babies) living in a leftover popcorn bag (from movie and popcorn day), and a cake in a plastic bakery container that was so old that nobody could figure out the original flavor and/or color.

One of my favorite little ladies was superficially appropriate, but 2-3 minutes into a conversation there was no doubt that some bulbs were dimming. She was generally cheerful, and had a buddy she hung out with. She also was not fond of showers or combing her hair (think Einstein plugged in to a household outlet), but would let me check her skin weekly (per required protocols everyone got weekly skin checks- head to toe). The CNAs and I got into a routine of doing the skin checks in the shower room, and since I needed to see ALL of her skin, she’d agree for the CNAs to ‘hold’ her clothing…funny how the shower would get turned on, and she’d get nice and clean- she was always very agreeable once she felt the warm water. One day before getting showered, she walked past one of the mirrors, and saw herself. She literally gasped loudly and stepped back from her own reflection… she looked at me and asked about a hairbrush.  At least she still knew it was her own reflection- some lost that.

Nursing homes get bad reputations, but there are so many nice ones. I had the chance to work at two that I really liked, each for about 2.5 years.  The residents become like extended family, and some of their families also became part of the daily routine.  I’ve worked with CNAs who have been at the same facility for over 30 years…when offered promotions, they refused, not wanting to leave ‘their’ people. ❤  I’m incredibly thankful for the coworkers and residents I met when I was working at those facilities. 🙂