Difficult Patients plus Haldol IV

How to manage difficult patients is a topic I would just love some advice on. I think on the top of the list of “hard to manage” would be the alcoholics in withdrawal compounded with liver failure and the ensuing metabolic encephalopathy. You know the bright yellow forty five year old with the huge 9 months pregnant looking belly climbing out of bed trying to escape the the non stop lactulose induced diarrhea. These patients are just so sick and their minds are gone! Trying to explain what needs to be done is just not reality. The families are just as difficult to treat often in denial flipping out on the “nurse” as if what is going on is the nurses fault!  Sometimes after having interactions with in denial family members, I just stop and wonder, wow, they really have no idea what is going on, or they just can not handle the reality.  Which of course I am not passing any sort of judgements on these patients or their families, I know it is a sickness.

What about patients who have surgery and do not fare well post operative due to anesthesia under sub optimal conditions to begin with such as lung problems, obesity or heavy drinkers.  I recently experienced a patient who post operative could not be weaned off the ventilator in the PACU, so the patient was intubated for days, sedated the whole time of course and then eventually made the way to the telemetry floor to Nurse Jane. I was exacerbated to say the least about the condition this patient was in. I desperately tried to manage what was labeled as “post operative psychosis/ ICU psychosis.” Of course I validate these diagnosis, but how long can it last? Days? Weeks? I tried to rationalize that the patient was given boat loads of medications and that was the reason for this continued persistent agitation and delirium. I gave the patient nothing for sedation or agitation trying to see if this patient would become orientated. It did not workand I broke my back. I really did break my back as well as the backs of my coworkers who had to constantly help me pull the 300 pound patient back to the middle of the bed instead of half over the side rails.  In between the “F**K yous”, amongst other curses I just wanted to keep the patient off the floor and to stop the patient from pulling out lines and catheters, and then the patient wanted to “box” with me! After 3 shifts of this I broke down. I had to call the attending and I had to give the patient with ATIVAN IV and HALDOL IV.  I felt defeated. I thought for sure when I received this patient from ICU on day 1 the patient would come to some senses if the as needed Haldol and Ativan were given a chance to get out of the patients system.  In the end a psychiatrist was consulted who ordered the Haldol IV around the clock.  Now since I am still a relatively new nurse I was surprised to read this from Pulmonary Roundtables post. I knew that the hospital policy is that all patients receiving IV Haldol need to be on a monitored floor, and that the QTc should be monitored for prolongation.  I was not happy about this ATC Haldol IV orders!

 

 

 

http://pulmonaryroundtable.blogspot.com/2008/08/intravenous-haldol-in-icu.html

Not Quiet

Unlike where KeepBreathing is working, community X has been super busy or at least on telemetry the place has been busy and I am pretty sure the whole place was busy.  The RTs I know have been super busy getting all those blood gases and  setting up bipaps all day today.  I am not sure if it is that time of the year or what is going on.  I am happy my 3 shifts for the week are done because I need some serious rest.

Zombie Nurse

The Zombie Nurse. She attacked me the other night at the end of my shift. Attacked me with, “Why did you pick me?” and “This group is to much work” and “I am going to be running all night”, and “This patient should be in ICU, (before even assessing the patient)”. Generally making me feel like a stupid jerk for not knowing that complaining was an option. I mean I just go to work and do my job the best that I can. I give it my A gameall day long and to have these Zombie nurses come in complaining and whining for the next thirty minutes when all you are trying to do is pass on the “essential” information is getting annoying.  I am done with verbalizing the whole chart to the next nurse in report, it should just be the “pertinent” information.  I am also tired of getting report from Zombie nurses, the ones who “couldn’t do this or couldn’t do that,” or who talk sooooo slooooow….while they are “yawning”  in your face trying to stay awake.  That just makes me want to run out of report and make sure that the patients are all alive since this Zombie is half asleep already.  It is funny how they complain so much about the work they have to do and yet somehow they find all this time to have their “night shift” parties. They have time to decorate for the holidays and have parties for each other during birthdays or weddings and such. I mean I and other day time nurses barely have time to eat lunch, drink some water or even “pee” if we want to: Assess our patients, continuously intervene, keep up with all the new orders and “now” orders to be done, make sure our patients get to testing and procedures, assess safety after procedures, worry about if the patients got breakfast lunch and dinner plus making sure that they do not get breakfast lunch or dinner if they are “NPO”, explain what the doctor just said, (the one who just left the room while the patient understood zero of what was just said.)  The family members! The night shift nurses tells them “visiting hours are over.” The family members stay with us all day long. (I do not usually mind)  I had this one nurse “freak” and seemingly get her panties in bunches because I left her patient in the chair. The patient was not ready to get back in bed. The patient was a two person “stand by” assist to get back into the bed. The nurse “freaked”. Lo and Behold!! a patient out of bed is unheard of to this particular RN. If I have a patient “in” bed all day I am unhappy! Needless to stay, I stayed over to help the patient back in bed since the nurse taking over seemed to be unable to fathom it.

Honestly we should all work together as a team to have optimal patient outcomes, and I do try. When I get fed up or irritated and start “complaining” I usually feel guilty afterwards.  I understand that it is not easy to work night shift, it is hard on the body and the mind. I think that studies show that the survival rate of code blues during nights and weekends are poorer than  those who arrest during day time hours-the article is here.  I am not “belittling” the night shift nurse, but I feel that the day time nurse is doing a lot more work and the night shift nurse is doing a lot of complaining to me lately.
I think we should have to swing shifts from time to time! A nice walk in my shoes shift.  I just want to be stop being attacked by Zombies as if they “hated” there job and are taking it out on me! “How could you manage doing this all day?” My response is I love my job, my patients need this, and I am into managing chaos! That is why I keep trying to do it better and better every week!

I want a new stethoscope.

  I am offically obsessed. Last week I somehow lost my stethoscope and had to “borrow” one from the drawer of left behind stethoscopes at work. There is usually the garden variety in that drawer, the disposables, the one without ear pieces, the big heavy one with 3 bells that looks funny. Well last week I grabbed the steth on top and had no idea the amazement that was to follow during my morning assessments! It was black, had no bell, and the tubing was engraved with the name of some nurse that did not work on our floor. The acoustics were so awesome that I could actually hear turbulent blood flow in the heart chambers! I swear I could hear that! Can you imagine? I found out that it was a Littman Master Cardiology Stethoscope.  What is neat is that there is no bell needed! Just by pressing lighter or with more pressure, low and high frequency sounds can be auscultated. It is so neat! I just want one!