Saturday, February 24, 2007

Good nurse, Bad nurse

Given the past popularity of my posts about nurses and nursing, I thought it best to break my week-long posting hiatus with another one. Fortunately, I have two stories to tell.

Overall, the quality of nurses in the ICU is better than on a ward. I assume, not knowing much about their training and hiring, that this is due to the higher intensity and complexity attracting the more intelligent, or at least more driven, people. However, I also assume that the more intelligent and driven of that bunch tend to stick around longer, and that they therefore are the more senior when it comes time for shift assignments. That's the way I explain to myself, anyway, the fact that the midweek graveyard shifts seems to collect the less competent staffing. The weekends are usually more exciting, since there is more of the shooting, stabbing, and generalized looting going on outside that brings people to a surgical ICU, so we get pretty good staff then. Anyway, Wednesday night.

One of our patients is a lot of pain. A very, very bad motor vehicle crash got him in here, sans his legs and with a host of other injuries. So he requires a lot of pain control, but it has been difficult to give him enough to control the pain, while not over sedating him. His English is also not great, so when he needs help, he tends to make loud groaning noises that can, I admit, be irritating.

None of this excuses the fact that Wednesday night a nurse decided to start him on a continuous dilaudid drip, without a doctor's order. And while that did keep him quiet, he was almost unarousable the following morning. Not in hemodynamic or respiratory distress, just very much asleep. In his (the nurse's) defense, the order had been on the chart, but it had been stopped over a week ago. My attending's reaction was simple. He told the nurse to stop the drip, and stated if it ever happened again, he would put the patient on Q1 hr neuro checks, with 1mg morphine injections and 15 minute follow up checks. This would (aside from being a complicated order to write) be a huge, almost constant drain on the nurse's time. Thankfully, that hasn't happened again. Dr. Benedikt's popularity hasn't risen any more with the staff though, either.

The second was a good experience. I was putting in an a-line, only my second attempt ever, and after placing it, was securing the tubing. This involves taping it around the patient's thumb, so as to keep them from pulling it out accidentally. First though, and this is key, the site where the catheter enters the patient has to be covered with a dressing. I had, however, forgotten competely about that step, with the intensity of my attending watching. The nurse angel assisting me noticed this before my attending did though, and rather than letting me look like an idiot, or even helping me out obviously and revealing my idiocy, she just asked "did you want a larger cover dressing?" Though I admit this doesn't prove anything about her ability, this reminder saved the day. Thank you, Florence.


Anonymous said...

This was a interesting post from a soon-to-be physician's vantage point. It sounds like you have a pretty good assessment of why nurses in ICU seem more competent and well-trained than nurses on the floor.

I may add one other observation. As a nurse with experience only on the floor, I can say that floor nursing has to be the toughest, most stressful form of nursing out there. You may have a good nurse with many years of experience but she may have such an overwhelming load that she forgets a few things or because of the need to prioritize for the most needy, higher acuity patient, she may put off a few other tasks.

I will be the first to say that this is no excuse for poor nursing care or inattention to details. However, this is the real world norm oftentimes on the floor.

I started at a smaller hospital about 8 months ago for several reasons and one of the most desirable was the ability to provide better care with lesser nurse to patient ratios. After a short 6 weeks at this new facility, the administration made the decision to fire all the CNAs on the spot. Now the nurse not only had her usual nursing duties but all the aide duties to attend to as well. This is also becoming more common practice as cost-cutting measures become a necessity in the highly competitive health care industry. So now the nurses taking care of your patients may have between 5-9 patients for which to provide nursing care along with giving basic daily care like bathing, dressing, ambulating, vital signs, blood sugar monitoring, ordering meals, picking up meal trays, passing out snacks and fresh water, changing bed linens, and keeping the rooms straightened.

Not to ramble on and on, but just something to keep in mind while you round on your floor patients. :)

I desire to give very competent, attentive care to all my patients. Unfortunately there are days when if everyone gets their AM medication before noon and everyone has their major systems assessed, and no one has meds given to them in error, and no one begins deteriorating during my shift, it has been a good day.

This was a great post and something I will keep in mind when I am out doing my work on the floor.

Thanks for sharing your thoughts. I would greatly appreciate more posts about nursing if you are so inclined.

BTW, how is Mr. Smith? I assume maybe a poor outcome since no follow-up post but I was just curious.

~Anonymous RN

P.S. I have told a couple of my nursing friends about your blog so you may have a readership with more nurses now. :)

Nathan said...

Annonymous, thanks for the comment. I do recognize the disparity in patient load between the two environments, but I'll keep your comments in mind through the frustrations of intern year. At least, I'll try to. :)

Mr. Smith is actually still with the living, though he won't be entering any trialthlons anytime soon. I plan on a follow up post shortly.