Mr. Fizzel might actually be or have been a nice person, socialized to treat other people with respect, and understanding normal boundaries. Currently it's difficult to tell, with his dementia. He has been continually entering other residents' rooms without permission, seeking the exits in the facility, and taking what the staff considers an unreasonable amount of attention to redirect him. He is not very redirectable. He sometimes requires one-to-one monitoring, and the staff for that is not readily available.
The other night, the medication nurse approached me in a rather excitable state and described Mr. Fizzel attempting to place his hand on another resident's breast. It was clear to her that the destination of his hand was mammary gland, and only her physical intervention prevented this purported grope.
This type of situation is very difficult to deal with in a politically correct manner. The professional is wrong no matter what you do. It feels like moving through a swamp.
All staff members who witness an event where there is any question of suspected abuse or neglect are considered "mandated reporters" who are required to call "state," the 800 number provided to initiate an investigation. But we are cautioned not to call state unless we have a plan for intervention. Confusing.
Also confusing are the guidelines for charting in these situations. I charted that Mr. Fizzel's hand was outstretched, palm open and fingers extended in the direction of another resident's breast, and that contact was prevented by the nurse. The director of nursing removed that page from the chart, making it necessary to chart again according to her guidelines. The use of the word "breast" was objectionable, and the assumption of the destination of his hand was objectionable, although, from the nurse's description, any fool could see what was transpiring.
The bosses were friendly about it. I emerged from an hour-long meeting [sleep-deprived] more confused than when I went in.
The usual rules of charting are clear: be specific. I love to chart about wounds. Describe the dimensions of the wound, the color of the wound bed, describe the wound edges and surrounding tissue, the color, consistency and [sorry!] odor of the fluid emerging from the wound, and the treatment, all in full living color. Wallow in it.
Rules for charting an interaction between patients: vague. "The resident reached in the direction of the other resident's left upper trunk." Period.
Argh!
Friday, October 9, 2009
The Freeze Dried Brain
I worked 36 hours in three days. I have absolutely nothing clever to say. Twelve hours at a time of continual human interaction and information processing. Usually about a third to halfway through the day my brain just sort of goes, "crunch." Suddenly my memory span is very short. I stop being able to process information.
To be fair, a lot of this is sleep deprivation. My car was finally ready after being vandalized, and the best time to pick it up seemed to be yesterday at 8 AM after going to sleep after midnight, so I woke at 0645.
A pharmacy calls to say that such and such medications are not covered by Medicaid. I am unable to hear the caller well enough to understand when she recites the medication so quickly, so she spells it, equally quickly. My ears are hearing but I just can't follow it that fast. I have her talk to the medication nurse. This decreased ability is terrifying.
My head feels as if the strands of my thoughts become tangled. I used to think I was eating and reading at the same time merely because it is soothing. But there is something about that activity that puts my mind in a trance-like state and enables the tangles to comb out again. Even though I have provided myself with ample plant-based, whole delicious foods, I find myself craving candies and natural Cheetos puffs and so forth. Not out of hunger, but out of trying to operate with a freeze-dried brain. And stress.
My plan is to find a way to detangle and unstress my brain in a healthy and efficient manner.
One triumph: I found a setting with the tape recorder at work which is sensitive enough to pick up my voice, so recording report went much smoother last night. Yay.
To be fair, a lot of this is sleep deprivation. My car was finally ready after being vandalized, and the best time to pick it up seemed to be yesterday at 8 AM after going to sleep after midnight, so I woke at 0645.
A pharmacy calls to say that such and such medications are not covered by Medicaid. I am unable to hear the caller well enough to understand when she recites the medication so quickly, so she spells it, equally quickly. My ears are hearing but I just can't follow it that fast. I have her talk to the medication nurse. This decreased ability is terrifying.
My head feels as if the strands of my thoughts become tangled. I used to think I was eating and reading at the same time merely because it is soothing. But there is something about that activity that puts my mind in a trance-like state and enables the tangles to comb out again. Even though I have provided myself with ample plant-based, whole delicious foods, I find myself craving candies and natural Cheetos puffs and so forth. Not out of hunger, but out of trying to operate with a freeze-dried brain. And stress.
My plan is to find a way to detangle and unstress my brain in a healthy and efficient manner.
One triumph: I found a setting with the tape recorder at work which is sensitive enough to pick up my voice, so recording report went much smoother last night. Yay.
Monday, October 5, 2009
Days Off
Our first two twelve hour overlapping charge nurse shifts went pretty well at Homeland. Busy, if you read the stories. I stopped by tonight after three days off to get organized for the next three shifts, and one of the new nurses on this side said, "I don't know how you did it all with just one nurse!" I said, we were really jumping.
My first day off I chilled out, bought groceries and did errands, then went to Eatonville late in the day. Early Sunday we went to Baha'i Convention at Clover Park College, Lakewood, at the uncharitable hour of 8:30 AM--kind of rough for people living 45 minutes away. I left my lights on, had to jump-start the car when we left at about noon, then we picked up food at Greek To Me restaurant and went to Wright Park, sitting in the sun at a picnic table.
Enayat always has felafel; I had a "veggie gyro." We shared side orders of their roasted potatoes and their green beans. I wish I had the recipes; the potatoes are soft and flavorful and tender, and the green beans meltingly soft. Enayat fed the seagulls and crows. I said he was encouraging mendicancy.
We drove out to Eatonville in time to spend sunset at my new favorite place: the balcony at the huge barn he refurbished by his farmhouse, surrounded by trees and pastures. There is such a feeling of peace there. Always, in clear weather, a slow and beautiful sunset. Grazing horses, prowling cats, passing small planes, distant gun practice at a gun club, but no traffic noise. If you stay late enough there are bats. A new "happy place" ; >. When we went out to the other barn where we have an apartment, we drove out to Ohop lake which borders the land. Elks were in the field. I called out, "Elks!!" very excited and he thought there was an emergency.
Today I had a quiet day at Eatonville, washing up from the delicious pasta dish I made last night. I had some [unfortunately white] garlic sourdough I used for garlic toast; some whole wheat penne pasta; a jar of Prego with mushrooms; and vegetables--leeks, mushrooms, a small yellow summer squash, garlic, and a bag of spinach. [Yes, in my book, garlic is a vegetable.] Yum! Very filling.
For once I requested a Persian movie, one about a shah being shot in the mosque, as Nasirih-Din Shah was, although they didn't use his name. Which they also made him a nice guy.
Owners of pit bulls, et al, always say "he won't hurt you. He's nice." What they don't realize is that, yes, the dog is nice to them. But not to other people. Kind of like Nasirih-Din Shah.
My first day off I chilled out, bought groceries and did errands, then went to Eatonville late in the day. Early Sunday we went to Baha'i Convention at Clover Park College, Lakewood, at the uncharitable hour of 8:30 AM--kind of rough for people living 45 minutes away. I left my lights on, had to jump-start the car when we left at about noon, then we picked up food at Greek To Me restaurant and went to Wright Park, sitting in the sun at a picnic table.
Enayat always has felafel; I had a "veggie gyro." We shared side orders of their roasted potatoes and their green beans. I wish I had the recipes; the potatoes are soft and flavorful and tender, and the green beans meltingly soft. Enayat fed the seagulls and crows. I said he was encouraging mendicancy.
We drove out to Eatonville in time to spend sunset at my new favorite place: the balcony at the huge barn he refurbished by his farmhouse, surrounded by trees and pastures. There is such a feeling of peace there. Always, in clear weather, a slow and beautiful sunset. Grazing horses, prowling cats, passing small planes, distant gun practice at a gun club, but no traffic noise. If you stay late enough there are bats. A new "happy place" ; >. When we went out to the other barn where we have an apartment, we drove out to Ohop lake which borders the land. Elks were in the field. I called out, "Elks!!" very excited and he thought there was an emergency.
Today I had a quiet day at Eatonville, washing up from the delicious pasta dish I made last night. I had some [unfortunately white] garlic sourdough I used for garlic toast; some whole wheat penne pasta; a jar of Prego with mushrooms; and vegetables--leeks, mushrooms, a small yellow summer squash, garlic, and a bag of spinach. [Yes, in my book, garlic is a vegetable.] Yum! Very filling.
For once I requested a Persian movie, one about a shah being shot in the mosque, as Nasirih-Din Shah was, although they didn't use his name. Which they also made him a nice guy.
Owners of pit bulls, et al, always say "he won't hurt you. He's nice." What they don't realize is that, yes, the dog is nice to them. But not to other people. Kind of like Nasirih-Din Shah.
Saturday, October 3, 2009
Stories From Homeland, Part 3
Mrs. Diaphanous went to the hospital with severe atrial fibrillation and an ejection fraction of 18%. Her heart is not working well, and her condition is fragile. She is just barely stable. She is alert and oriented, and walking with a steady gait. Naturally she has agitated to return home since she was admitted to Homeland several days ago, and likewise agitated her daughter.
Returning from visiting her cardiologist, who thought it would be fine to go home, she expected to just pack up her bags and take off right away. However, she is being followed at Homeland by Dr. Wildman, who needs to give his permission for discharge. That's how it works in a skilled nursing facility. Whichever doctor follows the residents here has to give the okay for any orders that consulting physicians give.
This happens frequently with people who have fractures. They work with the physical therapist, who remarks that they are doing well and should be ready to go home soon. Then they go out to the orthopedist, who says, "Okay, I think you're ready to go home now." The next the nurses hear of them is when the family member leans up against the counter, saying, "My wife went home; doctor Jointz said it was okay. Is there any paperwork you want me to sign?" "Only the AMA form."
So no one in the facility has done thoughtful discharge planning yet or completed the time-consuming paperwork needed for discharge, and Mrs. Diaphanous expects to go home this minute. I phone Dr. Wildman, expecting to just get a telephone order, but it's necessary to fill out the right paper requesting discharge and fax it over.
In the meantime I fill out discharge instructions and ask the daughter which pharmacy she would like me to phone the medications over to. While I work on the paperwork and wait for the doctor's faxed order, the daughter has approached the desk three times in twenty minutes, asking what we want her to do while she waits.
"Play cards?" I want to suggest.
She cut short my discharge instructions on taking the medications, saying the pharmacist would go over all that with them.
Coda: two hours later she was back, asking to clarify the discharge instructions. "I know you couldn't wait to get rid of me," she begins.
Returning from visiting her cardiologist, who thought it would be fine to go home, she expected to just pack up her bags and take off right away. However, she is being followed at Homeland by Dr. Wildman, who needs to give his permission for discharge. That's how it works in a skilled nursing facility. Whichever doctor follows the residents here has to give the okay for any orders that consulting physicians give.
This happens frequently with people who have fractures. They work with the physical therapist, who remarks that they are doing well and should be ready to go home soon. Then they go out to the orthopedist, who says, "Okay, I think you're ready to go home now." The next the nurses hear of them is when the family member leans up against the counter, saying, "My wife went home; doctor Jointz said it was okay. Is there any paperwork you want me to sign?" "Only the AMA form."
So no one in the facility has done thoughtful discharge planning yet or completed the time-consuming paperwork needed for discharge, and Mrs. Diaphanous expects to go home this minute. I phone Dr. Wildman, expecting to just get a telephone order, but it's necessary to fill out the right paper requesting discharge and fax it over.
In the meantime I fill out discharge instructions and ask the daughter which pharmacy she would like me to phone the medications over to. While I work on the paperwork and wait for the doctor's faxed order, the daughter has approached the desk three times in twenty minutes, asking what we want her to do while she waits.
"Play cards?" I want to suggest.
She cut short my discharge instructions on taking the medications, saying the pharmacist would go over all that with them.
Coda: two hours later she was back, asking to clarify the discharge instructions. "I know you couldn't wait to get rid of me," she begins.
Stories From Homeland, Part 2
Mrs. Mold, it turned out, had a bladder infection, with greater than 100,000 Aphus Glaphusiosa, according to the lab report. Dr. Bludgeon was visiting patients and charts at the Green Wing nurses station, and ordered Gentamycin via injections, dose to be calibrated by Evilgreen Pharmacy. I faxed off the order to the pharmacy, which called me and asked what the resident's last BUN and Creatinine labs were, which reflect kidney function.
Last such labs were done in June. Unacceptable. I pick up the phone and am in the midst of ordering a stat or ASAP lab draw when I remember that Mrs. Mold is currently out with her daughter, Isabel, dancing. I leave a message on her daughter's cell phone explaining the necessity of returning so the labs can be drawn.
A few hours later Isobel is standing at the nursing station counter. "I want her to have a urine dip!" We explain that this is not necessary, as the urine has already been cultured and proven to have this particular bug. "How do we know this was not contaminated?" "Because there is only one species of bacteria, not a mixture of normal flora." "Why can't I have her urine dipped? How do we even know this is her urine, not mixed up with someone else's?"
This is the great advantage of having several nurses present; my negotiation skills are very poor. At last Isobel accepts that yes, this infection exists, and we can move on. We call the lab back and they are now reluctant to come out for the draw, but eventually show up. After the results are in, the pharmacy can set the dose and finally the antibiotic will be started, but not within the usual four hour window of time required.
Intelligent minds may wonder, if the patient was out dancing, how sick is she anyway. In the world of nursing, required to follow doctor's orders unless really contraindicated, inquiring minds will just have to wonder.
Last such labs were done in June. Unacceptable. I pick up the phone and am in the midst of ordering a stat or ASAP lab draw when I remember that Mrs. Mold is currently out with her daughter, Isabel, dancing. I leave a message on her daughter's cell phone explaining the necessity of returning so the labs can be drawn.
A few hours later Isobel is standing at the nursing station counter. "I want her to have a urine dip!" We explain that this is not necessary, as the urine has already been cultured and proven to have this particular bug. "How do we know this was not contaminated?" "Because there is only one species of bacteria, not a mixture of normal flora." "Why can't I have her urine dipped? How do we even know this is her urine, not mixed up with someone else's?"
This is the great advantage of having several nurses present; my negotiation skills are very poor. At last Isobel accepts that yes, this infection exists, and we can move on. We call the lab back and they are now reluctant to come out for the draw, but eventually show up. After the results are in, the pharmacy can set the dose and finally the antibiotic will be started, but not within the usual four hour window of time required.
Intelligent minds may wonder, if the patient was out dancing, how sick is she anyway. In the world of nursing, required to follow doctor's orders unless really contraindicated, inquiring minds will just have to wonder.
Stories From Homeland, Part 1
With the new 12 hour charge nurse schedule, there is no more reporting in person to the night nurse, so the powers that be brought in a new Radio Shack tape recorder with voice activation, for recording report. The first night I couldn't make it work, and left my written notes. Last night I made it work, sort of.
I guess my voice is quiet for voice activation, so I had to hold the machine under my nose and practically shout. With even a nanosecond lull, the machine would stop recording [one can see the wheel turning when it's recording, much like a nurse deep in thought.] With all these technical challenges, my report came out kind of rough.
"Hello, this is Arlene reporting for the evening shift on, hello, are you working? October second. In room 201, Mr. Feebel has a Foley, what the hell, are you on? catheter which was leaking. We changed the catheter and, oh, bloody hell, now what? it has been patent. In Room 202, Mrs., hello, okey dokey then, Rheinland is on Keflex for pneumonia . . . "
I guess my voice is quiet for voice activation, so I had to hold the machine under my nose and practically shout. With even a nanosecond lull, the machine would stop recording [one can see the wheel turning when it's recording, much like a nurse deep in thought.] With all these technical challenges, my report came out kind of rough.
"Hello, this is Arlene reporting for the evening shift on, hello, are you working? October second. In room 201, Mr. Feebel has a Foley, what the hell, are you on? catheter which was leaking. We changed the catheter and, oh, bloody hell, now what? it has been patent. In Room 202, Mrs., hello, okey dokey then, Rheinland is on Keflex for pneumonia . . . "
Thursday, October 1, 2009
Too Many Garbanzo's
Started new 12 hour schedule at work this morning. Tuesday I thought I was working Wed, then having several days off, so I scheduled car repair status post break in for Thursday morning, 7:30 AM. Was up late, woke up at midnight, woke at 5 AM, dropped car off about 8 AM, went to work at 10, just got home. Night of the living nurse.
Yesterday [my one day off, after schedule revisions] my husband showed up at Tacoma, having had an appointment downtown. I had just made some garbanzo beans so he had some. Later we went to dinner with Pearl at the Indian restaurant, Sumay. At the end of the evening, Enayat confessed that he had a dish of garbanzo beans downtown at the India Mahal, then my garbanzos, then more Indian food. We had a good laugh over that.
Yesterday [my one day off, after schedule revisions] my husband showed up at Tacoma, having had an appointment downtown. I had just made some garbanzo beans so he had some. Later we went to dinner with Pearl at the Indian restaurant, Sumay. At the end of the evening, Enayat confessed that he had a dish of garbanzo beans downtown at the India Mahal, then my garbanzos, then more Indian food. We had a good laugh over that.
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