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The Little Blue Button

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A “code” is the term that medical professionals use to describe the orchestrated chaos that surrounds a patient that is on the brink of death.  Depending on the facility a code may be called a Code Blue, Code Red, Code CPR, or sometimes Code 99.  They all mean the same thing.  A person is about to die unless there are medical interventions made immediately.  Sometimes it means that death will come no matter how hard we try to stop it.

 

A few months past graduation I experienced my first code on my own patient.  The man had been verbally abusing me all day.  I had been running around trying to make him happy and also care for my other five patients.  He was bellowing from his bed that he was going to die.  A lot of patients speak in that way, but something about the way he said it terrified me a little.  All his vitals, physical assessment findings and that he was able to yell with so much energy all assured me that he was stable.  I called the physician anyway.  He agreed to assess the patient. I went to check on my suddenly quiet patient.  When I walked into the room I knew something was different.  I will never forget how grey he looked.  I froze in a moment that felt like eternity while I listened and looked for breathing.  It only took a few seconds to confirm.  I reached up above his head and pressed the small blue button.

 

I was the person yelling now.

 

I called above the alarm sound for help. Help came.  Almost before I could lay the patient flat in the bed, a nursing aid, with a football player build, began chest compressions.  Respiratory commanded the head of the bed, bagging and preparing for intubation. A metal crash cart clanked into existence, pushed by my charge nurse.  The emergency room physician and intensive care nurse rushed in together. The ICU nurse asked who the primary nurse was.  All I could think was ‘Oh Crap! That’s me.’  She told me to grab the chart (that’s back when patient’s records were big, clunky, 2-ringed, plastic folders stuffed with a ream of paper printouts and handwritten notes) and call the patient’s physician.

 

I ran to the desk and called the doctor again. He was just getting off the elevator. We met at the patient’s bedside. I calmly answered questions about history, vitals, and labs, all while the resuscitation dance continued.  I was calm only on the outside.  Inside my mind raced, searching for what I might have missed.  This man had been screaming at me all shift.  How could we be coding him now?  I couldn’t think of anything I could have or would have changed.  Even now looking back, with much more experience, I know gave him appropriate care.  I watched the code continue, clutching the hard plastic chart.  I optimistically observed that his color was pink again.  Surely that was a good sign, I told myself.

 

As if someone had flipped a switch, everything stopped.

 

The ER physician called time of death after nearly 40 minutes of trying to coax my patient back to life.  I watched as my patient lost his rosy color while the team waded through the open package wrappers that had been hastily discarded on the floor.  The CNA stayed and helped me to clear the debris and prepare my patient for the morgue.  The aftermath of the code was over quickly.  I think that is what stunned me the most.  The physicians and nurses went on caring for their patients.  Housekeeping came and cleaned the room for my next admission.  I did not have time to cry or sit in disbelief or process what had happened.

 

The shift went on and so did I.

 

I have since been to countless codes.  Sometimes I am doing the compressions.  Sometimes I am the nurse directing the chaos.  Occasionally I am the primary nurse questioning every action I did or didn’t make that shift. Luckily one aspect of patient codes has changed since I was a new nurse.  It is now an expectation in many hospitals that a debrief occurs after a code, regardless of the outcome.

 

A debrief is conducted as soon as possible after the event.  All available team members are expected to attend.  It is a confidential and non-discoverable group discussion of the event.  The purpose is to discuss the facts, problems, barriers, needed improvements and to acknowledge and share feelings.  This is not a time to place blame or try to find fault with one another. This opportunity to discuss the event and acknowledge how we feel about it is a valuable practice.  I never want to feel that losing a patient is business as usual.

 

Debriefing is the pause that we need to take to acknowledge, gain knowledge and make adjustments for the next time we press that little blue button.

 

 


Debriefing Steps 

1. Introduction: The facilitator establishes the group goals and rules and reinforces the need for confidentiality about anything that transpires within the group.

2. Fact gathering: Each staff person describes what happened and facts are gathered.

3. Reaction phase: Led by the facilitator, the group examines its feelings, thoughts, and responses to the event experienced. If the debriefing session happens soon after the event occurred, there might not be any symptoms.

4. Symptom phase: If some time has elapsed since the event, group members may be experiencing symptoms. The facilitator helps the group examine how these reactions have affected personal and work lives.

5. Stress response: The facilitator teaches group members about their stress response.

6. Suggestions: The facilitator offers guidance on how to cope with stress related to the incident.

7. Incident phase: Group members identify positive aspects of the event.

8. Referral phase: The facilitator concludes with this phase, whereby specific individuals who require additional support are referred for individual follow-up.     

Adapted from: Hanna, D., & Romana, M. (2007). Debriefing After A Crisis. Nursing Management (Springhouse), 38-42,44–45,47.


This post was written as part of the Nurse Blog Carnival.

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*all accounts are fictional
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13 Fundamentals for Practicing Nursing

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National Nurses Week is a time set aside for the public to recognize the amazing work of nurses.  Nurses will be the topic and focus of hospitals, newspapers and media outlets.  Our accomplishments, character and hard work will be applauded and we will receive all kinds of tokens of appreciation from employers, patients and family.

This year instead of another pen, coffee mug or tote bag, I want to give nurses something that that won’t end up in the summer yard sale.

 

Rosemarie Rizzo Parse’s 13 Fundamentals for Practicing Nursing

 

  • Know and use nursing frameworks and theories.

You can begin with Parse’s theory of Humanbecoming, which is an insightful nursing theory that describes how nurses and patients co-create the health experience.  Parse marries the art and science of nursing in a beautiful and applicable way.

 

  • Be available to others.

Nurses are busy.  Do not let the fast pace of healthcare prevent you from being available.  Remember to be available for the nurses around you. No one understands you quite like a fellow nurse. Take the time to listen, help and care for one another.

 

It is a poor coping mechanism to view patients as diseases, room numbers or annoyances.  Nursing is stressful, people are not always kind, and you may never hear a thank you, but it is important to value everyone as a human presence.

 

  • Respect differences in view.

Whether you are a new graduate or about to retire, you are a nurse with opinions.  Differences in opinions are good!  Respecting differences of view is important too.  Creating a safe and welcoming environment, for everyone to share their view, will allow nursing knowledge to evolve and grow.

 

  • Own what you believe and be accountable for your actions.

If you believe in something or someone, stand up and speak up.  If you turn out to be wrong, admit it and move on.

 

  • Move on to the new and untested.

Change is hard.  No one likes it, but change is necessary and good for us and nursing.  If we did not push forward and try new nursing interventions we would still be sterilizing our own needles and fetching coffee for physicians. Parse’s theory is a paradigm shift away from medical thinking that embraces nursing as a standalone science.

 

  • Connect with others.

Compassion, caring, respect, understanding are all qualities that nurses help nurses to connect with the healthcare team, including the patients.

 

  • Take pride in self.

You are not “just a nurse.” Being a nurse is exceptional.  Don’t shortchange your contributions to healthcare.  You are brilliant, own it!

 

  • Like what you do.

If you hate your job, find one where you can be happy.  There are endless opportunities in nursing.  You owe it to yourself and your patients to like coming to work every day.

 

  • Recognize the moments of joy in the struggles of living.

Life is hard.  Take time to recognize and feel joy when you find it.

 

  • Appreciate mystery and be open to new discoveries.

Nursing is a beautiful work. We are the companions to humanity throughout the life span and in every imaginable condition. We continue to discover what it means to be human day after day.  Be open to the mysteries of life and embrace what you find.

 

  • Be competent in your chosen area.

            What have you been doing since you graduated nursing school?  Have you been to a conference, read a journal, taken a class?  Choose your nursing niche and keep learning.

 

Taking time for self is vital in order to prevent compassion fatigue and nurse burnout.  Nurses are known for putting themselves last.  Their own health, spirituality, emotion and mental needs are often put aside in order to care for others.  Take care of yourself!  Take a few minutes to meditate, pray or sit quietly during a hectic shift and you will feel the difference, and so will your patients.

 

Thank you to all my nursing colleagues around the world!  This is the week that everyone remembers that nurses are a special kind of awesome. 

Let’s remember this about ourselves the other fifty-one weeks of the year!

 

 

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Bournes, D., & Mitchell, G. (2014). Humanbecoming. In Nursing Theorists and Their Work(8th ed., pp. 464-495). St. Louis: Elsevier Mosby.

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3 Small Ways to Bring Mindfulness to the Bedside

Nurses multitask.  We are expected to be flexible.  We accomplish more than any one person should be capable of achieving in twelve hours. We do it all with a smile on our face, at least most of the time.  Behind the smile, our minds our often far from the bedside.  We are thinking about the patient in another room, when pharmacy will tube up the medication that is late, whether our lunch buddy is back from eating, and the charting that needs to be finished from morning assessments.  It is difficult to be truly present with the people that we provide care.  There are many distractions for our attention and energy.  Nursing is also an emotional career.  Supporting, caring and healing people exposes nurses to intense emotion from patients, family and friends of the patient and the nurses own emotion.  Stress, crazy workloads and intense emotions can be huge barriers to nurses having mindfulness at the bedside.

Three tips to put mindfulness in action at the bedside:meditation-clipart-meditation-clipart-animal

 

  1. It is what it is This is one of my go-to-mantra’s.  This is not a surrender to fate, it is an acceptance of the limits of my power as a nurse.  When I truly have done all the intervening and advocating possible, I accept the outcome.

 

  1. Being present Mindfulness requires us to pull up a stool, sit down and be with our patients.  It is letting go of everything else in the world for a small space of time in order to be present.  It is important to connect with each other human to human.  Being present also allows our attention to focus on this patient’s needs, fears, wants and hopes.  Not being present causes errors and decreases the trust from the patient

 

  1. Suspending judgement Being critical of our patient’s actions, feelings, choices or lifestyle prevents us from being present and having mindfulness. It is important to meet people where they are in life.

 

We will not always be able to be 100% mindful as a nurse.  These three tips can help us be more mindful with our patients for their benefit and ours.

 

This post was written as part of the Nurse Blog Carnival. More posts on this topic can be found at The Balanced Nurse Blog. Find out how to participate.

 

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Nursing is Bigger on the Inside

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I love Doctor Who.  For anyone that is not familiar with this British television program, the basic premise is as follows.  There is a cool alien that looks human, but regenerates every few season to look like the next actor to play him.  This alien is called the ‘Doctor’ because no one can know his real name.  The Doctor is a time lord from a planet called Gallifrey and he travels in what looks like an old police call box, much like a telephone booth.  This police box, the TARDIS, takes the Doctor anywhere in time and space, but that is not the only amazing thing about the it.  The TARDIS is bigger on the inside.  We don’t know how big, but imagine the Star Trek Enterprise stuffed into a telephone booth and you get close. 

Nursing is like the TARDIS.  

People think they know about nursing.  The public only sees the outside. They see that nurses work 3 days a week and are paid well. They see that nursing is not a glamorous job. They see smiling faces and skilled hands.  

Nursing is bigger on the inside. 

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A lot of nurses look cute in scrubs, but even those scrubs lose their appeal when they are covered in various bodily fluids.  I am frequently told by family, friends and random strangers that they could never be a nurse.  I get it.  Nursing is not for everyone.  

Some of us do work 3 shifts a week.  Those 12 hour shifts stretch into 14 or 15 hour days when you add in lunch, report, extra charting and commute time.  The majority of nurses that I have known work much more than 36 hours a week.  

For the most part nurses can at least fake a good mood and do their best to smile.  Smiling and chatting with patients they perform the technical skills that keep patients safe and comfortable.  

Nurses need to be smart, caring, brave, strong willed, strong stomached and have a sense of humor.  We see the worst and best of humanity in our work.  We are happy when our patients do well and cry when they are not.  Nurses monitor, clean, feed, medicate, assess, educate, entertain, console, listen, advocate for and document about patients day and night.  After doctors, therapists, family, friends and even dietary leave for the night, nurses remain at the bedside.  

Caring for patients is rewarding, gratifying and exhausting.  To be trusted to such a degree by a stranger is an honor.  Helping people meet health goals or guiding them through milestones is an amazing feeling.  Even when our patients pass away, helping the patient and family through the process is fulfilling.  

Nursing is much bigger on the inside.  It is easy to get lost in charting, policy reviews and quality audits and forget the art of nursing.  Nurses need to be reminded of the amazing impact that we have on peoples lives.  Nurses not only impact health at the bedside, but have the power to transform healthcare practice.  

 

Take time to remember how big nursing is and why you do it. Energize and renew your yourself at the Art of Nursing 2.0 event from anywhere in the world.  

 

 

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This post was written as part of the Nurse Blog Carnival. More posts on this topic can be found at ElizabethScala.com. Find out how to participate.

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The Secret Awesomeness of Night Shift

The hospital feels different after 5 PM.  

The scheduled surgeries are finished for the day.  The short stays and clinics are emptied and closed.  Administrators, executives and their assistants all begin vanishing like the sun over the horizon.  The last few tired nurses clock out and the hectic cloud of day shift follows them into the elevator.  What is left behind is an alternate hospital universe that only true night shift staff discover and appreciate.

The bright lights are dimmed to signal to patients, visitors and staff that night has arrived.  The coffee and tea come out to greet the healthcare team to another night.  Some nursing units brew their own caffeinated delights,  others take turns making massive runs to Starbucks, Dutch Bros or another favorite coffee spot.  Patient assessments are completed and medications are passed.  Nurses and ancillary staff move quickly to check off all the tasks on their lists.  If they are lucky they will be able to tuck themselves in to the nursing station to chart and chat the hours away until dawn.

Everything is more a little more relaxed.  No topic is taboo by 4 AM.  Night shift staff know each other, the good, the bad and the unmentionables.  If a manager or administrator happens to come in on night shift, the news spreads quickly and the books, smart phones and uncovered cups disappear in an instant.  Those late night visits from administration are rare. Night-shifters learn to depend on each other like family.   

The calm can be misleading.

In the darkened corners of the nursing unit lurk the possibility of chaos.  Disaster can interrupt the laughter at the nursing station, despite the careful observation and care of patients.  When emergencies occur, the night shift team leaps into action.  The juicy conversations and cat videos are abandoned and the only priority is the patient.  An outsider may not see an emergency on a nursing unit as seriously as the team working in it.  It does not usually look like it does on television.  There are a lot of people.  Everyone is in motion.  It is often quiet with one or two people calling out times and actions.  Faces are focused.  Minds are alert and assessing, searching for causes and solutions within milliseconds of coming to the bedside.  They have done this before and settle into their comfortable roles.  The night shift team are a little more earnest and confident.  They know that reinforcements are not coming.  This is night shift.

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When the emergency has passed, for better or worse, the team returns to its tasks.  The work and night continue.  

Despite the craziness and sleep deprivation, night shift is awesome.  Most people dread working at night and do not understand why any sane person would choose to work the late shift.  It is not the frappicinos.  It is not the chance of watching cat videos for hours.  It comes down to the men and women sharing the nursing station with you.  They don’t always get along, but they are always in it together.  They create the secret awesomeness that is night shift.  

Shhhhhh don’t tell the boss! 

 

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Post Conference Tool: Delegation

Two challenging concepts to master, as a new nurse, are prioritization and delegation.  I am sharing the attached tool for anyone that teaches nursing students or new grads.  Its a quick delegation activity to get a discussion going on prioritzation and delegation.  There are suggested answers, but of course there will be more than one way to delegate the tasks.

 

Enjoy and I hope that at least one of your post conference activities will be covered.

 

Click for the Free PDF: Delegation activity

 

 

Delegation activity

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There are No Guaranties in Pregnancy

Moms are brave.

Pregnancy is a normal function of life.  Most pregnancies proceed on a predictable course and result in a healthy baby. Although it is a normal part of life, pregnancy is unpredictable. There are no guarantees.  Some of the bravest people I have met have been mothers that were facing unknown outcomes.  Women that faithfully endure days, weeks or months of bed rest amaze me.  Mothers whom have lost babies in previous pregnancies bravely try again, and again.  Starbucks and sushi are passed over for the health of the baby.  All these sacrifices and more moms willingly make. Moms bravely face the unknown with faith in the future.

One brave mom checked herself in to the hospital at the request of her obstetrician.  She was late in the second trimester and her baby was not doing well.  While I asked her the standard questions I saw the tears build in her eyes.  I turned away from the computer and sat next to her.  I asked her why she was being admitted.  I knew, but I wanted her to be able to tell me.  She opened up and began telling me, first her diagnosis, then her fears followed by her hopes.  My eyes stung as I forced back my own tears.  This woman had been smiling and laughing moments before.  She was incredibly brave.  I held her hand briefly and I told her that she was in exactly the right place for her baby.  I assured her that we, as her care team, would do all that we could to help her and her baby through the challenges that they were facing.  Those were not empty words.  I believe that we work miracles in OB every day. I am grateful that brave mamas place their trust and hope in our hands.  I never want to let them down.

 

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Free PDF: Caring for the Patient with an Eating Disorder

 

 

Perinatal nurses are now caring for patients that are higher acuity and with more comorbidities.  Caring for a mother with an eating disorder is rare, but does happen.  Your hospital should have policies in place for caring for these patients.  Attached is a free, one page, information sheet as a quick guide when a patient with eating disorders is admitted on your unit.  Pregnancy can be a stressful time in which old behaviors can return.  A better understanding of this disorder can help you care for mothers that are struggling with these issues.

This is general information is for all adult patients with eating disorders.  Each patient and care plan will be unique and take into the specific patient’s needs, assessment and input from the entire healthcare team.

CLICK BELOW FOR FREE PDF (with references):

Adult-Eating-Disorder-Patient-Overview-1

 

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10 Nursing Actions to Bring Compassion Back to the Bedside

Even the most benevolent and happy nurse can forget that every patient is someone’s special person. Some days feel like just another ordinary day at work.  Nurses have bad days just like everyone else. The difference is that a nurse’s bad day can darken a patient and family’s already stressful stay.

When nurses begin to lose sight of the how important their role is a patient’s recovery it is important to recharge, refresh and relearn what it takes to make each day special for patients.

 

Here are 1o ways to bring compassion back to your patient’s bedside:

 

1. Identify something you like about your patient. This may be difficult with some patients, but everyone has some redeeming quality. Find it.

 

2. Smile. If you smile your patient will feel welcome and it can change your attitude as well.  Fake it till you make it.

 

3. Acknowledge and speak to all the people in your patient’s room.  The patient’s family is important and they will appreciate being recognized.  Also they can be recruited to help get ice, hold emesis bags and feed the patient.  The people in the room will be the ones that will be there to support the patient at home when he is tired and needs help. Include the whole family in patient education so that the transition back to home be will be successful.

 

4. Include the partner or loved ones in conversations with the patient. A patient’s support person needs to understand and give input on the patient’s plan of care. The decisions are the patients to make, but they often look to their partner or loved ones for guidance.

Including the partner in the conversations with patient establishes trust and is an element of family centered care.

 

5. Take lunch off the unit. This may be impossible at some hospitals.  If at all possible, leave the unit for your break. Go outside and breathe real air. Take a walk in the sunshine and absorb some vitamin D.

 

6. Use your relaxation skills to relax yourself.  You teach these techniques to patients every day, those same relaxation techniques can benefit stressed nurses!

 

7. Use your vacation days! Don’t hoard vacation days. People that take less vacation days have less job satisfaction.

 

8. Join your professional nursing organization. Keeping up to date on new research is exciting and stimulating.  Challenge yourself and continue to grow in your specialty.

 

9. Go out of your way for your patient at least once a shift. They may not thank you, but you will know that you put in extra effort to make your patient’s stay better.

 

10. When the family is visiting take a few seconds to look away from the IV pump, computer and thermometer.  Witness how the family comforts and supports each other. Watch as a daughter holds her mother’s hand for the last time. See the happiness when a husband is told he can take his wife home.  These moments are what make us human.

 

Take the time to make every day special for your patients.

For nurses it is just another day at work, but for each patient it’s a day that can change their life.

 

 

 

 

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Nurses Lie

Nurses have been voted by the public as one of the most trusted professions year after year.

Let me share a secret with you, nurses lie. Of course all nurses are not saints. It is possible to run across a Nurse Ratched or Nurse Jackie from time to time. That is not what I mean. All GOOD nurses lie. Nurses may pride themselves on being honest and having integrity in their personal lives, but they can not stop lying at work.

Seven lies that nurses tell:jurse jackie

1. It’s just allergies.

Nurses are constantly exposed to illness. They work long hours with little time for resting, eating, drinking or potty breaks. Many nurses work the nightshift which further weakens their immune systems. The nature of their work leaves nurses vulnerable to illness. It is not possible to stay home every time a nurse is sick. Patients need cared for 24 hours a day. Bills still need to be paid. Hospitals fire nurses when they take too many sick days. All these factors create tremendous pressure to take an over-the-counter cocktail of medications and head on in to work.

2. You are dilated to 9cm.

This may be true. Maybe not. It depends if your doctor is impatient with moms while pushing. Three hours of pushing is normal for first time moms, but not all doctors will wait that long. Your nurse may be buying you time to avoid a cesarean section. She may see that you really need to rest before you start pushing. Maybe you are waiting on a family member to arrive and she is trying to buy you time. Maybe she needs to eat a snack before she passes out and she knows you want to start pushing right at 10 cm.

3. Don’t worry, it happens all the time. It’s not a problem.

Chances are it doesn’t happen all the time, but your nurse wants you to feel comfortable and not embarrassed. Even if it is a common occurrence it probably is still a problem. A patient passing gas while a nurse is inserting an urinary catheter does NOT happen all the time and it IS a problem. Nurses will lie through their teeth while they try to not inhale and also try to not break sterile technique.

drunk P
If I can’t have Dilaudid can I have my IV Phenergan? Don’t forget to push it fast!

4. You can’t have any more Dilaudid.

Chances are you technically could have more. When a patient is asking for more narcotics in between snoring sessions and they can’t tell the nurse from the IV pole, they are not getting any more Dilaudid!

5. I have time for you.

Nurses wish that statement was always true. It is often a lie. Heavy patient loads and mountains of charting take time away from the time at the bedside. In a rare moment when a nurse is caught up with his shift work he still has hospital, unit, certification and licensure education requirements to complete. Nurses will stay at the beside and make the time for you that is needed. Then they will stay late to chart and come in on their days off to complete their continuing education requirements.

 

6. I need to go check on a lab result. (or any excuse to get out of a room)

Sometimes this is nurse code for “If I don’t go to the bathroom right now I am going to have to call a code brown on my self.”

 

7. I don’t smell anything. Yes they do! They smell it. They are just being nice. If it is within the nurses power to fix the problem then they will bathe, deodorize or bandage up the offending odor. When there is nothing to be done about the smell, they will lie to preserve the dignity of their patient.

smelly

 

 

Nurses lie. Should a nurse share her battle with irritable bowel syndrome and explain how it will affect her time management of her patient care? Sometimes ignorance is bliss. Despite a history of lies, nurses deserve to be the most trusted profession.