I hate pysch-soc issues in nursing.

If you want warm fuzzies, I am not the nurse for you. Yes, there are nurses who excel at giving hugs, putting stickers on good behavior charts, and indiscriminately chatting ad inifitum with patients and families. I am not one of them. Every once in a while I will bond with a patient/family, but I generally want the critically ill, sedated and intubated patients. I am very happy to leave all the psych-soc aspects to someone else, namely the excellent social workers and chaplains that I work with.

Patient I had Sunday and today was a big load. Not only is she struggling with acute complications of an insidious chronic disease, but she (and the nursing staff) have to bear the ministratons of a possibly learning disabled mother whose actions sometimes put her daughter at risk. The mother absolutely loves her daughter, and wants to do what's best for her, and that's part of what's so hard. Examples of seemingly innocuous actions that can be dangerous to the patient:

1) Moving parts of the bed. Ostensibly mother wanted to make her daughter more comfortable. Not a bad thing in and of itself. However, unless the nurse is present to adjust monitoring equipment, moving the patient changes the displayed values of the arterial blood pressure, which was critical because we were treating the patient for episodes of hypertension in order to prevent seizures and maintain good perfusion. Also, the patient was being sedated with fentanyl and versed drips, and was already sleeping. Moving her around keeps her awake, less consolidated periods of sleep contributes to ICU psychosis, and the patient was already on psych meds prior to this hospital admission. I had multiple discussions with the mother about asking the nursing staff about any changes before acting on her own.

2) Picking at the tape around IV and deep line sites. The patient has a variety of skin issues related to her therapy. When the nurse on Monday was changing the dressings, the mother insisted that she remove the sutures stabilizing one of the deep lines, and leave all the sites open to air. In such a compromised patient who requires complex care, deep lines are gold ... we nurses guard them carefully because these are the portals by which we can give lifesaving medicines. Peripheral IV's can be tenuous because chronic patients generally have weak veins that can't support high volume flow, cardiac pressors, or medications with extravasant properties. And yet, I have to constantly monitor the mother because she still picks at these dressings that protect the site and the line integrity.

3) Demanding immediate attention for non-urgent matters. This isn't so much a danger to the patient as it is a drain on the nurse's time and patience. At one point, as I was gathering the supplies I needed to enter the patient's room and provide care for the next half hour, the mother called out to me with a degree of urgency. I immediately stopped what I was doing, hurried to gown/mask/glove up, and entered the room to assess the situation. Turns out that she wanted to loosen the pulse-oximeter, which she felt was too tight. The pulse-ox measures the percentage of oxygen in the bloodstream via a special monitor that gets wrapped around an extremity like a finger (or toe, foot, ear lobe, and sometimes even a penis if perfusion is extremely bad ... assuming the patient is male). It needs to fit snuggly in order to give accurate readings, which are vital to an intubated patient. I had to re-explain all this to the mother (in Spanish) and reiterate that we change the site every 12 hours. Then I had to de-gown/glove/mask, wash my hands, return outside to gather all the things I needed, come back in, re-gown/glove/mask, wash my hands, and give meds and do treatments. This was one example among many.

We had a family conference in the early evening, to update the family on the patient's condition, allow the family a forum to ask questions and ventilate concerns with a translator and the main medical services, and to do some teaching with the mother. The patient has been followed through one of the specialty clinics for several years, so the attending physician, the social worker and nurse educator from that service joined the PICU team at the conference. The conference went well. At the end, the mother had asked some pertinent questions, expressed an understanding of the patient's status, and expressed her thanks and confidence in the work we were doing.

After the conference, the clinic social worker and nurse educator pulled me aside and shared that despite numerous hours of family education, the mother has a history of repeatedly asking the same questions, and that there was some concern that she had a learning disability.

Less than half an hour later, the mother was arguing with the ophthalmologist about whether a dilated eye exam was necessary. I explained the steps to her, but she was particularly obstinate. Translator services were again required. My attending physician had to get involved before the mother would back down.

Anyway, I left work that night with a huge smile on my face. Maybe it was because I was due for two days off. Maybe because I'm going to see some good friends on Thursday. Maybe because there is a new episode of House tonight. Or just maybe because I just had my annual review. Brusquely Warm, my manager, said that my evaluation was being signed by the nursing director. Apparently the ND has to sign all evals that score an excellent. Huge smile from me indeed. BW also said that I could try being more "warm and fuzzy" toward the families of patients. Wry smile from me indeed.