I hate it when the nurse does X...

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I hate it when the nurse...

....says "Doctor, I can only do one thing at a time." My response: Then, go into some other specialty, because in EM you must be able to do multi-task. I especially hate this during code or critical situations.

When I ask you to do something, I expect only one of two responses: 1) "Already done." 2) "No problem, I'm on it." That's it.



...is busy charting on a critical patient, instead of providing actual medical care. How many nurses does it take to change a lightbulb? Four. One to change the lightbulb, and three to document it. Really, we should fight off this documentation culture, and push for actual patient care.



...[connected with the previous point] delays carrying out an order I just verbally conveyed. When I say something to do, you should do immediately. The fact I am conveying it to you personally is because I think it is a time-critical step. For example, steroids in a COPD/asthma case. Give it first, then you can document after that.



...doesn't get me the urine. I ordered it, get it. Threaten the patient with a cath. Give me someone else's urine, pee in the cup yourself, I don't care. Get me the urine. I swear, half of my life I'm waiting for a urine.



...is rude to patients. The other day I had an angry patient with back pain come to the desk, saying "How is it that the patient next to me got seen before me even though I've been here for way longer?" I was equally annoyed with this patient, but I prefer passive-aggressive sort of comments, and platitudes such as, "Sir, unfortunately patients are not seen in order of wait times. But, we'll get to you as soon as we can. Thank you very much for your patience." (Whenever I say "thank you for your patience", it really means that the patient is anything but patient.) I feel like fake Customer Service voice is a much better weapon against annoying patients, than the immature and unnecessarily abrasive, "You've only been here for 1.5 hours and it's not an emergency!"


What about you? What's your pet peeve with nursing?

EDIT: To be clear, this thread should not be seen as anti-nursing. Nurses are a vital part of care, and I work with some absolutely awesome nurses. However, like any occupation (including MD's), some of them really suck, and it kills care.
 
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The charting thing brought back a vivid memory of a nurse documenting instead of providing patient care:

Lady came in, respiratory distress, gets intubated. On a propofol drip. I discuss with intensivist, she's waiting to go to the ICU. I'm in another room when I hear my name called overhead to go to the room stat. I walk in, see the patient had pulled out her IV (rephrased: someone pulled it out moving her) and had ultimately partially awakened and extubated herself. The ET tube was sitting next to her head and she was fish breathing. I look over to the nurse who is busy charting. I said "she's extubated herself." "Oh, guess so. I called you in here because she was getting agitated." "Yea, she's not getting her propofol." "Crap, I have to start another IV! Can't you just put in a central line?"
 
southerndoc said:
The charting thing brought back a vivid memory of a nurse documenting instead of providing patient care:

Lady came in, respiratory distress, gets intubated. On a propofol drip. I discuss with intensivist, she's waiting to go to the ICU. I'm in another room when I hear my name called overhead to go to the room stat. I walk in, see the patient had pulled out her IV (rephrased: someone pulled it out moving her) and had ultimately partially awakened and extubated herself. The ET tube was sitting next to her head and she was fish breathing. I look over to the nurse who is busy charting. I said "she's extubated herself." "Oh, guess so. I called you in here because she was getting agitated." "Yea, she's not getting her propofol." "Crap, I have to start another IV! Can't you just put in a central line?"
Click to expand...
:boom:
 
Angry Birds said:
...doesn't get me the urine. I ordered it, get it. Threaten the patient with a cath. Give me someone else's urine, pee in the cup yourself, I don't care. Get me the urine. I swear, half of my life I'm waiting for a urine.
Click to expand...

link2swim06 said:
But most importantly, not telling me how to get the dam IV pump to stop beeping for more than 60 seconds....
Click to expand...

Yes and yes
 
Urine. Telling me there's nothing wrong with the patient when they happen to have a legitimate issue they didn't see and then question me when I start treating. (I don't mind if we disagree or if I can educate them on something. I just hate if they come to early closure and then question my plan)

gman33 said:
Urine.

Of course they don't get it.
We have different goals.
We want dispo and room turnover.

The nurse wants the patient to stay in the room and not get a new assignment.
Click to expand...
Uri
 
em1234 said:
discharges a patient with abnormal vitals and doesn't feel the need to tell me. (but 2h later, after I figure it out and raise hell, slips in a note in their charting that I was notified.)
Click to expand...

This is an act of cover-up on part of the nurse. An EMR will document the time and date of the annotation and you can go to the medical director and nurse manager that the note was introduced after the abnormal VS were appreciated and appropriately brought up with the nurse.
 
Has a CC that is a novel.

Labels a patient as drug seeker, just want X, Y or Z or whatever before I see the patient. I recently had a "drug seeker" having an MI and a "family just doesn't want to take care of granny" with an ICH. Had I allowed myself to participate, anchoring bias could have led to badness. I suspect I've done this in the past.

Urine.

Getting carried away with triage orders. I don't need a trop on the 23yoF with belly pain and vag bleeding. I do however need the urine for an hcg.
 
RustedFox said:
Second for "CC that is a novel".

We have one triage nurse who writes as little as humanly possible. I love her.
Click to expand...

Really? I hate this too. It's due to lazy she does that and then you can't tee up labs beforehand or prep yourself for what the patient presents with.
 
Angry Birds said:
Really? I hate this too. It's due to lazy she does that and then you can't tee up labs beforehand or prep yourself for what the patient presents with.
Click to expand...

I'll take it over having to justify all the things that aren't actually there that triage decided were important to write down anyways.

"Patient is lethargic and has chest pain (really means: wheezing) and thunderclap headache and passed out 11 times today and reports history of (whatever)"

I love it when I see: "ABD PAIN" and they stay the hell out of the charting.
 
Not following orders and not asking questions about the order (by all means, ask if you have a question, but don't just ignore it and not ask about it). The propofol for the intubated patient isn't a suggestion. Yes... I understand that the patient isn't agitated right now... but that's because we intubated 30 minutes ago... with Roc.
 
...interrupts me when I'm on a cath lab call, while dropping orders on an intubation & trying get to overhear a tele run, just to ask if a discharged patient can get Tylenol on the way out.

Wouldn't aggravate me much if the same nurse also didn't blow me off to finish an Amazon order. Grr...

Semper Brunneis Pallium
 
If you are hearing "I can only do one thing at a time" very often, from more than one nurse, it may be reasonable to assess whether there is a genuine resource limitation/allocation problem that they are coming up against. Or perhaps you are really asking for more than anyone can make happen in the time frame that you want the things done.

I once had words with a neurosurgeon who loved the word STAT a little too much. He wanted STAT scans on 4 different patients within 5 minutes when we only had one machine to work with. I asked him to please, just prioritize for me, which STAT was the most STAT, so that I could get it done first. It wasn't that I was lazy or unwilling. I just truly didn't have a conveyor belt that I could lay the patients on end to end to run them through the CT scanner.

Full agreement on the urine issue. I can't tell you how often I've had patients wait in the ED for 6 hours for a bed, then spend another 12-24 hours up on the floor waiting for an OR to open up, and then still show up in my holding area without anyone having collected the urine for hcg. Strangely, I had no difficulty to get the samples there, just by asking and providing a bedpan. I figure no one else must have tried that.
 
TimesNewRoman said:
Has a CC that is a novel.

Labels a patient as drug seeker, just want X, Y or Z or whatever before I see the patient. I recently had a "drug seeker" having an MI and a "family just doesn't want to take care of granny" with an ICH. Had I allowed myself to participate, anchoring bias could have led to badness. I suspect I've done this in the past.

Urine.

Getting carried away with triage orders. I don't need a trop on the 23yoF with belly pain and vag bleeding. I do however need the urine for an hcg.
Click to expand...

I rarely order urine hcg. I almost always order blood hcg now because I know blood will get drawn fairly quickly and put into the computer. The urine hcg can takes hours and hours. It can really hold up care otherwise.
 
1) Urine - and yes, the demented 90 year old female patient needs a straight cath. Also echo the above about ordering serum HCG half the time to speed up dispo.

2) Giving a hard time about obtaining rectal temp - shocker when the 99.0 oral becomes 103.4 rectally

3)Documenting craaaaazy vital signs - no, the 9 month old was not breathing at 90 (also, was not "lethargic")

I have to say though, when you have a team of rockstar nurses on your shift it is amazing. Everything goes much more smoothly.
 
This really isn't a nurse bashing thread.
Many or most most nurses do a great job and have saved my ass numerous times.

It's more just venting about the issues that get under our skin.

I've pioneered a new technique for diagnosing a uti. The ct read of likely cystitis.
That comes back much faster than a urine dip.
 
GonnaBeADoc2222 said:
1) Urine - and yes, the demented 90 year old female patient needs a straight cath. Also echo the above about ordering serum HCG half the time to speed up dispo.

2) Giving a hard time about obtaining rectal temp - shocker when the 99.0 oral becomes 103.4 rectally

3)Documenting craaaaazy vital signs - no, the 9 month old was not breathing at 90 (also, was not "lethargic")

I have to say though, when you have a team of rockstar nurses on your shift it is amazing. Everything goes much more smoothly.
Click to expand...

Granted, more of a floor issue, but... logging the same vital sign 5 times in a row. Not like they're lying, but more of a:

12:00 200/99
12:01 200/99
12:02 200/99
12:03 200/99

Of course now when someone looks, it looks like the patient has been hypertensive for hours and hours and hours and no one has done anything about it because people just see the number and not the time it was logged at.
 
Siggy said:
Granted, more of a floor issue, but... logging the same vital sign 5 times in a row. Not like they're lying, but more of a:

12:00 200/99
12:01 200/99
12:02 200/99
12:03 200/99

Of course now when someone looks, it looks like the patient has been hypertensive for hours and hours and hours and no one has done anything about it because people just see the number and not the time it was logged at.
Click to expand...

Do you need to do something about it?

Schedule a PCP appointment?
 
traxus said:
This is an act of cover-up on part of the nurse. An EMR will document the time and date of the annotation and you can go to the medical director and nurse manager that the note was introduced after the abnormal VS were appreciated and appropriately brought up with the nurse.
Click to expand...
While there is a time stamp, that's similar to an upstairs doc saying we're lying because we said we called them but didn't finish the chart until the end of the
RustedFox said:
Come to Florida. 1 out of 3 cases involve a senior, a BP value, and an obstructive RN staff member.
Click to expand...
I'm from there but I couldn't reconcile myself to practicing in God's waiting room.
 
GonnaBeADoc2222 said:
3)Documenting craaaaazy vital signs - no, the 9 month old was not breathing at 90 (also, was not "lethargic")

I have to say though, when you have a team of rockstar nurses on your shift it is amazing. Everything goes much more smoothly.
Click to expand...

I had what I thought was going to be a super interesting case when a 77yo walked into triage and had a temp of 109.6. Turned out to be 100.6... sigh
 
Didn't plan on contributing, but I got destroyed last night and dealt with a lot of nursing frustrations on top of it and still feel the need to be very selective in my battles as a lowly intern.

Urine. Had 3 patients just last night who sat 1-2+ hours waiting for urine until I went in the room and asked for it myself. Patient responses ranged from "Sure thing" to "Well, if you only need me to squeeze out a little bit, I can probably do that." 3/3. Plus another who had urine in the room during my initial physical which was not run until I found the nurse playing on his phone over an hour later to remind him that the sample was sitting on the counter.

Throwing a fit when asked to do something that would fall to nurses in the community. Visual acuity? Documenting fetal heart tones? Outrage.

Never documenting another set of vital signs after triage. Patient comes in with a heart rate of 130, which resolved by the time of my initial exam. Patient had 3 hour ED stay without another set of vitals documented, which I don't realize until finishing the note long after discharge.

No patient gown when it's clearly needed. Abscess on the butt or chest? The patient obviously can't stay in their two shirts and jeans... As a corollary, taking BP through bulky clothing.

Giving medications and then asking for an order. Usually just a heads up that the lactate was elevated or the BP took a dip with increased sedation dosing in an intubated patient so the nurse is hanging fluids, but recently had a request for fentanyl and said I'd give something longer lasting instead. They then told me they gave the fentanyl already before asking, since they thought there was a PRN order in. Not a huge deal in that case, but will eventually lead to badness.

Refusing to do something because "they'll take my license," when that something is completely reasonable, discussed with the attending, and explained physiologically to the nurse.

I am thankful when they volunteer to chaperone a pelvic exam on a patient that isn't theirs because the primary RN isn't available, or when they ask questions or express concern about a patient but are willing to follow the plan when the rationale behind a decision is given. I also can't think of a single complaint about our ED nurses when the patient is critical. They've also reminded me that a patient was breastfeeding on a few occasions when I was writing orders that caused me to change my plan.
 
I love my ED nurses but it kills me when they (sometimes, some nurses) interrupt me getting a history with asinine questions for their charting. Like when I'm trying to find out time of onset on a stroke alert patient and they yell over me to ask what clinic they go to or what pharmacy they prefer...

Maybe just because I'm an intern
 
Thought Crime Spree said:
I love my ED nurses but it kills me when they (sometimes, some nurses) interrupt me getting a history with asinine questions for their charting. Like when I'm trying to find out time of onset on a stroke alert patient and they yell over me to ask what clinic they go to or what pharmacy they prefer...
Click to expand...

Drunk MVC trauma alert: Have you been to West Africa recently?
 
Druggernaut said:
Giving medications and then asking for an order. Usually just a heads up that the lactate was elevated or the BP took a dip with increased sedation dosing in an intubated patient so the nurse is hanging fluids, but recently had a request for fentanyl and said I'd give something longer lasting instead. They then told me they gave the fentanyl already before asking, since they thought there was a PRN order in. Not a huge deal in that case, but will eventually lead to badness.
Click to expand...

How is this OK? Are there standing pain management orders? I can't imagine that it's OK for an RN to just bust out fentanyl without a documented order in place.

I can see acetaminophen, ibuprofen, ondanestron or something like that, but not a schedule II medication.
 
Fox800 said:
How is this OK? Are there standing pain management orders? I can't imagine that it's OK for an RN to just bust out fentanyl without a documented order in place.

I can see acetaminophen, ibuprofen, ondanestron or something like that, but not a schedule II medication.
Click to expand...

I've worked in many facilities and different departments, all operating under different EMR (I'm a nurse). I cannot fathom how one nurse have access to fentanyl for a patient when there is no standing PRN orders for pain. If there is no med listed under the patient list in the pyxis, then it means there was no order. Only way one can do this if a) they pulled the med from under a different patient, or b) pyxis override which is used mainly for emergency purposes, which requires documentation as to why did you override it.
 
I know you can pull medications that aren't controlled substances without an order, as I'll frequently get out my own lidocaine rather than placing an order and waiting for the nurse to bring it to the bedside. I'd imagine the same is true for opiates, though I've obviously never taken those out of the Pyxis. It would create a record that it was withdrawn, which might generate questions if no order had been placed. I could've refused to put in the order, but then I'm sure they'd escalate it to the attending who would then be annoyed and tell me to order it and be done with it. No harm was done and the nurse was apologetic, but if they pulled that and there was an adverse effect, things would've gotten uncomfortable.
 
NoTownPreMed said:
I've worked in many facilities and different departments, all operating under different EMR (I'm a nurse). I cannot fathom how one nurse have access to fentanyl for a patient when there is no standing PRN orders for pain. If there is no med listed under the patient list in the pyxis, then it means there was no order. Only way one can do this if a) they pulled the med from under a different patient, or b) pyxis override which is used mainly for emergency purposes, which requires documentation as to why did you override it.
Click to expand...

Not every facility has a pyxis. There are actually still places where drugs are just signed out of a locked cabinet in a med room, or where one can be issued a drug kit with a set of commonly used meds which are then counted back in to pharmacy if not used during the shift.

Also, not every pyxis-like system is set up the same way. For some, it is very easy to pull drugs without a lot of patient info. Particularly in OR / ER settings, were drugs may need to be pulled with the quickness for someone about whom little information is available.

I can totally see this happening. The nurse said that s/he thought that an order existed. Possibly, such an order did exist for one of the several other patients s/he was covering. Yes, the chart should absolutely be checked before giving, rather than after. But errors like this are the entirely predictable result of working in a setting where multi-tasking is expected, spending time in the chart is seen as lazy or superfluous behavior, and where the work load may indeed be set at a level where cutting corners is the only way to meet the demands.

Don't get me wrong. I'm not here to blindly defend the nurses just because I am one, and I do get that this isn't a nurse bashing thread. But I think it is important to say that there are systemic issues that set physicians and nurses up to fail. It is productive to look at why these things happen and asking whether there are ways to change the environment of care to make it safer for patients and health care providers alike.
 
EskimoFriend13 said:
Our nurses will write DISPO (all caps of course) next to a patient's name in our ER ticker. It drives me absolute insane. If I haven't dispo'ed someone, it's not because I've forgotten this key feature of my job. Grrr
Click to expand...
Are you writing URINE or CHANGE LINENS on the board?
 
Promethean said:
Not every facility has a pyxis. There are actually still places where drugs are just signed out of a locked cabinet in a med room, or where one can be issued a drug kit with a set of commonly used meds which are then counted back in to pharmacy if not used during the shift.

Also, not every pyxis-like system is set up the same way. For some, it is very easy to pull drugs without a lot of patient info. Particularly in OR / ER settings, were drugs may need to be pulled with the quickness for someone about whom little information is available.

I can totally see this happening. The nurse said that s/he thought that an order existed. Possibly, such an order did exist for one of the several other patients s/he was covering. Yes, the chart should absolutely be checked before giving, rather than after. But errors like this are the entirely predictable result of working in a setting where multi-tasking is expected, spending time in the chart is seen as lazy or superfluous behavior, and where the work load may indeed be set at a level where cutting corners is the only way to meet the demands.

Don't get me wrong. I'm not here to blindly defend the nurses just because I am one, and I do get that this isn't a nurse bashing thread. But I think it is important to say that there are systemic issues that set physicians and nurses up to fail. It is productive to look at why these things happen and asking whether there are ways to change the environment of care to make it safer for patients and health care providers alike.
Click to expand...

Gotcha promethean, thanks for the insight.
 
Promethean said:
If you are hearing "I can only do one thing at a time" very often, from more than one nurse, it may be reasonable to assess whether there is a genuine resource limitation/allocation problem that they are coming up against. Or perhaps you are really asking for more than anyone can make happen in the time frame that you want the things done.

I once had words with a neurosurgeon who loved the word STAT a little too much. He wanted STAT scans on 4 different patients within 5 minutes when we only had one machine to work with. I asked him to please, just prioritize for me, which STAT was the most STAT, so that I could get it done first. It wasn't that I was lazy or unwilling. I just truly didn't have a conveyor belt that I could lay the patients on end to end to run them through the CT scanner.

Full agreement on the urine issue. I can't tell you how often I've had patients wait in the ED for 6 hours for a bed, then spend another 12-24 hours up on the floor waiting for an OR to open up, and then still show up in my holding area without anyone having collected the urine for hcg. Strangely, I had no difficulty to get the samples there, just by asking and providing a bedpan. I figure no one else must have tried that.
Click to expand...

I just had a brilliant idea!
 
EskimoFriend13 said:
Our nurses will write DISPO (all caps of course) next to a patient's name in our ER ticker. It drives me absolute insane. If I haven't dispo'ed someone, it's not because I've forgotten this key feature of my job. Grrr
Click to expand...

One step further...they will write DISPO or come find me with half the labs or a CT still pending. I always ask whether they even look at the results before bothering me.


Sent from my iPhone using SDN mobile
 
Thought Crime Spree said:
I love my ED nurses but it kills me when they (sometimes, some nurses) interrupt me getting a history with asinine questions for their charting. Like when I'm trying to find out time of onset on a stroke alert patient and they yell over me to ask what clinic they go to or what pharmacy they prefer...

Maybe just because I'm an intern
Click to expand...


its because youre an intern. as an attending, nurses comes in with me and dont interrupt. its a completely different world.

Sent from my VS986 using Tapatalk
 
Siggy said:
Not following orders and not asking questions about the order (by all means, ask if you have a question, but don't just ignore it and not ask about it). The propofol for the intubated patient isn't a suggestion. Yes... I understand that the patient isn't agitated right now... but that's because we intubated 30 minutes ago... with Roc.
Click to expand...
I can't stand poor sedation. I've seen not sedating people because their pressure is low. Torturing an awake person with a tube? Absurd! Sedate and pressors.

Sent from my SM-G920T using SDN mobile
 
Druggernaut said:
Refusing to do something because "they'll take my license," when that something is completely reasonable, discussed with the attending, and explained physiologically to the nurse.
Click to expand...

I've gotten this response a lot before as well...I don't get it...can a nurse 'lose their license' by following a direct, repeated order from an MD? Doubt it, unless it was something very heinous or obviously malicious toward the patient. That's why they get paid 1/4 the doctor's salary...they don't carry the liability.
 
b-real said:
One step further...they will write DISPO or come find me with half the labs or a CT still pending. I always ask whether they even look at the results before bothering me.
Click to expand...


Yep. This, all the time. I delete their "DISPO, LULZ" and write what is needed in its place, such as: "AWAITING URINE" (which, 90% of the time, is what's holding up the dispo).
 
filhodeinferno said:
I've gotten this response a lot before as well...I don't get it...can a nurse 'lose their license' by following a direct, repeated order from an MD? Doubt it, unless it was something very heinous or obviously malicious toward the patient. That's why they get paid 1/4 the doctor's salary...they don't carry the liability.
Click to expand...


My understanding is that it's sort of a double edged sword.

As a physician, you can make a decision to break just about any protocol you decide is in the interest of your patient to break. As long as you are seen to be acting in good faith, people will generally be understanding. This is because you are expected to use your judgement. Also, you get punished for poor judgement and don't get to cover yourself with the "it's protocol!" excuse.

Because nurses aren't physicians, they have to rely on protocols. Nurses are largely shielded from blame as long as they stick to the protocols, but not at all if they step away from them in any direction. Despite the occasional physician rumblings against nursing power, individual nurses aren't really given a tremendous amount of decision making power in most hospitals. They are given protocols and can be heavily punished for violating them.
 
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