Patient care pet peeves

[Dr.LeoSpaceman]

Prompted by me finding this on rounds today, hit me with your patient care pet peeves.

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[siliso]

I’m trying and failing to interpret this photo. Their SCDs are not functioning properly because the valve is not open?

Or no wait it’s the knot in some tube. An NG sump? ???

 

[Dr.LeoSpaceman]

I’m trying and failing to interpret this photo. Their SCDs are not functioning properly because the valve is not open?

Or no wait it’s the knot in some tube. An NG sump? ???

Yes. Knot in the sump port of an NG "because it was leaking".

 

[CBG23]

Prompted by me finding this on rounds today, hit me with your patient care pet peeves.
View attachment 231656

As first I thought the suction tubing was connected to an IV line. Tying off the sump is very common where I work.

 

[DoctwoB]

Prompted by me finding this on rounds today, hit me with your patient care pet peeves.
View attachment 231656

Tied off or capped sump tubes were a big one when I was on gensurg. Just take the fIng thing out if you’re going to do that.

Now that I’m full time Uro, I’d have to say that letting CBI bags run empty is a big one. I love getting called to clot irrigate patients at midnight who only formed clots because the CBI ran dry.

Alternatively, we have a few ER docs/residents that start CBI on patients in the ER. I would applaud their effort, but invariably they put in a 16 French 3 way (should be 22 or greater) and then start the irrigation with a clotted off foley without manually getting the clot out, basically just distendjnf the poor guys bladder even more.

 

[evilbooyaa]

My life would flash before my eyes and I would see red everytime I saw a NG tube sump tied off like that. Needed a few minutes before having an educational session with as many of the floor nurses as humanely possible.

 

[akwho]

Ortho pet peeves

For RN's: SCD's not plugged in and on. Not knowing or understanding the basics of your patient's injury and surgery. Not helping patient mobilize and letting them lie in bed all day like a sack of potatoes. Telling the family medically inaccurate information which we then have to re-educate later (instead say, "I don't know, I'll find out."). Not being aware of when your patient's last BM was (instead chart it and pass it on at sign out). Not elevating fractured limbs and leaving them in a dependent position. Anytime there is poop or pee near a surgical site.

For intern's: Not having patient's on correct chemical dvt prophylaxis. Not completing NPO after midnight orders correctly. Not having list updated with correct room numbers, injuries, and surgeries. Drawing needless q24h labs. Having inaccurate documentation.

I'm only a R2, so I'll stop there.

 

[operaman]

When nurses remove the inner cannula from a tracheostomy tube “because the patient says he breathes better without it” and never calls or pages us about it. Bonus points if it’s a patient who is neither intubateable or maskable.

 

[ThoracicGuy]

Prompted by me finding this on rounds today, hit me with your patient care pet peeves.
View attachment 231656

Does your hospital have those terrible caps they put on the end? It's supposed to allow air to vent, but they never work.

 

[Dr.LeoSpaceman]

Does your hospital have those terrible caps they put on the end? It's supposed to allow air to vent, but they never work.

They do. I take them off and break them whenever I see them in use. They "work" until the filter gets wet, at which point it just turns into a cap...so for like 20 minutes after they get put on.

I used to do the same with the 3-way stopcocks which make it "easier" to flush. The old ones were narrow bore (likely meant for feeding tubes) and just exacerbated clogging. The hospital has recently got new ones (you can see one in the picture above) which are much larger bore and seemingly work ok.

 

[sinombre]

Does your hospital have those terrible caps they put on the end? It's supposed to allow air to vent, but they never work.

We have them here and they don't work. I take them off and throw them away when I see them now.

I like doing it because it's one of the few ways I feel useful as an intern.

 

[Winged Scapula]

Order: “ do not titrate oxygen to room air; leave at minimum 2 lpm”. NC off, nursing documenting patient on Room Air

Removing drains (or asking to remove drains) before discharge. WTF? Has any gen surg patient had a JP removed on POD 1?

Telling patients wrong info esp about limb restrictions s/p breast surgery, failing to accurately teach drain care

 

[siliso]

Oh then I thought of one. Order wean O2 to off for sat 88-92. COPD pt 98% on 3L x8 hours. I said Wean dammit!! Wean! 90% is fine!

 

[TraumaLlamaMD]

Order: “ do not titrate oxygen to room air; leave at minimum 2 lpm”. NC off, nursing documenting patient on Room Air

Removing drains (or asking to remove drains) before discharge. WTF? Has any gen surg patient had a JP removed on POD 1?

Telling patients wrong info esp about limb restrictions s/p breast surgery, failing to accurately teach drain care

If I had a quarter for every time I’ve had to swat away a limb restriction bracelet... hard to get through a PACU report on a lumpectomy or sentinel node before someone is trying to put one on the patient.

 

[Winged Scapula]

Oh then I thought of one. Order wean O2 to off for sat 88-92. COPD pt 98% on 3L x8 hours. I said Wean dammit!! Wean! 90% is fine!

Yes!!

Calls from the PACU that says “only” 90%!

 

[siliso]

Demented patient in the bed with the shades drawn all day. Followed by 3am page that pt can’t sleep and won’t stay in bed. Foley for incontinence unless I have really got to know the i&o to the milliliter (corollary not recording the i&o when I told you I really do need to know). Anticholinergics for elderly incontinence. Opioids without bowel regimens. Bed weights.

 

[LucidSplash]

“Hi from PACU, I see that you discontinued the heparin drip, do you want me to restart the heparin or not?”

“Hi this is radiology resident Jackass. Can you tell me more about this study that you ordered? I see that you clearly described the reasons you want it and the Surgery the patient has had and their symptoms in the comment box but I want to ask the same questions over and pretend I know more about your patient than you do and suggest you don’t want the study you ordered.”

I’m not doing gen surg anymore but the NGT sump port in a knot drove me nuts in residency.

 

[Smurfette]

"You ordered ancef but the patient is PCN allergic"----separate conversations with, or pages from, every pharmacist, pre-anesthesia testing RN, RN in ambulatory surgery, and circulating RN taking care of a patient with PCN allergy with documented reaction of "rash", "itching" or "nausea". Drives me absolutely CRAZY!

 

[Psai]

"You ordered ancef but the patient is PCN allergic"----separate conversations with, or pages from, every pharmacist, pre-anesthesia testing RN, RN in ambulatory surgery, and circulating RN taking care of a patient with PCN allergy with documented reaction of "rash", "itching" or "nausea". Drives me absolutely CRAZY!

There can be some crossreactivity between amoxicillin and keflex because of a very similar side chain but no way with penicillin and ancef.

Cephalosporins can be given to penicillin-allergic patients who do not exhibit an anaphylactic response. - PubMed - NCBI

 

[Jolie South]

Prompted by me finding this on rounds today, hit me with your patient care pet peeves.
View attachment 231656

In that case, I cut below the knot with a suture scissors.

 

[Jolie South]

I frequently write “dc Foley at midnight” for patients who should go home on POD1. NEVER GETS DONE.

Yes, nurse, I know the patient was sleeping. I asked you to dc their Foley at midnight so they could void by the time I round and go home in an appropriate time frame.

 

[LucidSplash]

I frequently write “dc Foley at midnight” for patients who should go home on POD1. NEVER GETS DONE.

Yes, nurse, I know the patient was sleeping. I asked you to dc their Foley at midnight so they could void by the time I round and go home in an appropriate time frame.

Yes this. And followed by complaints from social work/case management/admin about length of stay times and people not being discharged before 10am when on Obs.

 

[dpmd]

Patients with drains or tubes for which output is not documented. Usually these people have an I+O per unit protocol order so am I to believe the protocol is to completely ignore what is coming out of something we put in a patient?

Patients whose entire reason for admission has to do with no poop coming out and the nurses don't document that a patient pooped following admission.

Pain documented as zero instead of blank or some other designator that the patient was asleep. Bad for the nonoperative management folks I think are doing fine, and bad for the postop folks that the nurses don't bother to call when pain has been uncontrolled.

 

[vhawk]

Prompted by me finding this on rounds today, hit me with your patient care pet peeves.
View attachment 231656

Saw the thread title and this was instantly my first thought. I used to carry trauma shears, not so much for the traumas but mostly so that I could cut the tubing in the ngt every time I saw that

 

[vhawk]

My life would flash before my eyes and I would see red everytime I saw a NG tube sump tied off like that. Needed a few minutes before having an educational session with as many of the floor nurses as humanely possible.

It's such an insane "solution" to a problem. If the sump is leaking it means the tube isnt working. Tying a knot in it is about as effective a solution as just shutting the patients door, or going home.

 

[vhawk]

Order: “ do not titrate oxygen to room air; leave at minimum 2 lpm”. NC off, nursing documenting patient on Room Air

Removing drains (or asking to remove drains) before discharge. WTF? Has any gen surg patient had a JP removed on POD 1?

Telling patients wrong info esp about limb restrictions s/p breast surgery, failing to accurately teach drain care

This has me curious...why would you put in an order to maintain 2LNC regardless of sat? Is there some data about flap perfusion and aggressive o2 saturation? Not being sarcastic I am way out of the loop on breast stuff

 

[Psai]

It's such an insane "solution" to a problem. If the sump is leaking it means the tube isnt working. Tying a knot in it is about as effective a solution as just shutting the patients door, or going home.

What are you supposed to do with it?

 

[ThoracicGuy]

What are you supposed to do with it?

Flush the sump port with air until it is working. Flush the main port with air/saline/water as well. If you can hear a sound from the sump port, you know its working.

 

[evilbooyaa]

What are you supposed to do with it?

Flush the sump port with air until it is working. Flush the main port with air/saline/water as well. If you can hear a sound from the sump port, you know its working.

Or at worst, page surgery to let them know their tube isn't doing squat.

 

[ThoracicGuy]

Or at worst, page surgery to let them know their tube isn't doing squat.

It's really something the nurse should be able to do...

 

[vhawk]

Flush the sump port with air until it is working. Flush the main port with air/saline/water as well. If you can hear a sound from the sump port, you know its working.

This

 

[Jolie South]

Flush the sump port with air until it is working. Flush the main port with air/saline/water as well. If you can hear a sound from the sump port, you know its working.

It is not rocket science. Thus, why I cut the knot off with suture scissors. I then get calls like “it’s leaking”, to which I reply the tube is not working and tell them above instructions.

 

[Jolie South]

View attachment 232749
I wrote this order. What do you think was the outcome?

 

[ThoracicGuy]

View attachment 232750 View attachment 232749
I wrote this order. What do you think was the outcome?

 

[Dr.LeoSpaceman]

View attachment 232750 View attachment 232749
I wrote this order. What do you think was the outcome?

While the "I see you just put this order in, do you want to do that" routine is vexing, this is a bold move. Not sure I'd have the nerve to do it and have to deal with getting called into the principal's office...or worse yet find myself hammer paged by the floor for mundane issues over the next week.

 

[vhawk]

View attachment 232750 View attachment 232749
I wrote this order. What do you think was the outcome?

Called into principals office, mandatory sensitivity training?

 

[Jolie South]

Neither. Order was not followed. I called nurse in the morning to ask why the paient’s Foley was still in. He said “I didn’t see the order”

I got apologized to by nurse manager and charge nurse bc the order had been acknowledged and not followed. This has been an ongoing problem and units know they need to get our Foleys out. it has been affecting our LOS for cases that should go home POD1.

I am not a person that gets into arguments with nurses. When I called get called with stupid stuff I usually say “Thanks. I will take care of it” and don’t engage. This particular issue had been addressed a number of times in the recent past and still not rectified hence the very specific order.

 

[evilbooyaa]

It's really something the nurse should be able to do...

Oh I certainly agree but to me the better back-up option when it's not functioning and the nurse can't figure it out between "Call the surgery resident" and "Tie it off with a sick knot" is the former. At least the former allows for education (and sometimes some elbow grease) while the latter only allows for rage.

 

[HighPriest]

Just yesterday, I took a wound culture from a neck abscess at the bedside. Told the nurse I was going to do it. She asked if I wanted her to do it later that day, but I know how that turns out. So I said "no, don't worry about it, I'll do it right now." Took the culture. Labeled the tube. put it in a bio bag. Handed it to the same nurse and told her directly "this is the wound culture for Mrs. so-and-so in room 1014. Please send it to the lab."

Called today for a different reason. Same nurse. She says "Are you going to take that culture from Mrs. so-and-so's neck? The order has been in since yesterday."

Now...she put in the order, not me. She put in the order AFTER I gave her he culture tube, because it wasn't in there immediately after I took the culture.....So she took the tube, entered the order, and then apparently either threw the tube away or perhaps stuck it somewhere....we'll never know....

 

[vhawk]

Just yesterday, I took a wound culture from a neck abscess at the bedside. Told the nurse I was going to do it. She asked if I wanted her to do it later that day, but I know how that turns out. So I said "no, don't worry about it, I'll do it right now." Took the culture. Labeled the tube. put it in a bio bag. Handed it to the same nurse and told her directly "this is the wound culture for Mrs. so-and-so in room 1014. Please send it to the lab."

Called today for a different reason. Same nurse. She says "Are you going to take that culture from Mrs. so-and-so's neck? The order has been in since yesterday."

Now...she put in the order, not me. She put in the order AFTER I gave her he culture tube, because it wasn't in there immediately after I took the culture.....So she took the tube, entered the order, and then apparently either threw the tube away or perhaps stuck it somewhere....we'll never know....

You seem to be entirely discounting the possibility that this nurse has an identical (evil) twin

 

[HighPriest]

You seem to be entirely discounting the possibility that this nurse has an identical (evil) twin

A culture-keistering twin....of course!!

 

[Winged Scapula]

This has me curious...why would you put in an order to maintain 2LNC regardless of sat? Is there some data about flap perfusion and aggressive o2 saturation? Not being sarcastic I am way out of the loop on breast stuff

Yes.

Most of the data is in free flaps but there is evidence of small benefit in Mastectomy +/- reconstruction. My PRS guys like it.

 

[SurgeDO]

Whenever anybody sedates a TBI patient before I can get an exam on them. A patient's exam can determine if we take their skull off.

 

[DoctwoB]

Happened again. called to see patient for clot retention. Primary team placed 16 french 3-way catheter and called because "it wasn't working and she needs to go to the OR". Said they placed 3-way because it's for hematuria. I tried to patiently explain that the 3rd port is only for continuous irrigation. Otherwise it just means there are 3 lumens in the catheter to try and get clot out of instead of 2. The standard foley that came in the kit would have been better.