Tallywhacker Assessment 101

Yesterday was a good, but busy day in the E.R. I had the good fortune of taking care of Mr.R most of the day. Obese, with a chronic muscle disease that left him unable to change position and clear his secretions, he was with us for a new diagnosis of no surprise........pnuemonia. I got the impression he was a somewhat wealthy man by the way he spoke of his ranch, his horses and the around the clock home health assistance he had been able to finance at his own home for the past ten years.

He was pleasant and had a smile whenever I went by his room. Because we were not overly busy for the first half of the day, I had time to provide good nursing care. I (with help of course) had time to turn him almost every hour and a half, to encourage coughing and deep breathing and attempt to suction some of the secretions he was almost clearing. Heck, I even had time to wade through the 5 pages of admissions orders and home meds, figure them out and give him his meds on time. All things which are virtually unheard of when you have multiple tele hold patients in the E.R. He still has use of his arms, so basic tasks such as using the urinal and feeding himself were done by him. On top of all that, I even charted in the computer....a big deal for us one sheet driven E.R. nurses.

I was feeling very proud of myself....the epitome of good, strong, basic nursing care. And all of this was done in the E.R. Did I mention that ?

Towards the end of the shift, just as I had finally received a bed assignment, his home health aide came to visit. He introduced the two of us, said she was trained as a surgical technician, but had been his home health aide for years. I thanked him for a most excellent day in the E.R....for being so patient, so kind and so upbeat in the face of a lot of adversity and walked off to call report.

As I was just walking away, the home health aide looks at me and says under her breath "did you look at his tallywhacker ?" Umm, no. Cough, cough. Did she just say that ? "Excuse me ? What did you say ? She looked at Mr.R and said loudly "you need to show her your tallywhacker. It is swolled."

So I assessed his "tallywhacker." Indeed it was swollen, and it did require a call in to his MD and was worthy of mentioning to the nurse as I called report. According to the patient it had "just happened" and he thought it was because he had waited too long before using the urinal.

I looked and looked on the computer assessment form and there was no "tallywhacker" assessment criteria. Off to do some googling.

Drug of Choice

I have to admit that I've always been puzzled by nurses who have problems with narcotics. I've never enjoyed feeling drowsy and out of control and hazy of thought. To steal so I could feel that way has just always been a puzzle to me. Not even to mention the problems with job loss, the nursing boards and the whole public shame thing.

BUT....as much as I don't understand that feeling, I DO understand the need to not feel green. Pukey. The need to not feel as if in constant car-sick mode. The need to fight the fist sized mass in your stomach that is threatening to come up.

Therefore, I have to confess that I have a Phenergan drug stash. Not stolen, mind you, but culled from a few years of intermittent day surgeries and bouts with gastritis. Whether for myself, my daughter or my husband, the golden bullets end up in a coveted spot in the fridge door. Against my judgement and my better nursing knowledge, I keep them long past their over due dates. Knowing they are there, ready to plug me into a warm envelope of Phenergan induced sleep and into a land of NO NAUSEA....somehow makes me feel more bulletproof and stronger.

I guess that is all anyone needs to know to let you know how I spent my weekend. I need to start building up a stash of Zofran ODT. But the docs look at you a little suspiciously when you ask for that one by name.

Better than Thin Mints.....

Little girls in the green outfits, I hate to break it to you, but your cookies are getting old. And smaller. The Boy Scouts outdid you this year. Although a smidge more expensive, the chocolate coated caramel crunch popcorn totally whips up on the Thin Mints. Ya'll might want to get busy next year in the popcorn industry.

My favorite patient......

Little Missy is sick. I came home last night to find my husband curled up on the bed with her as she announced " my tummy hurts." After I pushed him out of the way, I stroked her tummy and kissed her head and then held the bucket. She is infinitely a better patient than I am when I am sick to my stomach. I groan, I tread my feet up and down the sheet in a completely futile attempt to stop the inevitable.......gawd how I HATE to throw up. Give me pnuemonia, give me strep throat but do not make me throw up.

Anyway, after she was done she went to sleep. Several times during the night she popped up, leaned over the bed and did her business. No carrying on, no moaning.

I have a delicious day off today and thankfully had nothing planned. It is cold outside, the Christmas tree is up and the pantry is stocked. There is nothing I like better than to lie next to her reading an "A to Z" mystery book or watch Care Bears on the portable DVD player. Crushed ice with gatorade, chicken noodle soup and jello are all on the menu. No one needs to get cleaned up and put on makeup or real clothes today, the dishes can pile up and no errands will be run. I'll be taking care of my favorite patient today.

Wee-Wee Poppers

This was the delighted and fearful cry of my 7 year old daughter the other night at a popular Tex-Mex restaurant. I had let her go to the restroom by herself, a big event for me. I have a weird phobia of letting little kids go around corners to bathrooms by themselves in restaurants. I know the odds are slim, but really.....any stupid perv can sneak in and climb onto a toilet seat and wait for his next victim.

Anyway, so I let her go in by herself. My husband and I waited and finished off our margaritas. We waited and waited and still no little missy. Fearful of what she may have encountered in the restroom, I strided over and opened the door.

The first stall was wide open and I could hear her giggling before I could even see her. She stood there, mesmerized and looked up at me. Just as I was about to ream her out for taking so long, she pointed to the toilet and said "look Mommy...a wee wee popper !"

Arghhhhhhhhh....a used tampon floating in the toilet. A floating question bomb it was. "Why ? What are those for ? Those look kind of like what you have in the bathroom cabinet ? Why does it have a string ? " Definitely NOT how I had planned to spend my Saturday night.

In the end, I managed to answer the basic questions without raining on her delight. In her mind, they are like the New Years Eve popper things (you know the ones you where you pull the string and then the pop and confetti comes out ?) Mysterious, maybe kind of fun and something involving some cool trigger action. I tried not to tell her about the pain, the ick factor, the nastiness and hopes and dreams that tide with those wee wee poppers.

No warm blanket for you !

The nursing shortage is front page news these days … or at least within the past year. It seems everyone knows that nurses are in demand and that hospitals can't find enough. Sign-on bonuses ! Winter plans ! WHATEVER YOU WANT if you come work here.

Really ? So why was I called into my nurse managers office last night and told that because our census has been so consistently low, they are going to be reducing hours ? WHAT ? Are you kidding me ? I should have noticed though, really. Because my shift yesterday wasn't so busy that I couldn't take a leisurely twenty minute lunch and I even peed once. Something is surely wrong when you have time to do all that. I can't believe I didn't notice.

Apparently there is a fine grey line that is blurred somewhere between the patient census/staff ratio numbers and the numbers reported back on customer satisfaction via Press Gainey. I wish I knew the formula. We are supposed to whittle the nursing staff down to the point where you don't get a lunch and don't get to pee because you are covering half of the E.R. BUT not so far that the Press-Gainey scores start to slide down the slippery slope.

And yet you must be able to still meet the tight time lines now required for STEMI and CAP. Never mind that those times are only met because every other patient one in the ER is IGNORED while the whole nursing crew (of two and maybe a tech !) is sucked into the care vortex of getting it all done for that patient ON TIME.

And so the little box on the assessment form that says "warm blanket provided" will sometimes go unchecked. But the heel clackers will notice that it us not checked and they will want to know why no warm blanket was provided. Hmm...I wonder what I will tell them ?

Ethel and Bob

I started a new very part-time gig today. I am now officially an independent nurse contractor for a company that provides assessments on people who have applied for long-term care insurance. They email the referral along with the evaluation form and I contact the people to arrange for an assessment. Everything must be done within seven days of the initial referral, but it can all be done at my convenience. The assessment takes about an hour, I fax it in and I'm DONE. No patient care, no poop, no blood, no follow-up. NADA.

The pay isn't bad either. I picked this gig up mainly because the census in our E.R. is down and I'm prn. Extra shifts there are just not happening at the moment. Plus, I'm kind of lazy and used to flexing my time according to my school schedule and my family life. I don't want to work a lot. Plus, I was recently told by an orthopedic surgeon that I have the articular cartilage of about a 70 year old. So picking up 12 hour shifts (if there were any) where I plod endlessly along on concrete floors, squat down to pick things up, assist patients in and out of bed and all sorts of articular cartilage requiring situations just does not sound appealing. Plus, I can do the assessments and still take little missy to school and pick her up.

A roaring crackling fire greeted me when I walked in the door. Ethel's latest quilting project was on a rack near the fire. The linoleum on the kitchen floor was worn away by Bob's chair from years or pushing himself back and heading out to work or to do his chores. They were sweet, they were fiercely independent and they were being responsible by attempting to obtain long-term care insurance

They answered all of the questions honestly (in my opinion, anyway.). How hard it must have been to answer questions about incontinence, adult diapers and bowel control to a youngster they didn't even know. Bob was reluctant to admit that Ethel handles all the medicine in the house and does his laundry. But he was quick to point out the small farm behind the house and he had just come in from feeding the sheep. Ethel was proud that she pays all of the bills and does all of the cooking and cleaning, but a bit sheepish to tell me that she sometimes needs to lean on Bob when they are on uneven surfaces.

The assessment itself took about 45 minutes with each. They could not help each other out and the other one had to be in another room while the other was being assessed. Bob is the most independent and strong…and yet the most dependent. Ethel does all of the cooking, cleaning, medication dispensing, laundrying and bill paying and everything related to the inside of the house just because she has always done those things. Ethel has a few mild impairments, but is the least dependent of the two.

They both were a little slow on the memory test, but then again, so was my 45 year old husband/ engineer when I practiced on him the night before. Bob correctly recalled 5 out of 10 words and Ethel upped him a bit and recalled 7 out of the 10. Still, even though Bob couldn't remember the words radio, table and grape and window and cup, he could remember how many cows he had and that he was remodeling a car in the garage.

I told them that I had no relationship with the insurance company and would never know if they were turned down or not. As I left, I realized that I wanted to know what would become of them. Would Ethel finish that quilt ? Who would end up taking care of whom ? Which one would need the long- term care first ? Would they even qualify for long term care ?


I got into nursing because I like to know the answers to these questions. I like knowing when Mr.X's grandson gets married, if Mr Y. was a truckdriver and if Mrs.L has six children. Even now, working in the E.R., I still ask these my patients "what do you do for a living ?" "How many children do you have ?" No matter how brief the encounter, I ask because I want to know. Everyone has a story. I am interested in that story and how I take care of them is very much dependent on that story.

As I prepared the assessment to be faxed in, I painted an honest picture of this fabulous elderly couple. This is what I wanted to write: Ethel has probably slowed down a bit , but Bob is going strong. If something happens to Ethel, Bob will go quick because he will be lost in the world that Ethel has maintained for him. If something happens to Bob first, Ethel will be fine. A little slow, a little weak, but fine. Ethel quilts lovely and Bob does an outstanding job maintaining the farm. They are sociable and nice and made an inviting fire and had a cup of coffee waiting for me. I did everything but say "this is sure how I want to be when I am approaching 80.

This isn't the information the insurance company wanted to know though. And so I answered the questions about mobility, transfer strength, continence and medication management. I marked down if Ethel could remember the words grape, chair, table and onion after a 9-minute elapse time. And I thought about how once again the art of nursing is sometimes erased through the mounds of required paperwork and people who are just after enough answers to help make important financial decisions.