It’s the Little Things

It is never the BIG things that will drive you mad, it is the little things, those continuous little irritating reminders that get under your skin that make work so damn frustrating.  It’s the little idiosyncrasies of some nurses practices that will drive you up a wall.  I’ve mentioned the “freak out over nothing” otherwise known as Chicken Little, but almost worse is the “I forgot the basics of nursing school.”

C’mon!  The basics, turns, intake/output, taking a temperature with vitals, all in all really easy simple things.  But it is like these don’t matter to a couple of my colleagues.  And lately it seems like I’ve gotten the shit for it.

Case #1:  obtunded patient.  On continuous IV fluids and a crap-load of IV meds.  Intake charted for entire shift:  nothing.  Nothing was charted.  According to the charting, they were incontinent 42 times.  OK, they’re basically hospice, but we have nothing official, shouldn’t we be doing the typical charting as if they were a regular patient?  Thanks for that, when the docs ask me if they had any intake at all during the day I look like the idiot.  Luckily I can point to my charting.  What gets me with this, is that it is the easiest thing to do on an obtunded patient.  If you can’t track accurate I&Os with them, how are you going to capture that on a mobile CHF patients – where it is really important?!

Case #2:  Afib patient, on an amiodarone drip.  Something doesn’t jive in the orders and when asked, they say,  “I don’t know, I’ve never hung amio, just followed what pharmacy wrote on the bag.”  First, I have to explain typical protocol is 1mg/min for 6 hours then a decreases to 0.5mg/min for 18 hours, standard loading protocol.  It’s not like I’m pulling it out of my ass, it’s from the book.  So what that the 1mg/min has be running for like 9 hours?  Second, why didn’t you look it up?  You admitted to me that you had never hung an amiodarone drip, we have a resource book that details floor protocol for initiation and maintenance, it’s all there, black and white.  Again, I get to call the docs, explain the situation and get new orders.  Truly it’s not a big deal, but it is the principle of it all.

If you can’t effectively manage simple situations, situations where you have available resources and ability to follow-up, how will you function when the shit hits the fan?  I now know most of the meds I give on a regular basis, but I get ones where I have no idea.  So what do I do?  Look ’em up.  It’s not like our patients are crashing and need them now, we have time to be thorough.  I&Os?  Yeah, on our basic patients I don’t always record.  But if they are getting fluids/meds/drips you’re damn sure that’s getting recorded.  I’m not perfect, never claimed to be.  I make bone-headed mistakes and overlook stuff.  Those are the exceptions though, not the normal.  I bitch about it because for some it is normal.  That’s the scary part.  When it happens I try to talk to them, but too often it gets left by the wayside, pushed aside and taken care of.

To me the leaving of the little things (these are just two recent examples – from multiple nurses), tells me that you’re either A.) not paying attention, or B.) don’t get it.  The little things are what differentiates the good nurses from the mediocre.  The little things are the keys to catching our patients before they crump.  The little things are what sets nurses apart and why techs can’t do our jobs.  And it’s the little things that piss you off the most.


  1. Hey guy

    Just wondering — in #1 why was a palliative pt on IV anyway?

    #2 is actually a big fricking deal. If you don’t understand why or how or the dosage range/rate of infusion, you need to look it up, because if you’re administering the drug, you are responsible. Not the doc. Not the nurse who originally hung the drip. Not pharmacy. You. This is how nurses lose their licences, and telling your professional standards organization “someone else said it was okay” is pretty lame.


    1. Patient wasn’t technically palliative only, yet. Family hadn’t made the full choice so we were continuing on as was had been. #2: yup.


  2. In my experience, the crash usually happens about 35 minutes after report, and I’m left cleaning up the mess. I find that doing walking rounds after report cuts down on a lot of those sticky situations. You have to hold those nurses accountable and get things cleared up before they leave the hospital.


  3. Thank god I’m not the only one who thinks like this. Fluid balances not being calculated or left vacant for entire shifts is a big thing I have to deal with regularly. Another huge thing is (working on a ward with a lot of tracheostomy patients), people who write “suctioned twice” in their general nursing care notes. We have specific trache suction obs sheets in my hospital. Eh, where is the detail in that statement, it tells me nothing. I think a lot of nurses fail to realise that the detail we put into our care and documentation is so, so important. To communicate from shift to shift and to avoid potential diasters.


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