Tomorrow will be better.

The clinical focus this week in med/surg was listed as "working with others". Communication is the underlying theme and requisite skill. Specific things we discussed in our conference were geared towards preparing us to communicate effectively with other members of the health care team, with some special attention given to how to communicate with MDs productively. We also went over "difficult" communications with patients and caregivers, and how to navigate them gracefully and professionally.

This semester, unlike in previous semesters, I'm getting the eerie feeling that the universe somehow knows what the clinical focus is and throws appropriate situations at me. When these types of avalanches of coincidence happen, I usually take it as a positive sign that I'm actively focusing on something. Another possible explanation is that the clinical foci this semester involve concepts that are pervasive in the workplace, rather than specific disease processes or injuries.

My personal goals for the week were to build on what I learned last week about the local charting norms, get through my first medication pass/pour at this particular facility, and evaluate my new one-page organization sheet for the day. I modeled this sheet after one made by someone else in my cohort, who in turn modeled hers off of the sheets issued by the hospital for this purpose.

So, let's meet this week's lucky winners of Student Nursing Care!

Patient X is male, in his late 30's, and admitted for an abdominal wall fistula. Every time I heard report from someone regarding him, the words "poor guy" came out of their mouths. In addition to Crohn's Disease (an autoimmune disease of the intestines), his history includes an ileostomy placed back in the early 90's, bowel obstruction, GERD, hyperchloresterolemia, back pain and sciatica. He works for the telephone company. He came in for a hernia repair towards the end of last month, and ended up having to stay due to a wound infection. In addition to having multiple fistulas, he now had an infected abdominal abscess. Ouch. They discontinued the ostomy on the left and gave him a brand new stoma on the right.

The first time I met this guy, I had the opportunity to listen in while the gastroenterologist checked in with him and discussed his case. They decided to try to heal the fistula by using a wound-vac rather than surgery, something I'm told has a low probability of success in the elderly patient prone to bowel obstructions and fistulas. Since Patient X is relatively young and healthy, they figure he has a good shot of healing with the added support of the wound-vac.

The difficulty in this comes from the fact that he can't receive enteral nutrition during this process! When I met him, he had been receiving Total Parenteral Nutrition for well over a week. I got caught off-guard when I was asked about his protein levels, because they were normal! I have to remember to be aware of normal lab values instead of just focusing on the abnormals. Besides making sure his protein levels were normal for proper wound healing, we had to keep watch for hyperglycemia and excess fluid volume, as these are symptoms of overfeeding. He was being weighed daily by the PCAs, and his fluid intake and output were strictly recorded.

His girlfriend was staying with him through visiting hours, and chatting with them both about their lives was pleasant. Patient X's girlfriend works for an organization that combats human trafficking. Exciting! Seeing them interact tugged on my heartstrings a bit, seeing them cuddled together in the hospital bed watching a movie on the TV and DVD player brought into the room for them. They had a large corner room to themselves (on the side of the hospital that had all two-bed rooms) that was festively decorated with things from home. I wonder if some of the special attention and accommodations made for Patient X were related to the fact that he suffered a wound infection after having surgery at this site.

Patient X cared for his ileostomy independently, ambulated without being reminded, and could draw a whopping 2.5 Liters on the incentive spirometer. He explained to me that the men in his family have "coal miners lungs", something he discovered in the process of his Father's terminal struggle with lung cancer. Mostly all I had to do for this guy was assess him and measure things. The only medications he received during my time with him were IV push medications, administered through a PICC line, and students can't administer those (due to the inherently dangerous nature of manually pushing any kind of medication directly into someone's central circulation). When one of the RNs came to administer his IVPush opiates, they decided to administer a partial dose based on the RN's pain assessment.

He jokingly asked "Hey, are you just going to throw the rest away?"

The RN nodded

"Just give it to me then!" He said

She laughed and told him she couldn't do that, something he knew full well already.

"Finish all your morphine, there's sober kids in china!" I said to him.

He started cracking up so hard he started guarding his abdomen. I took the opportunity to demonstrate abdominal splinting with a pillow, a non-pharmacological method of relieving post surgical abdominal pain during coughing and deep breathing. He said it helped, and I couldn't help but wonder why no one had showed him that before! He also didn't seem to understand what the wound-vac was for and what it did, so I went over some of the basics of how the wound-vac speeds up epithelialization and tissue granulization of the wound by drawing fluid and cells out of the capillaries and into the wound-bed, increasing perfusion and all of that great stuff. He seemed really interested and more "into" the idea of the wound-vac when I was done. I felt like I got along great with this guy, and I think he appreciated someone "getting nerdy" with him over his treatments, since he was motivated to be knowledgeable about his condition. I learned a lot from him telling me about how Crohn's contributed to the development of his abdominal fistulas.

Something that Didn't go so well with Patient X was changing his TPN bag. This links back to the communication aspect of our clinical focus. Switching back to having different co-assigned nurses every week after having a preceptor has been disorienting. A classmate and I have done some research for an NSNA resolution about preceptor programs, and one thing we encountered in the literature was reports from students who felt like they "took a step backward" in their understanding after transitioning back to clinical student practice without preceptors. I didn't feel this way the first three shifts, but on my second day with Patient X, where I was responsible for everyone's meds, I let the TPN run dry. Big no-no. TPN includes lots of substances that bacteria like, like amino acids, fats, sugar, you name it. I told my co-assigned RN that I thought the bag was running out a little ahead of schedule (which confused me since it was being regulated by a pump), and neither of us got to it until it had been empty for around a half-hour. She prepared the new bag for me (which I should have insisted on doing), and we connected it to the pump. *BEEEP* - distal occlusion. Oh no! The RN instructed me to flush the PICC with sterile saline, so I loaded up a 20cc syringe from the bag hanging near the med-room and attached it to the PICC. I remember PICCs offering a bit more resistance to flushes than peripheral sites, and I wasn't sure how much force to use to flush with. After a few pregnant moments of not pushing hard enough, the flush went in smoothly and the TPN continued. Patient X made lots of jokes like "hurry up, I'm hungry!" during that time. What I need to remember to do for next time is be more assertive about taking on everything I'm qualified to do, and make sure I touch base with the RN frequently so I'm aware of what she's doing.

Ok, enough about Patient X. Next door we had Patients Y and Z. They were both nurses, both in their early 60s. Patient Y was brought by ambulance for abdominal pain, later found to be caused by cholelithiasis, the formation of stones in the gall-bladder. She had an endoscopic cholecystectomy the day before I met her. She was due to be released that day, but she asked to stay another day, and her request was approved due to her abdominal distention and pain. Aside from the abdominal distension and pain and some diminished breath sounds, she assessed normally for the older post-op patient.

Her labs reflected the expected inflammation response, but she also had low protein values. She progressed to a standard diet (with low sodium modifications), but wasn't able to consume much. She denied nausea and vomiting, but said it hurt too much to sit in a position that would allow her to eat. I suggested abdominal splinting, but she wasn't receptive to that. I offered to try to find a pillow arrangement that would work for her, but she wasn't receptive to that either. What worried me the most about her was the fact that she could only draw about 100ml on the incentive spirometer, and every time I tried to broach the subject and try to find a way I could improve her respiratory effort, she half-jokingly, half-seriously ordered me out of the room in a stern manner. She was a corrections nurse, by the way.

Patient Z was in the other bed in the room, she arrived fresh from a laparoscopic gastric banding. This is a fairly new (2001 in the US, 1985 in Sweden) alternative to gastric bypass surgery that involves fewer risks and a speedier recovery. Patient Z was also a nurse, nearing retirement, who worked in occupational health. Her history includes hypertension, heart attack, degenerative joint disease and arthritis. She was still extremely groggy from the surgery, my priority assessments for her focused on respiratory rate, fluid volume status, blood pressure, extremity perfusion and level of consciousness. The chart showed she was up about three liters of fluid, so I was listening for crackles in her breath sounds that would indicate pulmonary edema. Thankfully, I didn't hear any.

When I first met her, her daughter (who was also a nurse at the same hospital I have been practicing in as a student) angrily informed me that someone had -just taken- her vitals and can we just let her rest, please? This sounded reasonable, so I told her I'd check the charting to make sure there were recent vitals for her, and that I would be back after I had seen the other patients to do the "other assessments required for her safety".

When I returned, Patient Z was already slightly more alert, and the co-assigned RN and I clustered our assessments together to minimize the disturbance. Despite being extremely groggy, she laughed at my jokes and asked me some questions about nursing school. Our big thing with her was going to be getting her up and out of bed to ambulate. Her first time out of bed was taken very slowly. At first, she briskly swung her legs out of bed, and then immediately became nauseous. The staff RN suggested a cool washcloth to the forehead and back rubbing, which Patient Z's daughter performed.

The whole time, Patient Z's daughter kept reiterating to her over and over suggestions for how to ambulate successfully. She seemed extremely overprotective, and I failed to recognize this as a warning sign of Patient Z's daughter's mounting anxiety over her mother's condition. Patient Z made a short trip through the hall at first. As she began to perk up a bit, I was taken aback by her eyes. Piercing, bright blue, and intense. I hadn't noticed while she was lying in the dark with her eyes closed. The Staff RN told patient Z that she could have small sips of clear liquids, 90ml per hour in 30ml cups. When she was told she had to sip them slowly, I told her "just because it's the same volume as a shot, doesn't mean you can knock it back by one!". She got a kick out of that.

The big flub I made with Patient Z was not being aware of the Due to Void time. There was a section in the bedside chart for this information, but it was blank. I was caught flat-footed yet again by the instructor when she asked me about it. When I went back to the staff RN, she said "oh, it's this" and jotted down the time, a range of times with the later number being about an hour into the future still. Patient Z was only able to produce 5-10ml of urine per attempt, and was -not- a fan of the idea of being straight-cathed. The Staff RN got some peppermint essence, which I've now learned helps stimulate the urge to void. This is a great application of aromatherapy, I'll have to remember that one. Patient Z did, eventually, void a sufficient quantity, and avoided the straight-cath.

When visiting hours ended, Patient Z's daughter insisted on staying overnight, and complained about Patient Y, who had repeatedly told them she wants them out of the room. Patient Z's daughter had been driving Patient Y up the wall with her constant "nagging", as patient Y put it. The staff RN assigned to the room apologized but insisted that the daughter and husband (who was a pleasant fellow) leave for the sake of patient Y's recovery. The daughter stormed out, visibly angered, and the RN chased after her. Rather than stand next to either the RN or the daughter, I stayed in earshot but occupied myself with another task (I didn't want to complicate the situation or make it worse somehow).

I heard the RN say things like "I know this is really scary for you, but there's two people in that room and I'm responsible for both of them". Her demeanor was interesting to observe, where she had been fairly quiet and calm most of the evening, she immediately became assertive, focused and direct (while still being calm). She exuded the sort of quiet lethality that "you don't want to screw with". At the same time she was respectful and to-the-point, but in a way that made it clear there was no point in arguing with her about it.

Patient Z perked up and exhibited what I would imagine was her baseline level of consciousness, fully alert and oriented. The dizziness and nausea and all but vanished after her second trip around the unit, and her gait became more steady and sure (I still stayed within arm's reach, mindful of her DJD and arthritis). She fully woke up...just in time for bedtime!

Patient Y and Z were discharged between my first and second shifts this week. Y and Z were replaced by Patient W and Patient V. I checked back in with Patient Y just as she was getting ready to leave. Her abdominal distension had resolved and she was fully clothed for discharge. She still did not seem very happy. I also checked back in with the Colostomy Closure from the previous week. He was much more oriented, and had finally gotten rid of the nasogastric tube. I didn't look at his chart or ask about his care (since technically I don't have a right or need to know that information) but still wanted to see how he was doing. I saw his daughter again and made some small talk and wished him well.

Patient W was brought by ambulance for confusion and anorexia. He said his wife noticed he wasn't "functioning as usual". He's in his late 80's, and served for many years as a law enforcement officer and volunteer fireman. His confusion and disorientation were fairly normal responses to the fact that he had the Flu (type A), a UTI, dehydration, and anemia from bleeding peptic ulcers. He was also in acute renal failure, with an estimated glomerular filtration rate in the 20s. Since he had a flu infection, his private room was on droplet precautions, so I did my little glove-and-mask ritual every time I entered the room, and my wipe-everything-down ritual every time I left.

Despite the poor eGFR, Patient W -was-, in fact, producing a sufficient quantity of urine. Unfortunately, it was all sitting in his bladder. I nudged his bladder with the bladder-scanner and found a little over half a liter of fluid in there. The orders said to call the MD with the results of the bladder scan. Score! One of the clinical foci was communicating with MDs, now I'll get to do something we just talked about. I learned a bit about the quick-page system on the computer and got to chat with the MD. I actually did get a chance to chat with an MD for a "call-MD" parameter at my last clinical site, thankfully I had all of the information he wanted to know memorized. Now that we're actually being prepared for this I had intended to have my organization sheet with me with all my assessment findings...but I had left it in the room of patient V, since I got called to the nurses station in the middle of a medication administration. All the MD wanted to know was information that was in my memory, thankfully, so the interaction went smoothly. I found myself slipping into spouting off unsolicited information, that's something I'll have to watch next time.

The MD gave me a verbal order (something I was only able to do because my instructor was there with me) to insert a foley catheter. I was told later that the only reason it was a foley catheter and not a straight-cath was that this way no one would have to call the doctor again later. After chatting about the situation with the instructor, I think that if I had more presence of mind while I was talking to the MD, I would have recommended a straight-cath, since it's less invasive and he has a UTI already. In any event, the next shift will probably just take the foley out and get an order for straight-cath if not voiding every 6 hours.

This was the second foley catheter I'd placed so far, and I was somewhat nervous. The first one was all the way back in my first semester. I sat down in the room and explained to Patient W and his visiting son why it was important for us to drain the urine in his bladder. Patient W, predictably enough, was not too keen on the idea, but when I explained that it was nessisary to prevent his "bladder muscle" from stretching out, he said "whatever you say" with a dismissive wave. I always feel slightly bad when I get consent this way, but I think that's why people react that way sometimes. A "control thing", like so many other responses. If they feel like they can't control what happens to them, they can at least control -that- part of it. The catheter insertion went smoothly, but I felt like I should have been able to talk my way through the procedure a little more intelligently. Even though it's been a while since I've done one or been quizzed on the process, many of the aspects of the procedure are universal and I should have been able to respond to questions during the procedure more appropriately.

During my time with Patient W I administered a couple of breathing treatments, something I had done many times before in previous settings. The computerized charting guides us to do pre and post respiratory assessments and document our results, which I thought was clever. The computerized charting system in the last site didn't have this feature. After administering the last breathing treatment of the evening, his oxygen saturation had declined a bit, 93%, down from 96%. He had been off the 2-Liters of 02 via nasal cannula because his oxygenation had been doing well, but we ended up putting him back on it through the night, figuring he'll be breathing more shallowly anyway while he's sleeping. His respiratory assessments were pretty decent during my time with him, his flu was abating, he was afebrile, and his breath sounds had a little coarseness to them but were mostly clear.

Patient V was a large (not obese), stoic European gentleman. I met his wife briefly at the beginning of the shift. He had just been transferred from the critical-care unit. He was brought in by ambulance for esophageal varices. His Hemoglobin was 3.8. His Hematocrit was 11.5. I don't even want to think about how much blood he swallowed and/or vomited for his numbers to get that low. He has a history of alcohol abuse, which he quit four years ago. He perceived himself to be in good health. He maxed out the volume on the incentive spirometer without even trying. I couldn't contain my shock! He explained that he was a "professional swimmer". When I asked him later what kind of swimming he did, he said he was in the (European country here) special forces, although he wouldn't say what exactly he did for them, just that he was able to swim to a depth of 100 feet unassisted. Wow.

Interacting with him was pleasant, as he was talkative (once we had some time to get to know each other) and interesting to talk to, but difficult at the same time. The difficulty came from the fact that he had a lot of questions about his health that I knew the answers to but couldn't discuss with him.

He had a cat-scan earlier that day. I had the results, but the doctor hadn't been up to discuss them with him. He figured since he quit drinking, he was out of the woods. Sadly, this is not the case. My very first patient in the med/surg environment quit drinking 15 years ago. As he aged, his liver function declined until the cirrhotic changes became a bigger issue..when you're young you can spare 20% or so of your liver function (or more, even), but once you age and are down to that last 30-40%, those cirrhotic changes become more of an issue. His esophageal varicies were caused by portal hypertension, since the collateral circulation establishes itself in the esophageal, hemorrhoidal and splanchnic plexuses. His history also included hemorrhoid removal surgery.

He mentioned that he didn't feel like the doctors understand him when he explains his symptoms. Looking at his history it was obvious that his liver was failing, so I don't know if no one had explained that to him, he didn't understand, or was in denial. Patient V was fixating a bit on his horrible experience in the CCU (not because of the care, but the pain).

His wife kept reminding him to forget about yesterday. Tomorrow will be better.

The cat-scan also showed a primary renal tumor, which means he's not eligible for a liver transplant.

I had a hard time looking him in the eye when he told me that there shouldn't be anything wrong with his liver and his stomach because he quit drinking. I knew his cat scan results, but couldn't say anything. I forced myself to look him in the eye, nodded, and told him that he'll know more tomorrow when the doctor visits him. I felt horrible at first, like I was keeping something from him.

Looking back, though, I'm glad he had one more day to rest before getting the news.

In summary, I feel like I was able to positively make use of some of my prior experience in caring for the post-surgical bariatric patient at my last clinical site. My first med pass experience at this new site, however, could have gone much better. I feel like I'm starting over, in a way, in the process of readjusting to not having a preceptor any more. The two big problems were organization and communication. My strategy for next time is to imagine that all of the med administration times are actually one hour earlier, and cluster together med administration tasks so I don't have to keep running back to the dispenser. My co-assigned RN on the second day was pleasant to work with, she "rounded" with me at the beginning of the day and took me through a lot of the charting, but then also carried out tasks for me without telling me about them. I need to make sure I'm aware of -everything- going on with each patient assigned to me, so I don't look like an idiot when the instructor asks me what happened with patient V's IV piggyback or Patient X's TPN. I'll accomplish this by taking charge of interventions more assertively, and making sure me and the staff RN are on the same page.

The other problem was how I had prepared for the day. I skipped the legislative luncheon that day, because the prior day's clinical practicum had me wound up until 3AM or so, and I didn't want to come to the second day sleep-deprived, since I've come to associate that with poor performance on my part. Although I think I did the right thing by getting enough sleep, I forgot to eat! Even worse, I was so far behind because of my med-administration confusion that I didn't get a chance to eat dinner either! I went to the "vendateria" or "vendatorium" or whatever they call it, only to find that they only accept $1's, not $5's. Thankfully someone brought a fruit basket to the floor, so I snacked on honeydew melon. I have consider my nutrition just as much as my sleep and rest in preparing for clinicals. I can get away with doing lots of things while undernourished and not even notice the difference. Providing care and administering medicines is not one of those things.

The big gain I feel I made was to more clearly understand the relationship between the paper charts on the carousel and the computerized charting. What I've learned this week is the computerized charting is for -entering- information, the paper charting is where I should be GETTING my information, since the computerized charting here can't be counted on to include all of the important information about that patient.

At the end of the day, the Staff RN said to me:

"You know what I bet you'd be good at after working with you for a day? Emergency!"

I inwardly swelled with pride at this, since that's what I'm most interested in doing. A faculty member told me once that emergency would eat me alive because I'm too slow. Maybe that's true now, but in building my assessment skills for a year or two on a med/surg unit, I think I can get there. I just have to get THIS, first.

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