2.28.2008

Home Nursing

Today was my home care nursing observation day. The home care agency I was assigned to is within walking distance from my home, a welcome change from far-flung clinical sites. The beginning of the day consisted of organization, collecting the patient assignment and calling ahead to make sure they were home and willing to allow a student to tag along. All of the nurses had laptops equipped with touch-screens, and outfitted with a Cerner product for charting and retrieving data.

The nurse who volunteered to take me with her demonstrated the staggering amount of assessment data required by medicare/medicaid, nearly 100 different "Screens" worth of check boxes and fields to type in. Thankfully the process is somewhat automated by the software, which populates some of the fields itself. She showed me the ropes of her personal organization scheme, which included a redundant paper copy of the charting that will eventually go into the computer. She explained that in the past, computer failures have wiped out irreplaceable assessment data, so she backs up everything by hand before charting it in the mobile electronic record. Another lamentable example of time-saving technology actually stealing more time from already busy people.

Once the charts had all been organized and all the patients had been contacted, it was time to roll. Home care nursing is one of the better excuses I can think of to get a swanky GPS navigation system installed in your car. The nurse who was driving, I came to find out, is the step-mother of one of my friends from high school. Small world! In the car, she showed me her bag of diagnostic equipment, and demonstrated appropriate "bag technique", which allows her to remove and replace equipment and cleaning supplies while minimizing the transfer of microbes from home to home.

First up was a middle-aged male with AIDS. His partner had recently died due to intentional non-compliance with his therapeutic regimen, and he had been adjusting to the loss and sorting out issues related to the property, which his partner left with debt still attached to.

The assessment took place in his living room, while his sister and father watched TV. A quick set of vitals, assessment of lung and heart sounds, some teaching about lowering his sodium intake, a couple of questions about his CD4 count and viral load, and it was all smiles and handshakes and on to the next site. The home care nurse told me she only needs to visit him once a month, since he manages his own medications effectively and takes good care of himself.

The next visit was a routine assessment of the home health aide's performance. The RN is responsible for making sure the aides are "doing their job" safely and thoroughly. The idea was to get there before the aide so the patient could be interviewed in private about the quality of care she has been receiving. The RN had worked with her for a long time and didn't have any concerns about this particular aide.

When we arrived, we found that the aide had arrived early, beating us there by several minutes. The patient was a pleasant Italian LOL (little old lady) with a colostomy on the left side. She had no active complaints and was able to demonstrate that she could, in fact, complete her own ostomy care, as she has been doing for well over 20 years now. The aide (the ostensible purpose of our trip there) was a bright, energetic 30-something who gave up on getting in to our nursing school because of the notorious (and artificially difficult) microbiology class that has lead me to council every pre-nursing student I meet NOT to take microbiology at our school. Thankfully, as part of a consortium of community colleges, there are plenty of other places to take it. She switched to ECE at that point. She really seemed to know her stuff, and after spending 3 years as an aide I told her she'd have a great head-start on the nursing program. I encouraged her to try Microbiology again at a different school and reapply for next year. I hope she does, I'd work with her any day! The aide, as the RN predicted, had been giving superior care.

Next up was an admission to the service. Admission was a funny way to think about it, since the patient was home-bound, and being "admitted" to a service rather than a place. I reviewed the chart with the RN before we went in, he's had a Ventrico-Peritoneal shunt in place for over 20 years! This tube connects the ventrical on the right side of his brain to his abdominal cavity, to shunt excess cerebro-spinal fluid. Hydrocephalus ("water on the brain") was the reason it was installed. After a nasty fall a few days ago, crippling headaches brought him to the hospital, where enlargement of the left ventrical was discovered through diagnostic imaging. A new shunt was implanted on the left side. The documentation from the hospital mentioned MRSA, but the agency paperwork made no mention of it.

Watching the admission assessment was instructive. In additional to the routine vital signs, a series of questions were asked about his ability to carry out his activities of daily living, bowel habits, drug/alcohol use and things of that nature. This seemed less detailed than the admission assessments I've seen performed in the hospital. The bandages from the surgery were clean, dry and intact. The orders said not to remove them for five days, and since there was no visible drainage, warmth or redness, the dressings were left in place. We reviewed his medications with him and made sure he could safely self-administer them. Mild mental retardation was present in the history, he was also receiving the services of a job coach. During the assessment he told us he had quit cigarettes three weeks ago, and alcohol over 100 days ago. In assessing his bowel function, he noted he hadn't had a bowel movement in 2 days, so we made sure someone would bring him some whole fruit and juice that day, and gave some teaching on increasing fluid intake besides just coffee. Since he was admitted under medicaid, he had to be home-bound. The advantage of this was that the RN could visit him as often as she was needed, instead of being limited to two visits per week.

Our last stop was another elite-LOL, just a week away from her 99th birthday. She was hard of hearing and had suffered extensive bone demineralization. She was able to get around more or less independently with the walker, but still depended on family to help her with her ADLs. She made several negative verbalizations while we were there, commenting on how all of her friends are dead, and how once you can't take care of your own house it was "time to go". She mentioned she had no idea why she was still alive and was "ready to die". A conflict arose when the RN told her that the mattress that was propped against the corridor wall was a threat to her safety and should be moved somewhere temporarily. The patient didn't want anyone to disturb it, she liked the house "just so". She has been waiting for over a month for people to finish remodeling her sunroom so she can sleep there during the summer. She was afraid moving the mattress from where it was left would somehow interfere with the remodeling process. This posed a problem, because in home care nursing the patient is "in charge", not the health care team. If she wanted to leave the mattress there, there was nothing we could do about it. With some patient explaining she finally agreed to let us move it out of the way temporarily so it wouldn't interfere with the use of her walker.

Reflecting on the day, it's clear that home care RNs benefit from self-directed organizational skills, independence and confidence in their skills. There is a strong support system in place for them, since they can call the agency if they encounter something they're not sure of. Following a home care RN around for a day was very enjoyable, home care lends itself to some unique challenges in lateral thinking and problem solving skills. The RN apologized, saying that she didn't have her usual full schedule of interesting wound-care, I told her that was alright, since I was mostly there to learn about her work rather than practice techniques. She serves an important and interesting role in the health of the community, the more care people can receive in their homes instead of in the hospital, the better!

2.27.2008

Back in the Saddle

Our clinical focus for our first week back in med/surg was "Leaders and Management". Some questions posed to us in our weekly topic related to the differences between leadership and management, the interdependence of leaders and followers, and the unsuitability of new graduates for management positions. Personally, my goal was to get through the day without any catastrophes!

I had a lot to ponder after the end of my last med/surg rotation in the winter. Some of my little quirky problems with spatial relationships combined with anxiety related to my personal life, resulting in mistakes that I shouldn't be making at this point in my development. My goals for getting back into the swing of things included getting as much input from the staff nurses about how to document correctly in this new environment, as well as familiarizing myself with the IV pumps. My history with IV pumps includes a number of amusing and not-so-amusing anecdotes, and after a semester of gravity and a semester of peristaltic pumps, I'm on a unit with volumetric pumps, which I haven't had to deal with during practicum yet. I made it a point to stop by the lab to practice with the unfamiliar pumps. The overarching goal for me lately has been improving my organizational skills. I'm warming up to the idea of pre-printing a sort of form/check-list to keep me on task. Although I balked at this at first, since we have all computerized charting, keeping some organized notes on paper seems more useful to me now than it did when all the charting was done in bedside notebooks.

Patient X was a gentleman brought in from a convalescent home for an infection related to diabetes. The peripheral vascular disease that accompanies diabetes had deprived one of his toes of nutrients to the point where it had to be amputated. Diagnostic imaging showed demineralization and other changes that were interpreted to be indicative of osteomyelitis, a bacterial infection of the bone. Bone infections are nasty, and are difficult to treat because chemotherapeutic agents don't diffuse through bone readily. The loss of a toe is a cheap price to pay to avoid sepsis! Especially if you're in your 90s. I quipped to the instructor that he didn't look a day over 80. Patient X also had a coronary artery bypass graft and mitral valve replacement about 13 years ago. He was also sporting a history of atrial fibrillation, hypertension, hyperchloresterolemia and non-insulin-dependant-diabetes. Hard of hearing and visually impaired. I got back into the habit of speaking loudly and slowly pretty quick!

The first thing I did when I met Patient X was a pain assessment. I know vital signs take priority, but I was just introducing myself and orienting the patient before collecting the equipment, and figured I might as well collect the info as I get it. Right off the bat, 8/10 pain at the amputation site. Resolved to 0/10 once I took the guy's sock off. Tadaa! I felt like I was off to a good start. My priorities in taking care of this guy included neurovascular assessments of the extremities, monitoring his pain and reactions to pain medication, promoting mobilization of pulmonary toilet (to prevent pneumonia and atelectasis) and making sure he's not sitting in the same position long enough for tissue breakdown to occur (especially important considering the age and diabetes-related changes to his vasculature). He would have gone home on that day, but while getting up to go to the bathroom he got dizzy, and his pulse dropped into the 40s. He became the lucky winner of an extra day in the hospital! Cardiac enzymes were drawn (CK and troponin) and an ECG were performed. These came up normal, so the thinking of the MD and PA on the scene was that Patient X was just sensitive to opiate analgesics. His constantly pinpoint pupils were another clue. I hit him with the penlight to make sure his pupils were reacting and accommodating. It was hard to tell, since they were so small, but I -did- see them move.

Pharmacotherapy for Patient X included two strong antibiotics, an interesting medication for fibromyalgia, seizures, and diabetic neuropathic pain (what Patient X was using it for). Although the mechanism of action is unknown, it's thought to act on calcium receptors in the peripheral nervous system. He was also getting lovenox. His PT and INR were high, but not in the therapeutic range. He has an aspirin allergy, so I was wondering if the lovenox was just DVT prophylaxis or if it was also regular anticoagulant therapy for him (because of the A-Fib, anticoagulants are often prescribed to prevent clots from forming in the atrium). This was something I should have asked around about, but I didn't get to it.

His children and granddaughter came in to visit during the evening, and I included them in reinforcing the incentive spirometry and the importance of adequate fluid intake. Chatting with the family between tasks served to give me some backround information on Patient X's baseline level of functioning and living situation. Socializing with the family also, I believe, made them feel welcome and gave them the impression that their elder was being cared for in an attentive, personalized way. I enjoy interacting with families. Most of the time.

I got to do some wound-care for Patient X, which I was excited about. Wound-care lends itself to some interesting and challenging procedures. I think I could have executed it better. I didn't have everything I needed at the bedside when it was time to change the dressing, something I've been instructed to work on numerous times. Getting through it with the instructor's help was good for my confidence, though, I just felt like I should have been able to change that dressing more independently. The important things I noted were the presence of granulation tissue and sensation in the wound-bed, both good signs that the amputation site was getting the perfusion it needed to heal.

When the surgeon removed the first dressing to observe the site, he pulled the dressing away rapidly. The tape tore the fragile skin on the bottom of his foot, so our replacement dressing used curlex wrapped up to the ankle to distribute the weight across a larger surface area. My co-assigned nurse, who was floating to our unit from oncology, replaced the dressing later with the taped kind he had originally due to a miscommunication. This gave me some things to ponder. I didn't want to disagree so bluntly with the RN who's been so friendly and accommodating with me so far, and taking the dressing off -again- to redo it wouldn't have made any sense, so I solicited advice from my instructor and other members of the team, and as a result I'm pretty sure the next dressing change he gets won't be taped to the bottom of his foot. This was an unexpected manifestation of our clinical focus for the week.

By the end of the day, Patient X was having difficulty urinating and producing stool, despite the colace and senna he had been getting. Out of curiosity I bladder-scanned him and saw that he had 255ml in his bladder. I wasn't sure exactly what to do with this info so I just reported it to the next shift so they could watch for changes and assess his urinary output.

The second day of the clinical experience, Patient X had gone back to the convalescent home. Over the course of the first day, his heart rate and blood pressure returned to baseline, although his pupils remained pinpoints the whole time I was caring for him. I wonder how they looked when he was discharged!

Patient Y was absent for much of that first day. All evening all I knew about him was that he had some kind of GI band procedure, and that he was still in the PACU. I'd find out more when the PACU called up to the unit with Report. His absence for most of the shift gave me extra time to monitor Patient X and help out the PCAs here or there on the unit.

Patient Y's case, when I thought about it, was actually a first for me in my short time practicing as a student. The band procedure was an ostomy closure. After three months of having a temporary colostomy appliance necessitated by diverticular disease, it was time to reconnect the GI tract and start using it again! Reflecting on this later, for all of the people that I've cared for with temporary and permanent ostomies, this was the first time I've cared for someone who had one reversed.

Patient Y wasn't out of the woods yet, however. Once you're up there in the 80's, in my limited experience, it seems as though surgically induced Ileus takes a while to resolve. I thought back to my first semester at the small private hospital in the northern part of the state, where one of my clients had a surgically induced ileus that lasted for two months. Two months on the med/surg unit, yikes. Patient Y needed to pass some flatus, and I was going to do whatever I could to make it happen. My first day with him was short, since he arrived on the surgical unit between 7 and 8pm. He was deliriously happy (maybe because his colon was attached to his anus once more!). He was also extremely disoriented. He thought it was 1987, and didn't know what hospital he was in. He did, however, know his name. He was fading in and out of consciousness, my priority assessments for him were respiration rate, breath sounds and NG tube. Because of his disorientation, he was a high fall risk as well as being at risk for pulling out his NG tube, IV access or JP drain. He was extremely lethargic but cooperative, and didn't try to get out of bed while I was around.

When I came back to check on Patient Y on day number two, however, I was told that he had been trying to pull his tubes and climb out of bed. Apparently when he saw his eldest daughter he figured it was time to leave and started to make a break for it. In other settings I've been in I've seen vest-restraints used for this kind of confusion caused by the confluence of age, narcotics and metabolic stress caused by surgery. The solution here was to put another layer of hospital gown on with tapered sleeves. In this configuration the patient was not as aware of the tubes in him in the first place. I wasn't sure if this was a good thing or not, but figured either way Patient Y should be oriented to the presence and purpose of the tubes sticking out of him.

I didn't have any of the problems other people described with Patient Y, this often seems to be the case when I take care of confused, elderly male patients that are described as "difficult", "moody" or "combative". His memory did not seem to be intact, but continuous reorientation to his surroundings and situation seemed helpful. I didn't make him feel bad when he couldn't figure out what day it was, I just reminded him what day it was ::shrug::.

I was determined to help Patient Y pass flatus, since that seemed to be what was holding him up in his clinical pathway. I didn't know what else to do for him but ambulate him as he could tolerate. His staff RN administered some carafate GI protectant syrup, since he had a strange reaction to the usual post-operative pepcid dose (it affected his level of consciousness, I've never heard of that kind of reaction). The syrup was instilled through the NG tube, which was then clamped before our ambulation adventure. Did I mention this guy used to play football? He got a craniotomy and everything (part of his skull was removed). He walked vigorously, I had to keep reminding him to slow down, and watch his habit of listing slightly to the left as we walked.

I picked a poor time to change the vacuum collection device attached to the NG tube, I didn't realize that the black marker line with "3p" written on it meant that someone had already recorded that amount of drainage at 3PM. Doh! I got some guidance from the staff nurse assigned to Patient Y at the end of the shift. I feel like that was obvious enough for me to pick up on, chalk it up to orienting to a new unit maybe. On my first day with Patient Y his JP drain put out 75mls of sanguinous drainage, the second day there was only about 8 or so while I was with him.

Patient Y was on PCA Morphine, but this was discontinued on the second day, because he was "using the PCA like the call button". Despite frequent reorientation to the PCA pump and the television remote, Patient Y was unable to effectively use either, so maybe he wasn't in the right mental state to self-administer analgesia (or use the call bell or operate the TV for that matter). I took note of this and made sure I kept an eye on him.

Looking over Patient Y's labs, I noticed a massive left-shift, and a pattern of CBC results I've come to associate with recovery from surgery (decreased H&H, RBC, Left-shift in the WBC, I'm told this combination of values represents reticuloendothelial blockade, a normal response to injury and infection). I monitored his temperature closely since he was also scheduled to receive a flu vaccine. His temp ran low throughout my time with him, I remember reading somewhere that low core temperatures are positively correlated with longevity. Another thing that jumped out at me was the Glomerular Filtration Rate in the 40's...ouch..renal impairment anyone? I didn't see anything in the history about renal disease or dysfunction, so I just made sure he was putting that 30ml/hr into his foley.

On the second day I had two additional playmates, Patient W and Patient Z. Patient W, who was by the window, came to the hospital for a colonoscopy. During the colonoscopy, a non-functional part of her bowl was perforated. She has a permanent colostomy that she cared for independently. She was due to be discharged "any time now", of course "any time" ended up meaning "four hours after she was told she was ready to leave". She was frustrated by this and attempted to wave off my initial assessments of her. I assured her that the brief assessment I was going to do was necessary to ensure her safety. I think the peach cobbler they brought up for her after dinner improved her mood dramatically. She slept most of my time with her, probably out of frustration. While she was awake I made sure she was comfortable, her biggest issue according to her was mustering the patience to wait quietly for the ambulance to take her back to her skilled nursing facility. Despite her admonitions, I made sure I checked for peritonitis with some light abdominal palpation, gave her the neuromuscular twice-over and checked for Homan's sign.

Patient Z was in the same room by the door, and she was a riot. She had been in the hospital for about three days, and had a polyp removed from her left arm as well as a left-sided colectomy. She had progressed to a clear liquid diet by the time I saw her, and was sporting 5 fashionable laporotomy sites, the left-most of which was much larger than the others. She was also in her 80s, and had comorbidities that included hypertension, supra-ventricular tachycardia, osteoporosis, arthritis and a left-sided mastectomy. When I came in for my initial assessment, the first thing I noticed was a sign hanging over her bed that said "NO BP ON LEFT ARM", because of the mastectomy. She said the "other girls" had been taking the BPs on the left side because they haven't been getting readings on the right. I told her I would try the right anyway, and got an extremely low reading. This was important because she was due to get blood pressure medication a few hours from now. I mis-prioritized getting a more accurate BP with the manual sphygmomanometer, but got a more accurate reading well in advance of the coreg and lopressor administration. In the future I'll make that a higher priority. I also made the mistake of stopping the IV infusion running in to that side, this caused a cartrige self-test error when I started the volumetric pump back up. Back in the nursing lab today, one of the lab tutors told me stopping the pump wasn't necessary, and the self-test failure was caused by the cuff squeezing a bubble back up into the cartridge. I wasn't around to see the staff RN correct this problem, but after going back to the mock-up in the lab I think I'll know what to do next time around.

Patient Z also hadn't passed any flatus since the operation, so we went on a stroll through the unit together as well. We took it slow, in case orthostatic hypotension reared it's ugly head. When she started moving with the walker, I was struck by how short she was. I didn't notice while she was lying in bed, but between the progressive bone demineralization and being "a little on the short and stumpy side" in her words, her head didn't even come up to my axilla. She visited another patient down the hall that lives in the same retirement community as her. She seemed to derive some of her self worth by encouraging her friend to keep a positive attitude, and to try to get out of bed like she was. Her friend had just received a permanent colostomy, and it was psychologically difficult to her, especially since she perceived that she would not be able to return to her retirement community as a result. She wasn't part of my assignment, so I didn't get to find out much more about this person.

All in all, it was a great two days back in med/surg. I think I provided great bedside care by focusing on the core interventions for elderly post-operative patients for integumentary integrity, pulmonary toilet, early ambulation and wound surveillance. I got right back into the flow of introducing myself to, joking around with, reorienting and assessing the surgical patient, interacting with the patients is, like many people I'm sure, my favorite part of the job, and its a point of pride for me to keep them laughing, even if it means they have to splint their abdominal incision. Laughing is good for the lungs! I'm sure there's some kind of positive psychoneuroimmune/neuroendocrine influence there as well.

These two days also reminded me that I have some serious obstacles to overcome in providing competent care, especially my organization and documentation skills. I feel like this will come through practice and attention, neuromuscular conditioning like riding a bike or waiting tables. Not giving medications this first week threw me off at first mentally, but looking back on the shifts, not having to worry about medication administration paved the way to a smooth orientation to an unfamiliar environment. I just have to remind myself, when I feel like I don't have "enough to do", I need to concentrate less on what I -can't- do and more on what I -can-.

I like this place. I like how it's designed, I like the people I've worked with so far, I like the computerized charting, and I like my cohort. I appreciate good industrial psychology in building design, it's a welcome change from the linear hallways and institutional angles of the busy urban hospital from the past two semesters. I learned a lot there, but it's nice to have a basis for comparison. The computerized charting is fun and extremely handy, but not as simple as I had initially assumed it would be. The system isn't used in a vacuum, like in the training, but instead has to stand up to chaotic and changing conditions. The ability to dynamically add, remove and rearrange elements helps, but the big confounding variable is the expectations and standards of the rest of the people utilizing the charting system that make mastering it's use a non-trivial task.

I can't wait to go back. I'd do this every day, if I could. For a while, anyway.

Generativity versus Stagnation

I'm comfortably tired. The next few weeks are going to keep me busy, this is the first chance I've gotten to sit down and do nothing all week! Yesterday and the day before were my first two days of med/surg this semester, that gets its own post next (since I owe a journal entry on those days, and it's due tomorrow!). Tomorrow I have my Home Care day with the local VNA (visiting nurse's association), Friday I'm giving a crash-course in first-aid to a troup of girl scouts (stop snickering, you), Saturday and Sunday will hopefully be devoted to spending some quality time with what few friends I have left, then it gets REALLY busy. Monday has me up at 7AM to drive across the state and give a talk to another community college's nursing class about starting up a Student Nurse's Association. After that, it's med/surg 'till midnight! The next day, I've got a state SNA meeting for all the chapter presidents early in the morning (focused on mobilizing Nurses in the political process), then..you guessed it! Back to med/surg! Fortunately on Tuesdays we get out a little early, because.....class begins at 8AM on Wednesday. I volunteered to do some kind of "read across america" function for Dr. Seuss' birthday on the Friday after that. Rather than reading, I was told I could do any kind of nursing-related demonstration without set beginnings or ends, so I figure I'll bring the laptop, the electric stethoscope and maybe some curlex to play with. Then, a little more time to rest before it's off to the NSNA convention in Grapevine TX.

Organizing the trip has been a little frustrating, since people kept changing their minds about going. Thankfully we're traveling with a relatively large number of students, four of which are first-year students! It'll be nice to set the next year's senior class up with a few key people who are looking beyond the limited coursework. This will be the most first-year students we've ever taken to a convention, we'll be getting them involved with the resolution and parliamentary stuff, as well as selling some coffee mugs and shirts. Gotta make some money back, hotels and plane tickets are expensive! A very small percentage of NSNA members actually go to the conventions, and it's a shame. There are great speakers, seminars and focus groups about everything from pharmacology to disaster response to the image of nursing in the media, nursing specialty groups like nurse midwife, travelers, and nurse anesthetists, how to manage people, how to be managed by people, you name it. Throw in a HUGE job-fair full of hungry recruiters and put it all in a swanky resort and you've got a winner.

Besides all of the interesting things to do there, I've appreciated the chance to connect with the faculty outside the structured academic environment. I got a lot out of it last time, when our program's director hung out with us, told us stories and gave us advice. This time, one of my clinical instructors from last year will be joining us. I'm looking forward to that, all of my clinical instructors (well, maybe with one exception) have been people I'd love to hang out with outside of school.

Meeting student nurses from other states is interesting, too. From diploma nurses all the way to graduate and doctoral students, every entry into practice and state is represented. Supposedly some states are hosting international students this year as well, I think that's a new thing. The chaos of the convergence of all of these different people with nothing in common but Nursing was most apparent to me in the House of Delegates. This is where the parliamentary business of the national organization is performed. Last year we got a resolution passed after a couple rounds of nailbiting debate and voting. This year, the resolution on the table was written by me and a classmate, so it will be -extra- exciting.

It's hard to motivate people to get involved with anything outside of the bare-minimum required to get licensed. It's like exercise. Feeling tired? Weak? Lethargic? Exercise might seem like it will make you weaker and more tired, but in fact it actually addresses the source of that weakness. The same holds true for Nursing School. If you just condition yourself to doing the bare minimum (and the academics are trivial compared to science or engineering), what makes you think you'll suddenly be able to summon the extra cleverness, motivation or spirit that practice demands of us? So far, Nursing seems like it can be a frustrating, disheartening experience to people or groups of people who passively accept their situation instead of advocating for themselves and their profession. It's a lonely scene to be a loner in.

There's a point where some of us wake up, take a look around, and realize that we aren't merely health care pros that show up for work and then leave at the end of the shift. We're a cultural institution. We're the most trusted profession in the US (according to polls). We're the conscience of a health care system blinded by monetary economics. We also comprise well over half the health care work force. Despite all this, Nursing gets the legislative shaft because "oh, this is hard enough already, I shouldn't have to do extra work, let someone else handle it". This is what makes things -easier-, not harder. Networking, forming professional relationships outside of the workplace, accumulating contacts for research, education and employment isn't merely a strategy for professional success.

What I'm talking about is the nature of the bonds between us that take our seemingly hopeless, impossible task and turn it into something that we can execute faithfully while taking joy and pleasure in our work....a method for providing context to the grim realities of life and death we're charged with managing

...and finally, when it's OUR turn to lie in that bed, to meet our fates with grace and serenity, comforted by the knowledge that the nurses we trained to replace us face THEIR task with all of the best wisdom, compassion and ambition we could preserve from our memories of our teachers back when we were students.

The alternative is to be in that bed surrounded by unmotivated, apathetic nurses-turned-technicians, and receive the level of care that goes along with that.

You don't have to accept pressure ulcer formation. You don't have to accept clients lying in their own filth for hours at a time. You don't have to accept the judgment of a politician that claims emergency departments are swell places to receive routine medical care. You don't have to accept bureaucratic dictates when they start to negatively impact patient care.

I realize a lot of this sounds like wistful idealism from someone who isn't even licensed yet, and I don't want to offend anyone else who has been frustrated or disheartened by these trends. When I look around at the other health care blogs floating around I see the same kind of nascent mob-intelligence that's been springing up in other fields, it's just restrained a little bit by tradition still. The apathy I've seen in my peers gives me pause, though, and it's given me an opportunity to reflect on the challenges that lie ahead.

I learned today that the director of our program will be leaving before the semester is through to take a position geared towards...what was it..some kind of state-wide faculty and staff development position. Her role at our school seemed to be geared towards faculty and staff development, so most of the students didn't get to interact with her much. I spent a bit of time with her between her being our faculty adviser for the SNA, along with my habit of occupying administrative offices whenever I'm in school. Like many of the faculty members, she's been an inspiring influence. When I heard the news I was sad at first, but then I realized I'm about to leave this place also, and we'll both be working to improve things wherever we are.

2.25.2008

Check

Stethoscope? ...check

Clipboard w/calculator? ...check

Self-Organization chart? ...check

Quick-E Spanish for Health Care Workers? ...Check

Penlight (for neuro exams)? ...check

Actual Pens? ...check check and check

Money for Dinner? ...check

PDA (with drug guide, med/surg and care plan books)? ...check

Alright, let's do this

Retrieval

So...here I am, about a half-day away from my last ten weeks of clinical practicum. Psych clinicals were a poorly timed vacation. This is where the action is. There's a lot of negative things to say about Med/Surg. The Nurse/Patient ratios are the worst, burnout is prevalent and the stakes are high. It makes sense to put students here, the need for extra help is the greatest, and the patients are sub-acute but need a lot of care, so it's the ideal environment for students.

This is going to be the deciding factor. Can I do it? I'm not sure. The tests are easy, the academics are trivial, the theory is elementary. Taking Care of someone is hard, and clinical practicum is pass/fail.

Anyone can be taught to hang a bag of IV fluids or give an injection or replace a bandage. What sets us apart, I think, is that we understand the entirety of the disease process, and anticipate problems before they occur. At least, that's what's supposed to happen.

I guess what's giving me pause is just being so close to the finish line. Am I really going to finish this or am I just going to sabotage myself? The deciding factor has always been my support system, and the people I've relied on the most are gone. Even the people I've come to rely on recently are absent.

If my last great personal tragedy taught me anything it's that it's possible to provide brilliantly constructed care in the midst of a catastrophe. If the few months that followed taught me anything, however, it's that sometimes the aftermath is worse than the event.

I don't fool myself into thinking there's a choice between walling yourself off and letting other people in. There's only the facts of the matter, and what you tell yourself to feel better at the end of the day. Your proximity to the ones you love is either something you celebrate or lament.

Tonight, I lament.

2.21.2008

Exanimation

Yesterday was our first quiz of the semester. Yawn. They're really making it easy on us during the home stretch. I found out later that I got a couple of simple ones wrong, but no matter. I'm pretty sure I got at least an 85. The content was all of the psych lectures and "labs" (extended lectures), and some questions about AIDS. Since people around my age have been getting education about AIDS since we were young, most of the information was old news. The questions from some of the older students highlighted the difference that education's made.

An AIDS-Care nurse came in to give a talk after the quiz (I don't know why they quiz us BEFORE they have experts come in to talk to us about it), she was a very entertaining speaker and gave an excellent presentation. Whenever one of us answered a question correctly, she gave us a condom. I answered a lot of questions, so I left with pockets full of prophylaxis. Hah! I was thinking of making a joke like "great, all I need now is a girlfriend!" but the words stuck in my throat.

After the nurse finished her presentation, a man and woman with HIV came in to talk about their experience living with the disease. They were both infected in the early 80s. The man attributed his longevity to aggressive pursuit of experimental therapies recommended by his trusted physician. The woman attributed her survival in spite of poor therapeutic regimen management to her stubborn nature. Both of them cited their physicians as their major source of hope and confidence in treating their condition, neither of them had been hospitalized for lengthy periods.

After class, I went to the student programs office to reserve our hotel rooms for the NSNA convention in Texas. I had to keep putting it off because I couldn't get definitive answers from my classmates as to whether or not they could travel, since there was some confusion about a quiz we'd miss while we were away. The convention center turned out to be full, as was the hotel they were suggesting as an alternative. I ended up reserving five rooms at another hotel about a mile away from the convention center. The hotel has free shuttle service, so it won't be that bad. I still don't know for sure how many students are coming with, but we can always cancel a room later if we need to.

Sorting out all the madness of the hotel rooms made me forget to meet up with the psych instructor for my evaluation. Whoops! I sent her an email, hopefully she can just reschedule it for later.

I'm thinking of doing my peer teaching project before graduation on combinatorial taxonomy in nursing diagnoses. Too dry? We'll see what the instructor thinks.

2.19.2008

Patient Storage



On our last day at the milieu we brought the traditional muffins and donuts for the staff. We do this at the end of med/surg rotations too, and we're simultaneously praised and jokingly admonished for bringing sweets around while people are trying to diet. I sat in the day room and filled out the survey that the hospital gives all its students. For things I liked, I said the staff was super-friendly and knowledgeable. My gripes centered mostly around how "coddled" we were, I didn't get to see any groups, and how short our time was there each day (we were basically on the unit at the times the least amount of people were likely to be there). I suggested in the future the rotation be more individualized according to comfort level and experience. Unreasonable request, maybe, but I had a good time either way.

During my last day there, I thought about something the instructor told us on the first day we were there. One of her patients from her days in maximum-security forensics came up and chatted with us on the first day. He mentioned a few times how he was due to get out of there soon. She told us later that he doesn't have any way of knowing really when he'll get out for sure, but saying that was his way of "letting us know he was ok". I thought about that today as a big (tall) fella around my age wearing orange sweatpants and a sweatshirt walked by with a handheld game, so I chatted with him about that for a while, and he told me about where he was from and how he's "gonna be getting out of here" soon, how he's not "mentally ill" (his chart did mention limited insight).

Later on in the day, that fella (whose Dx includes intermittent explosive disorder and conduct disorder) got into a shouting match with one of the other patients over that DS handheld. The other patient insists other people's belongings are his, it's a feature of his psychosis. When he claimed the guy in the sweats handheld game as his own, he blew up at him. This was the only real behavioral incident I've witnessed the whole time I was there. After that, the guy with the DS didn't talk to me for the rest of the short time I was there. I felt like telling him that he just has to realize that other guy's behavior is just part of his psychosis, and when he gets under his skin to just tell the staff, but it wasn't really my place to do so. Although I felt like I had established a rapport with him, I remained an observer.

The doctor who quizzed me on microbiology was back this time, and he challenged me and my unit-buddy to give him our thoughts on three pages of lab results for one of the patients. Besides being slightly leukopenic, his antibody titers for Hepatitis A, B, and C were positive, with B indicating immunity. He wanted to know what we could deduce from the chart. After a few guesses, and with time running short, he pointed out to us that the risk factors are important to identify, because the antibody titers can positive in the absence of the viruses. The chances of them being positive to a former IV drug user are 95%, whereas the percentage for someone who's just voluntarily donated blood is 25%. In the history, I found no mention of IV drug use, he pointed out the history of cocaine use, and how the virus can be passed on whatever instrument is used to insufflate the cocaine nasally (a dollar, commonly). The point he was trying to make, he said, is that knowing the patient is a lot more important than just the charting data.

After lunch we toured the TBI (traumatic brain injury), ABI (acquired brain injury), geriatric and general psych units. These units were a stark contrast to the forensic psych unit. Whereas the forensic psych unit was set up more or less like a college dorm room, these other four units were more like a sterile office complex. Rooms tended to be separated by cubical walls with no ceiling, up above was an office-style drop-ceiling streaked by bars of fluorescent lighting. There was no color to anything, it was all a bone-white or soft gray. When we arrived on the geriatric unit, the instructor left to find our guide. While she was away from the lobby, we heard one of the assistants raise her voice to one of the patients. This was the first time I had experienced that the whole time I was there, if you can believe that. What we heard was "do you want to go or not?!". The other students and I shot horrified glances at each other before she burst through the door.

On the TBI unit, our guide showed us the padded room..they call it something else, two names hyphenated. E-C I think. Our guide made a point of showing us the part of the unit that was farthest away from visibility by staff. It was at the end of a long row of rooms, ending in the area of refuge for emergency evacuation. He said that's where all the fighting and sex went on. I said "oh, like the back of the bus, right?". Our guide laughed and nodded. There was a parabolic mirror on the wall, but it wasn't positioned to let someone see into that secluded corner, it's hidden by the cubical walls. Strange.

The areas we toured that day seemed like places to store patients. Patient storage. We saw only a limited glimpse of life on that unit, and most of the patients were attending group activities so we only saw the few patients not attending groups, and most of them seemed sick or tired. We got to peak in to one of their groups, "reminiscence therapy", where a therapist showed line drawing pictures of current and former presidents to spur memories and conversation. I studied about this the night before, in preparation for our psych exam the next day.

I'm coming back in March for a make-up day, but I still feel slightly guilty about not going around and saying goodbye to a lot of the patients back on the forensic unit in person. I'll have to make up for that when I come back.

We found out this day that the abominable juvenile detention facility in the backyard was not only no longer being demolished, it's now being EXPANDED. Apparently there was a need for some smaller juvies in the state, and everyone said "not in my backyard!" so the capacity from those three are just being added on as an expansion to the one they were about to close because of inhumane conditions. See what you did, The State? You made one of my classmates pout:

2.13.2008

macropsychotic

Today was a holiday on the unit, I was lucky I remembered to come to clinical! I figured since it was a "holiday" that I wouldn't have clinical, but this was just one of those funny tricks of logistics. All the better, because of car trouble and other interfering factors, this was the first week where I got to spend two back-to-back patient contact days in the milieu.

This was a great opportunity, since all of the therapy groups were canceled. My case-study, my unit-buddy and myself settled in for a long-overdue game of RISK. Now, I haven't played this game except single-player on a very old black-and-white macintosh, while I was pre-literate (not much reading involved in the game anyway, except the rules). We selected a variant of the game that was "quick", that is, a game where one player only has to possess three particular territories to win, instead of controlling the entire board.

I enjoy strategy games, and my case-study is simply mad for them. We both agreed that you can learn a lot about someone by playing games with them that would not be explicit through use of language. I explained a bit about Go to him and he seemed interested, I'll try to bring my goban up next time and see how well he tolerates a new game. I was suprised how easy-going he was about playing, I think he enjoys that game in particular because of the involvement of dice. Pathological gambling is part of his diagnosis, and it's been a problem in the past to the point where he's excluded from Bingo. Risk offers an interesting alternative, where "bets" are taking place, but fully from within the context of the game, through weighing the probabilities of certain series of attacks' success. Tokens are moved around, exchanged and lost but they represent military power and are non-tradable outside of the game.

At lunch-time my case-study excused himself to walk down to the community cafe for lunch and a cigarette. My unit-buddy from my cohort stayed behind to work on paperwork, so I took the opportunity to walk with my case-study and learn a bit more about him. I suppose this is one of the advantages to being Male in this setting, the instructors admonitions to never be "alone" anywhere in or around the milieu don't really apply to us. I have to attend a make-up observation day, and I was actually surprised when the other student who needs to make a day up (a female) said that we both had to be on the same unit because we're not allowed to be anywhere alone. That's news to me!

Although my case-study has a level of restriction that allows him to roam the grounds unsupervised, he still can't open doors on his own. All of the doors in all of the buildings are locked. Although he could have had someone buzz him through the barriers, I figured I had nothing else to do, so I accompanied him just to get him through the doors. I wouldn't have done this if I hadn't verified his restriction level with staff! If he was on a restriction level that allowed him to traverse the grounds with an escort, I would need to find staff to accompany us.

On the walk over, he talked about his plans for relocation. He was still somewhat evasive about his expected timetable for his reentry into the community, but he mentioned a specific 24/7 community observation facility near our nursing school, where he plans to take accounting classes. Risk for Relocation Stress Syndrome definitely made an appearance in my nursing care plans. On the way we met another patient who works in the greenhouses. He was from a different unit, so I hadn't reviewed any of his information, but I was told that he and my case-study had been friends in the maximum-security unit, and that his RISK and stratego games were gifts from this person. They have been friends for about 8 years now. His friend was quiet but friendly, with gentle blue eyes and a mildly anxious affect. He "keeps up with hollywood" and knows the birthday of pretty much any celebrity I could name (which was about 2, don't ask me which ones). He also has a hobby of collecting maps, and has detailed knowledge of geography, a subject I never did very well. I told him that I used to collect maps of places that have never existed, he thought that was very odd.

The cohort made another attempt at watching a movie at the end of the day, so I excused myself again and returned to the unit. I've been enjoying the flexibility and autonomy. Patients were scares on my return, so I spent the remainder of my time with the head nurse of the unit (A different one from my orientation day).

The head nurse was practically pulling her hair out, because the state health inspection had instructed her to change some things about the way she writes care plans. For one, she can't phrase the problems in the second-person anymore. That is, she can't write "You are not compliant with medication therapy". She's not sure exactly what she should replace it with, but her best guess is replacing it with the third-person "Mr. X is not compliant with medication therapy". The second-person convention appeared...oh, I dunno, maybe 40 or 50 times throughout 8 different diagnoses. Not only that, she had to add long-term goals in addition to the short term goals and objectives, which were really a combination of short and long term goals as they stood. She made some progress on this earlier, but lost all of her work on the computer.

Watching her work, it wasn't difficult to imagine how this might have happened. I gave her some quick instruction in the finer points of copying and pasting text, and showed her the magical wonder of the CTL key, and how she can use it to highlight multiple things at once. She had been spending all day working on this, and with a few simple instructions she was zipping right along. I wonder how many nurses are wasting all day doing tasks that should really only take minutes if their word-processing software is being used properly? I suppose it creates some interesting possibilities in slacking off. What I thought was perhaps more surprising was that this seasoned nurse with multiple tracks of career experience didn't seem clear on exactly how to write a care plan, I practically did most of it for her. The interventions were unchanged, but the rest of it had to be completely reworked. I tried to stay out of it for the most part..after all..I'm not getting paid! After she asked me a few times for wording advice and suggestions for goals I decided this was actually a pretty constructive way to spend my time, compared to aimless browsing of patient charts. We plowed through all eight care plans in record time, and I got to learn a bit about how care-planning at a state institution works. We both agreed it can be maddening at times! She also expressed frustration that the whole exercise seemed somewhat pointless to her, as she wasn't sure anyone would really even be reading it except the people checking to see if she wrote it correctly.

Other things about her attitude also puzzled me..they're things that I've noticed in other people I've discussed my experiences in the milieu with. She spent a lot of time gossiping about the situations of some of the patients, and certain phrases kept coming up over and over. "He's not a nice person" "these aren't nice people" "some of these guys will never get better" and things like that. I dunno. Maybe what she was saying was true, but I'm not sure what the..erm..therapeutic rationale for phrasing it that way might be. She reflected aloud on an incident where one of the patients exposed himself to a nursing student from another school. She said that other nursing student was probably not educated about her rights, since if she reported this to the patient's parole officer, the patient would go back to jail. She seemed to view this as a positive thing..I asked her what therapeutic impact jail would provide. She shrugged and responded that the patient wasn't improving any here. Outside the milieu many people take it a step further and reason that what the people in the milieu are doing is a waste of time, that these people should all be executed or put in jail. Jail, of course, carries sentences of half the length, and executions are even more costly than life imprisonments, so I usually just chalk this up there with people who think the best way to deal with ten million illegal immigrants is to transport them physically to a border and wave good-bye. The question remains, though, not of what is necessarily just or reasonable at an individual level, but what actions can actually improve the mental health of the community at large. Tricky, tricky!

2.12.2008

His Crime

After a quick repair job on my car that failed to bring me to the psych unit last week, I made it back up to middletown, thermostat edging dangerously towards the red. I had to administer a fluid bolus in the parking lot before our customary breakfast in the community cafe. During our morning discussion, I reflected on something I mentioned in a previous discussion, on the preeminence of relationships, sexuality and attachment in forming the psychoses that lead the patients I had contact with to their commitments. One of my classmates turned to me and said "you realize you're on a sex offender unit, right?"

::facepalm:: riiight, it all makes sense now. It's kind of funny that I didn't realize this until now. Not all of the charts I reviewed were for sex offenders. Due to the limited availability of beds, patients with different diagnoses were housed in that unit just because there was no other place for them. Arsonists, violent offenders and psychotics with self-care deficits were housed among them, so I mistook the distribution for being representative for forensic psych as a whole.

On the unit, I continued to have positive interactions with staff and patients alike. I had a rematch in my battle of wits with the jolly psychologist, where he reminded me of the role of campylobacter jejuni in guillan-barre syndrome. Fun stuff.

The patient I'm following for my case study was, as usual, busy with groups. I spent most of the morning pulling information out of his chart for the Big Care Plan (tm). As valuable as care planning is, I can't help but view it as busy work, since the care planning we're doing involves interventions and assessments that we're not actually doing with our patients, no matter how well-adjusted they are. The other thing is that since this is an observational experience and we're given patients who are relatively stable, a lot of the assessments in the big care plan simply don't apply. No, he doesn't seem to be hallucinating. No, he doesn't appear to be employing any coping mechanisms. Yes, he does appear to be on the same planet as us. I could have picked a much more interesting patient on my own.

There's another thing. As helpful and friendly as the unit staff have been, being introduced to a patient by staff actually hinders as often as it facilitates. I've had great luck just walking into the day room and chatting up the occupants, playing a quick game of cards or just listening to them or letting them show off the awsome new CD they just got from the thrift store. When a staff member walks up to them and says something like "hey, do you feel like talking to a nursing student?" they usually get negative responses. I wonder if it has anything to do with the normal socially constructed image of a nurse...maybe some of the patients secretly suspect it's a trick or a put-on. At the very least, the prospect of being introduced to a pretty, young, student nurse might be perceived as disturbing to someone in treatment for paraphilias, or at least suspect.

When the cohort got together later to eat lunch, I was invited by the instructor to present my case to the group, since I was talking to her about it and she seems to dislike it when the cohort is bifurcated (an admirable quality in an instructor). I started rambling extemporaneously about everything I knew about the case. It's a shame I can't go into detail here, it's a pretty interesting case, but the all-powerful health insurance portability and accountability act prohibits me recounting the personal details of patients and sending them zipping about the airwaves. It seems like a fine enough line in the milieu!

Anyway, I got some guidance on something I posted about earlier, how it seemed to me that the wording in the chart that the patient "admits" to masturbating regularly somehow placed that behavior in a pejorative light. The instructor explained that the significance of that wording was actually that the patient has reached a level of comfort with the health care team that he can discuss that particular matter openly. Whether or not his denials of sexual fantasies about children can be taken at face value, however, remains to be seen.

Of course, at the first mention of "masturbation", my cohort erupted (tee-hee) into fits of giggles and crude humor. I'm all for giggles and crude humor, but I was put off by the breach of decorum during what seemed to me to be a perfectly legitimate discussion (one that had now gotten completely off-track and could not be followed). The instructor pointed out that their reaction indicated that they had not reached the level of comfort with that aspect of their sexuality that he had. When I asked if by "he" she meant me or the patient, she replied "both".

The cohort reacted with incredulity and disgust when I said that I felt that I could identify with my case study patient. I was expecting that reaction, and even constructed in those few short moments a tirade to respond with. Would they be so judgemental if confronted with a diabetic who is dying from non-compliance? A CABG blown by one too many cheezeburgers? Sometimes I have to question the motivations of my comrades at times, their compassion frequently seems limited and those limits frequently seem rigid. Maybe it's a maturity issue. I was thinking to myself "oh really? You're so great that there's no possible way you could ever identify with someone who has done something horrible? No way you could identify with someone who's ill?" I dunno. I get worked up over nothing sometimes.

The rest of the cohort decided to watch a video, so I excused myself and returned to the unit. I'm thankful for the easy time, but I'm really not interested in being educated on the subject of mental illness by the main-stream media, no matter how entertaining the presentation. Even if most of the patients were in groups or vocational rehab therapy, I figured I could at least talk to the nurses on the unit about their jobs.

As luck would have it, my case-study was on the unit and had nothing to do for a while, so we walked the grounds for a bit (his level of restriction allows him to walk around outside the unit without an escort, I can't be "responsible" for him), and he answered some of my questions about his therapy between drags on his cigarette and short episodes of anxiety posturing. He referred to the reason he was committed only as "My Crime". He didn't need to go into detail, I knew all the details already from his chart. I was more interested in what was important to him, what he finds helpful, and what he's looking forward to in the future. He identified the group therapy as being particularly helpful to him, and he goes to a lot. In addition to AA (mandated because he was under the influence of ETOH when he committed his crime), he attends a sex-offender's group, a male survivors of rape group, a trauma group, dialectical behavioral therapy group, and probably some others I don't know about. I'm disappointed that I haven't been able to attend any groups lately, but the therapists usually balk at the suggestion, even when the patients invite me to attend. Most likely, the only group I'll be able to attend will be AA (which is also the least interesting to me).

When I returned to the group, I discovered that the video-playing device was not operable, so those hours were spent in discussion. I can't say I'm sorry I missed it, the crazy people had more interesting things to say. That might sound harsh, but, well, I already KNOW what they think.

2.06.2008

Metrology Day

We begin each semester with a metrology test. Metrology is the knowledge of drug dosage calculations. This is a crucial understanding to achieve in Nursing, not because we decide what dosage to administer, but because we're the last line of defense ensuring that the substance is safe to administer to that particular patient at that particular time.

The actual math we're called upon to do in the general units is minimal. Most things are pre-packaged from the pharmacy and standardized in ways to reduce the amount of calculations required from the Nursing staff. The hardest calculations I've seen a Nurse do can be solved by simple dimensional analysis or simple analogy. X is to Y as Z is to W. Solve for one. Here are some examples from our practice questions:

*50 mg of nitroglycerin must be prepared. How many mL should be prepared using a 10 mL ampule labeled 5mg in 1 mL?

*0.25 mg of Rocephin must be prepared. Rocephin is available in mg. How many mg of Rocephin should be prepared? (that's not a typo, that's actually what appears in the list)

*How long will it take for an intravenous infusion of 1000ml of 5% Dextrose, set to run at 35 gtts per minute, when the drop factor is 20 gtts/ml?

*Epinephrine in D5W is to be titrated 0.1-1mcg/kg/min. The IV solution was prepared by adding 8mg of Epinephrine to D5W. The final solution contained a total volume of 500 mL. Your patient’s current weight is 91 lbs. You should infuse at a rate of ___ to ___ mL/hr.

*One half strength Osmolite must be prepared for a tube feeding. You have available full strength Osmolite. To prepare 90 mL of feeding, you dilute ___ mL of the full strength Osmolite with ___ mL of water.

That last one, believe it or not, was difficult for people who had successfully passed algebra. I had people coming up to me asking me how to solve that kind of question. Despite my acerbic tone here, I used to tutor math and I take it pretty seriously. I don't talk down to people or make them feel inferior when I'm demonstrating a problem (obviously, some people have a complex about this, so they'll always assume a neutral tone is threatening). I have a knack for breaking complex things down into simple steps and explaining things to people that they thought were beyond their ability to comprehend. This is fun to me, mainly because it results in there being more people for me to talk to. Also, I believe it's impossible to learn something from someone without becoming a little fond of them, and, well, that's an opportunity I tend to seize on. I can use all the friends I can get. I enjoy tutoring math for the same reason I enjoy Nursing. I seem to be good at it, it's fun, and people benefit from it and respect me for it. Most of the time.

The disparity in math skills is mystifying to me, though. Yes, I was an engineering student, yes, I took several advanced math classes, but the level of math we're being asked to do is several levels below what was required in the pre-requisite classes. We're being asked to divide, multiply, add and subtract numbers, and we even get to use calculators. I'll be the first to admit word problems can be tricky, they were the bane of my existence in pretty much every math class I took (although there's a great related-rate word problem involving the tip of a tightrope-walker's shadow that I always relate to get people interested in calculus), but when people are having trouble dividing a number in half and writing it down twice, there's an obvious break-down in reasoning skills that goes beyond inadequate training in maths. I think reading comprehension is a big part of it. Our educational systems (my favorite scapegoat) are training us to be marginally literate and incapable of abstract thought. Is it any wonder mental illness is on the rise?

I'm not saying any of this to denigrate my peers, they work hard and take what they do seriously (so seriously, in fact, that it sometimes gets in their way, but that's another topic for another day), but they've been failed egregiously by institutions that place social efficiency above personal growth and development. It does seem, by the way, that many people got into this biz because they thought they could get away with not knowing much math and science...and they're right. If current trends hold, more than half of us will stay at the lowest "Registered Nurse Technician" level anyway, maybe branching out into management or switching fields later on, so what does it matter?

What irritates me the most is how the tests have been modulated to ensure a higher success rate. This last metrology test of our ADN careers was a perfect example. Out of forty questions, at least 5 could be solved by taking the product of the only two numbers in the question, 3 or 4 only asked you to convert lbs to kg, two of the questions were duplicates, and all five or so of the feeding solution questions (that I posted an example of above) were half-strength feedings. Divide by two and type in twice. Not only that, even though we're told we are only given three chances to pass before we fail clinical, there have been multiple occasions where students have failed three times and then allowed to take it again after a week of supervised practice. I'm not saying that being flexible is a bad thing, but if you're going to lie about your standards, why have them in the first place? People are being given a free pass, to be sure, and some of them are going to be in for a rude awakening further down the line because of it.

It's clear that the people having trouble with this need one-on-one instruction to transmit the necessary skills and reduce anxiety, not only tests with grim warnings of failure. The false warning of failing clinical after three failed attempts can only be meant to "scare" the students into...what...performing better? A couple of semesters ago we had a 10-minute visit from someone from the math department who introduced basic elements of numerical problem solving with these goals in mind, but it was just one short, isolated encounter. There are tutoring resources available at school, maybe people are too busy or embarrassed or something. Who knows. I guess part of the learning process is figuring out what you need help with and getting it on your own, instead of waiting for someone to hold your hand through it. That's what they told us back in Theory, anyway.

After the mathamagical festivities, I learned that my classmate from the psych rotation got moved to a different unit because two of the patients were fixating on her. She was warned about this on the first day, one of the patients with an indecent exposure target-behavior exhibited some behavior that elicited a warning from his therapist.

What was to be my second day there, I stayed home. Car trouble. I'll have to make the day up, in the Maximum-security forensic unit instead of Medium. I'm lookin' forward to that. While I was gone, all this stuff happened. My partner for that unit will now be another one of the male students. Like in the field, males are an extreme minority in our class. I think it's somewhere around 7.5%, which is actually more than in the field (5% last I checked). In every clinical learning environment I've been in, at least half the other males in the class have been there with me, like we're being clumped together, despite being from far-flung reaches of the state.

The change in assignments (for them, I'm still in the same place) will turn out being a positive thing, though. My new psych-partner is someone I've worked with in the past, and he's one of the few people in my class that I actually look up to (and not just because he stands about three heads taller than me). Although he's knowledgeable and dependable, I enjoy having him around because he's friendly, and that's not as common as you might expect it to be.

The rest of the day was pretty empty. A student government meeting here, some personal stuff there (oh, how I wish I could write about that, but I don't even know where I would begin), and then off to the coffee shop to jam out on some experimental electronics, harmonica and uke' music.

Our actual "classes" seem to have become perfunctory. As much as I adore the instructors, I don't get much out of powerpoint slideshow presentations that take an hour to deliver information I can get in minutes by reading. I slept through the lecture this morning, not being able to sleep the night before made it necessary to spend that extra hour or three in bed. Since I missed lab last week, I dragged myself out of bed to make it for Lab (which counts as clinical time, even though it's just additional lecture time), which was canceled today...because of that useless metrology test, supposedly. It seems like the point of our academic psych content is just to get us used to the idea that mentally ill people exist, and that you aren't going to catch it from them like an infection. Valuable insight, I suppose, if you were lacking it. The psychopharmacology content is moderately interesting (since psychopharmacology got me interested in these matters initially), but also frustrating, since the methods of action of many of the agents is poorly understood. The side effects and adverse reactions of psych meds are obviously very important to know, though, and I'm glad it's included in our curriculum. Maybe I'm just bored because I learned about these meds back in the group-home.

2.04.2008

Five of Diamonds

Today was our first patient contact day in medium security forensic nursing. Our cohort of 8 split up into four groups (all the men were separated, of course) and checked in to four different units in the building. In the hallway between units, a xeroxed sign hung on the door. It read "Due to increased acuity..." and then a bit I can't remember now. Due to increased acuity something. You'd think that would be an important thing to take note of, eh?

Our instructors introduced us first to the unit's head nurse, a cute young RN from Jamaca. She selected a couple patients that she thought would agree to talk to us, and who aren't currently decompensating or in crisis. The other student and I hefted our charts and started perusing (a word that, you might be interested to know, means to examine in detail, not to browse quickly).

Paper charts seem so weird to me. I've heard stories of the state's massive warehouse repositories full of old charts. These charts were massive, by med/surg standards. People's entire life stories, sometimes from birth, just like the instructor said. Reams of incomprehensible hand-written notes from psychologists, nurses, MDs and social workers. All the gory details.

The chart in front of me was for a male, very close to my age, hospitalized because of a long history of pedophilia and child molestation. As the instructor predicted, an equally long history of being abused as a child was present. I've seen classmates shake with anger and say some rather uncharitable things when faced with the hypothetical prospect of having to care for someone who had committed the crimes this person had, I suppose this is where a little detachment is healthy.

One thing in particular caught my attention in the chart, while examining assessments of ideation and fantasies, a comment was made that the patient "admits to masturbating regularly". No mention of inappropriate sexual behavior was made, just that the patient masturbates regularly, in private. He's a young adult male. We tend to do that. The word "admit" gave me pause, as if he were admitting to drug use or criminal urges.

I sat and talked to him for a while, he mostly talked about his involvement with the unit's steering committee and peer advocacy, where he would speak on behalf of fellow patients who are pleading for a loosening of restriction or progression in therapy. He had a "group" to go to and I asked if I could come with. He invited me along enthusiastically, saying it was an "open group", but the therapist asked me not to attend. It was something called "dialectical behavior therapy", which sounded to me just like group psychotherapy. They sat in the dark, I think because they couldn't find the television remote to turn the TV off, and couldn't just unplug it without powering everything else in the room off. That was the last I saw of him for the day.

While my classmate hid in the nursing station, I hung out in the day room and had long conversations with 5 or 6 other patients. I reversed my technique for these, having the conversation first and reviewing the chart afterward. Some interesting patterns emerged, notably the presence of..how did they put it..."fixation on female staff"...acting as a barrier to therapy. Another pattern was the prevalence of sexuality in their psychoses and conduct disorders, in ways that were more subtle and indirect than the first chart I reviewed. Nearly all charts and plans stressed the importance of the patient's involvement in their own treatment, and required it for therapeutic progression.

I spent most of my down-time (it was all down-time, really) hanging out in front of the nurses station, chatting with staff and passers-by. I met a British LPN, a lively older chap who went to great lengths to introduce me to patients and explain the procedures and routines. One of the other RNs was orienting to her first day there was well. She immigrated to this country from one of the scandinavian ones about six years ago, and just switched jobs from high-security forensic psych to the medium-security one I'm observing. She seemed bored by her work, after challenging the boards she jumped right into forensic nursing. I asked her how maximum-security compared to this, she shrugged and said it was mostly the same. The nurses I saw there passed medications and plowed through paperwork. Specialized members of the health care team were carrying out assessments, providing therapy and doing the bulk of the patient contact.

My classmate and I sat in on the morning Report, attended by a couple of nurses, an aide, a physician and a social worker. The physician seemed gravely worried about everything that was said, his bald head and rectangular glasses emphasizing his furrowed brow and concerned expression. Some quick notes were given about behaviors and medication adjustments, and then it was back to work.

While we were reviewing charts, a jolly, rotund physician sat next to us and quizzed us on gastrointestinal diagnoses. I nailed his questions about antibiotic-related psuedomembranous colitis, but he tripped me up when he asked me to name the three etiological agents typically responsible for diarrhea. Microbiology isn't my strong subject, mostly because I had a miserable teacher for it. Salmonella, campylobacter jejuni and....crap, forgot the third one already. He smiled smugly and told me "don't worry, that's post-graduate stuff". Meh. If you say so. I still should have known it.

Out in the unit, a large bearded hispanic man with wild eyes walked back and forth. Obviously psychotic, with unintelligible speech, disorganized movements, sometimes a dance step or two. Smiled at us a lot, seemed quite pleasant, actually. I nodded and smiled whenever he went by. Eventually, he squared himself in front of me, and rather than speaking unintelligibly, said quite clearly "wanna pick a card?". I responded affirmatively and he motioned for me to follow him. Mindful of our instructor's warnings, I didn't follow him into his room, but took the opportunity to take a peek inside. The furniture reminded me of the furniture we had in the dorms at our state university, a comparison I would have been considerably less amused with while I was a student there. He returned with a deck of rider playing cards. He bent forward at the waist, painstakingly moving the cards from one pile to another with his thumbs, leaning forward all the time. Instinctively, I repositioned my feet just in case he fell towards me. I wouldn't have been able to hold him up, but I could at least help him land softly. Just when I thought he was about to topple into me, he snatched a card out of his thumb-shuffle, and held it so neither of us could see it. With a huge grin and a flourish, he flipped the card over. That was the trick. He started to go back to his room, but came back when I asked him if I could pick a card, His impossibly broad grin got even broader. I chose the Five of Diamonds.

Having been a bit of a cartomancer in the past, I couldn't help but think of it's meaning.

* HARD TIMES
* ILL HEALTH
* REJECTION


"The two figures on the Five of Pentacles are cold, hungry, tired, sick and poor. They show us what it feels like to be without - to lack the basic ingredients of life. This is the specter that haunts so many in our world - a reality that is all too immediate. Those of us who are more fortunate may not have experienced this extreme, but we still recognize suffering. When we do not have what we want and need, it hurts.

In readings, the Five of Pentacles can represent several kinds of lack. First, there is poor health. It is hard to tackle life's challenges when we do not have our vitality and strength. This card can be a signal that you are neglecting the needs of your body. You are moving away from complete physical well-being, so you must take steps to discover and correct the problem.

This card can also be a sign of material and economic setbacks. There is no doubt that life is harder when we lack money or a decent job. When we are struggling to make ends meet, all other problems are magnified. Even if we are comfortable, we can still feel insecure, afraid that misfortune will take away all that we have worked for.

The Five of Pentacles can also represent rejection or lack of acceptance. We are social animals and feel pain when excluded from our group. We want to be included, not only for our emotional well-being, but also for mutual support. Being rejected can mean physical hardship as well.

The Five of Pentacles relates to material lack, but it also has a spiritual component. From the stained glass window, we can guess that these two figures are outside of a church. Comfort is so close at hand, but they fail to see it. The church symbolizes our spirits which are perfect and whole in every way. We are meant to enjoy abundance in all areas of life, but sometimes we forget that this is our birthright. Whenever you experience hardship, know that it is only temporary. Look for the spiritual center that will take you in and give you shelter."



I think I may rely on this fellow for oracular guidance from time to time, at least for the remaining 32 hours or so of this rotation.


At lunchtime we brought our food to the basement of the unit and watched Sling Blade for the rest of the day. I hadn't seen it. It wasn't bad, but I couldn't help but think our time might have been better spent in the milieu, even if most of the patients were participating in vocational rehabilitation at the time. I should be thankful for the easy clinical time, but I can't shake the feeling that I'm slacking off, even if in a structured, approved manner.

2.01.2008

A New Site

Yesterday was orientation for my last acute med/surg rotation before I graduate. First semester was in a small private hospital, the next two were in a large community hospital, and this semester is in a large private hospital. Although the faculty claim to take geographical location into account when assigning clinical rotations, I've never driven less than 40 minutes to a site, even though there are two within 20 minutes of me. I can't complain, really, it's worked out well this way. I'm excited about this new hospital. I was so impressed with the Cerner computerized charting and medication administration record I applied for a job on the spot, during our computer training. I finished this training long before anyone else, even the students who had been here in previous semesters. I always get bored in those computer training situations. I couldn't suppress a squeak of glee when I saw the automatically generated fluid input/output graphs, and nearly lept out of my seat when I saw the ad-hoc charting interface. I decided I wanted to work there purely based on their computerized charting. The last site I worked at had a crummy application developed in-house, and the only feature that was being used was the bar-code medication charting. The one before that used paper. For everything.

Hopefully some day I'll be able to capitalize on the fact that I can function as a "superuser" (a peer that answers questions and trains peers on use of the IT resources) in a clinical setting after about a tenth as much time spent in training. After training a bunch of elderly secretaries to use the Office suite, everything else is cake.

Unlike my psych orientation, this orientation actually included a tour of the unit we'll be on. I like it. It's arranged in a torus shape, with the nurses' station in the center. Half are single-bed rooms, the other half are doubles. It's a relatively small unit, compared to other med/surg units I've been on, so we'll all be working closely. They use a lot more symbols on the door than other places I've been, there are different symbols hung on the door to signify DNR, various types of precautions, neutropenia, same-name and a bunch of other things. In the back of the unit are a couple pediatric rooms and a treatment room. We're told the treatment room doesn't get used much, you can bet I'll say something if someone tries an invasive treatment on a pediatric patient in their bed next to an empty treatment room (children sleep better if you don't try to stick things in them in the bed they'll be sleeping in).

The instructor is going to be a delight to work with, I can tell. She's energetic, focused and keeps current. I'm told she has high expectations, but she's also flexible and fair. One of the things I have to prepare for my first shift on that unit is a notes sheet for organizing care for the patients. At the last site I just printed out the orders and medication sheets for each of the patients and jotted down notes in the margins. No more of that! I have to come up with my own one-page chart for planning each day, since we're not supposed to rely on printouts. Since all of the charting is done on computers here, that shouldn't be too much of a problem.

I think the thing that we were most thrilled about was the end of the CDF. The CDF (clinical data form) was a monstrous 17-20 page stack of sloppily arranged spreadsheets that we had to populate with data from our clinical experience that week. All the meds, all the relevant interactions and side effects, all the assessments, care plans, functional health patterns, you name it. It's good that they had us go over all of those things, but it represented 3 or 4 hours of grueling look-up and data-entry (some of my peers were spending 12-15 hours a week on this!). Last semester we used a slightly condensed form that relied a little more on narrative. This semester, we write journal entries! Woohoo! We still have to present all the relevant data, but we can present it in a free-form manner. Our CDFs were only really scrutinized in our first two semesters, but I have a feeling our instructor is the type that actually reads everything we send her. Here's hopin', anyway. I like feedback (even the squealy amplifier type).

At the end of the semester I have to do a peer-teaching project, on a subject of my choosing. I'm drawing a blank on what to do it on, I'll have to keep an eye on the newsfeeds for ideas. It will be hard to plan for even with a topic, since I won't know ahead of time what room it will be in, or what kinds of facilities will be available. I enjoy this kind of thing, my case study presentation and lecture on the benefits of meditation in chronic illness went over well so I'll have to go out with a bang.

For our trends and issues class, we have to develop a group response to a question each week, and post it in a discussion forum specially designated for that assignment. For reasons I can't begin to comprehend, my classmates want to do the discussion in private, through email and person, and then only post the finished product in the discussion board. It's called a discussion board..shouldn't that be a clue? It seems like computers and nursing are mutually exclusive in a lot of cases, just like nursing and politics (beyond office-politics, which are excessive). Maybe it's the reading speed, maybe it's the typing speed, but the message forum format is definitely alien to a lot of my classmates. Maybe the message-forum format is familiar but learning through dialectic instead of lecture is alien. Who knows. Someone mentioned to me once that learning through dialectic is considered to be a feature of the study of Medicine, so why not Nursing as well? The answer to that question is probably the answer to a lot of questions that irritate me. Tradition. Habit. Convention.