3.29.2008

Convention

I'm in a hotel room in Grapevine, TX. I originally intended to blog every day about my experiences here, but things have been so busy I literally haven't had time to sit down and post! There's so much to write about I'll probably have to continue to remember it all over the next week or so. I lost my camera on the way here, it really was an excellent camera, one of my prized possessions. My plan of making a sort of video documentary of vignettes was smashed before I even got on the plane. Not having a camera on this trip pained me deeply. I took some pictures with my new PDA phone. I haven't examined them, but I can tell I won't be very happy with the quality (2-megapixel just don't cut it nowadays)

The bits that are hardest for my memory to hold on to I'll address first.

One of the highlights of this trip for me has been spending time with our new SNA faculty adviser, one of my previous clinical instructors, an MSN with 20+ years of critical care experience along with an education in management. Our previous advisor's taken a new job away from school, and our new advisor's first activity with us has been this trip. We discussed many interesting things that I want to record here so I don't forget about them.

One of the big problems facing nursing right now, as she sees it, is the folding in of administrative management duties into nursing. The Charge Nurse used to have a much different function than they do today. In the past, charge nurses and head nurses had a role that was more closely related to clinical leadership, supporting the nurses on the unit instead of working out schedules and sick-days. "No one is in charge anymore", is what she said. Something the conversation made me think of is that these administrative roles like "assistant nurse manager" and the like could be transplanted to the hierarchy that includes the Health Unit Coordinators (specialized, hard-core secretary types that any unit would explode without), freeing up the nurses to use their managerial powers for clinical leadership and patient care. She was trained in a diploma program, where towards the end she was passing meds and doing assessments and treatments for 20+ patients, with the support of the clinical leadership of the other nurses at her facility.

She told me that I could be really valuable to the profession as a Nurse Informaticist, partially because I have a computer science engineering background and am generally handy with computers. I replied that I'd been in the software development / system administration game before, and it's not really work that I enjoy. I think I can use my knowledge of computers to advocate for sensible technology use no matter what kind of nurse I am. I want my work to be satisfying and inspiring, and tending to the bit-buckets is not that (to me, anyway).

One of the resolutions that we're voting on tomorrow (I mean...today!) is in support of lobbying for the creation of an Office of the National Nurse. The presidents of the American nurses association AND the national league for nursing showed up at the informal resolution hearings to speak against it. I never saw so many camera flashes go off at one of these house of delegates meetings. They only had three minutes to speak, so I asked our adviser to clarify for me what their problem with this was. Apparently, instituting an office of the national nurse would -replace- all of the federal nurse offices that do a lot of good, targeted work with one figurehead who would have less influence and power. The supporters of the resolution think it's important to have a "visible" figurehead to advocate for nursing nationally, but I think most of us would agree that it's more important to get things done. After the presidents of the ANA and NLN spoke, a number of students were furious that non-NSNA members were participating in the debate, and calling points of order to follow the rules for business meetings that limited the speakers to NSNA members. What they failed to realize (because they were ignorant of the RULES) was that these hearings were informal, and although they shared the parliamentary format they were not, in fact, business meetings. People got angry and argued against their presence there because they didn't understand that their advisory roles in our organization are important so they can do exactly what they did. Clue the people who need it in on the "big picture" of how things work in the "real world". I didn't get a chance to meet them, maybe I will tomorrow.

Getting things done is the thing, isn't it?

The resolution I co-authored passed (yay!), in support of the inclusion of the preceptor model in nursing education for RN students. I think the main reason it passed was the positive experiences students in other states have had with preceptorship programs (of course, our research, writing, presentation and campaigning had a lot to do with it as well). Not all students did have positive experiences, but the actual implementation is something that's left up to each state anyway, one important lesson I took away from the process this time around is that the more specific your proposed interventions are in your "resolved" statements, the more things people will have to nitpick and debate with you over. Our adviser pointed out that the "whys and wherefores" are things for the faculty and hospital to figure out, as students we're advocating for advances in nursing education, let the nurse educators themselves figure out the best way to actually do it!

One line was removed from our resolution by a motion from the floor, the line that resolved to work with our constituents to include preceptorship for student RNs in the nursing practice acts of each state. Apparently the big problem with this is that the American Medical Association is trying to get their paws into our practice acts to reduce the independence of Nurse Practitioners. No-effing-bueno! I was incensed when I heard this. How can the AMA hold OUR practice acts hostage? Because they have the cash. Since they have the cash, they can hire the lobbyists with the connections to get the language they want put in the acts. How come they have the cash and we don't? Well, Nurses all belong to professional organizations that are specific to their specialty. Emergency nursing, nephrology nursing, wound-and-ostomy-care nursing, you name it. These are all great professional organizations that do important things, but as a result of all of this diffusion, a small percentage of nurses are dues paying members of one of the FOUR (!) national professional organizations for Nurses in general. Since there are so few dues paying members, and they're spread out between numerous organizations, we can't hire the lobbyists to compete with the AMA. My question for our adviser then was that why can't we, as nurse advocates, lobby directly for our causes? One of the more politically savvy students pointed out that it's illegal to lobby for your own organization. I snickered and supposed aloud that it was the lobbyists themselves who created that situation for their own benefit. The question in my mind, though, is if this diffuse nature of the nursing professional organizations can be used to our advantage, by having nurses from one professional organization lobby on behalf of another whose views they share. Where the lobbyists still have the edge, unfortunately, seems to be in "having connections". What a crappy system. So, nurses are paranoid about opening their nursing practice acts because of the kinds of language wealthier and better organized professional organizations of non-nurses could and would ram down our throats for the sake of their wallets instead of the patients. For shame, docs, for shame.

Our current president (until tomorrow when we vote in a new one..or rather later when they actually assume office) told us a story at the opening meeting of the house of delegates. She had to correct a medical interne's understanding of a physiological process. He received the tutoring gratefully and said "wow, you should really go to medical school!". She shot back with "you really should NOT go to nursing school". Hah! I like her, she's sassy.

During the candidates forum, she asked one of the presidential candidates to explain what his fiduciary responsibilities would be as the NSNA president. He asked for a definition of "fiduciary". She shot back with "I just asked YOU for the definition". Classic.

I spent a lot of my time helping out delegates and authors attached to resolutions that I wanted to see pass but didn't. One woman spoke eloquently and passionately about the need to reduce noise levels in the hospital, citing some alarming statistics about the decibel levels at night and during the day in med/surg and ICU environments. Having some acoustical engineering background, I felt compelled to jump into the debate. Her problem was that she included a number of specific ideas in the resolved statements for how to decrease noise. This wasn't necessary, this is something industrial psychologists and biomedical engineers need to hash out, we just need to tell them "hey, this is a problem, these people are dying from lack of sleep, do something about it!". I gave her some advice on how to rewrite the resolution, and also discovered she didn't understand much about parliamentary procedure, so I explained to her how she could get someone who voted against it to file a motion to reconsider at the next business meeting, and even hooked her up with delegates who voted against it so she could show them the revised language. I hope she makes it. I'm not a big fan of florence nightingale (for many years she was a strong proponent of excluding men from the nursing profession, and I trace a lot of the tradition-as-sickness we experience as a profession straight back to her and people who overvalue tradition), but the quote she included about how unnecessary noise is the cruelest failure of Care for the sick and the well, or something like that, was powerful and appropriate.

I even got a chance to utilize one of the more entertaining motions, rising to a point of order (calling attention to a breach of the rules). You can interrupt the speaker by doing this, just like you can with calling for a division (forcing a counted vote instead of a voice-vote), which I did for our resolution last year. My point of order was that one of the other students (who clearly didn't read or understand our resolution, because she got -all- of the facts wrong and was clearly only speaking on impulse and emotion) was debating a WHEREAS statement, something that is explicitly forbidden, since whereas statements are facts that have been supported by our research, reviewed by the resolutions committee and accepted. Many other debaters debated WHEREAS statements during these proceedings, and I'm kicking myself for not calling attention to it earlier. I think the president and resolution chair dropped the ball in a big way by not interrupting speakers when they did this. I actually did this by mistake last year and was interrupted by the previous president. A learning experience to be sure!

As usual, people came up to me to thank me and compliment me on my speaking. I don't think I spoke as well this time around as I did last year. I think the resolutions I debated last year were things that I was better prepared to speak to extemporaneously, I was just...."off" this time around. Still, I accomplished my goals and impressed a few people along the way just the same. Lots of the people I talked to thought I was a legislation education official or something like that. "No, just a school president", I'd say. Another student voiced something I would only think to myself after one of these incidents: "No, just someone who read the business book".

Seriously, people. There are rules. They tell you them. They print them out and give them to you, and expect you to read them. So read them! One of the delegates from a large constituency came up to me after my initial presentation and asked me for information that we included with our research to support the whereas statements. When I directed him to inspect the research that's been available in the resolutions office this -whole time-, he actually said to me "I don't -want- to read the research, just tell me". He admonished me by saying I should find it very difficult to get my resolution passed. Turns out, it was easy as pie. Much less of a nailbiter than our last resolution about education articulation programs.

I made a lot of friends and exchanged a lot of contact info, mostly with people who feel like I have "got it together" (how poorly they know me!) and would be helpful to them in writing and speaking on their behalf. I visited some of the caucuses, where state constituencies of delegates get together in conference rooms to go over resolutions and invite candidates to come speak in a smaller setting. This is where a lot of the politicking went on, which was interesting to see but also somewhat repulsive. I really enjoyed hanging out with the State officers from Arizona, I tagged along with them for a caucus and some late-night restaurant adventures. Good times were had and very dear friends were made. I must remember to visit Arizona sometime. Seriously. I will miss them.

What the caucuses pointed out to me was that my state constituency of delegates is relatively disorganized and ineffectual as a group, even though individuals (namely me), can still make some waves. Having an organized group in this process, though, carries a lot of advantages when getting deeper into the way things actually get done in the organization. We have some ideas as to how to address this. Interesting ideas.

Pictures to follow, stay tuned!

3.27.2008

Almost

This week's clinical focus was time management. This has been my albatross in the past few weeks, a lot of different variables have been coming together to challenge my time management abilities. I feel like I've made some headway in getting the information and materials together to improve my organization, shedding the clipboard was a step in the right direction for this, I think.

Unfortunately, this was not the med pass I should have executed, failing to check an ID bracelet spoiled what would have been, to me, a significant improvement in my process. I completed a tutor referral that was helpful, the tutor is really good at drilling skills and thought processes in a way that doesn't seem repetitive. It took 40 minutes (the same amount of time as my last aberrant med-pass), and I walked out of it feeling much more confident about some of the neuromuscular tasks that trip me up. She suggested I come back and continue practicing and I intend to do so.

On to the patients. When I first gathered the data on my charges, I was intimidated by the lengthy histories and home medication regimens I found in the charts, but I feel that I was able to apply that information towards focused assessments and interventions.

Patient X was experiencing a small bowel obstruction. I learned in report that this problem could have been avoided by continuing her prescribed bowl regimen medications. She was an interesting person to have met. Although her history cited paranoia, hallucinations, depression, basically every psych diagnosis you could imagine, I found her a friendly person who advocates passionately for herself and other disabled people. She's a quadriplegic due to a C5-C7 spinal injury. Even still, she had enough control over her right hand to grasp and pull enough to reposition her body during my respiratory assessment. The placement of her supra-pubic urinary catheter was novel to me, it protruded from her umbilicus. This placement was optimal for her mobility in regards to urinary self-care. Her chemotherapy included two medications for muscle spasm I usually associate with Multiple Sclerosis, Neurontin and Baclofen. She exhibited generalized edema and a pronounced foot-drop. She was in an isolation room due to a MRSA infection of her bladder. Because of this, her supra-pubic catheter was clamped, and a foley was inserted to fully empty the bladder. My main concerns for her were multi fold: She needed to produce stool, which our administrations of laxatives seemed to be helping. Her bladder infection needed to be taken care of, which we addressed with IV antibiotics. Her immobility and edema placed her at heightened risk for skin breakdown, which we addressed by repositioning her body and transferring her from chair to bed via hoyer lift. She was much more modest than I'm used to seeing, and insisted that males were not present during her toileting. I supported her in this and enlisted the aid of the nearby PCTs, who were extremely helpful in walking me through the operation of the hoyer lift, which I've had few experiences with (although it seems pretty self-explanatory, working with them was extremely instructive in how to operate it gracefully). She is a nurse, I feel like I'm caring for more and more of them (us!) the longer I do this.

Patient Y was status-post thyroid lobectomy, performed earlier that day. She's in her mid 40's, and recovered nicely from the anesthesia. Early on in our time together I supplied her with some crackers (she was on a regular diet), which she promptly emitted. The RN administered IV Push Phenegran, which made her pleasantly (to her) sleepy. I encouraged the use of the incentive spirometer, she had a pretty decent respiratory effort at 1750ml. At first I was focused on assessing for hypocalcemia as an adverse effect of her procedure, mostly because I think assessing for chvostek and trousseau's sign is "really neat". What I failed to identify before reporting to the instructor was the importance of assessing for laryngeal edema. Key thing to know!! Mindful of the dressed wound on her neck, I did pay close attention to her respirations as she dozed from the effects of the antiemetic, and I'm confident that if I heard stridor, I would have immediately connected what the problem was. Still, it's vital that I remain aware of these things even when they aren't actively going wrong. The antiemetic enabled her to take in some nutrition, but not as much as I would have liked. She ambulated to the bathroom without noticeable weakness or dizziness. She had a JP drain that collected 20mls of sanguineous drainage.

Patient Z had two embolectomies in the femoral artery of the right leg. Her dressings were clean and intact, without drainage. Her history cited dementia and a long list of cardiac abnormalities, so I took care to listen carefully to her heart sounds, which I was simultaneously relieved and disappointed to find completely normal. She didn't seem like the typical "demented" elderly patient while interacting with her. When I gave her time to talk to me, she reminisced at length about her children, her dead husband, and happy memories of their family vacations. She did seem to exhibit some of the memory problems cited in the history, but no more so than "neurologically typical" people I normally encounter outside the hospital. I sat and listened to her so long that I lost track of time, she recounted her experiences in an extremely lucid and articulate way, and yet couldn't reproduce some of the basic information I asked for during my neuro assessments. My care for her included my most grievous error during this med-pass, maybe ever. She recently had a GI-bleed, her PTT was over 100, and her coumadin was discontinued in favor of a heparin drip. I replaced this bag without checking her ID bag. I spent a lot of time talking to her about her concerns about the retirement community she was accepted into after three years of waiting, and her fears that she may now be too sick to live there.

Things are coming together. Much slower than they should be, and with ridiculously stupid errors in the meantime, but I feel like I'm making progress. Abstaining from coffee and bringing a protein shake and frozen dinner made a positive impact. Despite the error, I feel like I've made a positive gain in not letting a mistake ruin my game later on, not letting my disappointment in myself distract me from continuing the job. I can do this.

3.25.2008

third time's almost the charm

I drove 400 miles today, and then attended clinical practicum. Official entry to follow. I -almost- made it. I stupidly forgot to check a patient's armband before hanging a new heparin drip. Catastrophic. Nothing bad happened as a result, but I'm way to far along to be making these newbie mistakes, and I'm on notice that next time I screw up one of the "five rights" the consequences will be severe. Rightfully so, most medication errors (from what I hear) can be traced directly back to seemingly innocuous lapses like these. If it werent for that one little thing, the day would have been more or less perfect. I actually left feeling pretty good about the day, despite the berating I got for that one element of the med-pass. I got everything done on-time, and even had enough free time to float around and help the PCTs with some challenging care.

In 24 hours or so I'll be at the NSNA (national student nurse's association) convention in grapevine, TX. Our school is putting forth a resolution, which I'm pretty excited about. Last semester I debated fiercely for our school's resolution (which passed) as well as several others (many of which passed), and got a lot of positive feedback on my empty-handed, extemporaneous debating style. This semester the resolution on the debating block is mah baby (well, -our- baby, factoring in the co-author), so you know I'll be pulling out all the stops.

I'm looking forward to the vacation, these conferences have been valuable opportunities to decompress and enjoy myself (it must be some indication of how locked-in I am that talking about and listening to people talk about nursing passes for "fun" with me). Also, simply, I enjoy traveling, and having a purpose or destination is helpful but not required.

Any other nursing students going to be there? Depending on where you're reading this, there may be a button nearby that anonymously links to my cellphone.


The end of nursing school seems to be chock full of gala events, social calls and networking. Maybe it just seems that way to me, who draws these things about me out of habit. I downloaded an NCLEX-RN review program to my PDA/Cellphone, it's been an entertaining way to pass the time in those empty moments. The questions all seem so easy, though, I hope the real boards are that easy! It seems like my program is doing a good job to prepare me academically for the Boards, but clinically...I dunno..twice a week just isn't enough, and practicing in three hospitals during four semesters is harder than I thought it would be.


My luggage for this trip, like with all trips, is measured in processing power instead of kilograms. I just don't feel like I'm prepared if I'm not carrying enough hardware to render at least 97 trillion triangles-per-second. My laptop, my PPC-phone and my goban are all I need, the clothing and toiletries are an afterthought. Every time I travel, I teach Go to at least one person.

Go is a game over which strangers can instantly become friends, through which paltry concerns such as age, race and creed dissolve in the presence of the Unknowable.

Will you play Go with me?

3.21.2008

How geeky?

This geeky. Behold, my "information literacy assignment" busywork. It's meant to be an annotated bibliography, since apparently associate degree nursing students can't be bothered with proper academic papers. Ah well. I suppose I'll have plenty of opportunities to do actual research in graduate school.

Simpson, R.L. (2007). INCP: the language of worldwide nursing. Nursing Management, 38(2), 15, 18.
This article introduces the combinatorial taxonomy created by the INCP, and goes into some of the history of the organization and it's effort to establish a unified, non-enumerated nursing diagnostic taxonomy. It focuses on the benefit and necessity of an international diagnostic standard, but does not discuss it's combinatorial vs. enumerated nature at length.

Bales, M. E., Johnson, S. B., & Lussier, Y. A. (2007). Topological analysis of large-scale biomedical terminology structures. Journal of the American Medical Informatics Association, Nov-Dec; 14(6), 788-797.
This study compares several controlled terminologies gleaned from the Unified Medical Language System Metathesaurus and evaluates them for flexibility and growth potential. It concludes that some of the most effective controlled terminologies are indistinguishable from natural language networks. This is crucial research into the development of scalable terminologies, as it deepens understanding of how logic-based rule sets can evolve and change similarly to social networks and biological systems.

Mrayyan, M. T. (2005). The influence of standardized language on nurses' autonomy. Journal of Nursing Management, 13(3), 238-241.
This article discusses some of the ways in which standardized language systems add to or detract from nurses' autonomy. It concludes that mastery of the standardized language equates to mastery over nursing practice, and suggests that nurses master their standardized languages, whatever they may be, to increase their autonomy.

Hardiker, N. R., & Rector, A. L. (2001). Structural validation of nursing terminologies. Journal of the American Medical Informatics Association, May-Jun; 8(3), 212-221.
This research article is an experiment in using the ICNP to generate diagnoses that are already present in the NANDA. It was an interesting measure of the accuracy and completeness of this prototypical combinatorial nursing diagnosis taxonomy. It suggests that combinatorial taxonomies may be useful in automatically generating enumerated diagnostic taxonomies (like NANDA) on-the-fly, with the aim of refining and validating both techniques.

Henry, S. B., Moen, A., & Warren, J. J. (1999). Representing nursing judgements in the electronic health record. Journal of Advanced Nursing, 30(4), 990-997.
This article is a review of the progress made as NANDA and the ICNP evolve through multiple versions. It corelates these changes with suggestions by the Computer-based Patient Record Institute. It notes that improvements need to be made in granularity (depth and detail). Like many of the other articles, it suggests that the different approaches continue to refine and compliment each-other rather than becoming a replacement.


Button, P., Henry, S. B., Lange, L., & Warren, J. J. (1998). A review of major nursing vocabularies and the extent to which they have the characteristics required for implementation in computer-based systems: focus on implementation of nursing vocabularies in systems. Journal of the American Medical Informatics Association, Jul-Aug; 5(4), 321-328.
This article compares NANDA and the ICNP with the Home Health Care classification system, the Omaha System, the Nursing Interventions Classification and the Nursing Outcomes classification to determine their suitability for implementation in computer-based systems. None of the systems analyzed met the following criteria. Clear and non-redundant representation of concepts, administrative cross-references, syntax and grammar, synonyms, uncertainty, context-free identifiers and language independence. Looks like nursing diagnosis taxonomies, enumerated or combinatorial, still have a long way to go!

Reorientation

I had my make-up day at the mental hospital this week. One other student from my cohort was with me, and we were joined by one additional student from another cohort who missed her orientation day.

During our customary leisurely breakfast and decompression session, I exchanged greetings with two of the patients I've met already during the observational experience. It was nice to feel appreciated and recognized there already, even though I haven't provided any care as an RN. I got some useful ideas from the instructor about what to focus on for my peer-teaching project on neuro-linguistic programming, something that's been on the back-burner because of all of the other chores I have to attend to.

On our walk over to the medium-security forensics unit that had been our clinical "home" for the first month of the semester, another familiar face made an appearance, to "break in" the newcomer through a series of bawdy jokes, as is his custom.

While the new student toured the medium-security forensic unit, my classmate and I reported to an area of the unit neither of us had been to before. This unit was different than the other ones we've been to in that no one here had a level of restriction that allowed them to traverse the grounds of the hospital unescorted.

After briefly introducing ourselves to the RNs on the unit (who were busily attending to the paperwork required for medication order renewals and doctors appointments), we were almost immediately set upon by the patient "ambassador" of the unit, someone who appeared to be self-selected as the one who talks to the students. We spent our entire time in this unit talking to this patient in the "sun porch" area of the day room. He said that the other occupants of this unit wouldn't be comfortable talking to students, but I wonder how much truth there was to this. Personally I would have liked to mingle with the unit as a whole, but this patient had a lot to say and talk about, so I settled in for a long conversation.

This patient was in a film recorded at the hospital, a film about living with schizophrenia. It's required viewing for new-hires. I found this interesting, since I've been playing around with the idea of filming similar video-content, except story driven and focused on the providers of care in addition to the consumers of health care. His commitment to the hospital had ended, but he expressed a desire to remain in the hospital. Not only that, he was not interested in decreasing his level of restriction at all. He told us about advocacy unlimited, but was somewhat cagey as to what exactly he did for that organization.

While he was talking to us, he answered a question that wasn't even asked until later. It's the same answer I hear from everyone who's a consumer of mental health services. It's the answer to the question "what can I do to be a good nurse for someone like you?" whether that's in the milieu, the community or the hospital. It's a question my classmates ask reflexively, whenever we're given the chance. The response always seems to come down to the same things:

Treat us with respect,
Be humane, and
remember to smile.

After our conversation there, we took a tour of the maximum-security forensic unit, where our instructor worked. It was an interesting tour, we saw the instructor exchange warm greetings with patients and staff, and I even ran into someone I took anatomy & physiology with back before I was accepted into the nursing program. One of the RNs there graduated from my program last year, suggesting that although they -say- you need a year of general psych experience before switching to forensics, this is not always the case.

Our first stop after the security-bubble was a restraint room, where a staff member observed a patient through a window. I snuck a peek, even though I internally chided myself for not respecting the patient's privacy. Inside the room, a very large, very fit man was lying in a bed in four-point restraints, not moving at all. One of the other students mentioned how big he was, the instructor observed that he's also very difficult to wrestle. I'll bet! It made me wonder how much more difficult it is to manage restraints for someone with a seizure disorder. The restraint room definately sent us a message that we were in a very different environment from medium-security. The most restrictive level of restraint I saw there was seclusion, in which one of the patients was given a dark, quiet room with a mattress and blankets to rest in for a while.

I think that if I were to work in that environment, I should prioritize taking Aikido lessons, something I had been mulling for a while but conflicted with my school schedule. Taking Judo as a youth gave me a good foundation of how to manage people kinetically without injuring them, something that was built upon by the "physical management techniques" training I got while working in the group home for adults with MR/Autism. The instructor told a story about a particularly violent day on the unit that resulted in about..what was it..9 staff members carried out in stretchers with various injuries. When the dust settled and order was restored, the patient was completely unharmed, save for a tear in their pants. It really spoke to the professionalism of those mental health workers. I've seen enough punitive retribution against patients (in other settings) to be impressed with their restraint and professionalism. So, Judo is good for reducing the effect of variables like speed, strength and size on physical management outcomes, but it still involves "attack" and "defense". What I like about Aikido is that it's purely defensive. Demonstrations I've seen on video are highly entertaining, and feature things like 5-7 people attacking the demonstrator, only to have all of their arms tangled together, and then gently scooped up and laid to rest on the floor.

I don't mean to belabor the physical management side of things, I just think Aikido might come in handy some day, wherever I end up. It's far more important, of course, to de-escalate situations before violence occurs. Our academic work points to setting firm limits as a key measure to take, but doesn't get too much in depth after that, I suppose more specialized training awaits in the field.

One of the patients in maximum-security exchanged greetings with our instructor, and described "some difficulty" he had been having with his sore throat. He went on to explain something (my memory is fuzzy here) about being worried about the presence (or potential presence) of police, and was concerned some harm could come to us. He seemed to deflate when he said this, leaned against the wall, and seemed for a moment to be immeasurably sad. The instructor thanked him for his concern, and commented on how nice it was of him to be concerned about us.

What I appreciate the most about having the opportunity to observe these interactions in this setting is the degree to which our instructor models "mental health". In trying to explain this to people I get a lot of resistance, most commonly in the form of the idea that "mental health" is highly subjective and can take a lot of different forms. This may be true, but perhaps the difference is easier to notice when you're around people who are severely ill. Perhaps "mental health" is too broad or loaded a term. "Adaptive behaviors" might fit the bill better. The simple power of a greeting, active listening, showing concern, rephrasing, etc are all easy to overlook when it's written down on paper, but when actually practiced leads to effective and compassionate teaching. This reminds me of the "synergistic" model of nursing education I read about briefly in preparing the NSNA resolution..on some level, the way we teach our patients is the same way we teach our students and our peers. It also reminded me once again of the relationship between nursing and psychotherapy, in that it's easier to learn it by having it done to you than it is to approach it from a purely intellectual standpoint.

I've transitioned from being actively ambivalent about working at this facility to being somewhat optimistic and excited. It's still the only place that seems to be interested in hiring me, I just need to make sure I take steps to keep my clinical skills up, regardless of which unit I get hired into.

3.17.2008

Inroads, crossroads

Im having one of what I'm sure will be many professional development conundrums, maybe you can help:

My goal is to get into critical care (ED or ICU), but I need to get into a med/surg unit for a couple years until I take on that kind of challenge. The local hospitals are all either extremely competative for Graduate Nurse positions, or else I don't fit in with their local "culture" and get catty/evasive responses from HR drones. I feel I should point out that I personally think I'm great at interviewing, although in the past I've mainly interviewed for sales and engineering jobs.

Anyway, at the large state mental hospital that I've been writing about previously, it seems like RNs, instructors and administrators alike think I'd fit in great there and actively want me to work there. 50ish an hour. Boosh. I think I'd be great at it, and I think a lot of the computer skills I'll bring with me will really help out the RNs a great deal.

The thing is, the longer I spend in the Forensic Psych setting, it seems like I'll be getting further and further from my goal of critical care and DNP. I feel like I'm barely keeping my shiz together in acute med/surg clinicals as it is, and the problem is that I don't get enough -practice-. I can't pick this up doing it a couple times a week, with training wheels on. I need to be doing this every day to really pick up the skills I'm after. It doesn't seem like I'll get those in a forensic psych setting (or general psych, or even acute detox).

Still, There's valuable experience that I was planning on gaining in Psych at some point anyway, and if they really want me there right out of school, why fight it? Maybe its better this way, my classmates who are jumping right into the technically challenging nursing fields already have LPN or PCT experience, which I lack. Maybe this is just a way I can ease myself into practice.

I don't want to get stuck there, is the thing, and state forensic nursing jobs are sweet, sweet deals. Benefits, pay, vacation, any way you want to measure it, I'll be taking a Big Cut when I resume persuing my professional goals, which include Travel and trying out a lot of different fields (I'm a Synthesizer, at heart, it's true).

What I know for sure is that I can't do nothing, and if this is what I'm stuck with, I'll try to make the best of it.

What I need to know is how to leverage this into furthering my goals. If I took a per-diem med/surg job I think I'd have the same problem I'm having now in clinicals. A couple days a week isn't enough to really make the techniques and flow sink in for me. I really want to get certified as a paramedic anyway, maybe doing that while I'm a Psych RN will help build my assessment skills and prepare me for a critical-care RN role.

Thoughts? Criticisms?

3.16.2008

Sundown

I saw the video for this while i was in japan, on a particularly crummy evening. The sound in the place didn't match up, so I just figured there was another Daedelus. Nope, same one. Now that I'm listening to music again here or there I found my way back to this track:



And while I'm at it..



3.14.2008

Wit

I missed our classes viewing of "Wit" the other day, so instead of participating in the class discussion, I had to answer these questions, instead. Suits me fine.

Dr k is presented as the archetypal phd-md, detached the from the human element of his work. He makes the error of assuming that, since they were both professors, the protagonist would have the same cultural context for her condition. His interactions with vivian seem nearly inhuman from the audiences perspective. The rigours and requirements of research is something vivian links black to her own experiences in research. This commonality seemed to be central to vivian's decision to sacrifice the remainder of her life to the advancement of knowledge. Although dr k's behavior might seem monsterous, it is consistant with the relationship formed in the opening scene, a relationship of academic collegiality. The reminder here is not to treat personal tradegies as routine, even if they are to you.

The fellow has a similar yet opposite problem. He's inexperienced, but shares the same absorption into the complexity of the science. That's his job, but 'bedside manner' is not a priority for him. Despite his bungles, I think he accidently did a good thing when he shared his deep passion for his work with vivian, she saw her own passion for the great mysteries of life and death echoed bac to her from someone she taught. The end of the movie implies there may be hope for the fellow, as he finally admits he's made a mistake and advocates for his patient at the expense of his research.

Susie represents a rare, isolated presence in the scope of the movie. The fellow rags on her for not having a well rounded education, however she's the only one actually meeting vivians needs during the entire film. The two points of view come together here, and the interaction hit home to me, the teasing represents the struggle of these disparate facets of care provision to reconcile and learn from one another. The nurse could benefit from educational enrichment, while the fellow could use some grounding in immediate reality. The teasing masks veiled flirting, which offers hope that the human factor will cross pollinate te thinking towards improvement.

The ct guy represents the ultimate in non-care, leaving vivian in the scanning room while taking a break, detached from her care but also uncaring about it, treating it as an assembly line job.

To my mind, vivian agreed to the treatment so she could spend her death the same way she spent her life. Sacrificing the empty, playful moments of her life for the advancement of knowledge and scholarly rigor. We see her regrets, her passions and and her pride played out in her interactions with the healthcare team, where she satirizes her environment while appreciating the same paradoxes that interested her and motivated her throughout her life. Vivians own detachment subjects her to a withdrawn state that leads her to rely exclusively on her caregivers to determine what she needs. I can't say what lead to her decision to be DNR, besides the obvious rational analysis of her situation.

Vivian suffered losses of her work, which was her life. She found bits of it in her interactions of all of the health care team, the paradoxes, the jokes only apparent to her that we view through her experience. That gap is reunited in a scene where she shares a laugh with the nurse. Vivians needs were met in the sense that she was mentally prepared for what awaited her, but they weren't met by any external factor but the nurse that cared for her.

Dr k's communication techniques were discussed earlier, although ill add that his attitude towards the disease processes of his subjects, as maladaptive as it may be, represents an individual's attempt to model trancendent acceptance of the situation, the deficit lies in communicating this acceptance to the subject. The fellows interactions were mainly governed by inexperience and naivety, a level of which he can probably get away with as a researcher. Forgive me, but I dont remember who jason is.

'how are you feeling today' hit home, and its a reminder to be aware of how interactions that go unexamined can devolve into thoughtless routine.

Suzie's communication was unique in the film in that it was patient centered instead of disease centered, a dichotomy that is hyperbolized for clarity in the contrast between md-phds and nurses.


Dr kelegian sent off his fellow to conduct an assessment completely unprepared for his task. This tendancy of preparing students through trials by fire is not exclusive to medicine or research.

Just as the mangement of problems in general is focused on primary or preventative treatment, I think making sure the person communicating with the seriously ill or their families should endeavor to establish whatever rappot with the subject can be made in the time allowed.

Dr k should have been more up front about the chances of her treatment's success, but this is mitigated somewhat by the relationship he established with the patient initially, where she learned this information without it being explicitely said.

In caring for the terminally ill and their families, I feel its important to provide information and help the subjects meet their needs by asking questions and offering suggestions.

I think all of the elements in the dying patient's bill of rights are appropriate. They were not all expressed in vivians case by far, many of the people she dealt with did not provide compassionate care.

Advance directives provide a means for patients to exert control over what happens to them in the event they are deprived of the ability to make decisions. They are of fundamental importance to the human rght of self determination.

Objectively speaking, vivian would have been better off enjoying the time she has left rather than languishing in a hospital. Her decision, despite the suble presentation of her condition, was a choice she made and was willing to die with. Subjects for these experiments are self-selected, although if it was someone not as sarp as vivian they would have been mislead with false hope for a cure.

Im not sure what I would change about my care of the seriously ill. My impulse is to make them laugh, I hope the rest will come from experience.

3.12.2008

All Thumbs



This week our focus was Delegation, we discussed our experiences so far in delegating tasks to the PCTs on the unit, what's been working, what can use some improvement, and how to deal with problems as they arise. Just like last week, issues surrounding our clinical focus popped up throughout the day. I think I jinxed myself during our pre-clinical conference, by reflecting on the fact that I've had the same PCT assigned to my rooms during the last two weeks, and how we had a great working relationship.

Wouldn't you know it, I worked with a new PCT today, and problems arose I could have sidestepped by communicating with her better. I have to endeavor to come prepared for -positive- manifestations of our clinical foci, instead of looking back at the end of the week and saying "oh yeah, that's what went wrong!"

My main goal was still to get my meds in efficiently and on-time. Until I get this sorted out it doesn't seem reasonable or desirable to set additional goals (well, aside from making better use of the clinical foci).

Patient X is an elderly Italian woman who lives in an assisted living community. She was status-post open cholecystectomy. She had a T-Tube, which was placed in the bile duct. This allows for bile drainage as well as a means of introducing dye for diagnostic imaging. The T-Tube was clamped, and the JP drain was filling up with bile rather than the sero-sanguinous drainage I'm accustomed to seeing. I asked around about this, since I thought it was odd, all I could find out was that one doctor thought it was a Bad Thing and ordered the T-Tube unclamped, then the Surgeon informed the RNs that it was a Good Thing and ordered it clamped again. I asked if this meant that the bile duct was leaking into the wound (since that's where the JP drain is applying suction), but all I got were shrugs in response. She was extremely anxious, she attributed this to the death of her husband of 60 years. I saw many members of the team stop in to provide reassurance, hugs&kisses and orientation frequently. Since one of my patients was discontinued early in the shift, I spent a lot of time in this room doing the same. The RN told me it was a big help. Controlling her back pain was extremely challenging. Due to a near-fatal reaction to an analgesic administered elsewhere in the hospital, her pain coverage consisted of Tylanol and nothing else. She had some irritated skin on her spine, and after seeing how much pain removing the adhesive dressings caused her, I replaced them with non-stick telfa pads and tegaderms. That and application of warmth seemed to help. The RN described her as "the princess and the pea", but I still felt it important to take her reports of pain seriously. Near the end of the shift, she cried out in distress, and I found her making uncoordinated movements in bed, with the bedclothes strewn about. When I asked her what was wrong, she said that something was "very wrong with" her, she seemed to have the whole "impending doom" thing going on. History includes A-fib, palpitations and pulmonary fibrosis (and she was only drawing 100cc on the incentive spirometer), so my immediate concern was respiratory failure or cardiac abnormality. After a rapid assessment, I sat with her and held her hand until she went back to sleep. The reassuring findings were absence of cyanosis, baseline vital signs, good breath sounds and regular heart sounds that matched my last assessment of her. I really feel like I did a good job with this, stuck to my ABCs and was ready to get help if I noticed respiratory distress or abnormal assessment findings. Later I was told "impending doom" is an every night thing for her, and that she panics when prematurely roused. I would have done exactly the same thing every night, then. I think it might also have something to do with her nighttime Xanex (which was not administered by me), a combination of taking it before bed and being roused right while it should have been kicking in might have resulted in some confusion and dysphoria. She was discharged on the second day.

Patient Y was her neighbor, brought in for back pain and 3/6 pneumonia. This was my first "floridly" kyphotic patient, and controlling her back pain was also a challenge. She was also extremely depressed and withdrawn, and kept stating that my assessments were not necessary. I joked about it and got her to crack a smile a couple of times. Ambulating her was extremely difficult, watching the PCT helping her was instructive. What I learned about this was that it was necessary to actually provide forward momentum by gripping the clothing and pushing from behind, and then allowing the shuffling steps to catch up. Even after a solid span of time on an Ortho unit, I hadn't seen this technique. She stayed both days of my shifts, she should have left earlier, we felt, but she was waiting for an MRI and the machine was down. Like one of my patients last week, she was perturbed by the presence of multiple family members of her neighbor in the room. I reduced sensory stimulation by drawing the curtain, although she never expressed a preference for nearly everything I offered, except the warm compresses (which she liked). I asked her if the commode or the bedpan was easier on her (since I remember reading that the bedpan is generally harder on the patient), but she said it was about the same either way. On the second day with her, I walked in to find the day PCT assisting her to the commode. The PCT explained that she was a high fall risk and asked if I could stay with her until the patient was finished eliminating (it was past the end of her shift and I'm sure she was anxious to get moving). I explained that I still had to get report on two more patients and prepare to administer medications, and that I'd return soon. I made sure to let her know this in a friendly, non-confrontational manner.

Patient Z was in the process of being discharged when I arrived. He had a peritoneal abscess in his scrotum, and was also experiencing dementia and depression. He was just waiting for his ride when I met him. His RN was late getting to the unit due to the parking problems, so I focused my attention on Patients X and Y until I got report. When I did finally touch base with her I got the necessary info and carried out my assessments. I think she was perturbed that I hadn't found her sooner, but I didn't want to compromise the care of the two patients I did get report on, and Patient Z was still being cared for by the Day RN in the evening RN's absence.

Patient W was in for a Lap Choly, her big issue was nausea and dyspepsia. She didn't consume much nutrition, not because it was aggravating her stomach, but rather because the taste of the foods was too stimulating for her. She walked frequently and was mobilizing pulmonary secretions encouragingly. I noticed her breath sounds were diminished on the left but not the right, which makes sense since her JP drain and most of her abdominal pain were on the right side, and so she's been sleeping on the left.

Patient V had an open choly and a colostomy closure. She had a left-upper-lobectomy, so that was another interesting respiratory assessment for me. There was some confusion between me and her RN over whether or not we had to do a wet-to-dry dressing change, she had originally thought the dressing changes were ordered every shift, but when we examined the orders we saw that it was every day, and her dressing had been changed already in the ICU. There might have been a good argument for changing it again anyway, given the nature of the microbial profile of most ICUs but the RN and I decided to stick with the schedule in the orders. She had a caregiver with her, a nursing student, and she wanted to jump in for much of her care. I redirected her when she wanted to empty and record urinary output, but included her in appropriate aspects of Patient V's care, like helping her get changed and assisting with nutrition.

I'm still not meeting my goals. On the first day, I felt like I did really well, and got a lot of positive feedback from the RN. I passed a classmate in the hall and asked her why she was looking so down. She said she made a small mistake early on, and it snowballed into bigger mistakes due to anxiety and second-guessing. I had the same experience the next day, where it was my turn for meds. I started off early on gathering all of the things I would need for the day, and filled my pockets with NaCl flushes after noting the scheduled IV access flushes. When it came time to use them, I found that the plungers had all been depressed, and my leg was wet with saline. As funny as this seems to me after the fact, it threw me off for the rest of the day, even though it didn't directly impact anything else I did. Another thing I did poorly was, in adjusting to delegating vital signs to the PCTs, I didn't get the nessisary assessment data I needed for administering blood-pressure medications. To my credit, I realized this before attempting to make a serious medication error, but it added to the train wreck that was my second pass/pour at this facility. A combination of these things raised my anxiety to the point where I felt clumsy and stupid for most of the day.

Another factor continues to be my nutrition. I met with my cohabitants and worked out some solutions for arriving well-fed, and bringing food with me so I'm not dependent on the cafeteria or whatever stray carbs I can scavenge from the break room. My plan to deal with mistakes without allowing them to snowball into bigger ones is to cut down on the caffine. I drink coffee compulsively when I'm on the unit, and it's making me anxious and clumsy. I'm bringing tea next time. I do feel like I'm making progress with how I approach my organization for the day, and I think the Third time will be the charm. I'm going to make it a priority to track down the PCT and organize myself with them the same way I do with the staff RNs. I have changes to make to my organization sheet now, as well. My strategy so far has been to try a sheet that works for someone else, and then modify it based on my experience of using it for next week. I think I'm honing in on something that meshes with my thought process and penmanship.

Disheartening day / Different audience

Just got back from clinicals. Official post will follow tomorrow.

Today sucked. Yesterday was alright. It's the meds. I had this friggin' down last semester and the semester before that. I'm starting to wonder if trading my day shifts with a preceptor for night shifts with an instructor was a good idea (even with an amazing instructor).

I feel like I'm starting all over again. It's all about the organization. I'm making newbie mistakes left and right. Someone else in my cohort has had a similar experience, where one mistake snowballs into not getting anything done right. That's been both of my med passes so far. The instructor doesn't even bother asking me the pharmokinetics of the meds i'm passing, she knows (i think) that I already know them backwards and forwards. If she asked me what diovan or metoprolol or toradol or ceftriaxone or sucralfate or prinovil or pepcid -DO-, I could rattle off exactly what it does down to the cellular level. So far, she hasn't asked.

Getting them all adminsitered in an orderly matter has been beyond me these past two med-pours. I hate to blame it on the transition from having a preceptor to not having a preceptor, but that's definitely part of it. The other part is how my mental processes suddenly shit themselves when I have to simultaneously think independantly and take instruction. I ran into this two semesters ago, and I imagine i'll run into it again once I'm on Orientation at a facility as an RN (if i make it that far).

I think I'm running into a limit of my mental capacity that's bound by my nutrition. Both of these experiences have taken place under circumstances of nutritional deficit. This is the organization thing again. I recognized it last time, but didn't address it this time. Most of the things I do in a day I can do without having eaten, but not this. I have to take better care of myself. I think I'm just encountering tasks that require me to function normally, and I'm not used to that requirement. I only have 6 weeks left, not much time to get comfortable in the role of independent practitioner.

I'm sure the rest of my cohort thinks I look down on them, but I really do look up to them. I try to pry and agitate at the edges of where they silently tell me they could improve, and there's this overwhelming sense where if they could just give me what they have and I could give them what I have, we'd all be unstoppable.

It would be ironic if I ended up being good for nothing but Teaching. My ambition is to acquire a level of skill that I'm far, far away from...but I'm really good at sharing understanding, and breaking complex concepts down into easy to digest packets. I keep jumping ahead. I enjoy teaching, but I enjoy our work in our clinical practicum even more, so it disturbs me that I'm screwing it up. No matter what I do, I imagine I'll end up teaching in addition to Practicing as a nurse. The field could use some Male teachers, anyway, and some of our faculty are modeling success at teaching while practicing.

I have a lot of affection for our faculty members and my fellow students, every person, no matter how different from me they are, no matter how alien they seem, have something to show me that I deeply cherish. I think I sometimes show it in the wrong way...there's one other male in my cohort who's name starts with F that I called F-Bomb a couple of times. I thought it was clever, but he wasn't amused. With the rest it's mostly challenges to their habitual way of thought that strike me as ways to converge our two ways of thinking. Not always successful. Seems to be more successful when I tone it down a bit.

Less caffeine, more nutrition. That's what I gotta do. When these people see me, they see someone starved, crazy, and looking for a fight. Someone putting blocks together while they're consolidating complex structures. At the same time, I have many pieces to puzzles they're missing. Is it my fate to be the mad mystic? The socially isolated shaman?

I'll settle for having a job,

and I couldn't imagine better people to work beside.

3.10.2008

Gala




I went to a gala for my school the other day. I was notified of it at the last minute, and couldn't find anyone to come with me. I guess that happens. I hung out with some people, took some long car rides through apocalyptic rainfall, and documented some of it for your enjoyment. Observe:









These two are first-year students. Nice to know there'll be people to pick up where I left off!






This is one of my classmates. The group of people who are active in things is a small club, so we see each other often.




This is one of the prenursing students. I shoulda danced with her when I had the chance.



This was desert. Since I'm too lame to find a date, I got two of these. Small consolation.


This is me. Hi, me.




More pictures of my classmates



People talked a lot..Everyone stood up and then sat down. The guest of honor was referred to as a "goomba", which is a rather derrogatory way to refer to an italian american.



Then I went to the bar.

3.05.2008

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.

3.01.2008

Legacy

Something my friend and fellow health care blogger JackOfHares posted tied into something I posted previously.

What's the most elegant and cost-effective way you can think of to provide care for an elder who's one of your own? I'm not just talking about family, maybe a teacher, co-worker, friend, etc.

I'm approaching this question from the perspective of nursing, both because it's what I'm engaged in and they're the ones often charged with caring for the elderly.

So, how would you provide good nursing care to someone at home on the cheap?

Imagine, if you will, that you're a nursing instructor. You have a bunch of students and an elderly person who needs care at home. The students, due to the nature of the health care field, may have trouble finding a health care position before actually becoming licensed.

There's a natural fit, here. An instructor might hand-pick trusted students to care for this person at a lesser expense than hiring home health aides. The students can practice their assessments and the delivery of routine care (obviously they can't practice nursing or medicine without a license), and the elder benefits from enjoying the company of many different bright, young(ish) students to converse with and keep the mind active.

Thinking about this, it occured to me that this is, at least in theory, what's supposed to be happening on the medical/surgical units we tend to occupy during our clinical practicum. As far as hospital nurse/patient ratios, med/surg is pretty "bad", and they can always use the extra help the students bring to the floor. Better still, we can act pretty independantly so the staff RN's time can be used more efficiently. Of course, they still have to review all of our documentation, but if we can take, say, a lengthy wound-care procedure off their hands, they have more time to deal with the rest of their load.

So, someone's obviously had this idea before me. I love med/surg units because they have the potential to be so chaotic. To many of the people there, despite receiving excellent care, that unit is the worst place in the world to them. They may be dealing with stressfull news, painful wounds and/or diseases, and are too sick to go home, while also being too well to go to a specialty unit. The acuity is supposed to be low, but in reality it can fluctuate unpredictably. The RNs tend to be overburdened and stuck putting out fires, so when we actually have time to sit down with someone for 20 minutes and just keep them company, it can make a big difference to their level of consciousness, compliance and orientation to the therapeutic regimen.

I will be nice to students, when I'm a staff RN. Oh yes.

gave up

I played my first game of go against someone I've taught where I decided to decrease his handicap. Beau only lost by two (not counting komi), so he's going from a nine-stone handicap to eight.



While we were playing, one of my paramedic buddies was recording audio of our conversation on his laptop. I was stunned when I heard it later in his car. It perfectly encapsulated...so much of what my experience has been lately...it was painful..the thing it reminded me of was who I saw on the buddy list of his laptop that I can't see anymore...It also represents something I was never able to do with the people I've loved the most..We're going to make a show or podcast or something, about our experiences in the health care field. Stay tuned.