4.30.2008

Handing Off

We had our Elections/Handover meeting today in our school's chapter of the student nurse's association. I'm somewhat relieved to no longer be the president of anything for a while.

I dutifully printed up voting cards for everyone and drew out a checklist-agenda on the whiteboard, and even waited until the posted time to get started to see if anyone would want to run from the floor for a position, but no one did. Basically, the meeting consisted of the old board, the new board, and two active members from my own departing class who had information to share.

We had one nominee for each position, a rather peaceful way to transition. One of the two nominees for president took the secretary position that was vacant, and after skipping voting and candidate presentations and all of that rubbish, we set about imparting all of the advice we could come up with to ensure that the new officers hit the ground running this summer.

The new president was clearly annoyed, since she was one of the few first-year students in the room who HAD been active, but I think she may have forgotten that there were other people in the room besides her that we were addressing.

In any event, I'm excited for this new board, a couple of them bring some pretty heavy-duty experience from previous academic institutions with them, and their new faculty adviser is the best they could possibly have hoped for, with a strong interest in the organization and a strong background in management. I hope they find a way to get her to take over the faculty adviser position for our state, whoever's occupying that position now hasn't done us much good.

A few of us plan to make ourselves available in the coming years, we're forming the core of an alumni association, a rare thing for a two-year community college (in our experience, at least). I hope they aren't holding their breath for us to give them any financial support, but we at least plan to help them facilitate communication between the school and alumni, as well as getting pre-nursing students involved in the organization at the local and national levels (we think this should even the playing-field a little bit as far as four-year schools are concerned). We've already made some impact in the national arena, and this new board is poised to take it to the next level. It's nice to see.

What Now?

We departed somewhat from the schedule of clinical foci this week, since 3/4ths of my cohort took the second clinical day off this week, we skipped right to the last clinical focus, which can be more or less summed up by the phrase "what now?".

The other student and myself were asked to summarize what we thought our strengths and weaknesses are, something I found it difficult to do on-the-spot, even going second and having some time to prepare. We talked some about our plans after school, shared some ideas, and got some advice.

My goals this was to feel like I've gotten back to the comfort and awareness level that I felt I had in previous semesters. This week included one day with a four-patient+meds assignment, a challenge I had been looking forward to despite some of the missteps in earlier weeks. My morning routine has been getting more streamlined, a process that has taken much longer than I would have liked. Establishing effective routines is very challenging for me, and now that I feel like I'm getting the hang of it, it's almost time to leave! Still, my organizational routine has improved from one semester to the other, so positive gains have been made. My plan was to use this improved familiarity to quickly target and collect the data I needed to plan my care, get report from all of the RNs (four of them in the case of the second day!) and take some time to reflect on what my priorities would be.

Patient X was in for a perforated colon, a colonoscopy had resulted in a lower GI bleed so severe that pressors were necessary to control the bleeding. As I assessed her at the beginning of the shift, I noticed decreased, ronchorous breath sounds. She reported a little shortness of breath and unproductive coughing, Incentive Spirometry volume was a non-reassuring 500mls or so. After some fluids and some chest physio she started coughing up thick, sticky secretions and her breath sounds cleared up somewhat. She never got the Spirometer above 750, but she was satting well in to the 90's and remained eupnic. She was reported to have anasarca (generalized edema), although when I assessed her, only pedal and ankle edema was evident to me. She received diuretics over the past two days to get rid of some of that extra nine liters of fluid she had in her, from what I could tell from the I/O balance sheets she was still up about 3L or so. She had a history of heart failure, so the IV fluids were running at a leisurely 60ml/hr or so.

When Patient X's assistant and I transfered her back into the bed, we noticed black stains on the linen-saver, so we set about getting her cleaned up. The stool looked pretty dark, so I grabbed one of the heme-test kits from the bathroom, which turned up positive. Probably not surprising, considering her last bowel movement yesterday contained a good amount of blood and clots, and on the RN's advice I placed a note on the front of the chart for the MD to see next time they were in. During hygine, I noted a superficial disruption of the skin in the perianal area. The redness around it was blanchable, but I thought I'd have the RN come in and take a look anyway to suggest a dressing. The RN decided that it was a stage II pressure ulcer and instructed me to apply an allevyn dressing. Something seemed off about this to me, since the redness was blanchable, but the RN assured me that it should be documented as a new stage II pressure ulcer. Eager to get some more wound documentation under my belt, I set about gathering the forms. Two other RNs (one of which was referred to as the resident "wound expert") decided to see for themselves before I submitted a nosocomial pressure ulcer report, and declared that since the wound was not over a bony prominence, it could not be a pressure ulcer. THIS seemed off to me as well, since capillary pressure is around 32mmHg, sacral pressures on a hospital mattress can easily exceed 100mmHg, and this was a relatively massive patient...it didn't seem far-fetched for me to imagine pressures in the medial gluteal folds exceeding 32mmHg.. but the blanchable erythemia was the key, I think. We reclassified the wound as a skin-tear, after the dressing I had applied had been removed and then reapplied.

Patient Y had experienced cholelithiasis and pancreatitis secondary to an obstructive gallstone. He underwent endoscopic retrograde cholangiopancreatography (ERCP)to remove the offending stone. His diet was sips of clear liquids, which progressed to full clears on the second day. His chief complaint during my time with him was pain. Fortunately this pain didn't prevent him from walking around the unit. He was concerned about the fact that he wasn't able to produce stool. This wasn't surprising since he hadn't eaten anything in the five days or so before I met him. He reported feelings of lower GI fullness and discomfort which weren't relieved by colace or senna, so I suggested he walk some more and drink room-temperature fluids. He seemed very flat, withdrawn and depressed during my time with him. His ex-wife and brother came to visit him, and he was preoccupied with how he would obtain nursing care at home once he left the floor. This puzzled me, since he didn't seem to have anything wrong with him besides the constant "3/10" abdominal pain. In fact, I had difficulty figuring out what his clinical course was, since his amylase and lipase were back to normal (they weren't even measuring them anymore), his 'lytes were mostly normal (although we were supplementing his IV fluids with potassium), and his medical issue had been resolved. On further discussion and investigation, his RN mentioned that he could be discharged when his pain was well-controlled with oral analgesics, something the patient was fairly sure would happen the next day. The RN had the impression that he was somewhat drug-seeking (or at least requesting analgesia for the euphoric effect rather than pain-control) and "milking" his hospitalization for attention from his relatives (and ex-relatives). Looking back I see how she may have formed this impression, although "in the moment" I think I'm still at the stage where I take reports from patients more-or-less at face value. Either way in this case, the same conclusions are reached, the same steps taken, regardless of our impressions.

Patient Z was off the unit on the first day for a hepatobiliary iminodiacetic acid scan (HIDA), so I assessed her relatively late in the shift, when she returned from the scan. She was in good general health, although in the past she had experienced thoracic outlet syndrome. She spent most of her time talking on the phone and chatting with her visiting spouse, and in the meantime I got to go over the pre-operative checklist with her RN. The next day she returned from a lap-choly and got to do some discharge teaching with the instructor. I've had limited opportunities to "do" discharges, so it was interesting and novel.

Patient W was my abdominoplasty patient from the previous week. She was back for "wound ischemia", although her labs revealed psuedomonas infection. Her orders specified that she should remain in the "crunch" position at all times, to prevent stress on the abdominoplasty wound. We walked together a couple of times and her breath sounds were much clearer than the last time we met. Patient W had some lengthy wound-care orders, which I was excited about since I enjoy the hands-on, arts-and-crafts nature of wound care and I've hardly gotten to do any wound care in the past two semesters, although I got to do a fair amount in the first two. The wound-care could have gone more smoothly, It didn't occur to me to set up a sterile field, electing instead to use the sterile wrappers of the individual products. This would have worked fine for simple wound-care, but I had three JP drain sponges to change and a petroleum dressing to apply to the abdomen, so I could have simplified things greatly by setting the field up. My awareness of the sterile field needs more practice, dealing with those pesky paper packages is something I need more practice with. Something positive about the experience, though, was that I've gotten a lot better at applying sterile gloves than I was in the past. I plan to seek out more wound-care opportunities in the future, not only because there's plenty of room for improvement in my technique, but because I think it's something I could get good at doing simply because I think it's fun.

Patient V had gastric bypass surgery when I met him during the second clinical day. He was in a bariatric bed with padding on all of the siderails. This confused me for a moment and I went back to his chart to look for evidence of a seizure disorder. Apparently this is just how the bari-beds come. For a morbidly obese man who just had major abdominal surgery, Patient V was in great shape as far as recovery from surgery was concerned. He ambulated without difficulty and more than the minimum requirements of his clinical pathway, he was well educated about the stages of the gastric bypass diet, his pain was well controlled with patient-controlled analgesia, and had reassuring assessments all-around. It was difficult to auscultate his breath sounds, and I wasn't sure if this was because of his girth or not. He was able to max-out the incentive spirometer in one slow, deep breath, and used the IS independently while awake. His nasogastric tube didn't put much out in the way of drainage (another good sign), and his time with me was easy and uncomplicated.

I greatly enjoyed having a four-patient assignment for the first time. Some of the skills performed need some more work, and some of the success I did have was at least partially thanks to the supportive and helpful RNs and PCTs working alongside me, but I'm left with the overall impression of progress. Identifying areas of my routine that needed improvement was a long process that relied heavily on repetition, with minimal obvious gains at first, but there's a sense that something has "clicked" with the routine that's made more improvement possible. I find myself imagining giving report at the end of the day as I collect my information at the beginning of the day, systematically pulling out information from the charts and computers, instead of the "shotgun" approach I had employed earlier, where I just tried to mobilize as much data as possible and find a use for it later. Having four patients instead of three seemed easier, somehow (although I know things would have been much different if the patients I -did- have had heavy medication profiles), I think constant activity is somehow easier for me than activity punctuated by periods of time where I'm uncertain what to do.

4.26.2008

Final Formal Forum Filing

Today I synthesized some emails sent to me by other members of the cohort into a formal "discussion response" to the last of four questions posed to us by our faculty. The question was "As you consider employment over the next year what are potential strategies in preventing burnout?".

Unlike a true "discussion", however, the discussion forum they've set up is merely a repository for our formal responses, followed by paragraphs of "great job! I agree with you! This reminds me of something very similar to what you said!", without any true discussion taking place. This irritates me.

Anyway, here's what I wrote:





Who Guards the guards?

Who Polices the police?

The long garden-party of Student Nursing is about to come to a close, and soon we will become responsible for the health, safety, and general well-being of our communities. This responsibility is handed down to us through Law, through our personal and professional codes of Ethics, and our own biosurvival needs for gainful and fulfilling employment.

The World Health Organization has called job stress a "World Wide Epidemic", costing American industry in general 200-300 billion dollars annually. The US Bureau of Labor Statistics ranked "neurotic reaction to stress" as the fourth most prevalent disabling workplace injury (Medi-Smart, 2004).

Few would argue that Nursing is a profession typified by lower-than-average levels of stress. TRCC Clinical group Five supported this nicely by citing studies that reveal some worrisome figures about Nursing in particular in relation to Job Stress and burnout, particularly the fact that the rate at which new RNs leave their first position is higher than the turnover rate for RNs in general, for reasons directly related to Job Stress at that particular facility (Dufour, 2008).

The human physiologic stress response is a beneficial and necessary feature of our neuroendocrine system that allows domesticated primates such as ourselves to adjust our senses and our metabolism to meet (sometimes rapidly) changing demands (Medi-Smart, 2004).

Our own reaction to the experience of stress is the key factor in determining if the stress response is adaptive or maladaptive. When stress is allowed to persist and become chronic, numerous symptoms often develop, such as irritability, weight changes, frequent headaches, gastrointestinal disturbances, chronic fatigue, insomnia, depression, feelings of hopelessness, negativity and angry outbursts (Zerwekh, 2006).

Now imagine that person with a stethoscope around their neck. Would you want to be that person's patient? Would you want this person to be your teacher, your employee or your coworker? How about yourself? Obviously, no one -wants- to suffer from chronic stress, and yet it is a problem of pandemic proportions (Medi-Smart, 2004).

To answer the riddles/koans posed above, consider that Guards and Police, by virtue of their specialized nature and responsibilities, are charged with the burden of guarding themselves, policing themselves.

So, who cares for the caregiver? Can you guess the answer?

The Nursing Process itself offers the solution. Assess, diagnose, plan, implement, evaluate. Recognition of the symptoms of Job Stress and Burnout are vital in any practitioner's self-care strategy (Timmerman, 1999). Once symptoms have been detected through routine self-assessment, an analysis can take place to identify deficits in self-care, which may then be ameliorated by changing diet and exercise routines, workload, or even one's outlook (Zerwekh, 2006).

The ability to self-assess is not an easy one to develop, and so establishing a network of peer-support is of vital importance. In working together towards a common goal, one person's breakdown can soon effect everyone, so it's necessary to not only care for and support your peers, but to ACCEPT that support from -them- at the same time by resisting defensiveness and egotism.

Treatment of Burnout after the symptoms are evident, of course, would not qualify as "Primary Prevention", which is commonly understood to be the most efficient, effective, and elegant mode of treatment. We most effectively treat pressure ulcers by not allowing them to happen in the first place, for example. It's far easier to prevent a nosocomial infection than it is to treat it once it's taken hold.

Graduate Nurses can save themselves a lot of anguish and frustration by doing a little research on the facility where they plan to enter into practice. What do you think of your future employers? Your future co-workers? What are the patient-to-nurse ratios like? Did you get to meet any of the preceptors? Talk to the staff (staff YOU select to speak to). Do they feel like they can speak their minds and raise concerns freely? You can maximize your control over this by asking and answering these questions early, so you can apply to the facility that is truly your choice and not just the facility that has openings left. Other GNs are doing their homework, too, and the facility with openings "left over" is likely to be the one where no one wanted to work (Formanek, 2008).

Don't be afraid to speak your mind, and don't settle for a Bad Situation just because you don't want to look for another job. There are plenty of opportunities in the Nursing field, and you have to put your own life and happiness above that of your employer and even your patients. The alternative can be ruinous to yourself and your family, who may depend on you for support as much as you depend on them. Equally ruinous is the effect on your patients if their caregiver feels trapped and miserable (Formanek, 2008).

Whether you live to work or work to live, having a life that is separate from work (even if it's shared with coworkers) may be a crucial strategy to avoid burnout. One major impediment to this is taking a lot of overtime shifts. We all need more money than we have, and those shift-differentials sure are tempting, but self-care has to come first if we are to preserve our licenses, patients and sanity.

So, my friends and future colleagues, take care of yourselves, take care of each other, and together we'll take care of everyone.


Bibliography:

Claborn, J., & Zerwekh, J. (2006). Nursing Today: transition and trends (5th ed.). St. Louis: Missouri Saunders.

Dufor, M. (2008, April 25) Final Posting [Msg 1]. Posted to http://vista.ctdlc.org/webct, archived at http://vista.ctdlc.org/webct

Formanek, F. (2008, April 21) RE: discusion topic [Msg 2]. Message posted to http://vista.ctdlc.org/webct, archived at http://vista.ctdlc.org/webct

Medi-Smart (2004). Facts about workplace stress. Retrieved April 17, 2008, from http://www.medi-smart.com/stress1.htm

Timmerman, G. M. , (1999). Using self care strategies to make lifestyle changes. Journal of Holistic Nursing, 17. Retrieved April 17, 2008 from http://jhn.sagepub.com/cgi/content/abstract/17/2/169.

4.24.2008

Home Stretch

This week our clinical focus was Law and Ethics. Of particular interest was identifying situations that raise ethical issues, as well as resources that support nurses in executing their duties ethically.

My goal lately has been to continue to improve my care planning (at the bedside, rather than on paper). In collecting all of my information for the day, I'm not as prepared as I could be to describe what my plan of care is while giving report to the instructor. What I plan to do to improve this in these last few shifts of student nurse practice is to set aside some time at the beginning of the shift to come up with one or two nursing diagnoses for each patient. This will also better prepare me to answer questions about my patient's pathophysiologies, a couple of questions about these patients came up that I wasn't able to answer as well as I might have if I were answering test questions or just having a simple conversation with someone, so I think this provides a couple of good hints as to how I can better prepare during the beginning of my shift.

Patient X is a middle-aged woman who was admitted for rectal bleeding. She had a band-lap a year ago and a colectomy one week ago (also for GI-bleed). I found her busily making her bed and arranging her room when I walked in to introduce myself after report. She was being held for just one more day to ensure the rectal bleeding had subsided. She walked around the unit and puffed on her incentive spirometer without being prompted. She expressed some frustration at having to wait for someone to remove the sequential compression devices wrapped around her calves. Easy fix! I demonstrated how the device worked, and she demonstrated to me that she could apply and remove the SCDs. Problem solved! I stopped in to check on her after dinnertime, and found her SCDs detached and at the bedside. When I reminded her that she has to wear them whenever she's in bed, she said she was about to get back up anyway. Towards the end of the day, her call-bell went off, and I found her resting peacefully in bed with the SCDs in place. "There ya go. Aren't ya proud of me?" she quipped. We chatted for a bit about how her diet had changed since undergoing the lap-band procedure, she felt slightly guilty about having a tray of food out (since it took her about an hour to finish her meal), since her neighbor was wheeled in unable to consume solid foods. Her neighbor is Patient Y.

Patient Y was status-post "abdominoplasty and ventral hernia repair", due to "crease dermatitis". Her history included hypertension, shortness-of-breath on exertion, hypothyroidism, DVT and heart palpitations. RN1 called me over to take phone report on Patient Y, and I took down a complete set of notes from the RN in the post-anesthesia recovery unit, which was probably one of the most complete and concise reports on a patient I'd ever heard. Patient Y had three JP-drains, a flank-to-flank abdominal dressing, and some pretty severe abdominal pain. Even now, I'm not sure if she ever did, in fact, have a ventral hernia OR crease dermatitis, since it was explained to me that these indications were fabricated to benefit the surgeon's paycheck somehow, and that all that was really done was an abdominoplasty to remove excess skin from a gastric bypass surgery two years ago. A fellow student overheard me going over my plan with RN1 and said something like "Oh, another one of Dr. X's 'hernia repairs', eh?". In retrospect it would have been interesting to get one of the RNs to get me into the results viewer so I could read the dictated report of the surgery. I got the opportunity to conduct the admission assessment on Patient Y, and got some input from RN1 how to streamline the process and get it done efficiently. In retrospect I think I should have had the patient's chart with me at the bedside (on the COW) while I was going over the health history.

Patient Y's biggest challenges over the two days I was with her were pain control and ambulation. She was way behind the ambulation she needed to complete to progress through her clinical pathway, and I only succeeded in getting her out of bed once, after which she walked about 20-30 feet. She walked stooped-over, saying that standing straight worsened her incisional pain. I premedicated her with oral dilaudid AND had the RN push IV dilaudid in an attempt to control her pain well enough to get her to cough and walk. Her lung sounds were pretty rough and juicy both days, but particularly after surgery. After some incentive spirometry they cleared up somewhat, but she still hadn't gotten rid of all of that inspiratory wheeze and ronchi. She required a lot of assistance to ambulate (fortunately I could do it myself), and I kept reminding her not to look down. As her posture stooped more and more, rather than -telling- her to lift her head up, I -asked- her if she was dizzy. This effectively prompted her to look straight ahead, although with her stooped posture this meant extending the neck somewhat. Abdominal splinting didn't seem to help much.

On my second day with Patient Y, she received reiki from a volunteer at the hospital, which was interrupted somewhat by the other occupant of the room, who was somewhat hard of hearing and didn't understand what was going on. I think if I were there during that previous shift, I would have tried to temporarily relocate the other occupant of the room. There were plenty of empty rooms, since the census was low, and if that wasn't appropriate she could always lounge in a recliner near the nurses' station for however long a reiki session is. In any event, when I came on shift I noticed Patient Y hadn't received her ordered muscle-relaxant, so RN1 and myself split up to track down the RN from the previous shift and ask her about it (along with an uncharted dose of heparin for patient Z, which I'll get to in a minute). Before finding her I found the med at the bedside, still sealed in it's envelope. Apparently the previous shift's RN left it there because reiki was being performed at the time she had intended to administer it. I think I would have put it in my pocket (or some kind of utility belt if I ever get one).

Patient Z is in his early 80s and was admitted for a UTI and kidney infection. It wasn't clear to me if the UTI came first or the kidney infection, but either way, assessing for changes in flank pain, ureter pain and urinary output were key priorities. I feel like I should have came up with this on my own without being lead so much to those conclusions, all I would have needed to do was take a moment after collecting all my data to reflect on the pathophysiology. The weak start I got off to this semester made it difficult to take in the "big picture", but I think this is improving (albeit late).

I got an opportunity to sit in on Patient Z''s doctor coming in to explain his clinical course to the patient and his family. He explained that the plan is to attempt to resolve the infection with antibiotics and fluid support, and if that fails, to surgically place a nephrostomy which would later be converted to an internal shunt to the bladder. This was not the preferred option due to the patient's age and history, which included unilateral renal failure and rectal cancer. He was on NPO at the time, but the doctor indicated while he was in the room that he could eat a regular diet as tolerated until midnight the next day. This was good news, since the normal saline infusion wasn't giving him any of the nutrition he would need to fight off the infection. The diet order wasn't entered into the chart, however, so I caught up with RN2, who took a phone order from Patient Z's doctor. At this point, all I could offer him was one of the boxed lunches kept around for late admissions, but the cold-cut sandwitch and banana were better than nothing!

What concerned me the most about Patient Z was his insufficient urinary output. He was found to have a low glomerular filtration rate, but I took the opportunity to palpate and ultra-sound the bladder anyway to confirm that he was not, in fact, producing any urine. He only produced 100ccs during the 8 hour shift, and the bladder scanner came up triple-zeroes (I tried several times). He consumed a couple cans of ginger ale, but still nothing. Figuring all that fluid was going -somewhere- I kept an eye on his breath sounds (for fine crackles) and blood pressure, but didn't detect those or any other signs of fluid overload (no edema, dyspnea, etc). His history included depression, and although he seemed in high spirits when the doctor and his family were around, this quickly changed after visiting hours. Thinking back to some of my NCLEX prep questions, I figured the best thing to do would be to allow for time to hang out in the room for short periods of time, being clear on how long I had and when I'd be back (when I could, I wasn't always successful at this, something else for me to work on). Patient Z was rockin' the highest white blood cell count I had ever seen..about 41x10^3!! At least his immune response wasn't diminished by age...or was it? The differential WBC looked like what I usually see in inflammatory processes, I wasn't quite sure what to make of this high number, I did notice that it had practically tripled in the past day or so. Another thing I intend to remind myself to do (so other people don't have to remind me) more often is put the laboratory data in context by examining trends instead of just values.

Patient W was one of the more difficult and rewarding assignments I've had this semester. Her admitting complaint was altered mental status, and on examination was found to have a UTI, renal insufficiency and dehydration. Her history had a term I hadn't encountered before, "undersocialized conduct disorder". Sounds pretty self-explanitory. She also had a history of ETOH dependency, ETOH psychosis, severe aggressive behavior and encephalopathy. The encephalopathy had me scouring the chart, since it didn't specify "hepatic encephalopathy", which I would expect with an ETOH history, and there were no hepatic issues in the chart that I could find (I was expecting at least cirrhosis, if not failure). She's in her mid-80s, and in conversation with her husband I learned she was able to work before the mental status change that brought her to the hospital (her work consisted of sweeping and cooking, from what I could tell).

She was severely incapacitated when I met her. She had a vest restraint on, because she kept trying to get out of bed. My first impulse in situations like this is to try to improve the level of consciousness to the point where the restraints could be removed, but this was infeasible in this case, at least during my time with her. She had an extremely limited ability to communicate, the previous shift said she was completely non-verbal. Her speech was heavily slurred and confused, but I was able to piece together word here and there. Throughout the day her ability to express herself improved, she turned to me at one point and forlornly said "I'm not a party girl anymore". On the first day she was incontinent of black-green, liquid stool that oozed more or less constantly through the day. PCT1 and I had a great working relationship, and we got her cleaned up several times throughout the day. Good thing, too, given her condition the last thing she needed was a foley covered in stool. The whole situation was tickling my "efficiency" itch in my brain, I found it somewhat frustrating that there was no better way to manage her incontinence than to let her soil herself and then clean it up after the fact. Since the catheter was somewhat movable, I was worried about the possibility of even more microbes colonizing that short female urethra. I've heard there are specialized "continence care nurses", maybe one of them can give me some ideas. Maybe some kind of "cuff" near the proximal end of the catheter? A rectal tube, a device with a foam end that molds to the rectum, seems to be something reserved for the critically ill in The Unit, and I'm guessing would have been inappropriate for this patient due to the potentially short length of time that she would be incontinent (this ended up being true, as I got her to the commode the next day). A rectal pouch wouldn't have worked either, due to the level of consciousness and relative immobility of the patient. My secondary concern besides the foley catheter was a scabbed-over wound that was open-to-air over her coccyx. The erythema around the wound was reassuringly blanchable, but still, there was a wound with a movable scab on it that was covered with stool periodically. We gently cleansed the area and put barrier cream on it, I learned that placing an occlusive dressing wouldn't have been a good idea because it would rip the scab off later, and telfa+tape would have just slid off and gotten saturated. Thinking back, maybe I could have sealed the edges of the telfa with a tegaderm, but the same shear effect probably would have rolled the edges up anyway, like I saw with an abrasion over the spine with a previous patient.

On the second day, her alertness seemed to have been improved, and I was able to decipher more of her speech. I repeated much of what she said, so she could answer "yes" or "no", to confirm what she was saying, I noticed at times she contradicted herself, and sometimes I misunderstood what she said. She got a long overdue visit from a speech therapist for a swallowing evaluation today, after which she was placed on aspiration precautions. Attempts to feed her a ground diet the night before were unsuccessful, she spit that and the protein shake out during feeding. After the swallowing eval she was also ordered to be spoon-fed one-to-one.

Her nutrition was involved in one of a few small conflicts with PCT2 on that second day. At the beginning of the day, during my head-to-toe assessment, she expressed a need to use the toilet. Once I had confirmed she needed to produce stool, I got her out of bed and on the commode. I still had a lot I needed to do to prepare my care, so I hit the call-bell and asked the PCT to stay with her (or find someone to stay with her) while I carried out the rest of my assessments and prepared to administer medications. She rolled her eyes at me, I apologized, and left to continue my assessments. After the last of my three assessments (of patient Z, to give you an idea of how I prioritized them..the post-op day 1 was prioritized higher), the PCT came up to me and said "you're doing everyone's vitals, right?". I apologized again and explained that I had to prepare medications and wouldn't have time. She seemed surprised. The third and final issue came when Patient W's ground diet arrived from the nutrition cart. As I passed the room, PCT2 walked out and said "hey, maybe you can try feeding her". I walked in and woke patient W up by placing a hand on her shoulder and repeating her name. She awoke, and I got about half of the entree into her without any coughing or pocketing. When PCT2 came back, she said "oh, so she wakes up for -you-". I handed the spoon back to her and told her where I would be, preparing to hang an IV bag. When I walked by a few minutes later, the dinner tray was gone. "No more food?" I asked PCT2 in passing. "Nah, she's done", she said. I didn't review what she charted of her nutritional intake, but I think Patient W could have benefited from more attention in feeding her, and I don't feel like I had time to manage it myself. I considered raising a concern about this to RN2 (who was my co-assigned nurse for patients X, Y and W), but decided my priority should be to focus on the continued demands of patient W's care, figuring I could try to get her protein shake into her later (I couldn't).

RN2 was proactive about helping me "do everything" that our patients required, but with two, slightly troubling exceptions. While I was performing Patient Y's admission assessment, she hung a bag of IV antibiotics for me, telling me that when one RN is stuck with an admission assessment, another helps them out by hanging the IV med. I explained to her that this might get me into some hot water with my instructor, and she verbalized understanding. Later, while I was ambulating patient Y, a newly ordered unit of whole blood arrived on the unit, destined for Patient W's circulatory system. While I was ambulating the patient, RN2 ran in another bag of IV antibiotics and initiated the blood infusion. This made me panic for a moment, because I felt like this was something I should have been doing (I've only assisted in a blood infusion once in the ED at the inner-city hospital I served at last semester). When I saw the difference it made in patient W's condition, however, I could understand why RN2 felt it was more important to get it done immediately than wait for me to be free to initiate the infusion. As the blood infused into her, patient W's level of consciousness improved dramatically. It improved so much, she hit me with a couple of gems like "when are you taking me home, you stupid guy?!" and "if you don't let me out, I'll sue you. My husband will sue." I spent a lot of time comforting her while she cried, the episodes would usually start with a long vocal tone that was probably meant on some level of the brain to be a string of words, and then ended in sobs. Reviewing her labs, I saw that her BUN to Creatinine ratio was such that she was not legally competent to make decisions regarding her care (a previous instructor introduced me to this concept, I think it's anything higher than 1:40). The high BUN (well in excess of 80) was an expected finding considering she was dehydrated. The half-normal saline and free water intake probably resulted in some dilutional anemia, her MD believed she had chronic anemia as well. I kept reminding her that it was too late to go anywhere tonight, and that when she woke up in the morning, she would see her husband, who had been spending pretty much all of the available visiting hours with her (something she had no memory of).

A couple of mistakes I made with Patient W was heme testing the stool on day one, when there was no order, and then not testing it on day two, when there was. I scanned through the chart at the beginning of the shift, I need to schedule regular intervals to re-review the orders in search of changes, since the computerized charting system isn't updated reliably. Another near-disaster involved that name-band again..I had prepared her crushed PO medications ahead of time, determined that she had a preference for peach-sauce instead of apple-sauce, and knelt by her recliner (parked just outside the nursing station) to reorient and comfort her while I was waiting for the opportunity to administer the meds. After a few minutes of telling her "your name is patient W, you're in Hospital-A, you'll see your husband tomorrow", I still needed a gentle reminder to finger the ID bracelet (which was clearly visible from where I was sitting). This time, unlike previous med-admin encounters, she was able to repeat her name and birthday with prompting, a definite sign of improvement. I think my strategy of anchoring the idea of "check the ID band as soon as you enter the room" needs to be modified to handle med-admin "outside the room". I managed to postpone the worry and pensiveness over that occurrence until I got in my car at the end of the shift. What I think I learned from that sequence of events is that pretending the instructor "isn't there" and trying to just "act natural" is a denial of the facts and reality of the situation. I'm there to do a job, but also to demonstrate for someone else that I can do the job correctly. I should conceptualize what I'm doing as having an audience of two people instead of one.

I left, as usual, with mixed feelings about my week. I ended on a good note with PCT2, although we didn't discuss directly the sublimated conflicts we had been having, we spent some time engaging in mutually supportive conversation in the break-room, so I was glad we parted company in that fashion, and I think this will make it easier for us to communicate better in the future. I won some mild praise from RNs 1 and 2, and got some feedback on how to better convey confidence (by suggesting things for me to NOT do rather than to do) and maintain client confidentiality while talking in the nurse's station. It seems like I don't catch on to the fact that some of the things people clue me into are things I shouldn't discuss openly, like the questionable nature of patient Y's "crease dermatitis and ventral hernia repair" and the lack of an infusion pump in that same patient's room. I half-jokingly refer to this as "tourist syndrome", since some of my slowness in picking up the cultural landscape of my surroundings reminds me somewhat of a tourist. I make light of it but also recognize it as an important deficit to monitor, since so much of this job seems to rely on linguistic and cultural savvy (for staff as well as patient interactions).

4.22.2008

You Are Getting Very Sleepy

I had put off and put off preparing for my peer teaching assignment for weeks. Finally, a wake, a funeral, and a uke festival made it necessary to complete all of the preparation for this in between clinical shifts. I worked on it between about 1AM and 1:30AM. It's about neuro-linguistic programming. I suppose this is feeding into my developing stereotype as a soon-to-be "psych nurse", but I think a lot of these concepts are just as applicable to med-surg or any other nursing environment as they are in psych. In fact, its the utility for these techniques IN those settings that made me think it would be a good peer teaching project.

It's kind of like guerrilla psychotherapy. I'm not a psychotherapist, nor will I ever be one, but Erickson's concept of "brief therapy" can be extrapolated into the therapeutic relationships we should all be establishing as caregivers, and if we have the opportunity to improve outcomes with a kind touch or a well-placed word, why shouldn't we?

The other side of this is that we're conditioning people to respond to stimuli whether we're aware of it or not, so we might as well be aware of it. While we're at it, we might as well develop an awareness of how WE are conditioned and what can be done about that.

Unfortunately, half of my cohort is taking tomorrow off to prepare for our quiz on degenerative neuro and rehab, so I'll be giving my presentation to a mostly empty room. Maybe I'll video-record it. This is an amusing inverse of my last two peer-teaching presentations, during which my cohort was present but the instructors were absent.

4.17.2008

Updated concept map


Just for the heck of it, here's what the finished concept map ended up looking like.

Like Nurse Practitioners Save Lives said, it's busywork, one more unneeded hassle in the run-up to the NCLEX.

Still, though, while working on it, I remembered a conversation I had here at the coffee shop with a medical student. She mentioned that her education and training didn't really leave her with any idea of what nurses do, what the scope of their practice is, and what their training entails.

I didn't pick a very good patient for this assignment, it was somewhat "simple", but even the care of simple patients can become as complex as you're willing to make it.

three weeks to go...

This week's clinical focus was Management of Patient Care. This was timed nicely to coincide with my personal goals for this pair of shifts. I had a lot of good support and advice towards that goal this week, and some interesting semi-conflicts that tested my willingness to take control of the assignment, even if it means disagreeing with someone I'm working with.

Patient X (a man in his late 70s) was in for left-sided pneumothorax (his third!). The history was notable for chronic obstructive pulmonary disease with moderate activity limitations, asbestos exposure, hypertension and hypercholesterolemia. He was dependent on continuous 4-liters of oxygen via nasal cannulae. This was my first patient with a chest tube, something I had spent a lot of time studying for our critical care content last semester. This was also the first time I had palpated and auscultated crepitus. One of the major assessment points that I got from this hands-on experience is that firm palpation may be required to detect crepitus. His clinical course had been delayed somewhat due to air leaks in his chest-tube setup. The suction had been lessened from 20ccH20 to 10ccH20, ostensibly to allow the pneumothorax to resolve without further leaking.

His skin was extremely fragile, and he had a skin tear on one leg covered by Telfa, and a stage-one pressure ulcer on the thigh that was covered by an occlusive dressing. I've been focusing on my wound documentation lately, so changing the Telfa pad with RN-A gave me opportunities to fill out some fields in the computerized charting I don't always encounter. The occlusive dressing over the pressure sore was left in place, to spare his paper-like skin the repeated trauma of removing the adhesives.

My goal with him was to get him out of bed. He stated he had been laid up in bed for some time, and was skeptical that he could get very far. I encouraged him by saying just a few feet would be beneficial, and I set about gathering everything I needed to get him up and around. Now that I've been on this unit for a while, I'm finally starting to get the sense of where everything is, so I gathered up a walker and a portable O2 canister.

This is the setup for a lesson about O2 canisters I'll never forget. I found the only O2 canister in the storage room, opened the valve, and saw 4L of O2 come hissing out. Perfect, I thought. I dropped it in a hand-truck and brought it back to the room. We hooked up his chest-tube and foley collection device to the walker, and I stood next to him with the O2, still putting out the 4L. About ten steps down the hall, something starts to go wrong. His steps falter, he intensified his pursed-lip breathing (a technique that helps COPDers expel CO2), and he asked for a chair. I called out to one of my classmates, who hurried over with one. Fortunately, this attracted some attention, and the instructor came over and took charge of the situation, directing us to get a chair with wheels and get him back to his room ASAP. Due to what I believe was air hunger, he became irritable, demanding that we get more O2 instead of bringing him back to his room. It was explained to him that going back to the room was the quickest way to get him to the oxygen, but this wasn't very reassuring to him. We got him back on O2 in a matter of seconds, and I pensively watched the O2 sats go from in the 70s to the high 80s (his baseline). This could have been averted if I had noticed the -other- indicator attached to the tank, which shows the amount of O2 left in the tank. A hard lesson, thankfully no one got hurt. In trying to be more independent, I had made the mistake of thinking I could carry out a task I had no experience with, because it “looked simple enough”.

Down the hall was Patient Y, a pleasant elderly Austrian woman with the Flu (A-type). For some reason, I was tickled at the fact that she referred to Xanax by it's generic name, Alprazolam. It sounds nice in an Austrian accent. She had a history of congestive heart failure, atrial fibrilation, diabetes and arthritis. Oh, and she's another COPDer. Pulmonary assessments, obviously, were prioritized very highly, not only because of the flu, but the possibility of pulmonary edema secondary to her heart failure. I kept an eye on her jugular vein (for distention), pushed PO fluid intake, and praised her for ambulating with her husband and puffing on her incentive spirometer regularly.

During my initial assessment of her, her family was present (around 2 generations, from the looks of it), and I enjoyed answering their questions about what I was doing and why, it was a great way to think critically about my own assessment by having other people ask questions about it. This was my only patient with RN-B for this week, who was great about letting me “run the show”, while also offering advice and encouragement.

Next up is Patient Z, a woman in her late 80s with Hematuria of unknown etiology. History of rheumatoid arthritis, Skin cancer, Breast cancer (left-sided mastectomy) and diabetes. When I arrived on the unit, she was away for a cystoscopy, I was able to coordinate well with RN-A to make sure we were both close at hand when she arrived. This one had me mentally chewing on my nails, and questions posed to me by the instructor about this patient demonstrated to me that I had been too focused on the actual medical diagnoses in how I approach planning patient care. My primary concern with her (which I had to cajole RN-A into giving me a hint about) was that a blood clot might obstruct her bladder or ureters. I smacked my forehead, because I could have figured that out if I had just thought it through. Obviously I'm going to be watching her foley drainage closely, since she's putting out relatively small amounts of opaque red urine. I didn't put that together when asked, I think, because I was too hung up on the “unknowns”, which weren't really relevant to my plan of care anyway. The problem was that there was blood coming out of her foley. The “solution”, as far as I was concerned, was to carefully monitor the drainage for clots and volume of output. Blood pressure and level of consciousness were important assessments to me as well, because of the bleeding. One of her daughters is a clinical educator in oncology at our facility, I valued her input concerning what her expectations for her mother's care were (which were, you know, the things I'm supposed to be doing anyway, but I think giving her the opportunity to relate her expectations to me was helpful to both of us, as far as peace-of-mind is concerned).

New arrivals on day-two included Patients W and V. Another new addition was the opportunity to work with RN-C, an agency nurse who posed a particular set of challenges and rewards as far as my goal of becoming a manager of care are concerned. When we started off she...kind of treated me like I didn't know anything. This only bothered me momentarily, because rounding with her was very rewarding. She gave me some pro-tips from her experience as a Neuro nurse about how to conduct cognitive assessments, namely that asking about the year and the month is more constructive than asking for what day it was, since, she pointed out, neither of us could really remember what day it was half the time anyway. We also assessed an epidural together, something she's had a lot of experience with. In the past, in other environments (not in the hospital), I've had a tendency to be somewhat annoyed when someone explains to me something I already know. In this case, it took me a while throughout the shift to show her what I -do- know and what I can do. I won some praise from one of the nurses who was demonstrating the epidural infuser's operation to RN-C for rattling off the priority assessments for epidural anesthesia.

The epidural was running into Patient W, a woman in her late 70s who was one day status-post left-upper lung lobectomy, secondary to lung cancer. She had bilateral masectomies secondary to breast cancer, so blood pressures for her were obtained by wrapping the cuff around the calf, slightly above the ankle. She experienced 10/10 bladder pain that was preventing her from taking in any nutrition. After adjusting the position of the catheter and palpating the bladder, I decided to hunt down RN-C for her input. She decided the best course of action would be to replace the foley. She spun around to leave to grab a foley kit (she really is a whirlwind of activity!), before I stopped her and suggested that I could do this with my instructor. It would have been my first foley-insertion on a female! I asked the patient if she had a preference as to who did the procedure, and she said it didn't matter to her. RN-C then expressed that she would rather do it her self “because....” and then she trailed off. When I caught up with her later, she said “oh, it was really tricky anatomy anyway, you wouldn't have gotten it”. I was slightly miffed by this but I didn't show it. How am I supposed to “get it” without trying? I didn't let this get to me, though, since I'll have lots of opportunities to practice and perform -skills-, I just felt like I was being slightly excluded. I could have run the bladder scanner for her, I bet she didn't know I could operate one of those. Later she mentioned offhand that she forgot to put a thigh-strap on the patient to secure the foley, this time I just said “Don't worry about that, I'll take care of it” and dove into the clean-utility room to retrieve the strap.

Patient W also exhibited rising back-pain, which she rated as “12/10”. She said it felt the same as when she threw out her back. This started setting alarm bells off in my head, and after taking a peak at the epidural site and making sure sensation was present in the dermatome around the site, I tracked down RN-C again to see what she thought we should do. I saw there was an order that allowed us to slightly increase the epidural infusion rate, but RN-C figured administering Morphine IVPush and getting a toradol order would be the way to go. Thinking about this later, that makes sense, since the epidural is for the constant pain and the morphine is for breakthrough pain (in this case). The sudden extreme back-pain made me panic for a moment, I felt like there's something related to epidural anesthesia I should be worried about, but couldn't put my finger on it. CSF leak? No, that's headache. I don't know what exactly I was worried about, but that only contributed to how ominous the occurrence seemed to me.

Patient W also had a chest tube, except this one was hooked up to wall suction, with a pressure of 20ccHg. I confused cc's of Hg and H20 in the report. The level of drainage was 120ccs above the last marked volume on the collection device, so I charted that as output and kept an eye on it. It didn't increase again all shift, which makes me wonder if perhaps it just hadn't been marked in a while.

One of the PCTs got a blood pressure of 207/78 on her, which I suppose isn't all that surprising considering she's on medication for hypertension, didn't receive her AM dose due to hypotension, and just had an episode of excruciating pain. The orders included a parameter to call the MD if the systolic blood pressure was higher than 190. I started to track down RN-C once again and thought to myself “She's in with a patient, I'll just have the HUC page the MD for me, I have all the info I need”. I had the MD paged and then caught up with RN-C to tell her what the situation was. Just then, the HUC shouted down the hall for me, the MD had answered the page almost immediately. I headed over to the phone, not even thinking to check to see if RN-C was following me or not. I sat down and answered the phone, and gave a nice, concise SBAR report to the MD. When he asked “you administered IV Morphine in addition to the epidural?” I said “well, I can't give IV push morphine because I'm a student, the RN administered it.” “Let me talk to the RN”, he said. “Just one second..”, I hit the Hold button and retrieved RN-C, who was still down the hall. The mistake I made here was letting my enthusiasm for doing something on my own prevent me from following through to the next logical thought in the sequence I had just initiated. Ok, I had just reported something to an MD...but what if he has an order in response? I can't take a phone order on my own, I need to have an RN with me. I was able to do this whole sequence of events on my own at the last facility, because MD's ordered purely electronically there, no phone orders at the last facility (or at least they were very rare). This is a poor excuse, I know.

Last but not least was Patient V, a man in his early 80s who was with us for a perforated bladder. Apparently, he was here the previous day for cytoscopy related to a bladder tumor. At home, he was unable to urinate and his bladder swelled to epic proportions. In a way, Patient Z from the day before had prepared me a little better to care for patient V, and I monitored his foley output closely for clots and volume. He put out a reassuring 750ccs or so for me. I saw his MD come and visit, he heard good bowel sounds and noticed decreased abdominal distention (back to baseline, according to patient V), so he said they would just observe him for another day and that surgery wouldn't be necessary. Patient V slept for a lot of the shift, but I got him out of bed to weigh him for his admission assessment (which still wasn't complete when I arrived, it was only missing that weight), checked his abdomen for warmth and firmness, and even did that fun little fluid-wave test for ascites (it was negative). I hung a bag of maintenance fluid for him, which I flubbed. I feel like I've demonstrated progress in how I've been hanging IV piggyback infusions, but for some reason doing something similar but slightly different caused me to be clumsier than I should have been. All I need to do is remember not to try to hold so much in my hands at once. I get so worried about keeping the tips sterile that I'm afraid to let go of anything, lest something bump into something else out of my control. What I need to remember is that I don't need to hold on to the tip when it's covered, it doesn't matter if it rests on the bed or even the floor. I clearly need to practice more with the cartridge-based volumetric infusion sets, having three different types of infusion sets in three clinical sites (gravity, peristaltic, volumetric) has made me not only “master of none” but “barely competent with any”. I spent some time in the lab today going through the steps with the cartridge, I think as long as I remember to invert the cartridge first I'll get it right next time.

There was some question as to whether patient V was aphasic, the previous shift thought he seemed somewhat confused, and reported occasionally having difficulty coming up with the words he wants to say. This piqued RN-C's interest, and when I followed her into patient V's room I got a front-row seat to the previously mentioned pro-neuro assessment. He was easily aroused, knew what year and month it was, but struggled with the name of the president. A good tip I picked up on from her was if someone's struggling with an answer, to give three choices rather than just sitting there and letting them flounder or cutting their train of thought off. She didn't detect any obvious neuro deficit, so we chalked up the non-aphasia to the fact that he's..well, in his 80s.

This week provided some interesting challenges, some hard lessons, and some clues as to how to get to where I'm going. It's a little frustrating that I've made what I feel are substantial gains in hanging IV piggyback infusions, only to screw up something even more basic. The point is, though, that the practicing I did with the piggybacks paid off, and so it's clear what I need to do to smooth out the primaries. I feel like I kept it together pretty well, too, staying relatively positive and goal-oriented in the face of setbacks.

I'm not sure how much progress I've made in being a better manager of care, this week. I'm staying aware of the documentation more conscientiously and communicating better with the rest of the team, but I feel like there's still too much I defer to the staff RN's in terms of decision-making. I don't think its a bad thing for me to keep them up-to-date with the goings-on, but I think in the future I need to include my own recommendations for what I plan to do instead of phrasing it in a way that prompts them to give me instructions.

4.15.2008

My friend pH died yesterday. I pulled up to the watering hole where we usually hung out after a long and harrowing clinical shift, and utility vehicles lined the street, digging up some thing or other, bathing the downtown arcade of bars in yellow strobe.

When I walked in, this dude who had appointed himself as the "tell everyone what happened guy" tells me what happened. I look around and saw all of his friends that I knew of, all hanging out, laughing, crying, sharing stories..it was a Wake. I don't know if there's going to be an "official" wake, but this was the wake. This was the group of people who memorialized him -that same day-. His bandmates, his scene, everyone came together to help eachother deal, feel normal, and celebrate a life that had enriched their own.

He could shred on the guitar. Everyone I know describes him as a "guitar prodigy". The only band I know him from was a platform from which he played solos over western-rock murder ballads (songs detailing serious crimes) with both ease and rediculous complexity. If you look around on google video you might catch a glimpse of him, I captured as much as i could of him on video.

He wasn't my friend for a very long time, but as soon as I met him he was so deeply intertwined into the random connections between people from different scenes and places (nursing school, rhode island, downtown newlondon, what?!) that I knew he was part of that cosmic giggle that ...

and then I couldn't finish the sentance.

when i walked into the bar, the guy who told me jostled me (well, we jostled eachother) and I spilled my beer on the floor. "One for my homie", I bleated. We had a good laugh over that.

I hiked up to another local band's practice space and sat around for a while exchanging ribald jokes for a few minutes before retrieivng my cellphone from where i had left it and returning home.

I still can't believe he's gone.

I miss my friend.

4.14.2008

64 hours to go...

I've polished my white $20 reeboks until they sparkled, replaced the battery in my stethascope, printed out an organization sheet, gathered up my nutrition supplies, scrounged up a pen, so all that remains is to watch the last few minutes silently pass before heading to the hospital for the day's assignment.

I've got another sixty-four hours of bedside care to get through before I'm through with acute med/surg, and ADN school in general. I'm about one screw-up away from the faculty conclave having to "make a decision" about me. Unlike the rest of the cohort, who passes medications on one shift of the week and not the other, I'll be passing medications every shift until I'm through. This is actually fine by me, it's how it was back when I had a preceptor.

While the rest of the cohort skips out on a clinical day to go to some lecture or other about "ecological health" or something of that nature, I'll be on the unit with the isntructor, with no other students around. The reason for this was technically that I couldn't come up with the $25 fee for the luncheon, but the instructor feels that it would be a smart thing for me to do anyway. The rest of the cohort seem to be miffed that I'm depriving them of this bonding experience with the instructor so close to graduation, but...well, too bad, I guess.

In these few quiet moments before leaving for the hospital, I always get the nagging feeling that I'm forgetting something. I often do. One week it was my nametag (I put a peice of cloth tape over my chest and had a classmate write my name in sharpie), another it was my stethascope (I borrowed one from the med-room), another week it was money and/or food (I snacked on some positively repulsive bagels coated with granulated sugar left in the break-room from the previous shift).

This week it will definately be my PDA/Cellphone, which is probably sitting on the floor of an apartment downtown. I mainly use it as a drug-referance and care-planning guide on the unit, and browse through my RSS feeds while I'm eating (if I get a chance to eat). Looks like I'll be going back to flippin' the pages in good 'ol Mosby's today.

I passed my midterm evaluation, but only just barely. I was rated "weak" in several objectives, which are contained neatly in this week's clinical focus. "Management of Patient Care". I have a very short period of time to show a great deal of improvement.

So, off we go, then.

4.12.2008

...if you show me yours

Since posting your concept maps is apparently all the rage nowadays, here's what I've got so far. Im totally done working on this today, Ill have to finish up tomorrow. Click for zoomed-in version.

Enter Little Heck

One of my classmates has joined me here in the blogosphere, check out Little Heck at "Rants of an Angry White Girl".

She was the other half of our dynamic resolution writin' and passin' duo, and she's well on her way to becoming a Certified Registered Nurse Anesthetist and kicking some major scholarly booty.

There are few people I consider friends or allies, particularly among my classmates, and this, I suspect, will be the only person I'll miss when I leave ADN school. Good thing she's bloggin' now!

Our friendship's been an exercise in the synthesis and synergy of opposites, of opposing views, beliefs and aesthetics, thrown together by virtue of the necessity created by being two of the few willing to step up and reach beyond the next class or the next test.

When things need to get done, it doesn't matter if the people at hand believe in the individual or the community, in red or blue, anarchy or social control, white bread versus wheat, beer versus cocktails, or anything arbitrary of that nature. What matters is the acceptance of a common goal, and the willingness to put all the small crap aside so that goal can be achieved with the help of domesticated primates (such as ourselves) with similar goals....

...while still being comfortable enough to give her crap for being a republican-votin' southern gal and her to give me crap for being a space-cadet hippy weirdo.

Cheers, Heck, and Thanks.

4.09.2008

Change

This week our clinical focus was change. Change, in the sense of institutional change, change in the nature and standards of practice, perhaps changes in policies and procedures. Being mindful of how previous foci turned up during the day in unexpected ways, I breathed a sigh of relief when I saw this new topic. I've gotten through conflict, delegation, and the rest, how bad could change be? Surely some new change in policy or the nature of nursing practice in general wouldn't suddenly make an appearance in my assignment, the way the previous foci have. Right?

Well, although these kinds of Change didn't figure in to my day, plenty of other kinds of change did. This was a sort of make-or-break week for me, my last chance to turn around some of my issues with clumsiness and organization skills before the mid-term evaluation. Now that I've built up some comfort and confidence by having some smooth medication administrations, my goals have expanded to include:

*Taking charge of my assignments, showing that I can -manage- my patient's care instead of just accomplishing scheduled tasks.

*Improving my understanding of the "administrative" side of my tasks, the paper work that goes into this particular hospital's care-planning strategy, and the chain of information between Nursing, MDs and PharmDs.

I think I underestimated how difficult it would be to change hospital assignments during my last semester. Reflecting on the last two semesters spent in a large inner-city hospital, the aspects of the health care delivery system that I'm having trouble wrapping my head around now are the same ones that took me so long to figure out in the previous environment. I pride myself on being adaptable and thinking "on my feet", however, the challenges I've had are pointing out to me that there are some things that take me longer to figure out. What's been working well during the past couple of weeks is getting support from other members of the cohort. Some things that are common sense to them aren't obvious to me, and vice versa. Unfortunately, the things I'm lagging behind on (compared to them) are rather serious, deeply-rooted, and need to be addressed during my last 64 hours of providing bedside care as a student.

I had a short conversation with one of the other students that made me feel a bit better about the problems I had been having. This guy was with me at my last hospital assignment, where the med administration system required that we scan barcodes on the patient's bracelet. Transitioning to the system we're working with now resulted in him making the same mistake I had made (not checking the bracelet). Of course, he only made that mistake once. Hearing that made me feel a little better, because he's very "with it" and has tons of experience (in pediatric oncology, no less!), and what I took from that short conversation was a reiteration of the idea that learning from mistakes instead of feeling bad about them is crucial.

Change was the order of the day(s), I dropped back down to a 2-patient assignment on the first day (Patients X and Y), and was slightly dismayed to discover that the RN I had the conflict with last week was my co-assigned nurse once again. I was told that this had more to do with the assignment (it had more opportunities to practice med admin skills) than my previous experience with her, but I looked at it as an opportunity to get right some of the things I got wrong during the prior week. In a sense, being assigned to part of an RN's assignment who seems to actively dislike me has been beneficial, since I'm spending less time with the RN and more time at the bedside (which is good for building independence). I made sure to run by her the times I was planning on administering Insulin (since students can't do finger-sticks at this hospital). For purposes of this post, we'll call her RN1.

On the second day, I had my two patients from the first day, plus a post-op (Patient Z). I met RN3 who was assigned to the two patients I was already familiar with, and then she was floated upstairs immediately afterward. Change ahoy! The nurse who took that assignment was....the same RN1 from yesterday and last week. Meet the new nurse, same as the old nurse! Last week I dropped the ball on a post-op admission, so I made sure to write down the cellphone number of RN2 (who was assigned to the post-op patient), and coordinate with her to prepare for Patient Z's arrival. Working with RN2 is much different than RN1. She communicates with me much more openly, gives me some advice and direction here or there and helps me be more independent without ignoring me. Another student in the cohort told me they have had the exact opposite experiences with RNs 1 and 2, it seems like with some people it all comes down to their personal "feelings" about you, whether they have 2 years of experience or 20.

Patient X was brought in for cellulitis of the Left Lower Leg, history of a syncopal episode, diabetes, peripheral vascular disease, hypertension, weakness and dementia. Although I'm familiar with the pathophys. of cellulitis, this was the first time someone in my assignment had this as their medical diagnosis. The warmth radiating from the affected tissue was clearly palpable. Since the infection was evident circumferentially around the limb, I placed a high priority on neurovascular assessments of the lower extremities (my reasoning for this was that although cellulitis isn't the same as a burn, there may still be reason to worry about constriction of the blood supply or even compartment syndrome, especially given his co-morbidities). Pulses were auscultated by doppler, and I noted that the affected side was much quieter. Hello bilateral +3 pitting pedal edema (say that 3 times fast)! His orders included elevating the left-lower extremity with 3 pillows. A thorough assessment revealed a reassuring lack of capillary congestion over dependant bony prominences. His co-morbidities led me to make sure his heels were off the bed as much as possible. I had to readjust his pillows to make sure this was done (pedal edema+diabetes+PVD = protect those heels). His chief complaint during my time with him was neck pain, which I addressed with PRN tylanol and warm compresses.

His pharmacotherapy included a couple of novel items for me to look up. He received Namenda (Memantine) at bedtime. "Binds to CNS N-methyl-D-aspartate (NMDA) receptor sites, preventing binding of glutamate, an excitatory neurotransmitter". That's what I memorized in preparation for administration. What I SHOULD have memorized was "Decreased symptoms of dementia. Does not slow progression. Does not cure disease.". It has some hypertensive properties, which theoretically should peak about 3-7 hours after administration. He was also receiving Ketorolac (Toradol) eyedrops for a chronic inflammation of one of his retinas. I believe this is due to diabetic retinopathy, I wonder if the fact that it's happening to one retina and not the other suggests an asymmetry in his vasculature that could have some impact on stroke risk.

My care for Patient X included a lot of reorientation, a lot of time spent sitting down and giving him a chance to exercise his "cognition muscles" through verbal interaction. Although in some senses his memory was poor (couldn't recall his birthday, what day it was or where he was), he remembered making fun of my instructor's hair and felt bad about it the next day. I told him not to worry about it, and we both had a good laugh over it. Towards the end of the second day, I watched RN1 talk to Patient X's spouse about his living will, Patient X tried to enter the conversation but was ignored. I was sitting with him, and he turned to me, pointed to his wife and said to me "that's one hell of a woman. She'd have to be to put up with me. I'm not easy to live with, you know." I told him he's a lucky guy, didn't know what else to say, really. Something interesting I learned listening to RN1 (who also has experience as a visiting nurse) was that people are generally told to put their living wills in a safe deposit box, but not told to keep a copy of it handy. Living wills stored in safe deposit boxes are difficult to retrieve in the middle of the night on the weekend. Something about how the conversation transpired in front of Patient X as though he wasn't there bothered me, but I suppose time is limited and things have to get done with the time available.

Patient Y was Patient X's neighbor, he was in for a Left Total Knee Removal, due to a bacterial infection of his artificial knee. He had been a guest at our facility for 17 days by the time I met him, he was originally admitted for an incision and drainage, which was followed by a removal and insertion of a spacer four days later. He has been staying so long, RN1 explained to me, because he'll only be able to receive the treatments he needs (IV antibiotics) while he's hospitalized, his insurance wouldn't cover it on an outpatient basis. This is the second time RN1 pointed out to me a patient that has an economic, not medical, necessity for remaining in the hospital. "It's the game we play with the insurance", she said to me once again. His knee incision was open-to-air with no drainage. Something interesting about this fellow was a discoloration of his extremity below the level of the surgical incision. The skin was brown/black, a discoloration that began during a hip fusion, during which his left femoral nerve was severed. RN1 was skeptical about Patient Y's reports of pain distal to the severed nerve, which seemed odd to me considering pain can be subjectively experienced even from completely severed limbs. His pain was well controlled with controlled-release oxycontin, but a problem arose before my time with him, when the order for oxycontin expired and no order was entered to replace it. This gave me something to reflect on with my own confusion about how the orders work at this particular site, at the last site the med-loop (including orders) was 100% electronic, when changes occurred it triggered a print-out that was placed in my preceptors (and by extension, mine) wall-box reserved for this purpose. I got some valuable re-orientation to how the orders work here, I think I'll be able to be more independent in this in future weeks.

Patient Z was brought to the unit during my second day, freshly post-op from an incisional hernia repair with mesh. Mindful of past mistakes, I checked in with RN2 frequently to make sure I got report and had a good idea of when he would arrive. We prepared his room together and chatted with the PCT for that room so she would know what to expect. Patient Z was on contact precautions for MRSA, since a previous abdominal wound was infected with that agent. In the past he had a colon resection due to diverticular disease, and a temporary colostomy that was closed two years ago (had a nifty scar for me to check out). Post-op assessments are something I haven't gotten to do many of this semester compared to previous, so I was glad to do it in tandem with RN2. Noting a saturated dressing, we removed the abdominal pads and applied Montgomery Straps. He was medicated for pain with patient-controlled analgesia, the device was loaded with dilauded. While we were removing and reapplying the dressing, even light brushing stimulation of his right-upper abdominal quadrant caused intense pain. What stood out about this guy, to me, was that he was pretty alert and talkative for someone who just had major abdominal surgery. His blood-pressure was low enough for us to hold his prophylactic beta-blockers, but he walked two laps with me without any problems. He told me the reason he felt he was doing so well had a lot to do with his mental discipline from being an athlete during much of his young life. He said that he "felt like crap" physically, but mentally he was well-informed about his condition, experienced with hospital routine, and knew what he needed to do to get better. Most importantly, he didn't "feel bad about feeling bad", which we supposed causes a lot of post-operative patients to have a rougher time than they could potentially have. What was valuable to me about my time with Patient Z was that he modeled some behaviors and attitudes that are highly adaptive to the process of recovering from surgery, which I think will help me model that behavior more successfully for future patients.

I feel good about how things went this week, although every positive gain reveals new ground to cover. Repetition has been the key to building confidence and efficiency so far, and having the opportunity to pass medications on both of my shifts instead of just one has been extremely helpful. I think I'm "over the hump", in a sense, in building the familiarity I need to execute my duties efficiently. I still have a ways to go, but I think I'm moving in the right direction. Next week I'm going to focus on putting all of these pieces together, establishing strong lines of communication with the PCTs and RNs, and "taking control" of the documentation so I know what's going on without having to ask people.

The sort of tricky paradox I'm working with here is that, on the one hand, my major goal for this semester is to become an independent practitioner. On the other hand, I've been attempting to transition into an environment where all of the independence I've built up in a different hospital has been stripped away from me. It's uncontroversial to assert that people behave differently (sometimes radically differently) when they're being observed and actively critiqued, so despite the difficulties it's presented me so far, I think this has been a good way to prepare for being "on orientation" as a graduate nurse. I'm basically re-experiencing the "stage-fright" I had back in first semester -now- instead of when I enter into practice.

4.04.2008

Conventional

Now with pictures!



The Gaylord Texan resort was pretty swanky, but we stayed at a spring hill suites down the road. This actually turned out pretty well, the hotel we stayed at had free shuttles within 5 miles, free breakfast in the AM and free drinks from 5-7 four days a week. The rooms were bigger also! The resort was pretty fabulous, though. The center of the resort was enclosed in a giant dome, with a huge fountain and some interesting illumination.



There was no shortage of overpriced foodstuffs and incidentals.



Our merch table did pretty well, we raised just about enough money to offset the cost of one of the 8 people in our group.



More views of the resort:




Here are some views of the infamous house of delegates, which took up most of my time during this trip.




The resort, of course, had a fancy steakhouse. They also had a wine bar. The prices seemed reasonable at first until I noticed they were BY THE OUNCE!



I spent a lot of my downtime chillin with the AZ kids, I got to check out some restaurants outside the hotel, and saw an authentic texas boot store.




And, of course, what visit to a resort would be complete without the man painted a metallic hue pretending to be a statue:



I seemed to meet interesting people at a more and more rapid pace as the end of the week drew near. I met an RN with a PhD in human sexuality that used to do mobile field-testing for HIV and hepatitis outside of San Fransisco nightclubs. I met a hotel valet conducting his own research into remote viewing and parapsychology (we had a great conversation about neuro-linguistic programming, you can check out his website here), I met a clinical nurse specialist who's dually specialized in psych and med/surg, and dozens of interesting and articulate student nurses.

I think the resolutions process would go more smoothly if the resolutions were made available online in advance of our business meetings. There was too much uninformed debate going on, too many people debating the technically undebatable, a new parliamentarian and chairs unwilling to cut people off when they're polluting the debate. If the resolutions and supporting documentation were made available online, we'd be able to hash all that out in advance of the business meetings, and use that time for more productive debate.

I'm going to try to stay on as a sustaining member, but there's a chance that if I go right into an RN to MSN program, I could maintain my student membership until I'm actually accepted into the graduate school nursing program. These conventions are just fun. Not as much fun as the national nursing professional organizations conventions, from what I've been told by members. Maybe we can change that!

An update on my thoughts about the dominance of the AMA's lobbying machine: There are a lot of issues on which all of the fragmented nursing professional organizations agree, but they all compartmentalize the revenue from dues so no one really has enough money to exert the appropriate lobbying influence. What if all the professional nursing organizations contributed to a central lobbying fund, sending delegates to a meta-professional convention proportional to the amount payed into the fund? Then meetings can be held and priorities for lobbying could be agreed upon in a way similar (but hopefully better) than the process the NSNA uses, except the actions resolved to undertake at these conventions would then directly become lobbying priorities. Just a thought.

4.02.2008

Source of Conflict

This week was another one-day week, due to the stresses of travel and my jealous guarding of my precarious status. The clinical focus this week was Conflict. Given how all of the previous clinical foci had a way of turning up in unexpected ways throughout the day, I was a little apprehensive about what kind of situations would turn up. I'm a conflict-avoider. That may surprise some people, but it's true. At least, according to some test they made me take when I worked at the group-home indicates as much. There was a time when I liked nothing better than to argue with people on the internet, through discussion forums and the like, but now just the thought of that sort of thing fills me with a sort of nameless dread.

The goal for this week was to have a smooth med-pass. That's it!

Client A was in for removal of the hardware in her left knee. There was concern of an infection, so a spacer was placed, and IV antibiotics were administered empirically. There was also a question about MRSA colonization of the nares, so this patient was on contact precautions. She had a long history of knee and abdominal surgeries, history was also notable for osteoarthritis, heart palpitations, depression and sleep apnea. She ambulated to the bathroom on her own, at which point I saw what's probably the worst example of incontinence dermatitis I've ever seen. Apparently, the foley catheter she had before I arrived was found to only be inserted a couple of inches when it was removed, and leakage had resulted in a large, red rash that was darkest in the perianal area but involved the back as well. I applied barrier cream, it took a LOT to cover all of the involved area. Neurovascular assessment took priority for this patient, particularly that of the left leg. My other chief concern for this client was skin integrity. That contact dermatitis, although blanchable throughout, had the potential to become one nasty sore. The client reported that she'd been spending all her time on her back, and that she couldn't rest comfortably on her side because of her knee pain. Fortunately, she was able to reposition herself pretty independently, so we worked together to find a good body position she could maintain restfully for an hour here and there. I could have -sworn- I saw an order in the chart for the use of an abductor pillow, and I mentioned this to the RN. She had one sent up from sterile service and we tried it out while she was in bed. She said it was comfortable at first, but then later elected to switch to a regular pillow between the legs. She had extensive pharmacotherapy, including a huge dose of seroquel, lexapro, lamictal, mirapex (for restless leg) and restoril (for sleeping). Her chart indicated that she is -not- med-naive by any means, but since the exact combination of medications is somewhat different for her in the hospital, I made follow up pain, neuro and respiratory assessments a high priority. A potential conflict with the RN arose over her assertions that this patient "Asks for her PRNs like clockwork", and suggested that I tell her that her pain meds were q3h instead of q2h. I thought this was an odd suggestion, and chalked it up to that RN's personal style. In my pain assessments I found that the client knew full well what her PRN schedule was, but at the end of the shift, the RN was suprised to discover that she had not requested every dose of her medication, which was the RN's goal for her. The client DID request her nighttime toredol IV-push, which was administered by the RN. I think the client and I worked well together to find strategies to minimize her discomfort, and that's why her PRN use was less than the RN expected.

Client X was a gastric bypass patient on post-operative day number one. She was behind on her clinical pathway, I think her history of multiple spinal fusions, status as a chronic pain patient and arthritis all contributed to a difficult recovery from surgery for her. My initial assessment found positive bowel sounds in all quadrants, a pleasant surprise for me since her last assessment by an RN was recorded as absent bowel sounds in all quadrants. She was on clear sips of liquid, 30ml an hour, which she recorded herself at the bedside. Our main priority with her was getting her up and walking. The anti-nausea medication she received made her sleepy, so she required some redirecting to get her out of bed for her second 3-laps of the unit for the shift. I made sure to walk with her to ensure stability, once she got herself moving she was stable and completed all of her expected ambulation easily. The care of this patient resulted in a conflict. At this facility, only staff RNs can collect blood sugar samples, and as the time to administer insulin came and went, the client's RN hadn't collected the sample yet. I made the mistake of telling her that the Insulin was overdue while she was eating, and she was extremely hostile to me afterwards. I apologized and spread my hands in acquiescence, and the rest of my interactions with her for the evening went on like the event hadn't occurred.

Finally, we have Client Z, another part of the previously mentioned RN's caseload. She was held in the emergency department for an "unknown" length of time, until enough time had passed and enough medications had been administered and enough treatments had been performed to "justify" admitting the patient to our unit. The RN explained that this was the "Game they play" with the insurance companies. After the fact, I was informed that the patient arrived -before- I went down to the meal. I don't have any memory of this now, but the sequence of events was somewhat jumbled in my mind. The RN conducted the assessment without me, I should have stuck around for longer until the client was situated and assessed to be stable. This client was PSTP from a laproscopic ventral hernia repair. What concerned me most about this patient was her sommnolence. After the RN pushed dilauded through the IV site, the client started nodding off in the middle of eating her juice-pop. I stayed with her a while to help her stay awake long enough to finish the pop (and not smear herself with the juice), and spent some time listening long and hard to her breathing. What concerned me most was the periods of apnea. I didn't see sleep apnea in her history, but she would have a good 12 resps per minute, but interrupted by 10-20 second periods of apnea that would end with her waking up, slightly startled. She was well oxygenated on 2L of O2 via nasal cannula, and exhibited brisk pupil responses and round, open, non-pinpoint pupils, so I was somewhat reassured by my assessments of her.

My plan to have a better pair of shifts next week is to ALWAYS CHECK THE NAME BAND FIRST before I do anything. Everyone I've talked to, be they nurses, paramedics or doctors, stress this as the most vital step in preventing medication errors. I also need to improve my communication with some of the RNs, the co-assigned RN for two of my patients in particular. Being a conflict avoider, I usually react to coldness or distance in-kind, I have to make sure I don't let someone else's stand-offishness control how -I- communicate.