Catching the ball....run Forrest run.

The last few weeks were difficult for our unit. We lost three patients close together. Two of the three patients were patients my preceptor and I had the weeks before. Nursing puts us all in that delicate position of helping people at their most vulnerable hours of sickness and death. One of the unique aspects of what we all do, is that when we go to work, we never know what the day will bring.

This week, however, my preceptor allowed me to take the ball and run with the patients I wanted. I always try to challenge myself to pick patients who are the "sickest"...however, in oncology, everyone is usually pretty sick, so the two I picked this week were a great opportunity to exercise old skills learned in med-surg. Taking and giving report, assuming total care, planning, assessments, interventions and evaluations. How would I plan and approach the day? Since I had good role modeling from my preceptor, I decided to use "her" method and hit the ground running the way she does. We round on our patients in the AM, pull labs and meds and bring everything at once to do assessments. This allows for the unexpected admission in the morning, the surprise fall backs and any other delays that frustrate any nurses' best laid plans. It also allows us plenty of time in the room, avoiding the back and forth. So, while one med is running over 10 mins, I can assess other things, do a little teaching and reassess before the next one is given.

The oppty to reconstitute and administer meds, try things with patients with my PRNs to see if they would help. These are all the things I love about nursing and of course, patient teaching. I know I probably won't always be this optimistic, but I like to see nurses who still love what they do 20 years later. It is the kind of nurse I hope to be.

While my patients weren't as critical this week as they were in the previous two weeks, I loved the independence of trying to do everything on my own, classifying, and getting all my charting done and being able to measure over the course of several days how decisions I made, impacted my patients. Running never felt so good!

Seeing the big picture.....at the end of life.

As a student, learning in the Hem/Onc/BMT unit has been a positive experience primarily because we care for the same patients over a longer term. In many case, patients are in for new diagnosis, post operative, and/or being stabilized towards going home, the outpatient setting, or they are inpatient due to relapse and now our goal is to help them transition toward death.

I've had several opportunities to work with patients who are new to their cancer treatments and those who are at the end of life. Perhaps the most difficult case I've had over the last two weeks is a female patient with Ovarian cancer/mets throughout, whose spouse is in the worst case of denial I've ever witnessed. The patient has intractable pain, unable to tolerate any intervention including sips of water or touching her, and the poor spouse is thinking the next ABX or blood transfusion is going to be the magic bullet. I know how hope and faith serve in rescuing our loved ones in crisis, but this patient had already crossed those turning points. Her body was fighting every intervention and was shutting down in violent opposition.

This has been going on for months...with the last month being the most painful: 3+ pitting edema, an abdomen 10X it's normal size, full of cancer. While I was changing and packing her open abdominal wound yesterday, I told her that she needed to get him ready and tell him what she wanted (she wants hospice..he wants her to eat and gets mad at her for not eating. He wants PT to work with her and she is no longer able to bear weight on her joints and cannot tolerate being elevated or turned in bed.) She cries that he doesn't listen and refuses to talk about it. I told her that it is difficult for him to let go, and she needs to help him.

The situation is like a big elephant in the room everyone refuses to acknowledge. She doesn't want anyone touching her due to her intractable pain, but yet, she is a full code, meaning that when her BP, heart rate and respirations slow down or cease, our response is to intervene with full force, including but not limited to CPR, chest cracking/opening/manual massage, mechanical ventilation, vasopressors, fluid resusciation etc.)

Nursing is struggling with this particular patient because medicine has been slow to address it with the spouse. Social work is waiting for nursing and nursing is waiting for medicine and this patient potentially could code any hour and the husband is still thinking his wife is going to beat the end stage diagnosis/prognosis.

Yesterday, the chaplain came by and wanted to know how she was doing. After reviewing the case with him, he took the husband aside and asked him to consider making his wife a no code, explaining what a full code would look like. A body FULL of cancer that has intractable pain should not be cracked open, compressed and pushed full of more fluids. The amount of intervention in a full code would be agonizing for the dying patient. I also talked to the patient about the importance of getting her husband ready...telling him, even though it would be hard for him to hear it, that she wanted to die, that she was ready to die. The body goes through the shutting down process and she has already started that process.

Death is the big elephant in the room that nursing in concert with medicine and psych-social, needs to acknowledge in unison, in order that we might more effectively guide our patients toward the end of their life in a manner that promotes for their optimal comfort, preserves their dignity and assists their loved ones in their grief toward acceptance.

PS: I got a call from my preceptor today that this patient passed away last night, just a few hours after her code status was changed from full to DNR. I was grateful to hear that she passed away peacefully in her sleep, which was the last thing she said to me, "please...let me sleep".

Comprehensive RN Exam - ATI graduation assessment

Most nursing schools require that you demonstrate a certain competency in all nursing subjects prior to graduation. It is the precursor to the NCLEX exam administered by the Board of Nursing. In fact, when you finish the assessment, it scores your assessment against all students taking the exam and predicts the statistical probability of whether you will pass the National Boards on the first attempt.

I started studying for this in October and was cramming up and until late last night, with a quick review this morning. The exam was three hours and I took it this afternoon.

With great relief, I passed the exam, 4 percentage points above the national mean and a 95% statistical that I'll pass boards. Kaplan will be my extra insurance policy and brushing up on topics I missed on ATI will help prepare me for Boards. Thanks to St. Joseph of Cupertino for the help. I guess I can graduate now. Whew. (The film of his life is called 'The Reluctant Saint") It's a great story.

Let the Precepting Begin!

First day of clinical, we hit the ground running with(3) patients right off the top and actually, it turned out to be a great shift. Two cancer patients and one post op Crohn's patient. One of the cancer patient patients was post op bilateral mastectomy/lumpectomy; the second patient was a new acute leukemia diagnosis (2nd day)..which for me was a great opportunity to provide time to the patient and spouse to do some psych/social counseling and research on support groups. The patient happens to live in my neighborhood, so it was great to be able to tell her about Marshall Hospital's leukemia group which she and her husband can attend when she gets out of the hospital. It was also a great opportunity to share with her a copy of Bev Hall's book ~Surviving & Thriving (*thanks to the class for donating these!) The raw grief of the new diagnosis was something I hadn't experienced yet as a nursing student even though I spent alot of my med-surg time on the oncology floor @ Sutter Roseville and a lot of my peds time with the onc patients @ Sutter Memorial. One of my objectives was to work with a patient with a new cancer diagnosis & already this happened the first weekend of precepting.

It wasn't that long ago that I recall getting bad news about someone I cared about & how devastating that can be when you first hear the news. I could see it on the face of my patient and her husband. One minute you are walking the dog at the dog park and the next minute, you are unable to walk, your husband is taking you to the ER and the physicians are telling you that you have LEUKEMIA. *this is what happened to my patient. For a very active 67 y/o female whose been married for 45 years and living a very fit lifestyle prior to two days ago...this was very devastating. To be the nurse that cares for this person up front, is a privilege...there is a lot that can make the transition easier or even more devastating. The 1:1 time I had with her today was very rewarding. I was grateful for the opportunity to have that very intimate contact as a nurse.

It was fun to do procedures today. It was fun passing meds, assessing all three patients and learning all about blood products from the order verification/laboratory verifications and how the PRBCs are primed with NS and administered.

The best part of the experience for me was working with a preceptor who is also a SMU alumna from the ELMSN Case Mgr. program. She has been am RN for the last 18 months and loves working with students (lucky me).

To say that I love the teamwork on this unit is an understatement. I know I am going to learn a lot.