It's Pat!!

I've known a few Pat(s) in my life. My father in law & brother in law, my next door neighbor's mom (when I was growing up), and my favorite professor who was my medical terminology instructor at CRC are all "Pats". The television series, Saturday Night Live poked fun at the unisex nature of Pat & the confusion over whether Patricia is really a Patrick and vis versa. Today in lab, we had sim-Pat. Our procedure was to intubate him with a nasogastric tube for suctions, feedings/medication administrations etc.

The roadies had watched the video over the weekend and were anxious to see how we'd do in the simulation of it. Essentially you have a patient in bed (sitting up) in what is called a high Fowler's position. Pat was conscious (as much as a dummy can be) and part of it was working through the approach to prepping for the procedure, explaining it to the patient and gaining their trust and cooperation, "Ok, Pat, I'm student nurse. I'm going to stick this long piece of hose up your nose & down your throat...which will pass along your oropharynx and into your esophagus where it will enter into either your stomach or your lungs. I am going to shoot for the stomach - but I want you to hold up your index finger, if something doesn't seem too right, you just let me know..but...first thing's first, I am going to make this tube nice and slippery, ask you to tilt your head back and when it hits the back of your throat and you feel the gag reflex, I'm going to have you tilt your head forward chin down, while sipping this water, which will help the tube slide down the back of your throat and into your stomach."

Piece of cake. Right.

Once the tube is in the stomach, the nurse then verifies that the tube is in the right place. The process involves pushing an air bolus through a syringe into the tubing while auscultating (using the stethoscope) the stomach to see if you hear a swoosh. After that, the nurse aspirates gastric juice to assess it visually and either re-injects it and/or tests the gastric fluid's pH. If that doesn't satisfy the nurse's assurance of the tubing arriving at ground zero, then radiology will bring up a port and confirm placement with an x-ray. Whew. I'm feeling a little sweaty.

After securing the line, everything is charted. Rechecking placement occurs often & according to suction, feeding and/or medication schedules.

The class was so focused on Sim Pat's throat, we didn't know he was a she until we went to ausculate 'his stomach...that's when the big reveal occurred. Whoops. Hello Patricia.

Just when you think you've seen everything

The way the roadies are coping with the workload is dividing and conquering the reading through outlining and presenting. This is helpful when approaching quizzes because its easier for me to remember that Pebbles talked about Integumentary, and Bam-Bam's chapter was on the heart.

My chapter this week was about the breasts. When I think about breasts, I tend to focus on BSEs (breast self-examinations) and the methods we use to evaluate them. The common methods noted in the text are the Circular, Vertical and pie methods; the medical standards for assessing breasts. However, in outlining the chapter today I came upon a phenomenon I had no idea existed and one that nursing protocols insist we assess - that of multiple nipples...or supernumerary nipples. Not only can you have them on your chest in different places, but they can even grow on the bottom of your foot! Whoa. Just when you think you've seen everything...

Palpating the peeps

Having TAs for labs from the ELMSNs program has been great. They have one year on us, having been in the clinical setting for several months now. They are prepping for the last of their pre-licensure work, so their tips for doing things are fresh and insightful. It gives them opportunities to teach and mentor and gives us the perspectives we are craving, facing the uncertain days ahead in clinical. The Roadies were discussing how confident the ELMSNs students are now that they have been student nurses for one year. They reassure us by saying we will be the same way too, and sooner than we think.

For instance, a good example of this was during our health assessment lab today. We all had to practice and demonstrate head-waist assessments, verbalizing our thought processes, using the appropriate medical terminology and techniques, while modeling how one comes to certain conclusions on what they are feeling or seeing. I liked this exercise because it allowed us to not only make objective observations (mostly we were observing a lot of "normal" things), but we were also learning about how assessment is so important to the nursing process. We keep talking about how early intervention saves lives, and assessment is a big piece of this. Thinking critically about how someone looks as their status is changing, avoiding a full crash by recognizing signs and symptoms of "going south" and how things look, feel and sound abnormal.

Perhaps the most compelling thing I discovered this week in the reading was how one important assessment tool could have been utilized on my Dad pre-op in 2005, which might have prevented his surgical complications. There is a technique of assessing the ankle-brachial indexes for a high risk patient that helps spot signs of peripheral vascular disease..by taking specific blood pressures and using dopplers at the posterior tibialis and dorsalis pedis pulse points. The test is also helpful in diabetics who present with vascular calcifications. These assessments show whether someone might have problems perfusing O2 or if they exhibit signs of PAD. I can't help but wonder if some of these specific assessment tests had been done on my Dad pre-op, would it have been a good indicator for the use of Lovanox during his AAA repair...but hindsight is 20/20. The only reason I make this comparison about the use of mild amounts of anticoagulants during surgery, was due to the fact that it worked so well a couple months ago and he had such an excellent post op course.

Personally as a patient, I've never had the kind of physical assessment that we are doing on each other in nursing school. This leads me to believe that at some point, people cut corners, recognize obvious things only, and fail to see what may be hidden most of the time. Another student made the comment that she has caught things on rounds that staff RNs have not, only because of the prep she has done at school. Let's face it, students are more eager to do well, spend more time with their patients and are open to learning. At what point does the apathy set in and what should the nurse do who is burned out? I guess each person has to answer that for themselves. I know we are going to run into the super nurses, the ones who like students and want to teach them the right way to do things. I also know that there are going to be difficult people, like anywhere else, who would rather see anyone-except a student on their units. I guess the best approach is the diplomatic approach and when someone wants you out of the way, "step aside". In the meantime, Ms. Pebbles..appears alert, oriented X3 and resting.

We found some nice polyps, enlarged taste buds and a deviated septum today. It was interesting to discover that crepitus can be felt in/around the thyroid gland. The work we are doing on each other is giving us a good idea of what abnormal will look like once we get into the Skilled nursing facility and on our clinical rotations at the different agencies (that's ANA-speak for hospitals).

The feedback from our TA was very helpful today...and palpating the peeps never felt so good. (in a purely professional sense...you know what I mean)

The final analysis...anyway

People are often unreasonable, irrational, and self-centered. Forgive them anyway.

If you are kind, people may accuse you of selfish, ulterior motives. Be kind anyway.

If you are successful, you will win some unfaithful friends and some genuine enemies. Succeed anyway.

If you are honest and sincere people may deceive you. Be honest and sincere anyway.

What you spend years creating, others could destroy overnight. Create anyway.

If you find serenity and happiness, some may be jealous. Be happy anyway.

The good you do today, will often be forgotten. Do good anyway.

Give the best you have, and it will never be enough. Give your best anyway.

In the final analysis, it is between you and God. It was never between you and them anyway.

-this version is credited to Mother Teresa

____________________________

2. The Original Version:

The Paradoxical Commandments

by Dr. Kent M. Keith

1. People are illogical, unreasonable, and self-centered.
   Love them anyway.
   
2. If you do good, people will accuse you of selfish ulterior motives.
   Do good anyway.
   
3. If you are successful, you win false friends and true enemies.
   Succeed anyway.
   
4. The good you do today will be forgotten tomorrow.
   Do good anyway.
   
5. Honesty and frankness make you vulnerable.
   Be honest and frank anyway.
   
6. The biggest men and women with the biggest ideas can be shot down by the smallest men and women with the smallest minds.
   Think big anyway.
   
7. People favor underdogs but follow only top dogs.
   Fight for a few underdogs anyway.
   
8. What you spend years building may be destroyed overnight.
   Build anyway.
   
9. People really need help but may attack you if you do help them.
   Help people anyway.
   
10. Give the world the best you have and you'll get kicked in the teeth.
    Give the world the best you have anyway.

Cry baby

I hit a wall this afternoon and wondered what the heck I'm doing. I feel like I'm totally in this washing machine that I can't get out of. I stayed up late studying..watching skills video that made me laugh. (Demonstrations on how to brush and comb someone's hair and clean their dentures) It felt insane to watch a step by step procedure that any monkey can do (i.e. "use careful brush strokes first horizontally and then vertically, spritzing and arranging....) Like an episode of Twilight Zone where I landed on a planet where no one knew how to brush their teeth or comb their hair and the only person who could was Nurse Betty who was holding classes at the Y for $59.99 on how to brush your dentures. In the video, Nurse Betty was providing oral care to her comatose patient. It was all so Marcus Welby. I thought to myself, I don't remember once...not once, that a nurse did this for my Dad during his 3 month stay in the hospital, not even while he was in the ICU. In fact, the first thing he did when he "came out of it" was sit up in bed and brush his own teeth. I remember writing a column about what a freaking miracle it was to see my Dad escape from the the throes of death and brush his chops; Monday - he gets last rites...by Friday, he is brushing his teeth. As we sat around crying with relief at the sight of him brushing his teeth, his nurses stood around looking at us like we were crazy. Were we the only ones who knew a miracle when we saw it?

My aunt (who is more like a sister to me) called last night and wanted my advice about Grandpa, who is dying in the hospital ....I shut down. I was outlining chapter 15 in Health Assessment about the peripheral vascular system and all these memories flooded back about Dad and those long days in the hospital...like PTSD and overwhelmed me. Can I do this again? Will I be a good nurse? Or is this a big act and someone will walk up to me and say, "you can't do this...you won't do this...or we don't do things like that anymore - we just CYA on the medical charts"

Sometimes, I wonder if I have just gone down a rabbit hole that I don't belong in. The really hard part of being a nursing student in an accelerated program, is that so much is last minute - repetitive or too much and the difficult days of school haven't even started yet. I want to be nurse. I don't want to write a paper APA style. APA? I thought I left all that behind in 1985. We had a three hour lecture on APA. I want to do what most nurses don't have the time or patience to do...take care of sick people. Wash their hair, brush their damn dentures and teeth (even when they are in coma), give them good ADL care, even help them manage their toileting (something no one wanted to do for my Dad). Tell me now, if I won't have time to do that. Tell me my patient will be my patient and not the chart. I don't want to work with people who don't want to be there, who resent sick people and their families, who hate their colleagues who do care about the little things like pain mangement, and comfort care. I already did the medical - legal thing. I don't want to be a claims person again. I took a quiz on the law and almost feel asleep. I know this stuff is important. I know you aren't supposed to slap your patient, restrain him against his will or talk about him to other people. I only got an 80% on that stupid computer quiz that took over one hour. How does this validate what kind of nurse I will be? I want to take care of sick people. What a cry baby.

Seven habits of highly effective nurses

.......who do we want to be when all is said and done?

1. Proactive
2. Thinking ahead about the last thing - Seeing the big picture - the finish line
3. Thinking about the first thing - Understanding why you are doing something
4. ~ Collaborating ~ Seeking out the Success of Others ~ Team Building
5. Exhorting/Encouraging ~ our clients and our colleagues
6. Mentoring and Educating ~ those behind us and those in front of us
7. Reforming ourselves and our profession



Good luck to all the Kaiser scholar candidates as you interview tomorrow. All shall be well!

Shut your boca...and when to speak up

Something struck a chord with me today probably because I am an older person. I guess nothing you do in school can prepare for the circumstantial things that will stay with you in clinical. For instance we were in lab doing assessments (this is the practical applications of nursing without real patients~but scenarios and role playing ...I think that's probably why I was such an intuitive claims person and fraud investigator, I loved putting the puzzles together and I played with a lot of barbies when I was young, so there was hours of role playing. Today, we did vitals again and also pain and skin assessments. Hospital Barbie (I thank you) and all those little old people at PVCH who put up with me when I was a CNA kid.

When you are in pretend situations, story telling comes out of real life experience and so we get to hear a lot of war stories from more experienced student nurses and instructors. I like the war stories because they bring the theory down to tangible learning...I call that my 'note to self' moments...for instance, so-so told me she did this...don't do that! Or so-so told me about a great thing she or he did, I am going to file that away for future reference - remember to do that! That's the primary reason mentors and preceptors are so important when it comes to the healthcare professions.

The war story I heard today reminded me of the days I spent in the hospital with my Dad and daughter. I learned more from seeing how good nursing affects outcomes and how bad nursing makes the situation worse. One of the stories we heard today was a nursing student who was doing a dressing change on a patient that was a terminal patient who had all kinds of multi-system complications, including lesions, organ failure and intractable, excruciating pain. The student didn't want to change dressings without providing pain relief prior to starting procedure (essentially wanting the patient medicated 30 mins before) and the supervising RN working with the patient said no. No reason, no explanation..just no with a cursory intonation "don't ask me why, it's none of your business...get to work"

How to handle the difficult people...the politics of students/nurses/faculty and then the ethical issues that come along with what one perceives to be their primary responsibility (the patient)..why these should be in conflict is a mystery to me when you consider that the new wave of healthcare is supposed to be collaboration and team building. Are we that much of a threat to someone's ego, that patient care gets compromised? Is it politically incorrect for me to even think that this is some sort of travesty. Am I an idealist student nurse who will soon be a burn-out? Doesn't it seem reasonable to think that with a little prioritizing and planning that we will have time to provide pain relief prior to dressing changes or will we stop caring about these minor little details. It seems to me that the nurse who had this patient, had little time to either pay attention to the student nurse, the patient or what is the best practice. Does this happen to everyone at some point? These are all hypothetical questions that our whole group talked about today.

We talked about whether it would be a good idea to speak up, because after all, we are supposed to be advocates. Who knows when to shut your boca and when to speak up. I've always spoken my mind (not in a harsh manner, but asking questions in a probing way that seeks to clarify a purpose - we are supposed to do this as students and patient advocates). When to speak up...? I guess I'll find out for myself as time goes on, whether I will have to shut my boca or speak up. In effect, we need to challenge ourselves to ask questions in a manner that is non-threatening or in a way that seeks to clarify a procedure or the best way to do it. Right now, I think diplomacy goes a long way, whether you are a patient's family member, a friend, a colleague or a merely a student nurse. I pray I have the patience to listen when it's my turn, be patient in the process and grateful that someone else has provided input. It could mean so much to a client, having the courage to speak up in a diplomatic way without calling someone's expertise into question.