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.

Community Health ...TNT Health Clinic

It was a bittersweet day ending out little clinic in the transitional homeless community, where we open for business and do assessments, administer OTCs and triage. We stocked up the medicine cabinet, cleaned up and put out a new sign that read, "while TNT clinic hours are done, we will be back as nurse volunteers throughout the winter to assist you with your health needs. Look for our doors to be back open in November.

We spent the last week doing a lot of patient teaching, handing out OTCs for colds, muscle aches and even assessed a client who had been in a motorcycle accident. Our clinic room houses educational materials, an examination table, medicine cabinet, scale and two desks where we park it during our clinic hours. We did smoking cessation, Hepatitis C education, followed a skin cancer patient and handed out goodie bags. We decided we'd partner up with the Recreation Social Worker intern and do a couple movie/education nights in the Rec Room in Nov. just to get people together and talking about their health. We were able see our regular HTN/diabetic patients and get a lot of homework done. There is something about an open door that says c'mon in, because people came by to talk and we listened...because that what nurses do.

57 Days to Pinning....

We are planning our class pinning ceremony with all the zest of people who are about to be released from captivity...not necessarily the serious POW kind, but in a sense, the walls of our classroom have no windows and some days feel like hostage crisis, Day 283, especially today. So with a little creativity and somewhere sandwiched between mental and community health, a couple classmates put their photography skills to work shooting headshots and candids of all our classmates for our pinning ceremony, to be held on Dec. 10, 2009, approximately 57 days from now (not that I have a countdown on my lap top or anything like that!)

As we approach this milestone, thoughts about the people I've shared my life with over the last 283 days are fond. We navigated some serious landmines in theory and clinical, shared a lot of laughs and tears. I made friends in nursing school that will be life long friends, professional colleagues I know I could turn to in a crisis. ABSN programs are unique nursing programs, pouring out insane amounts of learning wherein 38 adults from all walks of life, dedicate a year of their lives in pursuit of a common goal, supporting each other, knowing what we have emotionally, physically and financially invested in this journey. I can't begin to count the sacrifices we and our loved ones have had to make in order for us to get to this point. These are the best people...super human student nurses, supported by super human family and friends. The nursing profession is going to benefit from the heart this ABSN centennial class will bring to it. That's not to say there haven't been moments of sheer irritation. It's a lot like family.

Breathe. The roller coaster is starting to slow down. Hallelujah.

Psychiatric Nursing ~ Can we talk?

Psych nursing is different. You have the med room, the nurses' station and the hallway. Interspersed are bare bones rooms without any exterior trimming to allow for someone to harm themselves. The inpatient facility where we are rotating resembles a really old prison ward. There is a day room and a TV room. The facility is locked down and the LPTs wander the halls looking after the clients. The clients have access to meds (which they obtain at the nurses' station) from the med room nurse, and they have access to television. Other than that, there is groups during the day to attend, and meetings with psychiatrists/conservators and family members. If you are not insured, this is where you go and to be honest, if it were not for the generally optimistic people that work there; hell would be a picnic. Comrade X talked once about how painting a psych intake room the color pink would, in effect, calm a patient who was in crisis. After being in the concrete walled rooms of this facility, especially the intake/isolation rooms, I got the picture and thought it was research worth looking into. I've seen better dog beds at Costco. It's a sad indictment. Luckily, the best thing going at this agency, are the employees and it seems the long termers...the nurses and social workers, truly care about the patients.

My last day of clinical involved interviewing a paranoid schizophrenic patient with a long involved psych history and drug abuse history. This patient also had a history of violence and conduct disorder as well as developmental delays. It was not a situation where you would sit down and talk, much like the patients I met with who had major depressive disorders, bipolar and personality disorders. This patient was suspicious and tentative, was careful to keep his distance and took a very long time to get comfortable with me. I sat across the room so that he could get his bearings and then waited. It was a long wait. When he was ready, he talked. I didn't ask a lot of questions, because I noticed one thing about this patient that I had not experienced with any of the others...this patient made no sense at all. Disjointed sentences, with little connection between first and second thoughts, subject verb agreement, word salad...people inserted into thoughts that had no congruence or meaning. "I worked at a top secret place, my land lord dipped me upside down into a vat. She does not hear me. It didn't burn it did. He will kill me. They kicked me out. My parents are dead. I was adopted. I saw my dad today. I have 4 brothers. 2 brothers. Four years....and...."

This went on for an hour. Any attempt to redirect failed. Any thought became negated by another or an illusion. He could not maintain eye contact as he was always checking around us to see if I had moved was planning to move, or if someone else was coming. The affect was guarded and tense. As long as I wasn't talking, he was calm. It became apparent that interactions on the simplest terms could affect these patients dramatically, as if their sensory perceptions were all on another plane or out of whack or heightened or lessened.

I waited a long time to write about this because I realized that there was absolutely nothing I could do first as a student, or as nurse, other than listen, redirect, listen, accommodate and accommodate. Nothing I said mattered. I haven't been around someone whose defensiveness was so palpable. It was an interesting learning experience that I won't soon forget. Mental illness can not be dismissed or trivialized. How we deal with the mentally ill in society is certainly an ongoing subject that needs to be addressed, because obviously not much is left for the mentally ill other than hopelessness, despair, long roads and new challenges.