Spring Break? Are you out there?

Oh my goodness! I'm tired. This is intense. I'm realizing that it's not actually the intensity of school that's killing me, but the need for endurance. I've always been a sprinter, but I thought that was only for running. Apparently not. Nursing students are just working at a high level of activity...all the time! It kind of goes like this: 

ME: ok. I turned in my research paper, so now a little break. 

school's response: NO, YOU FOOL! There's a midterm on Monday!

ME: oh, so then Monday afternoon?

response: Have you forgotten you have pt teaching at post-conference on Tuesday!? and how                       about learning your pt's meds for this week? You think you'll get that done by                                 watching The Office?

ME: oh, right. I forgot those things. Ok, then, for sure after Wednesday I'll be golden.

response: JUST KIDDING! What about that other midterm next week? Then it's practically                         finals, so you might as well just forget about it, sucker! You're DESTINED for fatigue!

ME: whimper...

      

Hodge-podge

Since my epigastric pain pt was D/C'd on. So, I got someone /c MRSA (methicillin resistant staphylococcus aureus). Med Dx: aspiration pneumonia. Also presenting /c hypotension & tachycardia probably secondary to dehydration. Also /c Hx of non-Hodgkins lymphoma, and here's the string of events: non-Hodgkins lymphoma --> Tx (treatment) --> esophageal striction (from the treatment) --> aspirating food, etc --> aspiration pneumonia --> Tx /c balloon esophageal & vancomycin x2 weeks via PICC line.  I don't really remember anything about this pt b/c I didn't do my careplan on this one, and I was helping the nurse /c his other pts too. But this one was definitely Contact Precautions.

However, one I do remember a bit better was the man who came in /c aspiration pneumonia d/t esophogeal stricture as result of radiation for non-Hodgkins lymphoma. He also had a PE (Pulmonary Embolism - a blood clot in the leg, usually, that dislodges and goes to your lungs. Not good.) He also happened to be an IV drug user, so he had lots of advice for the nurse as how to best administer his IV meds.

"I'm not diggin' that idea"

Week 2: 70 yo female

Med Dx: chest pain

PMHx: CHF (chronic heart failure), CKD (chronic kidney disease), HTN, DM Type II,  Hyperlipidemia, LBBB, Hyponatremia, chronic epigastric abd pain, anemia, atherosclerosis, allergic rhinitis

Isolation: standard precautions

This lady was admitted for chest pain, but as you can see, she has a host of other problems as well. The two main problems for her this week were her epigastric pain and CKD. Though she came in /c chest pain, that must have resolved pretty quickly b/c every time I did a pain assessment she said her only pain was the abd pain. (Btw, chronic epigastric abd pain is like a burning feeling in your gut d/t over production of acid. Protonix is a good med for reducing this excess acid.) Here's my SOAPE note for her abd pain:

S - pt c/o burning abd pain x1 week. pt states: "it burns, especially after I eat".

O - pt frequently mentions abd pain. pt no grimacing or showing other signs of discomfort.

A - abd soft, not distended. BT audible.

P - admin Protonix (40mg - schedule 0900 med). re-assess pain in 30-60mins /p admin.

E - Gave Protonix (40mg) @ 1000. 1045: following med admin & breakfast, pt reports burning pain decreased. 1230: reassess pt's pain, and pt reports not pain.

Problem Solved. :) The Protonix seemed to help and she really wanted to go home, but really, she also needed kidney dialysis (d/t the CKD). She really wasn't diggin' this idea, although she already has the fistula for it. (Fistula: this one was in her L arm at the elbow, near the area where you would have blood drawn. To make it, the surgeon connects an artery to a vein. The blood moves very turbulently through it, called "bruit", pronounced broo-ee, which you can feel, and hear (with the stethoscope). Anyhow, she "won" this battle and went home saying she would think more about dialysis.

                                         

There's a Rumbly in My Tumbly

week 1: 77 yo male. 

Med Dx: gastroenteritis, tachycardia, dehydration

Isolation: contact precautions (gown & gloves) d/t possible C. diff infection

This guy came to the ER from a SNF (skilled nursing facility. i.e. nursing home) /c S/S of the above. The tachycardia is why he's on Tele. Apparently several other residents at his SNF also presented at ER with same S/S, and so, he was tested for C. diff infection. His dehydration is probably related to his gastroenteritis (diarrhea, which gets rid of fluids fast), and OA's tend to drink less water anyway. It was also noted that the gastroenteritis was the suspected cause of the tachycardia (SVT-supraventricular tachycardia), which was resolved after 12mg adenosine & amiodarone gtt. 

Clinicals

This week was the first full week of clinicals, and I'm lovin' it! I'm on Telemetry (cardiac) floor, which is not too intense, but exciting none-the-less. I like having a variety of pts, and more acute problems to deal /c than in the nursing home. The Tele unit if for anyone who needs to be on a portable heart monitor, which includes some surgery pts (i.e. those who had nasal surgery), so not everyone here is a potential MI. Many of the pts have Chief Complaints pertaining to something entirely different from cardiac, but they have some cardiac component. For instance, one of my pts came in /c gastroenteritis but was on Tele b/c he also presented /c tachycardia. It was determined that this was likely d/t the gastroenteritis...

Medical Jibberish

I've decided to make a list of terminology and abbreviations I use in this blog:

/c = with

/s = without

/a = before

/p = after

d/t = due to

r/t = related to

AEB = as evidence by

Dx = diagnosis

Tx = treatment

r/o = rule out

Eh, that's all I can think of now

Work Avoidance Report Card

For Christmas, I received a "Work Avoidance Report Card". At first I was only slightly offended: "I am not a procrastinator!" Then I quickly realized that it really could be a guide to more productive non-productivity.

Light Sabers and Force Fields

Lately, it's all about Sterile Fields. So naturally, Star Wars came to mind (I don't even know why though. I don't even like Star Wars...or Star Trek for that matter). Anyway, the Sterile Field is kind of like a Force Field of sorts. Well, I dunno. Maybe it's not, but it's sacred anyway...you've gotta keep it separate from everything that's not sterile. 

Hmmm...maybe it's more like magic, b/c a lot of things just seem to magically become sterile (i.e. we "consider" various things sterile). Clearly, things that are pre-packaged sterile (like sterile gloves, catheter kits, etc) are sterile, but other stuff is just "considered" sterile (i.e. b/w your collarbone and your waist or the table is sterile, but anything outside that is not. Your armpits are not considered sterile...even if you use deodorant. 

If you even touch the air outside this Sterile Field with something sterile, cuidado! you have just broken the Force Field; the Siths* are gonna take you out! It's suicide to even think about moving something not sterile through a sterile field. That'd be like, I dunno, leaving the house without your Lightsaber...or your cell phone.

*I'm really not a Star Wars nerd. I had to Wikipedia that one.

Just Because We're Not MDs...

I hate Care Plans!...particularly the Nursing Diagnosis. When ever we're told to do a Care Plan, I think, can't we just skip this and send the pt a "Get Well Soon" card instead? Ok, I know they're important, but what a round-about way of saying what's wrong with the patient. I guess in some situations it may be more helpful like for emotional/psych issues, but what about for someone who has a Fib/Tib Fx. Let's do a Care Plan for that one, shall we? 

Nursing Diagnosis: Mobility: Physical, Impaired.   r/t: pt remaining in bed x3 days (wonder why? read further...as evidenced by: (oh, there it is) BROKEN LEG! (but we can't actually say that b/c we're nurses and only docs get to really say what's wrong with someone.) 

I mean, I don't blame them for being protective of that right...they did go to school for a long time. Alternatively, we get to rummage around in some groddy old corner store to scrounge up some totally vague problem the patient is having, like impaired mobility, /s actually diagnosing them medically and just saying "this guy's got a broken leg". 

Shoot. Impaired mobility. That's really a one-size-fits-all kind of statement. I mean it could be d/t a broken leg, conversion reaction, LE amputation, gain greene, CVA, trauma of various flavors, arthritis, surgery, edema, etc, etc, etc... Well, now I come to think of it, it's not that general. There is also Mobility: Bed, Impaired and Mobility: Wheelchair, Impaired. I don't really see how those can't fit into "physical, impaired", but maybe it's b/c then "Impaired mobility" would be too general...it's likely I should know that by now...hmmm.

But maybe our Nursing Diagnosis really does give the doc a hint as to the medical diagnosis, 'cuz, ya know, we know the answer too! By the nurse saying "impaired mobility: physical" we are kind of hinting to the doc "broken leg" but letting him/her come up with the official terminology on his/her own so they don't look dumb if they didn't notice the patient's foot sticking out to the side like their doing the Charleston.

Whoa! I just found an even better one..."Risk for Disuse Syndrome"...what the heck! 

Here's another one..."Self-care Deficit". That's a nice way of saying someone looks like they were pulled through a hedge backwards. Or how about "Health Maintenance, altered" this is maybe how you could describe a funky dresser? Oh, or maybe those people who wear way too much cologne...

Or if saying they look ugly isn't enough, you can also call them dumb..."Knowledge Deficit". I think I will have to start using this one in every day conversation.

Aaahhh...I'm going to forgo the "Care Plan" idea. I've worked myself into a twitter from this Nursing Dx thing, and am bored with this post...likely you feel the same way.