Pain

Is the quarter almost over? I keep telling my friend and fellow nursing student, S., "It's only two more weeks!" and she says, "Uh, no, it's three." I'm just going to keep telling myself it's only two weeks because I'm pretty sure I can make it two more weeks without popping, imploding or screaming up and down the street in the rain. And, you know, it's not the care plans, it's not the impending math test that I have yet to study for, it's not learning the language of pharm (acology), and it's not the lack of sleep. It's all of the above and/or I'm ready to move on. I'll have fewer classes next quarter, for one thing. I'll be working at a hospital much closer to home. Patho and Pharm will become History of Nursing and, heck, history used to be one of my majors. How hard can it be? How boring can it be? (don't answer the last question if you already know. I want to be surprised!)

My patient last week was a sprightly woman in her late sixties. I was impressed by a) the normalcy of her toenails b) the amount of pain medication she takes on a daily basis and still describes her pain as an "8" on the pain scale (that's on a scale of zero to ten, zero is "no pain" and ten is "the worst pain you've ever had in your life"). Eight. And she has a fat fentanyl patch on her chest. I had to pick, the night before, between studying for my pharm test and stdying pain and I, crappy nurse, picked the pharm test. So I was useless to her. And I couldn't even hear her heart murmur.

The Isolation Ward

Every week we get to pick a new patient. It's a little frantic...A bunch of us descend upon the Skilled Nursing Facility at the same time after our skills lab and scramble through the "cardex" looking for patients who are going to be there the whole week and who, ideally, have problems we comprehend. It's either luck or an art form, but three students out of eleven had their patients go home by Thursday. The other fun part about picking a patient is deciphering the patient's file. These things usually weigh about twenty pounds and every one of them is different. Sometimes, it's pretty easy to figure out what they're "in for". A lot of times the medications take several pages to list. And where is the "nursing language" class? LOC? Is that Loss Of Consciousness? Is that Locus of Control? Level of Care? Laxative of Choice? All of the above? You betcha!

So, I picked a "bad patient." I panicked. I wanted to pick someone who looked like they'd be there all week and I picked a patient recovering from MRSA (methicillin resistant staph aureus) sepsis and who had T-cell lymphoma. She was in the isolation ward. When I got there the next day, she was barely conscious. I was ready in my plastic gown and gloves to give her a bed bath, when the occupational therapist called out to me, "Oh no, she needs to do her ADLs [activities of daily living]." Uh. OK. This woman can barely move. And, not only that, but apparently T-cell lymphoma makes a person itchy. VERY itchy. My patient had bloody lesions all over her body from scratching (my care plan will correctly id them as "excoriations" and I'll have them listed in a range of measurements from 3-7 mm). And my patient was 5'7" and weighed 160 pounds. I'm almost 5'1" on a good day. So I had to get my patient out of bed and into the wheelchair, And then off of the wheelchair and onto the potty (oops, too late, Code Brown). And back into the wheelchair and back into bed and then, says the occupational therapist, "Oh no, she can't be in bed. She needs to sit up in the wheelchair." And, here's the suck-y thing about the isolation ward, you can't leave the room in the gown, you have to take it off, take off the gloves and THEN you go find help. It took several heftings of my patient before I realized: I can't do this. I can't move this woman by myself. So, every time I needed to move her somewhere, off goes the gown and gloves, out to the hall to track another student down (heh, heh, can't hide from me: white scrubs REALLY stick out), new gown, new gloves and on the count of three up she goes.

Somehow I made it through the clinical. I got to school and I realized: shoot, I helped my patient put underwear on and she had a catheter. That's got to be contraindicated! I'm the worst nurse ever. What if it prevents the urine from draining? What if she's really uncomfortable but too out of it to say anything? What if I get thrown out of the program for being an idiot? I went home. I finished my care plan: 20 diagnoses and Impaired Physical Mobility. On Tuesday she could barely lift her head, but on Thursday, she got up out of bed and walkered her way to the bathroom! I hadn't killed my patient! She was much better (despite another Code Brown on her wheelchair) and my Expected Outcomes? Out with the contaminated gloves. I was just hoping she'd sit up in her wheelchair for an hour. I told my patient I was proud of how much she'd improved. Maybe I can be a nurse.

Sugar Cookies

This is an easy recipe. It produces a tasty yet sturdy cookie. I made about 150 of them for my daughter's 100 Days of School Celebration.

3 1/2 cups AP flour
1/4 tsp salt
1 tsp baking powder
1 cup chilled butter
1 1/2 cups sugar
2 large eggs
2 tsp vanilla extract
sanding sugar (or just extra white sugar) or royal icing

Whisk together flour, salt and baking powder. Set aside.

Beat butter and sugar using paddle attachment. It'll take little while, but beat until creamy. (I think the chilled butter makes a flakier cookie without compromising the structural integrity)

While beating the butter and sugar, whisk together the eggs and vanilla. Drizzle slowly into the creamed butter and sugar with the mixer on low. Combine. Add flour half the flour and combine. Add the other half. (Heck, you could add it all at once, but if I do I get a huge flour cloud).

Divide dough in half and wrap in plastic, fridge for an hour.

Line two cookie sheets w/ parchment paper. (you don't have to, it just makes the cookies so much easier to remove)

Roll one dough blob on a lightly floured surface with a lightly floured rolling pin. 1/4 is a good thickness. Cut out cookies. put on cookie sheet. If you're not using icing, sprinkle with sugar.
Bake for about 10-12 minutes or until just brown around the edges. Leave them on cookie sheet for a few minutes and then transfer them to a wire rack for cooling.

Patience

Our real clinicals started this week and I'm so tired after having gotten up at 5:30 AM to get to my clinical site at 7 AM and then onto my classes all afternoon. Up until this week I thought: wow, being in nursing school is *way* easier than getting into nursing school and the prereq courses, but I'm revising that. This has been an exhausting week. Perhaps part of the exhaustion is that my two kids have been sick with some horrible coughing plague (my daughter sounds like a barking seal and my son is like an accordion with the "breathe" key pushed in.) and there's been extra juggling on everyone's part to make sure they have an adult caring for them all day. And the night waking: my daughter's little fever-y body smashed right next to me in the middle of the night barking like a seal and, me, awake counting down the hours until the alarm goes off. It's always weird to leave the house when it is still dark. There's a semi-exciting/ partially nauseating feeling and it should be dream time, but now I'm on the highway and it's still dark when I get to my clinical site.

So I picked my first patient. I thought, phew, this woman has congestive heart failure, TIAs and is on a million medications (including the drug I feared the most for nasty side effects in my first pharmacology test: amiodarone). I thought: this is going to be hard. And it was really hard. She didn't really want any help from me. The first day I "took care" of her I was panicky. She was happy to let me take her vital signs, but, while all of my fellow students were merrily bed-bathing their patients,wiping patient's butts and checking heart and lung sounds, I was chatting with my patient. She didn't really want me to check her for edema or help her with her range of motion exercises. It was...very pleasant, but I felt like I wasn't doing my job. I had a list of assessments I should have been doing. The form sat on my clipboard, ignored, until I got home. And then I realized, Hey! I did a lot of assessing in chatting with my patient. I was able to fill in information about almost every one of the body systems (cardiopulmonary, integument, etc).

Then came my first care plan. I spent more than two hours trying to write my Expected Outcomes (um, they're goal statements with a very specific language and format). Two sentences. Two hours. OK, some of that time was on the phone talking about the expected outcomes, but still. Two hours! And, here's the "funny" part. I didn't implement my plan. My patient's sister had died and she found out while I was there. I was mostly an ear today. And, even if I was able to implement my plan, it was all wrong for my patient. I was going to ask her to change her routine and I think that's what keeps her going every day: the steady regularity of her day (get up, breakfast, meds, get dressed etc) that is in contrast to her heart's dysrhythmias.

This is hard.

The Long Week

oops. I wasn't able to do my post yesterday. I had my first clinical today and I had my first pharmacology test today and I had to wake up at 5:30 AM and somehow make it happen. The clinical was at a skilled nursing facility. Today we just followed around nurses and CNAs and tried to stay out of the way and help as much as possible. The first CNA we followed was not the friendliest person around. She mostly gave bed baths to patients (not one of whom was younger than 90) and checked blood pressures. My partner and I were cringing. She didn't use bath blankets on any of the women we saw her bathe. She squeezed a wet washcloth on the patients so the water splashed down on them in a startling way. She was rolling the patients over like they were slabs of beef. One woman (she was 104!) -when the CNA left the room - said, "She's a terrible teacher! Use your own discretion." I think I will pick her as my patient for next week so that I can give her a more gentle bath. I mean, she's 104. That's amazing. She shouldn't be rolled over like meat. The next CNA was very gentle with the patients. Introduced herself, touched them gently, chatted with them. I realized today that, hm, maybe I can do this. Maybe I will be a good nurse. I enjoyed talking to the people who were able to talk. It was exciting to try and find the pedal pulse (top of the foot) on a patient who had had knee surgery. She also let my partner and I test her for pitting edema (I'm a gal who knows how to have fun!). The elderly folks had such interesting bodies that were actually lovely in their own way.
The downside: well, I'm not that into making beds and we had to clean up a poopy bed. The nurse we attempted to follow was not thrilled to have a bunch of nursing students dressed like marshmallows (remember, we have to wear white from head to toe) hovering over her. And, it seemed like the nurses spent all morning scanning medications. We had our first pharmacology test afterwards so I was trying to read all of the labels and detect possible drug-drug interactions (The only one I came up with was Tums and ferrous sulfate).

The pharm test? I knew right off that I got the first question wrong. Pharmacotherapeutics isn't reeeally a word, is it? Um, apparently, but tell that to my spell checker. I did ok, somehow, but it was a squeak.