"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"

Sunday, July 22, 2012

Another WIN for Therapeutic Modalities

Hello everyone! Sorry I haven't posted in approximately ten years. I have either been out of town, nothing to say/write, or just trying to find seconds to spare just to breathe. But there's no excuse! So look for a lot of upcoming posts. Many weeks of no posts= a lot of pent up thoughts waiting to escape into blog posts! Yay!

So this post stemmed from last night at work. Here's the situation:

My patient had a total abdominal hysterectomy approximately 2 days before she was under my care.  Under report I learned that she had not had a bowel movement since surgery (but this is common with recent abdominal surgery), and that she has having a lot of bloating and pent up gas cramps/pain.  When I first saw her, she was having some intense nausea. However she had just received a one time dose of morphine, which can very often cause some intense nausea, especially depending on how its given. She also received a PO (by mouth) dose of percocet (she was in a lot of pain). Percocet can also cause nausea. So I decided to give it a little while and told her I would come back.

Well, not ten minutes later is she throwing up, but not much. I still attributed it to the recent doses of narcotics and helped her clean up and decided just to keep an eye on it. However about thirty minutes later she was in intense nausea again, so much so that she couldn't stand up, and was vomiting. My mind started reeling....is there an obstruction? As with any abdominal tampering, its possible to get an unfortunate bowel obstruction. If severe enough, this would then cause anything that's in your intestines above the blockage to come out upwards because it has no where else to go. Keep in mind that she was promoted to a regular diet, just as of the previous day.

So keeping in mind the very real possibility that we were facing an obstruction and may be putting in an NG tube (this would drain out the contents from your intestines above the obstruction), I didn't want to scare her so I didn't even mention it yet. She was already having enough anxiety from her pain and nausea.

Then a thought occurred to me....I always try and put myself in patients shoes. I have had my own very extensive share of gastrointestinal problems and have a lot of experience with different therapeutic techniques, both with western and alternative therapy. 

So despite the fact that I've been blessed enough to have never had abdominal surgery, I have had my fair share of "gas issues", especially thanks to my ever so lovely lactose intolerance. So I thought, what do I do for gas cramps/pain?

I went in the room and asked if anyone had taught her the "Left side trick". She looked at me strange because I pretty much made up that phrase on my own, but what else do you really call it in a quick bundle?  She obviously said no and I then proceeded to have her lay on her left side and massage her entire abdominal wall in a clockwise motion, slowly and rather firmly (but not enough that it hurts). This follows the natural pathway of your intestines and helps guide the gas out the exit door, so to speak.  If you're super lucky, it may even promote the probability of having a bowel movement, in addition to the gas passage increasing the then probability of a bowel movement.

So I had her concentrate on this technique, as I so often do when I'm in gas pain. I also encouraged her to take some deep breaths, and to remain on left side, while also in the fetal position. I find that in the fetal position, the pressure of your knees against your abdomen also helps guide things out the exit door, and....well, it "opens up" the exit door completely, making it that much easier to pass gas.

Now for the epic result?? I checked back in about thirty minutes after that education time, and I honestly didn't have much faith in my alternative non-medication therapies. I came  in offering a powerful anti-emetic that she was now eligible to receive, but turns out? She was feeling much better already. Her nausea had receded slightly and the gas cramps were improving. Win!

Even more win, when I went to go to check on her in the middle of the night, I heard some unexpected news that she actually passed gas! Woot! She even managed to pass a very tiny (but one all the same!) bowel movement. Woo hoo! A + for non-medication therapies, for the win!

I couldn't believe it worked. I mean, I thought everyone knew that trick. I thought it was an old age wive's tale, or whatever they call it. I learned the trick in a mother-baby class in college, when we were taught how to alleviate gas in babies. I assumed it would work for adults, and its always worked for me and now for my patients too! :)

So, thanks for reading through a rather gaseous post.....it can be helpful if you also suffer at times! Who the heck doesn't??!  Admit it. You probably just farted.  Yeah, I just said fart.

Anyway, like I said, I'll try to post more upcoming! Stay tuned....

With Love, WNB


Sunday, July 1, 2012

Not the Sense I Wanted

So, for anyone thats ever gone to nursing school, chances are you've heard of Patricia Benner's "Novice to Expert" model. The five stages depict what stage of nursing you are in based on your experience and performance. THe stages range from being a:

-  "novice", which means you are by-the-book, no experience, new grad.
-  "Advanced Beginner", meaning you have enough experience to help formulate future guided actions, you start developing your "nursing spidey sense"
-  "Competent", meaning you usually have 2-3 years experience, you start thinking about your patients long term goals and health, rather than just the textbook here-and-now.
-  "Proficient"- Meaning you have learned from enough experiences to modify plans, change others perspectives, teach others your skills, and your nursing spidey sense is pretty strong.
-  "Expert"- Well, here is where you're just awesome. You've been a nurse for a looooooooong time and your Nursing spidey sense is just out of this world.

Now, what exactly do I mean by 'Nursing Spidey Sense'? Simple. Let me explain.

At the stage of a Novice, which I was not too long ago, I was so scared with my patients. I saw the more experienced nurses (I work with a lot of 'Competents and Proficients') and I would witness them catch a patient going downhill pretty early. I thought, how did you know? What if My patient is suffering and going downhill and I missed something in my assessment? My assessment skills aren't good enough, what if I am missing something simple, or something huge that could save their life? The more experienced nurses on my floor assured me that it was important that I just keep learning and always doing my best, always being on guard. I listened.

Now, almost hitting my one year anniversary in nursing, I feel like I have graduated to "Advanced beginner", and suddenly, I don't have that constant fear. I know I have a LOT to learn, but I feel comfortable in my assessments. I can feel my nursing spidey sense definitely getting stronger.

Point being, At the stage of a Novice, you have no nursing spidey sense. None. Zip. You go by facts, whats presented to you, lab values, evidence. There is no "intuition" developing just yet that something is wrong without any evidence.

Although I cannot speak from personal experience, from what I understand, "Expert" is when that same intuition of the nursing spidey sense is at its peak. You can enter a room and look at a patient and you just KNOW that something is very wrong with that patient before you even lay a stethoscope on them.

So, my nursing spidey sense is helping me in a lot of ways. I like having that "gut feeling" developing...it comes in handy when its time to make a decision. However, there are ways that it can be a huge bummer.

For instance, lately I seem to have developed the skill/spidey sense (I'm not sure which you could call it), of being able to predict if someone is dying or not. Not necessarily on my shift (in fact I do almost anything to NOT let you die on my shift!), but I've learned enough in nursing to know when someone just simply isn't going to pull through whatever they are going through.

I had a very kind patient not too long ago. He touched my heart with his generosity and patience, he was a very sweet elderly gentleman and was going through a lot of hard times. He had advanced stage lung cancer and frequent bouts of pneumonia, due to frequent aspirations related to the lung cancer and intubations. Well, one day I heard he was discharged and doing a little bit better. Well, a couple weeks later, I was doing a small rotation in my ICU, and I saw a man in one of the beds, intubated and hooked up to every possible wire and tube you can think of. Drips, tube feedings, multiple IV pumps, vital signs, you name it. I thought, "Wow, poor guy." But something made me look further, I saw his name and realized it was my guy. My heart dropped to the floor, along with my jaw. I couldn't believe the last I heard he was home and doing better and now he was in the ICU, unconscious. I walked closer to his room and watched him, watched the ventilator breathing air into his lungs methodically for him. I couldn't believe it. And I knew, at that point, regardless of all evidence, even though I knew nothing about his current medical status, I knew- that he was facing death any day now. I could feel it in the room, it was as if he wasn't even there any more. His lively and kindred spirit wasn't there and that deadweight feeling was left in the room, daunting.

As for on my floor, I work on an oncology unit. That being said, I've had multiple patients in the past that simply couldn't pull through the advanced cancer. This knowledge has helped me develop pretty early on in a patients diagnosis on whether or not I think they will make it, and sadly......I have been right, lately. And that makes it so hard, staying with these patients for weeks, months, prolonging the inevitable. Watching them suffer slowly. When you know they probably won't pull through and yet the family has no idea. Sometimes even the patient doesn't have an idea....but most of the time they do, too.

 This same sense has proved to be intact with patients outside of oncology as well. Recently I had an 83 year old with advanced end stage COPD. I knew he wasn't going to make it til the end of the week. In fact, (and this was the first patient I ever did this for), I prepped him for a code blue on my shift. I made sure my IV was definitely intact, made sure the room had a lot of spce, made sure the code cart was handy, because I was that sure he was looking at the light.  He died that week.

I was just blessed enough to have about 8 days off from work, I went on vacation and had some free brain time, away from all the nursing and death and living. The only medicine I had to think about was my own, and I gave my cousin a bandaid and some neosporin. 

However, when I got home, the very first night I had to sleep, I had this awful- frighteningly lifelike dream. I was at work, and in the dream I was standing over a patient's bed. She was a young female, in her 40s. She was a mom, I knew that in my head in the dream. I also knew she had advanced cancer and she was going to die, soon. In the dream I was faced with the ultimate daunting task, the husband asked me, "Is she going to die? What do you think? I've heard what the doctors have said, but what do you say? When will it happen?"  No nurse ever wants to answer that question, ever. In the dream we were in an absolute white room, white floors,white walls, no furniture. I sat there in the dream checking her foley output, knowing how much it decreases before death. I held her hand and told him nonverbally what I thought, what he already knew.

What kind of dream is that? What happened to dreams about princes and frogs and fairytales? Seriously, but it just goes to show that a nurses mind never shuts out the world of medicine. Once you start developing that nursing spidey sense, it never shuts off, even if its in your dreams as well.

I love my nursing spidey sense. Like I said, its been handy when deciding what to do next with my patients and helps guiding long term thinking for your patient. But sometimes, I'd like to not be right about the death sense. :-\ Its a strange conundrum.