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




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You've Got a Point

So I have this 93 year old gentleman, who is 100% "with it", aka he's still got it all up there. These are the patients I truly cherish as they are fascinating to talk to. The stories they can tell can blow you away and sometimes you feel like you're working with a truly honorable person, even for just making it this far in life. Anyone that climbs past 90 gets a special medal in my book.

Anyway, this poor gentleman had an NG tube in his nose, which travels down to the stomach. Patients may get these for different reasons, but in this case its purpose was to drain out contents that was impeding a potential small bowel obstruction.

Patients generally hate these tubes, as it is a tube that goes into a nose nostril, travels down the back of your throat. Patients hate it. I would, too. Everytime you swallow, a tube is there and you have to walk around with a tube coming out of nose, on top of totally feeling like crap.

So this one patients tube was giving me a little trouble and I was resultingly in there more working with it, which unfortunately causes him more discomfort. So this is how our conversation went during this whole ordeal:

Patient: "I don't like this tube, it's stuck in my throat."

Me: " mr patient I can imagine this is very uncomfortable and I am very sorry for that. I'm going to do the best I can to make it a little more comfortable for you."

Patient: "what you CAN do is take it out! That will make it all better."

Me: "I know that would make you feel less discomfort but Right now your doctor thinks its best to leave it in, at least for tonight."

Patient: "yeah, he's not the one with a tube down his nose!"


Me, thinking: "touché."



WNB.

In Sickness and in Health

This has been probably the weekend with the most lessons learned in one spree of shifts since working as an RN. My first shift started with a set of all new patients, as I hadn't been there in a couple days. The words "You have a brand new ICU transfer" are never exceedingly happy words to a new graduates ears. And this case was exceedingly unique.

This lady had been in the hospital for weeks before her ICU trip and before she was my patient. Just two days before receiving her as my own, she had a major abdominal surgery, taking out 20 pounds of subcutaneous fat that was touching her knees and therefore creating a pressure ulcer, on her abdomen. Yikes.

So, this lady is still, even minus the 20 pounds, a good 400 pounds. She is 71 years old.  She has four drains coming out of her abdomen that are draining the fluid from the surgery site. Meanwhile, guess how many I'd worked with before these four? You guessed it, none. As an aide I had come from a Medical oriented floor rather than surgical. Anyway, her incision site was 1.5 feet (yes, feet) across her abdomen, and it was leaking. A lot. Can I add here that I have minimal experience in uncovering, cleaning, and redressing surgery sites?

I guess there's nothing like throwing you into the worst of the worst and learning that way. After working with her all weekend, I have a lot better of a handle on surgery drains, and surgery incision care. I even felt that I had a really good way of doing it that was actually working for her, being that they were leaking so much.  Its a hard internal battle with yourself as a new graduate, because you want to desperately trust your instincts on how to do something. You really do think you know what to do. But then theres that part of you that says, questionquestionquestion!!! So you begin to doubt yourself. You lose all faith that you're even doing a remotely good job, because you're so new. How can we even tell the difference? We think we're doing a good job and then it all comes crashing down on us.

So, having this patient before me, (in addition to another ICU transfer, a chemotherapy patient, and another hard case, also in addition to 2 PICC lines, and 1 Port-a-cath), i knew it was not going to be an easy weekend.

Trips to the commode were an extreme hardship with this woman, who was beginning to really have respiratory distress, let alone her size. She needed a special commode, special chair, etc.  Her dressings needed to be changed 2-3 times a shift, which took no less than 30 minutes each time. Her drains needed to be emptied 4-5 times a shift. Basically, my care during my shift was centered primarily around her as I was in there the most, and attending to my other three when ever they needed me.

But theres nothing like that daunting feeling that you really don't think this patient is going to pull through, in the long run, and you just pray they can just survive the night. With her worsening respiratory status, I got a couple of her doctors on the phone, who all advised getting the ICU on board. So In comes the ICU resident, who orders a stronger source of oxygen, (she was already on 5L) and some breathing treatments to help ease her breathing and her wheezing. Her oxygen levels were dropping down into the mid-80s, which is, really not good, particularly with someone with no existing respiratory disease.

Needless to say, this morning, she eventually got sent to the ICU and I can only pray for her from here on out.

What was most unique and heartfelt about her case, besides the fact that she was a very nice and enjoyable lady to talk to and work with, was her husband. Her husband, also in his 70s and very thin,  was by her side every minute. Being that I work nightshift, I can tell you that he slept over both nights on this little tiny recliner, and got up to every unique sound she made or mention of his name. He got her everything she needed. He gave her a massage when she sat on the commode. He didn't just hold her hand, he grasped it. She grasped it back. His eyes, they were so beyond exhausted but also so madly deeply in love. You could just tell she was his everything. Which is, beyond amazing. I'm not implying that all guys leave a relationship when the woman gains excess weight, but most guys don't stick around. But he not only stuck around, he was her caregiver, her nurse, her husband, her best friend. They played around with cute little inside sayings and banter. They had their own way of saying I love you, without even saying it. There were times that she would wake up in the middle of the night and just say her husbands name, making sure he was still there. And even with him being a little hard of hearing, he jumped up and held her hand whenever she did call out.

It got to the point however, that I extended whatever care I could come up with to her husband, because I was seriously concerned over his well being. Not only emotionally but physically. I hadn't been sure of his sleep cycle during the day, but on my shift he was there every minute and only took intermittent naps. He was literally exhausted. I got him all set up on a comfortable recliner and highly encouraged that he needed to get some rest and to eat some food, water, etc.






Thanks for reading everyone. Round three tonight.... more blogs on the way this week. Love you all,


~WNB


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