Tuesday, August 28, 2007

Tagged!? Me?

I was soooo about to do my nursing note for the day's shift, practicing my SBAR format and then start to type some of my IPR (Interpersonal Process Recording - a word for word account of what he said/I said with notes about what I think he meant and whether I think I did a good job of responding/redirecting). I also planned on getting physically ill thinking about what in god's name I will talk about with my patient tomorrow and wondering how in god's greenest I managed to select the one man on the unit who looks 85% like my dead father. Well, other than the right BKA and left AKA. And the tweety bird tattooed on the side of his head and the CBR and the flaming eight ball on his hand.
But no.

*RULES - Post rules before giving the facts - Players start with eight random facts/habits about themselves - People who are tagged need to write their own blog about their eight things and post these rules - At the end of the your blog you need to tag six people and list their names - Leave them a comment on their blog, telling them they have been tagged and not to forget to read your blog.*

1. I feel weird saying I'm queer since I've never had a girlfriend. a sketchy sexual history, but never a sustained relationship. And I don't see that happening in the next 18 months either.

2. speaking of 18 months, I haven't had sex with another person in at least that long. Apparently, when I decided to stop sleeping with men for a while, I sent some sort of "No, thanks" to the universe.

3. I really enjoy picking the dead skin off my feet. I have become brave enough to get one of those horrid shaver-things recently, but I'm terrified to use it with the force needed, scared that it will slip and I'll slice off the end of my toe.

4. Speaking of toes, I can't feel the tips of my great toes. It happened about six months after I started waiting tables (HOLY BIRTHDAYS BATMAN, that was 12 years ago!), and I was still covered by my mom's insurance. The doc squeezed my toes and shrugged. They look sort of long-bath-prune-y all the time.

5. I haven't been to the dentist in 7 years. I overheard a woman that I was waiting on say, "Well, everyone goes to the dentist twice a year, I just don't understand how something like that could happen!" And until I left my husband, I know that I never considered the possibility that I might not be able to get my teeth cleaned q 6 months.

6. Secretly, I love the abbreviations of medical terminology. It makes me feel proud to be able to remember what the NOS in a psych diagnosis stands for. (not otherwise specified, when something's not *quite* in the diagnostic criteria)

7. I'm a know-it-all. Always have been. I can remember being aware of this in kindergarten and chasing around the girls that had told me they didn't like me, asking them if "it was me, or my big mouth" that they didn't like. cringe.

8. I have given myself a series of mouth ulcers this summer from eating tomatoes from my mom's garden, and I'm getting ready to go make another tomato sandwich!

Friday, August 24, 2007

I love newFNP

She refers to herself in the third person in a very not-annoying way. She is not afraid of the well-placed f-bomb. She provides excellent insight into the aspects of practice that my lecture professors are not even hinting at.

Go read. Really.

She reminded me of the importance of diction when talking with patients -

It took me the entire med-surg rotation to recognize that the reason that I was getting frustrated when trying to assess my patient's pain was related to my own diction...

On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst pain you can imagine, where would you say your pain is right now?

My belly.

Oh. I see. Yes, ma'am, I see here that you have multiple abscess caths and even a PBD* or two, so I imagine that your pain is centered in your belly. What with the bile duct cancer and all. But how bad is it? Because, as the staff nurse who sent me in here to ask you so kindly pointed out, you won't be getting a single speck of your potential 15 mg of PRN oxycodone until you give me a number.

*It took me forever to find out that PBD stands for Percutaneous Biliary Drain, and then an equally long time to realize that I would actually be draining plastic bags of bile hanging off of this woman 3x/day. Doesn't bile digest its way through plastic? Shouldn't these things be glass or silicon or something?

Wednesday, August 22, 2007

*psst. people on the left, don't tell the people on the right, but we hate them!

my friend reminded me of that paula poundstone bit recently.

Yesterday was tough - orienation for psych clinical, which I hadn't realized I was nervous about. Additionally, my usual clunky awkwardness was exacerbated by the fact that I spent four hours sitting in a room with Ponytail Perfect Priscilla and her flawless-skinned sister Elizabeth and their five friends, Polly, Perky, Baby Spice, Paris and Azaela. I am not a person who looks smooth and polished, not even when I think that I do to be honest.
I have unkempt and overly hairy eyebrows, which I pluck erratically. I have persistent adult acne, which I keep thinking I'm spend a portion of financial aid money to fix, but then get all caught up with utility bills and other luxuries. I have thrift store clothes, which no matter how carefully I inspect at the store and at home and after the inital run through the laundry, invariably have a stain on the butt, or a hole in the armpit or some such thing.
It's cool with me, usually, really it is. I have lived in this messy body for 35 years now and I'm okay with it, usually. But it's hard to remember that I'm good enough, smart enough and doggone it, people like me, when I am stuck in a room for hours on end with no reality check with folks that are cuter than me, slimmer than me, and doggone it, firmer than me.

So I went to water aerobics last night, and hung out with my people who have rolls, big ones, and not just boring old belly rolls, either. This group has ankle rolls and triceps rolls and I love them. I worried at first that my comfort was at their expense, that I loved these women because of that subconscious habit I have of scanning the room to see if I'm the fattest woman in the room. And I've decided that one of the reasons that I feel comfortable in the locker room is that I see other women who have thighs that look like mine. A whole room of women who have that canyon-y thing around their navel (I wonder if they know that if they squish their belly in the right way, it looks like either a butt or a bagel?!)! Joy. Happiness. Belonging.

The worst part of psych today was walking on the unit. After that, I was cool. I fucked up by not saying goodbye to the patient that I was talking to when we left the unit to have lunch and do our notes. I need to brush up on my open-ended questions. I kept asking informational, factual type questions, and then we'd sort of stare at each other for a bit, and then look back at the TV, or at the man who was grinding his teeth loudly enough to be heard across the room!

The other worst part of psych is that all summer I was in the swanky private hospital (which has places that are sorta gross and undesirable) to the federally operated hospital built in the 50s and not renovated since. Four and six beds to a room, with common showers and bathrooms! This weird yellow tile brick in the walls. Hallways that are pre-fab and feel like that ramp you walk down to get on the airplane. Staff bathrooms that make me regret heartily the bottle of water I carried with me. Big oil paintings of the President. A cafeteria that smells like mustard and old eggs, not sushi and oatmeal bars for breakfast. Where's all those footpedal faucet handsinks? Snort. Still giving patients Haldol?! Sure, it's cheap because it's so old. Course, that's the reason why most folks who can afford to don't use it anymore, because there's a thousand things safer and better...

off to look up whether bruxism could be a form of extrapyramidal side effect... Jo?

What's in the clinical bag?

cross-posted at the SON's new blog, of which I am a contributor! Kay Supreez!

One of my favorite nurse bloggers recently did a post on his toolkit - the bits of debris that he intentionally fills the 85 pockets of his cargo scrubs with. At one point during this summer's rotation, I realized that I needed to learn to either tie sturdier bows with my drawstring pants or carry less stuff.

The clinical bag* for Med-Surg always had this:

*not that I carried an actual bag while I was on the floor this summer during my med-surg rotation. After a couple of weeks of searching desperately for each of these things each Monday night before 7am Tuesday clinicals, I started keeping them all in a little tote. I'd empty my pockets into the tote before throwing the scrubs in the laundry, and then fill the clean scrubs from the tote the next clinical day. I still managed to wash quite a few alcohol swabs.
  • my little notebook. Mine was from the dollar store, about the size of my palm, and fit nicely in my pocket. It had:
my clinical instructor's cell phone number, in case I got eaten by a monster on the way to the hospital and had to call out
my plan for the shift, broken down by hour, written the night before and then edited during report, when I found out that ECT had been cancelled for the day because my patient had a sandwich for breakfast
lists of the questions that I wanted to ask later
abbreviations to ask about - UC? (ulcerative colitis), R/O? (rule out), 2/2? (secondary to).
my patient's meds - what is it, how does it work, why/when/how/how often are they taking it, are they taking the right amount, how will we know if they have taken too much, and how will it react with the other med they're taking? I soon realized that many of my patients were on the same drugs (stool softeners for pts on opioids, magnesium for those with borderline mag levels, proton pump inhibitor to lower gastric acidity, etc) so having the info already written out, ready to read off to my clinical instructor when we pulled meds was really handy!
  • 2 black ink pens - since I invariably lost one during the shift. remind me to tell you the one about the nurse, the checkbook and the rectal thermometer.
  • watch with a second hand. I really resisted this one, and went the whole first semester without one, doing all my evals with the second hand on the clock in the classroom. But then I couldn't count resp rates or take a pulse one morning because my patient's room didn't have a clock and I knew I was going to have to break down and stop by the drug store on the way home and get a $30 watch.
  • penlight, for shining in people's eyes and looking into the cabinets where the canisters of NG tube drainage are kept before you go reaching your hand in!
  • stethoscope, labeled indelibly, of course. It was surprising how many folks laid their stethoscopes down around the unit. The big cargo pants pockets were good to stash mine in, especially when I had a patient on contact precautions and was going to be using the one in the patient's room all day anyway.
  • lip balm. tricky, this one. I always washed my hands before and after putting it on. But the nice minty smell and the familiar ritual of lip balm was really important to me while I was getting acclimated to the unit.
  • tiny bottle of hand sanitizer, rarely used because my unit had three handsinks every two feet.
  • a super compact OB tampon, because, hello! white scrubs!
  • two granola bars. After a week, I realized that I had to bring food that I could eat using sterile technique. I never *felt* like my hands were clean, even knowing that I'd been wearing gloves and washing them constantly. It made me happier to eat things in wrappers.
  • at least 10 of those little alcohol wipes, good for wiping down the earpieces of the afore-mentioned stethoscopes in the contact precautions rooms. for that matter, I put a couple of the big dinner napkins sized individually wrapped alcohol wipes in my pocket when I had patients on contact, because the Dinomaps and glucometers all had to be wiped down as they left the room.
  • I also always had a letter sized piece of paper, like my patient's latest CBC or my write-up from last week, folded lengthwise in my pants pocket, half sticking out. When I took vitals (since I did it the old fashioned way, without the fancy machines), I could write down BP and HR and temp on the back of that paper, using my own leg to bear down. It worked really well, even better when I started writing down the time beside the numbers so that when I got out to the chart and opened up the paper, I could tell the 8am numbers from the noon numbers!


For my Psych rotation this fall, the bag is pretty different. First off, it's actually a bag, and I have no pocket-stuffing to do. We're wearing professional clothes on the unit, and we're not carrying ANYTHING in our pockets. We're also not doing any writing or note taking while with the patients. So, my little notebook stays with my pens in my bag until I can come back to the breakroom every hour or so and make some quick notes. No wallet, and only my car key ring, since I can't lock my bag up, just lock it away from the patients. I never carried my cellphone this summer either, except on a day that I knew something sketchy could happen child-care-wise, and then I kept it in the break room on silent and checked it every hour for missed calls. No stethoscope - I feel pretty confident it would go on the same list with belts and sharp objects. A bigger bottle of hand sanitizer, though, since I'm in an older facility and there's just two easily accessible sinks on the unit that aren't that easily accessible most of the time. Granola bars, lip balm, and tampons still essential, but they all stay in the bag, along with a bottle of water.

There are a thousand differences between med-surg and psych, but the most obvious at the moment is that all the time I spent writing up meds and labs and chief complaints and medical history before I did any patient care for med-surg is now spent after interacting with the patient, writing up our conversations, analyzing for therapeutic communication techniques, writing nursing notes about the shift, looking at the files and finding that things are sometimes quite different from how the patient perceives them. Oh, insight, you are a wily beast! Off to write up my observations from today, before I forget them forever!

Sunday, August 19, 2007

Grampi's Meds

I had an excellent chance to use my Pharmacology this week while visiting my octogenarian grandparents.

I stumble into the kitchen where Grampi has already made coffee since he’s been up since dawn. I mumble good morning and he pounces.

Grampi: What do you know about Prilosec and Coumadin?

kati: Wow. Um. Can I get my coffee first? Let’s see. Prilosec is cimetidine, yes? Over the counter medication for heartburn? an H2 receptor blocker? Okay, I’m waking up now.

Coumadin is warfarin, a blood thinner. You’re taking it to keep clots from forming because of your atrial fibrillation (when the atria quiver instead of pumping efficiently). Clots are bad, they could mean strokes or pulmonary emboli, so we’d like to prevent them.

But according to my textbook, cimetidine and warfarin are bad business together, because they both are metabolized by the same enzymes in the liver. And I can’t remember at 7am if cimetidine ramps up the enzymes (lowering the active levels of drugs) or slow the metabolism of those enzymes (raising the levels of active warfarin). I do remember that there’s a pretty strong caution not to use them together if it’s avoidable, because one of them affects the level of the other.

And I remember that last night you said that your docs were having a tough time getting your INR stabilized between 2 and 3 (INR measures how the warfarin is working, how it is affecting the clotting factors of the blood). So, no, Grampi, in my two semesters under my belt student nurse opinion, you should not take Prilosec and Coumadin unless your doc specifically says it’s okay. And even then, I’d like to know why she thinks it’s okay.

Grampi: Hmmph. You are learning something at nursing school, aren’t you! Here - look at the rest of this. Now, why am I taking…

It was a little scary to realize that I’ve already taken a certain role in the family, only two semesters into nursing school. It’s the same role that Grampi was in while he was a practicing veterinarian (”What do we do about this weird red spot on Muffin’s belly?”), but it’s not one that I was prepared to assume until I graduated.

Last January, when my friend who is in the midst of a chemo regimen for metastatic breast cancer started throwing out names of drugs and interactions and cautions, and said “Well, I’m sure you know about this already”, I had to admit that no, no I didn’t know any of that. But now I can talk with her about the recent switch from one drug to another, and the whys and hows of that change.

I also know that I could have stammered that I had no idea about Prilosec and Coumadin and we would have had a lovely conversation about the front page of the paper, but I knew that stuff! And that’s a great feeling - that I didn’t just learn it for the test - that the knowledge is in there, retrievable upon command. Perhaps because it is so new to me, I can pretty easily translate it out of medical jargon and into plain English. And that is a skill that I hope I never lose, because patient education and the ability to communicate clearly with patients is absolutely essential to how I want to practice as a nurse.

It’s nice to know that I felt pretty comfortable doing patient education on P450 enzymes in my grandfather’s kitchen, and I’m not the least bit ashamed that I ran upstairs after my first cup of coffee and pulled up my powerpoint notes on warfarin on my laptop to make sure I had told him the right thing*.

* According to my notes, cimetidine strongly inhibits hepatic metabolizing enzymes, therefore drug levels of these substrates (one of which is warfarin) will rise (and in the case of warfarin, increase the risk of bleeding and blows one’s INR out the target range).

Wednesday, August 15, 2007

Summer Reading Program

Every year, I signed up for the summer reading program. There was always a silly theme. I had a clipboard to hold the list of the books I'd read, and I got a bookmark if I read 25, a certificate for a free balloon for 50 books, and a gift certificate for $5 at McDonalds if I read the top end of 500 books. I was always on track for the 500, with multiple mimeographed copies of the Title-Author-Favorite Part sheets to track my books and my stack of YA books that I had to carry with two straightened arms out to the car. I can't remember if I got the gift certificate or not. I'm the kind of kid to have gotten distracted the week before 475 and not realized that I only needed 25 more to hit the goal.

I signed the kid up for the summer reading program one year, the year that we lived the closest to the library. He was not yet reading himself and it seemed like it was even more obviously for me than for him, since he a) had no idea what a Summer Reading Program was, b) would have been more likely to gnaw on the bookmark than use it, and c) was excited about books, sure, but was also excited about empty boxes and cat food dishes. So. Since then, it's just seemed so arbitrary to start tracking all the reading we do from June to August, when it's not as if we are a family that needs to be prompted to read for the love of pete. There's a whisper of fear, that if I don't sign him up, and we don't meticulously track all the books he's read this summer (and HEY, how come I never got to keep that sheet with my accomplishments for the summer! How come the librarian got that and I got the lousy bookmark! I'd rather have the list!) if I don't, then maybe he'll be the generation that stops reading, that doesn't have books in his house, that becomes an adult who shrugs and says he just doesn't like reading all that much. God, that would be like him growing up to be an ultra conservative police officer.

I did check swimming lessons for him off the list of Things Good Parents Do for Their Children (aka Things that My Parents Did for Me that I Liked and Want to Repeat). Maybe next year will be the summer reading program.

ANYwho, I've been reading my butt off, of course. What else is there to do when you're on the cheaper generic version of Wellbutrin that must be taken twice a day and you can't remember to take it at noon so you take it around 4pm and then can't sleep til 3am, but aren't willing to use the Ambien that your doc also prescribed for you? What else, I ask?!

Leap Into Summer Reading! by That Biggirl

Still in Progress:
(an anomaly. I'm a finish all your peas, then eat your carrots kind of reader usually. Blame my meds.)
Galileo's Daughter by Dava Sobel (good and excellent for falling asleep)
Killing the Black Body by Dorothy Roberts
Kayaking the Full Moon by Steven Chapple (non-fiction and full of T. going back unfinished)
What are You Looking At? The First Fat Fiction Anthology edited by Donna Jarrell and Ira Sukrungruang (which includes one of my favorite short stories of all time, Waltzing the Cat by Pam Houston and is now on my to buy wish list)
The School of Beauty and Charm by Sumner (good, but going back today)
The Lavender Hour by Anne LeClaire (hospice volunteer, Cape Cod, pancreatic cancer. good)

Hooked by Matt Richtel (look up the review on NPR. I give it two thumbs up.)
I'm Dying to Take Care of You by Snow and Willard (okay, I didn't finish it, but I couldn't see the word codependent any more)
Clinical Decision Making for Nurse Practitioners: A Case Study Approach by Denise Robinson (I love case studies! Love them!)

Leap into Summer Crafting!

In Progress: (this is normal, and in fact the only way that I craft.)
Prayer shawl begun on spring break with Cascade Quatro in teal and purple (halfway across one shoulder!)
Criss Cross crochet squares for kitchen decoration in Swish Superwash pine green
Stockinette Kitchen Towel in kitchen cotton blue and yellow
Tomato Napkins for my BF (pulled the fabric out of the bag yesterday and found the receipt dated 6-10-06!)

Leap into Summer Responsibilities!
Financial Aid paperwork turned in
Bank Account firmly into the negative from trips to Target and the thrift store for hangers, trashcans, meds, and fall work clothes for psych rotation (I'm up to -$225 by now, with likely more overdraft charges to follow. It's amazing that I can still have electricity, and food and clothes when I am $1600 in debt right this second, including the money I had to borrow against my fall financial aid money to pay July and August's rent! I feel like I should be sitting in a box right now, waiting until next Tuesday when magically money will appear in my bank account.)
Museum visited each afternoon
Tomatoes at mom's harvested (though negative balance will likely preclude another trip before financial aid disbursement)
Boxes unpacked in one corner of living room, another bookshelf and three boxes in kid's room to go.
Ex-Mother-In-Law visited and confirmed surviving an infiltration blood transfusion and a change in chemo.
Credit report pulled and list of letters of dispute made.
List of thank you notes for birthday presents or various small kindnesses over the past month made and stashed beside thank you cards.
Most meals made at home, with dishes washed afterwards.
Lots of movies watched, staying up late, waking up late and jacking around till 11:30 in the morning on the computer looking at stuff like this: