HOW’S YOUR NURSING PRACTICE HANGIN’

August 13, 2007

Recently, Beajerry at the Cosmic Watercooler wrote about his/her thoughts on the definition of nursing practice (provided by Wikipedia.org) and his/her opinion of the nursing diagnosis.

To me there’s no “theory” or anything specific to “nursing”. It’s all real and it’s all medicine, baby!I’m not some Nightingale cult member practicing ‘theory’ over in the corner separate from the medical team. I don’t sit around shuffling idiotic nursing diagnosis cards trying to translate a medical problem into Fisher-Price speak.

Nurses aren’t allowed to officially diagnose and prescribe treatment – that’s the doctors’ job and they get paid for it. However, nurses are on their team and they do most of the skilled labor.If some nurse ‘researcher’ knows more about how to treat a medical problem than a doctor then I’m proud of ’em, but it seems a waste of time since they don’t have an M.D.

I don’t know of any people with a high degree in architecture and design who would rather pound rivets all day. 

I disagree with Beajerry that there is no theory being used. Instead, I believe that theory is being used, its just that it’s beneath the surface and we are never really required to think about it in terms of pure theory. That said, having studied the core concepts of many nursing theories, I consider many complete bunk.

And, in my experience, there’s a direct relationship between nursing theory and the nursing diagnosis: The more far-fetched a nursing theory (see the Orem Model of Nursing or any of the Holistic nursing theories), the more completely it incorporates the ideas of the nursing diagnosis.

In my work environment, an ICU, we are required to “write” a nursing careplan for each patient upon admission to the ICU. But it is not as complex or time-consuming as it sounds. By “write” I mean we select 3-5 nursing diagnoses that are applicable to the particular patient from a list in the computer program we use, highlight those diagnoses, and hit enter. We don’t revisit them. They are a hoop we are required to jump through.

And then we return to the bedside where, as nurses, we provide a high level of nursing care that derives its focus from critical care medicine. Does that make me less of nurse? I don’t think so. I enjoy being part of a critical care team that uses a multivary approach and one language. I think it works best.

What do you think? 

HEALTHCARE COUNSELING AND COMMUNICATION PRACTICES

April 22, 2007

*Recently, a friend of mine asked for my assistance with a project she and her colleagues were developing for a course they were taking at a local university. Specifically, she asked if I would host a video of a mock conversation concerning the communication practices in one area of the healthcare arena. I agreed, and so I’ll now segue into her introduction to the issue as well as the video. You can watch the video by clicking on the image above or by clicking on the link at the end of the post. Your thoughts and comments on the issue are desired. Thanks for reading, watching and responding.

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The purpose of this video is to examine communication practices of healthcare professionals as they relate to the controversy surrounding prenatal genetic counseling. We consider both how this counseling affects people in everyday life and questions relating to policy and regulation.

Specifically, the primary scene in this video is a meeting with a member of Congress, a lobbyist who represents Americans with disabilities, and a lobbyist for a fictional organization, HOPE (the Humane Organization for Parental Empowerment). The topic for this meeting is a discussion of potential legislation that addresses genetic counseling activities. To support their positions, the lobbyists refer to video clips from two genetic counseling sessions. Both of these sessions involve post-screening genetic counseling on the issue of Down syndrome, a genetic condition that can be tested for prenatally with amniocentesis.

While the situations in this video are fictional, they are not without parallel to ongoing issues in the United States. Studies suggest that counseling sessions are not “non-directive,” despite professional codes of conduct that suggest that they should be. As a result, legislation continues to be introduced on this issue, including a 2005 bill by Senators Edward Kennedy and Sam Brownback known as the Prenatally Diagnosed Conditions Awareness Act. Therefore, this continues to be a timely issue for the health care community, the policy community, and all of us as individuals.

Instead of attempting to advocate on behalf of one side of this debate, we are interested in engaging members of the health care community, as well as people associated with political regulations in the area, to continue this conversation. Therefore, we are very interested in your involvement in this ongoing discussion. Please comment and reflect, either on the video itself, or the broader controversy, so that we can generate an active discussion on this website. Any topic about this issue is fair game, but there are a few specific issues with which we are particularly concerned:

• In your opinion, which of the genetic counseling session cases most accurately represent what actually occurs in the bulk of real genetic counseling sessions?

• More generally, do you feel that directedness in genetic counseling occurs commonly? One difficulty for us as non-experts looking at this issue was the frequency of directed counseling practices in prenatal genetic counseling sessions is not well documented.

• Our enactment of the policy deliberation scene was based on our estimation of the likely positions taken by insider lobbyists on this issue. How well does our representation square with the reality on the ground in Beltway deliberations on the Kennedy-Brownback bill and related legislation?

SO IT GOES

April 12, 2007

Kurt Vonnegut, underappreciated and overlooked, is dead. I first read Vonnegut when I was 25: Slaughterhouse-Five (or The Children’s Crusade). And then I read everything else. I learned of his death last night while working a 7p-7a shift in the ICU. 

I wanted to cry. You love a writer so much, you think he is a part of you, and you him. But when he dies, you realize, he is not, and you are not. It was a passing fancy. You still have to empty out the foley bag. You still have to gown-up to protect yourself from MRSA. You still have to peel the dried skin off your patient’s lips, you still have to suction thick yellow mucous from his trach. You still have to do your 12 o’clock assessment when all you really want to do is go outside and smoke a cigarette with “Kurt Vonnegut of the mind.” 

You have to act as if nothing has changed. But it has. I think this is what Kurt Vonnegut was trying to tell me, us. “The reason why I am having you read my novel is because … 

When the last living thing
has died on account of us,
how poetical it would be
if Earth could say,
in a voice
floating up
perhaps from the floor
of the Grand Canyon,
“It is done.”
People did not like it here.

– from Requiem, by Kurt Vonnegut

WHAT LANDED YOU UPON THIS DESOLATE SHORE

March 26, 2007

where the hulks of ruined vessels rest?
Some great calamity of the mind, or at least the brain.

We attached monitor leads to your chest
So we could hear your heart tapping out Morris code,

and into your bulwark an arterial line was threaded
to reveal the barometric pressure of a life.

Tubes were snaked down into your head
to drain the fluid from your overburdened bilge.

But our interventions proved futile,
we could not keep you afloat, so we watched you capsize,

your hull to smash against the rocks of life.

THE CARPET WEREN’T ROLLED OUT

February 25, 2007

In six hours I will awaken, slowly, in a dark room, the breath of my lover on my cheek, her warm body warming me. And I will rise. And in seven hours I will walk out my front door, eyes looking to the bus stop, ears filled with the haunting and incredible sound of Sheila, thumping and screaming through my headphones.

It will be cold, but not frigid. I will pull my collar up, look up across the road to my bedroom window, and imagine her sleeping beyond it in our bed. I know by this time she has rolled over onto my pillow, her slight body now lying diagonal across the bed.

The bus will round the corner three stops down. The woman I will marry in two months.

And like this I will be on my way to work my first shift in the ICU. A confession: this is the closest I have felt to poetry in years. My fingers move swiftly over her body, over the keyboard, knowing where to touch lightly, and when to stop.

CHANGE OF SHIFT, Vol. 1, No. 18

February 22, 2007

Well, I’ve been luck enough to reprise my first time hosting Change of Shift on December 14, 2006, and though there were slightly fewer submissions this time around, the writing does Change of Shift justice and is testament to the amazing people out there working long shifts and then coming home only to do more work by blogging about their experiences.For this edition of Change of Shift I elected to go with the same layout as the first, a “journal-style” table of contents, and restrict my own comments. Thank you for supporting all these writers/healthcare workers and Protect the Airway. I’ll leave you to it. Enjoy!

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NURSE/PATIENT EXPERIENCES
Mistakes
Let’s start here: I’ve never killed anybody. Yes! Score one for the big guy. To the best of my knowledge I’ve never caused serious harm either. But I have made mistakes. Here are a few.
by PaedsRN, Mediblogopathy

Bump
A story of a minor emergency and how one nurse dealt with it by sacrificing his street cred. (Translation note: keeker = goose egg)
by Christopher Dallman, Deacon Barry

I Love My Job
A seasoned ER nurse describes how experience behind the triage desk helped save a life.
by ERnursey, ERnursey

How Do You Guys Turn It Off?
An ER nurse explains how he gets over the emotional ups and downs of life and death in the Emergency Room.
by DisappearingJohn, DisappearingJohn RN

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PERSONAL HEALTH
Alzheimer’s, Ulcerative Colitis and the Poetry of Donald Rumsfeld
Why one person continues to research treatments for her brother’s ulcerative colitis and the dementia her father had despite (or maybe because of) what Donald Rumsfeld called the “unknown unknowns.”
by Mona, The Tangled Neuron

Monday, Monday, So Good To Me
What do The Mamas and Papas have in common with what’s inside the Washington DC beltway? A psychiatric nurse with flower power and beads? Love, war, and politics.
by Mother Jones, Nurse Ratched’s Place

My Medical Nightmares
Warning: you may find this disturbing. But on a more positive note, it may be good copy for “House.” The nightmares of a MICU nurse.
by Beth, PixelRN

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PASTORAL CARE
Clergy Night
A volunteer ER chaplain talks about her experiencesprovinding pastoral care to four retired ministers and the imposter syndrome.
by Susan Palwick, Rickety Contrivances of Doing Good

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CRITICAL CARE
Buff Tuesdays
Patients are stripped of their dignity at the resuscitation room door. Why should healthcare workers be stripped of theirs?
by Ian Miller, impactEDnurse

I’m the Lucky One
When someone discovers I’m a NICU RN, I get one of two responses: “Oh, how lucky you are to take care of little babies. It must be so much fun to cuddle babies all the time,” or “Oh my, what a sad place to work. It must be so hard to work there.” They’re both true.
by Laura, Adventures in Juggling

Burnt
A NICU RN wants to give babies the medical care they need while holding them and giving whatever love is appropriate for their level of care. And then send them home. The problem: Sometimes “home” isn’t appropriate.
by Marcia, Ants Marching

Ladies and Gentlemen, Start Your Engines! It’s NASC-ER Season!
Like in NASCAR, some patients will head back out onto the “track” of their lives while others will go straight to the “garage” for repairs. If life is a race, the ER is pit row.
by Kim, Emergiblog

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STUDENT NURSING
How to Get By in the Operating Room
Two days of OR rotation: It’s not much, but with all that time to be quiet, it provided this author the time to ponder some helpful tips to help put other students on the fast track in their OR rotation.
by Mark, Mark on the World

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NURSING EDUCATION
I Need Ideas …
An ER nurse who sits on a committee charged with finding ways to reduce “door-to-balloon” time issues an open call helpful ideas.
by DisappearingJohn, DisappearingJohn RN

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POLITICS & POLICY
A Breakthrough Drug, but Only for Women
The human papillomavirus (HPV) vaccine is a breakthrough drug because it dramatically reduces the odds of women getting deadly cervical cancer. But why stop at vaccinating only half of the at-risk population?
by Shaun Mullen, Kiko’s House

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THE ART OF NURSING
Fossils Over Fences
A fond, and perhaps humorous, look back at the technology and practices nurses employed in the past.
by Universal Health, Universal Health

Who Pushes Your Buttons?
There’s an old adage that says “If you spot it, you got it.” This means that we are often irritated by people who display the very qualities we most fear in ourselves.
by Barbra Sundquist, HomeBusinessWiz

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CHANGE OF SHIFT
Thanks for visiting Protect The Airway and this edition of Change of Shift. The next edition of Change of Shift will be hosted by its creator, Kim, at Emergiblog, on March 8th.

AN ERA COMES TO AN END, A NEW ONE BEGINS

February 20, 2007

The end of an era is upon me: This week I will cross the line from the ED into the ICU and matriculate from the absurd and traumatic to the truly sick (and possibly absurd too).To mark the occasion I revisited my past and hand-picked 10 of my favorite posts as an ED nurse to count down, what I consider my most memorable experiences and my best writing. Maybe you’ve already read them all, or, maybe you “came to the table late,” and thus some of these may be “new” to you. In any event, I hope you enjoy them, and I hope you enjoy revisiting them. Until next we meet in the ICU …

UNKNOWN QUANTITIES: NOVICES AND EXPERTS
Learning the ins-and-outs of nursing, as with many careers, is an ongoing process. My development as a nurse is no different. While I am a professional nurse, I am nonetheless a novice professional nurse, not an expert. And the gulf between the two is wide and deep. …

 

PASTICHE OF ABSURDITY & SUFFERING
The tale of four patients is a pastiche of absurdity and suffering eliciting everything from ridicule and a wickedly rueful grin to sorrow and sadness. It describes how the real becomes surreal, captured in the details. Consider. …

 

A MIDDLE-DISTANCE RACE
I began my shift at 7 in the morning, and took report on three patients, but only one is important here: X arrived at the Emergency Department at about 3 am extremely intoxicated. He was found passed out on the street, dead drunk. At the ED, he was passed out and awoke only to painful stimuli (like pinching his skin as hard as one could). Make no mistake, X is not a drunk college kid; X is a hardcore alcoholic. A blood test would later reveal his alcohol level to be 401, which equates to 0.4 in popular law enforcement tests (0.08 being legally drunk in many states). A BAC of 401 is oftentimes inconsistent with life. …

 

COCAINE AND CRACK ON SUPERBOWL SUNDAY
By all appearances the day looked as if if it would be a quiet one in the ED. I started my shift at 11am and it was dead slow for some reason (Superbowl Sunday). I took report on the two patients I was assuming care for knowing that one would require little attention and who wold be discharged soon, and the other, well, he was strapped to his stretcher, yelling at passers by, clearly out of his mind on drugs. The nurse I took report from informed me that X had snorted cocaine in the wee morning hours, swallowed some “blue pills” and possibly may have eaten his crack cocaine! Great. …

 

A MONSTER, HER WEE CHILD, AND HER WEE MONSTER DOLLS
Recently a patient delivered herself to the ED, small child in tow, with the ever popular complaint of “abdominal pain.” The PT complained of diffuse pain throughout her abdomen, and I thought to myself, “Self, this is clearly an acute emergent abdomen. Precautions must be taken, IVs inserted, blood tested, urine collected.” And so that is what I did. Though I already knew the eventual diagnosis: nonspecific abdominal pain (also known as a tummy ache). …

 

MY BRUTAL ANNIVERSARY WEEK PATIENT
I picked up an extra four-hour shift for a little overtime the week of my one-year anniversary as a nurse, and I thought it would be like most other four-hour shifts – relatively easy and over almost as soon as it began. Boy was I wrong. This is a timeline of my brutal anniversary week patient …

 

THEY GIVE BIRTH ASTRIDE OF A GRAVE
I have discovered my béte noire of nursing. It was not violent murder, nor the accidental death of a child, nor the unexpected arrest. A patient was brought back to one of my rooms. I read the traige note, and learned she suffered an ankle injury falling down a few steps outside an apartment. Straightforward, I thought to myself. I’ll check for distal pulses, obvious signs of deformity, swelling, etc. As I turned to enter the room, the physician stopped me and asked of the charge nurse had told me “the whole story.” …

 

BATTLES ARE LOST IN THE SAME SPIRIT IN WHICH THEY ARE WON
Today is Veterans Day in America, as I’m sure my American readers are aware. But my readers from other countries may not know this. Or care. In light of the recent war my country has been embroiled in, I wouldn’t be suprised if that were the case. When I think of the current civilian and military leadership in America, I think to myself, I have seen better men than these die in battle, and they were called my enemy. …

 

EUPHEMISTICALLY SPEAKING: OH SNAP!
The chief complaint often changes, sometimes drastically, in the space between being triaged an being put into a room. Sometimes it changes because the nurse is asking different questions than the triage nurse asked, and vice versa. And sometimes the chief complain changes because patients forgot to mention something in triage that they now believe releveant to their treatment. And yet sometimes the chief complaint changes because the patient is deliberately misleading, unconcerned about the accuracy of her complaint, completely ignorant or obnoxious or both, or (and this is rare) the chief complaint changes because of all of these reasons. …

 

THE SUN FOR WHAT IT IS
Recently, a mother brought her son into the ED after he had been mauled by the neighborhood cat. She was concerned because she thought his lips were swollen, perhaps an allergic reaction to the cat, and so she was worried that he may soon have difficulty breathing. After a quick assessment, I was convinced the boy was not a risk for an obstructed airway, and his wounds, while numerous and bloody, were nonetheless superficial. He had approximately 10 scratch and bite sites on his arms and legs. …

CALL FOR SUBMISSIONS: PTA TO HOST “CHANGE OF SHIFT”

February 13, 2007

PTA will host Change of Shift, a nursing carnival, on Thursday, February 22nd. If you happen to post to Grand Rounds that week, please submit a different post for Change of Shift.

Please email a link to your submission, including a short synopsis, to Airway Control. All submissions must be in by 5pm (EST) on Wednesday, February 21st. Please use “Change of Shift” as the subject for your email.

The Inbox is open – Submit!

OK, NOW COME AT ME LIKE YOU’RE GOING TO STAB ME WITH A KNIFE

February 1, 2007

Those who know me know that I’m a fairly small guy, kind of skinny, and thus not given to physical conflict. My Army days have long since passed, and with them a soldier’s endurance, mettle, and penchant for finding a fight. (If there is a God, God love the 18th Airborne Corp, the 101st Airborne Division, and anyone who jumps out of a plane or helicopter to do business.) I cut my teeth in the 101st, but like I said, that was a long time ago, and I digress.

Somewhere along the way, after my military career ended, I softened up a bit, I let the outside in and the inside out. And, as Robert Frost once wrote on the same theme, that has made all the difference. I like who and what I am. Nonetheless, in the same span of time I have noticed that I have become a slightly more nervous person, more worried, given nowadays to minor, infrequent episodes of anxiety or nervousness. I never dreampt in all my life that I may someday begin to understand what it is to be a “scaredy-cat.” I thought I might just go on forever protecting them (as should be done).

Over the past few years I began having palpitations every 4-6 months that usually lasts about 3-7 days and resolve. I’ve had my heart check several times: I have an incomplete right bundle branch block – a normal variant – nothing alarming. A stress test and echo confirmed my heart is normal in size and function. Who knows what causes these “palpitations” – stress, anxiety, too much caffeine – but I do know what they look like when converted into a visual representation of their electrical origins: premature ventricular contractions.

As doctors and nurses know, PVCs occur when the ventricles of the heart contract because an ectopic pacemaker has fired. The normal conduction pathway in the heart begins with the Sinoatrial (SA) node, not an ectopic site in the ventricles!If you would like to read more about PVCs, here is an excellent primer, Premature Ventricular Contraction, written by Sarah Stahmer, MD, Residency Director, Associate Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School. And here is a very simple diagram and explanation of the conduction pathway of the heart.

A RHETORIC OF MOTIVES

January 25, 2007

“The medical equipment of a doctor’s office is not to be judged purely for its diagnostic usefulness, but also has a function in the rhetoric of medicine. Whatever it is as apparatus, it also appeals as imagery; and if a man has been treated to a fulsome series of tappings, scrutinizings, and listenings, with the aid of various scopes, meters, and gauges, he may feel content to have participated as a patient in such histrionic action, though absolutely no material thing has been done for him, whereas he might count himself cheated if he were given a real cure, but without the pageantry.”

– from A Rhetoric of Motives, by Kenneth Burke


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