5150dx

Aloha, I recently graduated and have begun to work in a local hospital. My only experience with Hospice was when my dear friend was dying of leukemia and complications last year -- the Hospice was great! I am 38 and have worked as an EMT on fire dept. and ambulance so am not new to dealing with pts. and family at time of death -- just not the long drawn out kind. I am finishing my first month, with a preceptor, on the medical unit. 3 CA patients whom I met early on, have all returned, in varying stages of condition. Yesterday, a dear man with lung ca with mets to spine, brain and probably abdominal organs appears to be nearing death. He had been going into Hospice when I met him first, but then a family member convinced him "you cand just do nothing" so he changed his living will to include all efforts. My pt. is mostly unable to respond, no oral intake to speak of for a week, on iv fluids, getting decadron ever 6 hrs and iv ms every 2 -- ativan appears to increase moaning and thrashing so I stopped using, seeing him mellow more and be more restful with just the ms. HOB elevation, relieves his acute respiratory distress. 2 days ago his feet ballooned up and he and I joked about when they would "pop". Now, they have improved because we have a "compliant" patient who has ended his efforts to sit on the edge of the bed -- of course the fluid appears to have just gone to his belly, sacrum and lungs. As long as he doesn't get moved (which we still have to do to avoid decubs), he seems mostly comfortable. The poor doctor is so frustrated with the patient's code status, and is even considering interpreting the pt's living will which says he wants the "normal standards of care for his disease process" to mean no cpr or artificial feedings. I feel for him and am impressed that he cares enough to think this way, even if he ends up not risking it for fear of being sued by distraught family. The other pts. both will likely be called terminal soon -- advanced small-cell lung ca with mets to brain upon diagnosis, doing poorly with chemo and radiation and a lady with met ca to lungs, uterus, bladder and more. Yet another is fighting met. cervical CA, at a point with bi-lat nephrostomies, bili bag and now dialysis, and tpn. She already did chemo and other options which doctors could offer, with no great success. I guess I am struggling with my own feelings that they should be working with hospice -- trying to balance that with patience that each person needs to figure it out in their own way and time -- and some may never choose it. It just saddens me and I know I will find a way to choose the best words to help the families and not color them with my frustration about THEIR denial. Thanks for listening!

Hello all :) So sorry I did not respond back sooner -- The training was great! Gunter Klose is an excellent teacher of the skills and extremely experienced. After the training, however, I had to focus on passing my NCLEX, selling our home and moving to another state. All of that is finished and I am just beginning to explore the possibilities that lay before me. I will follow up later! Thanks again for these forums! Kristin

I just finished this winter, ADN, and am very thankful for the opportunity. I had a strong background in emergency medicine/ambulance and passed the NCLEX at 75 questions - with no study for that particular test. Now, I am having no trouble finding work. I agree with whoever said that the NLN has stringent standards for schools which want to be accredited... and EC has met them time and time again! There will be the occasional "mistake" that happens to make it through the EC program but, I suspect, no more often then those produced by traditional "programs"... yegads! I could point out quite a few nurses who went the traditional route and can't think themselves out of a corner OR have any real experience with patients.... sigh.... I strongly support the programs that Excelsior College offers. Kristin

Well, I leave in an hour for the airport -- looking forward to the training experience, though I have never been away from my husband and son for two weeks I have also found an AHA BLS Instructor course for the week after I return. I am trying to give myself options... The neat thing was that this instructor has a business in northern California providing safety training to people in the community. Apparently some years ago she injured her back as an R.N. and could no longer lift pts. So she told me she searched ideas and decided to teach one CPR class per week. Then it became more involved and she has become "The" resource that medics, docs, nurses, firefighters, etc. can go to for training on a regular schedule. In fact, that is how I found her... a medic friend of mine also teaches a medic course, 4+ hours away from this instructor, but knew to suggest I contact her.... she has earned the reputation far and wide. Now, there is another entrepreneurial idea. I was a little surprised that no one had responded to my first post -- I guess it sounded like I was advertising... but I was not. I was simply posting a business idea that is open to nurses and is something that I have found to be actually working for several nurses, some as independent nurses, others describing it as a wonderful skill when working as an oncology nurse, in hospital. Anyhow... I love reading the posts here! Thanks, especially, to Lois Jean -- I have since printed out copies of the diabetic foot survey form - I think it was from a government website -- to use with my (future) students! Kristin Graduating Feb. 20th!!!

Hello, Cheerfuldoer, I feel like you do about the uniform. At almost 40 I have not viewed those wearing whites as slutty, sex kittens, subservient hand maidens or such. They can look clean, crisp and professional looking and it seems very unlikely that would not be to the liking of our "clients" and professional peers. When I wrote about my thoughts about client/patient I was trying to point out the fact that it can, with some people, make them feel a bit more empowered to stand up for their rights as a consumer of our services. Now, will it make ALL the difference? No, of course not. But over 8 years of working with "clients" in their homes I found that, once I got over my initial resistance to using the term, I understood the significance. I realize that there are many great nurses and they are providing excellent, professional nursing care to their patients/clients. Also, I realize that there are (perhaps) more clients who are realizing that they don't have to take such a passive role in their in-hospital care. It seems, however, that this would be a minor thing that we could do to "take the high road" but I see that some others see it as just another "politically correct" rule being churned out by the powers-that-be and they resent that. Maybe I am just sad that I see the career of nursing as being something that fewer and fewer good people will want to pursue, and for good reasons. There are so many problems with understaffing, bad attitudes from docs and others, etcetera. I guess I am just in the camp of looking for ways we can use to portray us as a more (united?) professional force "to be reckoned with". It makes me sad that so many leave the role they loved because they hated the awful "job". I don't have all the answers (now THAT'S the understatement of the century ) and I guess I am old-fashioned but I just hope that we can find ways to help our profession be one that we can find more satisfying and true to our hopes. There is such bitterness from so many nurses about things like nursing diagnoses, whites, terms like client vs patient, and more. I realize that it can be difficult to see how those details might be valid when you are in the trenches, day after day, understaffed and frustrated. I guess I just had my vision tweaked by several dear friends who are those "crazies' who envision something better. A while back, I called a friend who had been a bedside nurse for 15 years before going into education and contributing to nursing research for several years now. I asked her about these "semantics" and she convinced me they were important to our role as professional nurses and to the continued autonomy we are supposed to enjoy. Another nurse I am lucky to call a friend, told me not to be discouraged but to keep on visualizing that it will get better. She has her doctorate in nursing, is a respected authority on the care of terminal patients and is out on the pioneering edge of defining what nursing can be. An advocate of change she, among other things, is building a wellness center that will utilize complementary and traditional medicine for her clients. I found her when I was desperately seeking protocols on providing massage to my friend with leukemia. One of the studies she had published covered just that subject. My point (is there one? ) is that perhaps, just maybe, these semantics might help us, and incidently the public/docs/hospital administrators/etc, to see nursing as the profession that it can be and to ascribe (?) more value to those who choose that path. I have to believe that there is hope. Thanks all :kiss

Hello all, First of all I want to say how much I appreciate the feedback. Second: to the person who wrote, "Plus, when I wear white it seems to attract coffee. I can't remember a day when I wore white that I didn't dribble some coffee on myself. Don't do it any other time except when I wear white.", I certainly understand :) Please know that I wasn't implying that anyone not wearing whites was dirty -- just that, if your scrubs are getting so nasty during a shift, try to take a fresh look at the situation... either we should be making more use of the disposable protective gowns and such, because the fabric of your scrubs is not stopping blood from soaking your skin and/or a change is needed. Believe me, I understand how easy it is to get whites soiled.... I also want to make it clear that I am not in love with the color white -- it's just that the public identifies whites with professional nurses. My point about "uniforms" designating a profession identity still holds .... call them monkey suits if you want but folks recognize them. I disagree that the public perceives the whites as you described ... that the public expects us to give up our seat for doctors, etcetera. Repeatedly patients are allowed to remain vaguely confused about the various people who care for them, often lumping them all into the role of "nurse". I absolutely value each team member I work with HOWEVER I still hold that clients/patients are unaware how few nurses there are on duty. Maybe that's not such an important point, but my gut tells me otherwise. And in no way am I saying that it should be mandatory to wear whites -- Thanks you all!

Hello again - well, now that I am not shaky from low blood sugar, perhaps I can participate a little more thoughtfully Deb, you wrote: "wearing whites is NOT practical in all clinical areas...." -- now, I am sure you can give me some examples however the ones I think of all would still benefit from the wearing of light or white clothing. Meaning, if you get dirty, it is obvious and you know you must change before going to your next patient... dirty. I have read and heard nurses say things like "I'm a slob -- I can't wear white". Now, outside of the hospital setting, I can tend to agree, which is why I don't include it in my civies wardrobe But, at work, to me, it just seems "clean" to wear whites -- if blood or some nasty bodily fluid ends up on them, it is very clear they are soiled and not to be worn until washed. Yes, I realize that means keeping extra whites in a locker. If big spills are happening often then that means we should be wearing disposable protective gowns more frequently... right? As far as respect goes, I mention the wearing of whites because it is something most of our customers/clients and peers/coworkers will recognize. Even though it should not matter, the fact remains that it does. If how we dress didn't matter we would not see every other profession having their own sense of "proper" attire. Think of business black, the whole red tie/orange tie thing, white collar, shined shoes, 3 pc. suit versus friday casual. Would most attorneys show up in court dressed in a washed out t-shirt or Goofy print shirt? Very unlikely, though we can all think of exceptions. Why do firefighters wear uniforms? Police officers? Believe me, they wouldn't if it wasn't very beneficial to them. I still believe we would appear more professional and would make progress towards the public becoming more aware of how few R.N.s are on duty AND that there is a distinction between the professional licensure of the staff. You also wrote: "In some areas, this is true, as healthcare is NOT a right, but a PRIVELEDGE in the USA, anyhow." Shouldn't clients/patients still have the right to good "customer service" even if it were a "right" (which I wish it was, too)? MJLRN97 wrote: "we're supposed to be thinking in business terms, e.g."customer service", but the truth of it is, most of us are not business people---we're NURSES, and we take care of patients!" -- I understand where you are coming from but if we DON"T think and portray ourselves like professional business people we will continue to be taken for granted. We are professionals who are partnered with the other healthcare professionals and the clients. The care/service we provide is unique from the rest. We are not simply "following orders". If we continue to allow the public to see us that way I am doubtful that we will make as much "professional" progress as we might hope. I think we need to look at the whole "customer service" issue from a variety of angles, not just blasting it because it reeks of "money" -- Must go... thanks so much for the thoughtful responses!

Oh, and another thing -- considering ourselves as "professionals" working with "clients" might shift our thinking and the way we present ourselves so that we aren't just "part of the room charge". Maybe that and more of us wearing whites would heighten our clients awareness of who the registered nurses are and why there is a difference in titles, duties and responsibilities. I know that your ability to provide excellent care doesn't rely on the color of clothes you wear or the length of nails (yikes, perhaps it does!), but over and over, I read posts from nurses who comment on the increased respect they get from patients when they wear their whites. I think it would be good for non-hospital staff to realize how few R.N.s are actually on duty. Yegads... I will stop now...

Hello, I personally prefer the use of the word "client". For all of you who don't like to think of the "patient" as having contracted with you so you will provide them a "professional service", I am sorry that is how you see it. I have been hospitalized several times and saw a great difference in the attitudes of the various nurses who provided my care -- several of which provided LESS THAN professional service. Those same nurses were the ones who acted like I had no business asking them to contact my doctor when I kept vomiting and dry heaving post adominal surgery (laparotomy (sp?)) -- they kept telling me they had given me "everything" they could. Luckily the anesthesiologist looked in on me, found me drenched in vomit, crying and crouched in the chair the nurse had insisted I sit in... he quickly ordered something more effective and I was immediately relieved. Or the time my son was hospitalized and was becoming over-hydrated and after 1 hour of my mentioning it to the nurse I finally reached over and wheeled the da*ned thing closed -- oohh did that piss her off! All she could think was to be angry at me instead of noting my 3 year old's puffy lids and doughboy arms. Patient implies that we are suffering and blessed/lucky to have someone to care for us. Physicians have long had a terrible reputation of having god complexes and many still intimidate their "patients" into procedures and treatments because "doctor knows best". We should be doing what we can to encourage our "clients" into working with us to improve their health -- and maybe if we think of them as clients and, as such, entitled to good "customer service" we would provide better nursing care. I could go on but that would not be productive. They really are clients of ours. Sorry, anything we can do to improve the attitudes of nurses like that, I welcome... within reason of course Rant mode off... I do appreciate reading the different opinions. I guess I just see a terrible lack of professionalism in a significant number of the nurses I encounter. Maybe some will say it is just political correctness but that is what many still say about the "n" word. Sorry if I stepped on toes... or appear rash... I just get heated up when I think of how sarcastic and snide some nurses can be as soon as they think they are out of their patient/client's hearing. Okay, I'll shut up now

Hi Dave, I read you post with interest but am wondering if that would be most appropriate for someone who had a history of using large amounts of opiates - either legitimately or abusively - not a current addict. If a self-admitted heroin addict is hospitalized for surgery, when do we make sure he gets the opioid he needs to avoid withdrawal and heightened sensation of pain? By the time he/she is post surgery, hours have passed since his last "hit"... possibly bringing all sorts of complications related to withdrawal... I don't have the answers and am new to this but it still seems a little uncertain to me. Thanks for your feedback. Kristin

Hi there, I just wanted to make you all aware of Manual Lymph Drainage and Complete Decongestive Therapy. I just finished nursing school and want to have skills that may allow me some freedom in the setting I work in. My focus is oncology and this training will complement it beautifully. There is one nurse I have been talking with who has made a very successful business in the Sacramento metro area. Some healthcare plans she is able to bill directly, others get billed through the Physical Therapist she opened the clinic with. It's the end of a long day so I can't think clearly to write out more detail but will list several links for you to research. I am signed up to attend a 2 week training intensive in Santa Monica, beginning on Feb. 9th. I chose to go with Guenter Klose's program as it was highly recommended by several R.N.'s I spoke with and it is a short, intense training instead of spread over 3-4 weeks. http://www.klosetraining.com http://www.lymphnet.org http://www.lymphnotes.com http://www.clt-lana.org There are more... just do a search. There is one training group headed by a Physical Therapist who is irritated that others (I.e. Nurses and Doctors) are being allowed to be trained and bill medical insurance for this therapy -- I am glad her view is the minority Keep in mind that the main client base will be anyone who has gone through cancer treatment and or surgery, or burn injury that involved lymph vessels. It is also important that patients receive education on this as a preventative measure, accompanying their procedure so they will know how to minimize their risks and recognize early lymphedema. To me this has some serious entrepreneurial potential. Email me if you have any questions and I will try to help. Kristin beautifulbooks@@Hotmail.com (just drop the extra @) ?

Wow! I will stop laughing now and tell something I learned from a patient... 1.a. Don't follow your bosses instructions to pour a half-gallon of gasoline on that rubbish pile.. and THEN wait 5 minutes to approach it again and set a match to it. 1.b. Then DON"T drive yourself home and climb in a cool bath as you are in denial about the increasing difficulty you are having breathing. 1.c. THEN DON'T expect your wife to handle it very well when she is working as an EMT on an ambulance, happens to be driving and gets dispatched CODE 3 to her own house to pick up her own husband who has burns to his face and crispy nasal hairs. Thankfully my supervisor came at the same time, meeting me at my home and offering to swap vehicles with me so HE would drive my husband to the E.R. Yeah... the things we learn from our patients - my poor husband will never live that one down. Kristin

Hello, Please realize there is a big difference in protocols for treating Lymphedema (either primary or secondary) versus edema caused by cardiac "issues". Diuresis as a treatment to reduce Lymphedema is absolutely contradicted because though it dehydrates the fluid buildup it leaves the remaining interstitial fluid even more concentrated with protein which makes infection, fibrosis formation and other complications even more likely. Lymphedema is mostly seen in patients who have undergone surgery which either removed or damaged a region of lymph glands -- commonly seen with breast cancer pts. Others are secondary to severe burns or radiation treatments. Still a few more were born with missing or malfunctioning lymph vessels and organs -- this would be Primary Lymphedema. Please take a look at this website: http://www.lymphnet.org/ and remember there are a growing number of nurses, physical therapists and doctors who have undergone specialized training for this problem and are certified to do so. Also beware of some massage therapists who claim to do "lymph massage" -- this has nothing to do with the medically oriented and clinically proven Manual Lymph Drainage combined with Complete Decongestive Therapy which these patients need. CDT will include the Manual Lymph Drainage with restorative exercise, skin and nail care of the affected limb, compression bandages throughout the initial treatment and then the professional fitting of compression garments to keep the lymphedma in check. The patient will also be educated about caring for the limb, including, but not limited to, not allowing invasive procedures to be performed on it (ie: blood draws, injections, blood pressure cuff, and more). The use of mechanical compression devices is becoming rapidly more controversial because of its ability to actually damage the lymph vessels, among other things. Kristin

I just realized that the placement of my prior post might make you think I meant Narcan for Ketamine or Versed reversal... nope. Meant to refer to earlier posts where using Narcan was mentioned. Thanks!

Please just remember that you can titrate Narcan during the procedure, definitely no need to jolt the pt. completely with viscious return of pain. I am new to all of this but thought I would share that reminder. It disgusts me that there are docs who perform painful procedures on pts. without including adequate analgesia. If no narcs are the goal, then how about parenteral ketorolac??? I think we are seeing way too much dependence on causing (and relying on) amnesia in our patients. Just my not-so-humble opinion. As a newbie, I should probably tone my expression down but this subject is a biggie for me Kristin Waiting for Feb. graduation!!!