Jump to content

Topics About 'Oncology Nursing'.

These are topics that staff believe are closely related. If you want to search all posts for a phrase or term please use the Search feature.

Found 9 results

  1. SoldierNurse22

    Little Brother

    It was a story I'd seen before: 19-year-old airman, T-cell lymphoma, air evac'd from overseas after a plethora of symptoms led to the discovery of his cancer .I headed boldly into the room, my orientee close behind me. A young black male, no older than my younger brother, sat in bed, large headphones on his ears. A teenaged boy slept on the couch. Both of them looked up as I entered the room with suspicion in their eyes. I introduced myself. I asked about his pain. His voice was quiet, his eyes avoiding mine, his body language closed. As I assessed him, listened to his heart, listened to his lungs, checked his pulses and asked him questions, he muttered his replies, his eyes flickering downward toward the white sheets on his bed. He was distant in his answers, as though replying from somewhere out of his body. Unruffled, I reminded him of his NPO status for his pending bone marrow biopsy that morning and headed back to the computer to chart. Poor kid, I thought. He's clearly afraid. I showed my orientee how to chart the assessment, put in the vitals, and together, we continued on our way. An hour or so later, the physicians called. They were ready for the bone marrow biopsy. My orientee and I premedicated the patient for the procedure, took our time with answering his questions and put him in the hands of the oncology fellow, a short, bubbly lady physician who was only too happy to answer his questions and hold his hand. My orientee and I returned to our other patients. An hour later, he returned to the floor. He was just in time to order breakfast. I gave him the menu and he called downstairs for his food as I stood next to the bed. Once again, we asked him if we could get him anything, and upon his denial, we encouraged him to call and headed on our way. Forty-five minutes passed. We returned to the room to see him and he had no tray. I called downstairs to order; the kitchen had closed. No more diet techs were leaving for the wards for food delivery. My 19-year-old bottomless pit would have to suffer through the next hour and a half on an empty stomach, all because the diet techs were too lazy to bring up his tray. This was not right. My orientee once more on my heels, I took to the elevators, the two of us storming the galley. I was frustrated and outraged on behalf of my patient. As we entered the galley, two young enlisted sailors met us at the door, ready to deny us entrance. I don't know if it was the determination in my eyes or the fire in my tongue that convinced them to open the doors to the food prep area, but there we were, donning hairnets and traveling through the forbidden bowels of the basement. The sailors took me to their civilians counterparts, the phone-answering folks and those responsible for assesmbling and dispatching the trays to the inpatient wards. "Ma'am, the kitchen is closed." A civilian was barreling my way, her tone haughty. "My patient didn't get his tray. I'm here to get it for him." I said, turning to face my opposition. "I'm sorry, ma'am, the kitchen is closed." She insisted. I squared off. "And I'm sorry, ma'am, but I'm not leaving until I get his food. You still have food out in the prep area. I'll put the tray together myself. But understand this--I'm not leaving without his food." I replied evenly. Her eyes darted from my face to my rank. I was just another second lieutenant at the time, one of hundreds at the command, but apparently the gold bar was enough to convince her that I'd take the matter higher if it wasn't dealt with immediately. "All right." She conceded. Within ten minutes, we were on our way back upstairs with our hard-earned tray. My orientee brought him the tray, presenting it like the trophy it was. He barely looked at us, murmured a thank-you as we left his room, both of us admittedly disappointed at his response to our heroic efforts. A half hour later, his call bell rang and we returned to his room. The pain from the biopsy was intense, much more intense than I'd seen in any patient before. I got an order for breakthrough pain meds, overrode the order in the Pyxis and began to push his morphine. As I delivered the dose, he began to whimper, suddenly asking me to stop. "What's wrong?" I asked. "It burns!" He exclaimed through tears. I felt irritation flash through my chest. Here I was bending over backward for this kid, charging the kitchen and fighting with the pyxis and putting on my happiest face, and he was complaining about the pain meds he had just been crying for? I choked back my frustration and flushed the line, the pain abating instantly as the saline replaced the narcotic. At the desk, I explained what had happened to our intern, who rolled his eyes. "Fine. Percocet. It's not nearly as strong or as fast-acting, but if he can't take the IV narcs, it's the best I've got." I returned to the room, provided the once again overridden med, and left the room after making sure he was all right. Not so much as a thank-you followed me to the nurse's station. For the sake of my orientee and my pride, I held it together. On the surface, I was frustrated with his lack of response to my compassion. I was irritated by his apparently impervious take to my Herculean effort to make him comfortable. What I wouldn't realize until much later is that I was really just afraid. The shift continued similarly. I did my best to reassure him, to calm him, to sit with him, but he wanted none of my empathy. When his mother arrived, he collapsed onto her chest, and I was relieved that he finally had someone who he trusted to fall against. But the frustration I had felt earlier still grated against me and against my genuine efforts to secure a good rapport. The next day, I had him back. All day, I medicated not his pain, not his physical body, but his fear. With incredibly diluted IV pushes of dilaudid, I realized that I numbed his mind from the reality of his physical state and induced the sleep that spared him from the mental agony of his cancer. My coworkers, nurses and doctors alike who were familiar with the situation, sighed in a similar frustration. When was this airman going to man up? When was he going to accept this diagnosis and snap out of it? We aired our grievances privately to each other, and I though I knew full well that what we were witnessing was simply the ineffective coping mechanisms of a patient who was not yet truly an adult, his inability to accept our kindness and his own disease still poked at me like a thorn in the side. Perhaps I'm becoming too jaded, I told myself. Perhaps it's time for me to get out of oncology. Weeks later, he returned to our ward. He was early for his chemo admission, still withdrawn and difficult to illicit even the most basic responses from. It was as though he had regressed to his early teenaged years under the stress of his disease. He was not my patient, but when he reacted to his blood transfusion on the weekend, I, as charge nurse, assisted his primary nurse and my good friend in collecting the necessary samples and setting up the IV fluids that were warranted. He was just as I remembered him from before: a quiet, whimpering little brother, afraid, alone now that his mother was 500 miles away, and painfully withdrawn. But this time, I recognized the emotion that hid behind the veil of my old frustration. It had been fear. I was afraid that, as a nurse, my care was ineffective and inadequate to soothe his fears. I was afraid that I didn't have the emotional capacity to calm him. I was afraid that if I were to find a way to reassure him, I'd lose the bubble that insulated me from the cruel reality of my patients' often grim conditions. It was fortuitous that I had the weekend to consider these facts, because today, Little Brother returned from the PICU to our ward. Despite my hesitation to take him as my patient, all the other nurses were busy. His care fell to me. I prepared myself emotionally for the long haul. I was exiting another room when I saw the PICU nurses in their maroon scrubs returning down the hall with an empty wheelchair. I got a quick follow-up report, bid them farewell and met my tech outside the room. We entered together, fully ready to continue cajoling this adolescent-like young adult into cooperating with our care. To my shock, he sat up on the bed, fully emerged from his blanket-like cocoon, and he smiled as we entered. "Good afternoon. How are you feeling?" I asked him. He looked me square in the eye. "Much better, ma�m." He replied. I almost fell squarely on my fifth point of contact. He spoke! "Any pain today? Any nausea?" I asked. He shook his head. "Nope. I've been able to eat now and keep it down for a day or so." And on went the discussion. I set up his IV antibiotics, explained what they were, and as I did so, he talked. We found that we both had very particular taste in water of all things. While he preferred bottled, I was staunchly in favor of tap. He told me about a girl on facebook who had friended him. "Do you ever have it happen where you see someone and you know you've met them before, but you don't remember when?" He asked. "It's awful, isn't it?" I empathized. "Oh, it's terrible!" He exclaimed. He told me about how things were going outpatient, about how he missed his mom, about how he was glad to be back on our floor because he had been lonely in the PICU. I listened and nodded, interjected my opinion when it seemed warranted, and eventually, as I programmed the pump for his vancomycin, he asked me a question. "How do you do this?" He asked, his tone suddenly serious. I stopped my work and made eye contact with him. "What do you mean?" "I mean this." He said, looking around. "How do you work with people who have cancer and diagnoses like this all day?" I sighed. It was a question I'd been asking myself a lot, lately. "Well, I guess practically speaking, people are going to get sick. I figure they'll get sick whether I'm there to help them or not, so I'd rather be there and have a chance at making it better than just giving up." I said. He nodded, visibly chewing on my words. I continued. "As for patients--I guess I can't really come at it from that angle. I know it's got to be difficult to be young and have cancer, especially when you were in such good physical shape before. I have a friend who survived leukemia and he told me he had similar struggles, but y'know, he's healthy now. He's been in remission for a few years. It's not like this diagnosis is a death sentence." He nodded, his eyes flickering with the thinly veiled hope in my words. "I just hope it doesn't come back." I wanted to tell him it wouldn't, but I knew better than to make promises. So I nodded in return. "Me, too." "I was so angry when I found out I had cancer. I mean, why me? Why am I the one who gets this at nineteen?" He said. "It's just not fair." I was amazed at what I was hearing. To listen to him discussing what he had been feeling and what he had been through was therapeutic to be certain--for him and for me. "No, it's not." I agreed. "I guess I'm just coming to terms with it now. I didn't realize I could be depressed and angry." He told me. "Acceptance usually comes after going through many stages, and not always just once. It's not quite as tangible or definable as some people will have you believe, and it's very normal to go back and forth. Some days will be better than others." I reassured him. He nodded. "I'm just ready to get this chemo over with." The rest of the shift only improved. Every time I went to see him, I stuck around to talk. He made me laugh, I made him laugh, and eventually, I'd say goodbye and see him in the next hour only to repeat the previous interaction with different jokes and discussion topics. By the end of the day, I introduced the night nurse and said goodnight, genuinely looking forward to seeing him again. So tonight, I sit here to write about things that I know I must remember. The girl who graduated nursing school two years ago and found herself unwillingly placed on an oncology ward met me today. She shook me by the shoulders and reminded me that pain is often masked in anger and fear, that sarcasm and cynicism do not often improve patient outcomes, and that a little patience with the most difficult patient goes a long way. She reminded me of the longsuffering nature she had entered her field with, of how she could often see through the coping mechanisms that those more experienced and more calloused had lost the ability (or at least the willingness) to identify, and how she had hoped as a young nurse that she might never lose that talent when it came to understanding the pain of others, however masked or distorted. Tomorrow, the day will dawn new. And I'll return with the most knowledge, the most skill and more compassion than I've ever known to the care of Little Brother and countless others like him.
  2. "Transfusions 101" Everything you need to know about blood products and administration Many patients require transfusions of blood products for acute or chronic issues. Here, we'll discuss an overview of the products used, possible transfusion related reactions, general administration, and all of the special ways the products can be prepared for patient use. Types of blood products Whole blood is what is directly drawn from the bloodstream; made up of many different types of cells including, red blood cells, white blood cells, platelets, and plasma. "There are very few indications for the use of whole blood transfusions. The major indication for whole blood transfusion would be in some cases of cardiac surgery or situations of massive hemorrhage when more than 10 units of red blood cells are required in any 24-hour period. The other rare situation would be in which blood transfusion is required immediately for rapid, life-threatening hemorrhage when red-blood-cell component therapy is not available" (Mitsuyasu, 2004). Blood bank laboratories can separate whole blood into the specific components needed. An alternative to donating whole blood is the process of apheresis. It is a "special kind of blood donation that allows a donor to give specific blood components, such as platelets. During the apheresis procedure, all but the needed blood component are returned to the donor" (Blood & Tissue Services | Donating Platelets, 2017). Packed red blood cells (PRBC) can be given in emergency settings to replace blood lost in trauma or in more chronic settings for anemia (these can be chronic hematologic diseases such as diamond blackfan anemia, beta thalassemia, iron deficiency or even secondary to myelosuppression due to chemotherapy administration). General symptoms of anemia may include fatigue, pallor, shortness of breath, dizziness and headache. The hemoglobin, iron and oxygen levels should rise post-transfusion and the symptoms above should improve. Administration times may vary depending on the clinical situation, desired volume and patient weight (refer to your hospitals policy). I've seen standard administrations (~10ml/kg) given in both pediatric and adult oncology settings over anywhere from 2-4 hours. Premedications such as Tylenol, Benadryl and Solumedrol (or other steroid) may be required if the patient has experienced a previous transfusion reaction. Vital signs are frequently monitored, usually at baseline (before transfusion or any premeds), 15 minutes into infusion (assess for potential reaction symptoms), and at least every hour thereafter. Platelets (PLT) play a role in blood clotting. These transfusion are given when the platelet count is low and bleeding symptoms are present (nose bleeds, petechiae, purpura, etc). PLT may be needed in certain cases related to surgery, trauma, thrombocytopenia and in rare cases of some hematologic diseases, such as symptomatic idiopathic thrombocytopenic purpura. These infusions are typically given quickly (less than 30 minutes) and may require premedication if necessary. Plasma is the clear yellow liquid portion of blood, making up for over half your bloods content. It contains proteins, enzymes and antibodies and can be used in cases of burns, infection, liver failure, treatment for thrombotic thrombocytopenic purpura (TTP), as well as some chronic illnesses related to the immune system or coagulation issues. Fresh frozen plasma (FFP) and Cryoprecipitate (cryo) and even intravenous immune globulin (IVIG) are all specialized portions of plasma that can be used in the different clinical situations listed above. Infusions times vary depending on product used and patient status. Vital signs and general assessment should be performed at regular intervals, as with all blood products listed above. Transfusion Reactions It is important to assess your patient for potential transfusion-related reactions during and after treatment. Possible symptoms to be on the lookout for include facial/chest flushing, hives, rash, tachycardia, shortness of breath, back pain and chills. These can be treated quickly with the use of supportive measures (oxygen and IVF bolus) and emergency medications (antihistamines, steroids, epinephrine, etc). It is important to ensure you are prepared to give the patient a transfusion compatible with their blood type. Compatibility "There are eight different common blood types, which are determined by the presence or absence of certain antigens - substances that can trigger an immune response if they are foreign to the body. Since some antigens can trigger a patient's immune system to attack the transfused blood, safe blood transfusions depend on careful blood typing and crossmatching" (The American National Red Cross, 2017). While O positive is the most common blood type, O negative is considered a universal donor and can be received by anyone, no matter their blood type. You can find a simple compatibility chart here. Double checking compatibility of the unit (along with other patient identifiers) before starting the transfusion can prevent life-threatening reactions. Preparation of Units If you have ever had to check a unit of blood with a co-worker prior to administration, you know there can be lots of transfusional lingo on the bag. Let's break it down. Washed: This process is done to remove extra proteins that may cause an immune-mediated reaction to the blood product. Typically used for patients with history of certain severe transfusion reactions and those with rare immune deficiencies. These products usually take longer to get from the blood bank and have a much shorter expiration than most units (a few hours). Leukoreduced: May also be called leukocyte reduced or leukodepleted. This filtration process helps to remove a large portion of leukocytes (white blood cells), needed for many immune suppressed oncology patients, transplant patients and reduces the risk of cytomegalovirus (CMV) transmission. Many units of PRBC and PLT are now marked CMV negative also. Irradiated: This process involves using radiation to kill leukocytes, also used for those who are immune suppressed, preventing exposure to these leukocytes can minimize future complications like graft versus host disease (GVHD) for these patients. Antigen Negative: You may see something like "C,E,K Negative" or "phenotypically matched" on the unit you are about to transfuse. This means the unit has been tested for certain antigens. It can be used for patients who have received multiple transfusions and may begin to develop antibodies, causing transfusion reactions. These kinds of units are commonly given to oncology patients and those with sickle cell disease. Conclusion Whew! Are you still with me? Now that we've covered all of that, let's bring up one of my favorite topics related to transfusions...donation! If you're able, please consider donating to your local blood bank or plasma center. Being a hem/onc RN I can tell you the number of blood products being given every day is just massive. It seems there is always a shortage of product available and many patients depend on the life-saving gift of donation. Spread the word to your family, co-workers and friends. References: Blood Types. (2017). Retrieved February 13, 2017, from Blood Types Chart | Blood Group Information | American Red Cross Donating Platelets. (2017). Retrieved February 13, 2017, from Blood & Tissue Services | Donating Platelets Klatt, E. C., MD. (n.d.). Blood Products. Retrieved February 13, 2017, from Blood Products Mitsuyasu, R. T., MD. (2004, March 23). Use of Whole Fresh Blood for Transfusions. Retrieved February 13, 2017, from Medscape: Medscape Access Peterson, B. R. (2006). New developments in blood transfusion research. Retrieved February 13, 2017, from Google Books Types of Blood Transfusions. (n.d.). Retrieved February 13, 2017, from Types of Blood Transfusions | Red Blood Cell, Platelets & Plasma | American Red Cross Use of fresh frozen plasma. (n.d.). Retrieved February 13, 2017, from https://www.transfusion.com.au/blood_products/components/plasma/use What Is Plasma? (n.d.). Retrieved February 13, 2017, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=160&ContentID=37
  3. Despite advances in cancer treatment that have led to higher rates of survival after treatment, the medical approach has continued to treat a patient with a disease, and though the disease often goes into remission, a patient remains. Helping cancer survivors restore their quality of life after treatment requires skill and a level of expertise that encompasses empathy, a focus on their quality of life, and is holistic in its approach. Nurses are the ideal professionals to lead this change. The Way We "Do" Cancer As an oncology nurse working in a hospital-based outpatient clinic, my tasks at work were specialized, but basic: check orders for chemotherapy rule out any contraindications to going forward with treatment assess the patient for adverse effects contact the oncologist with any concerns communicate with the lab and pharmacy do safety checks on orders and doses with another nurse administer premedications before treatment observe the patient during the infusion While making the patient comfortable, doing my assessment, tapping their port or access device, and while the bags of chemo were infusing, there was time to talk and listen. What I heard from the patients and their family members were numerous concerns and questions that seemed to have been unaddressed by their oncologists, information that would enhance the patient's comfort, safety, and tolerance of their treatment regimen. Much of that information seemed integral to the success and safety of therapy, such as vulnerability to infection, bleeding, electrolyte imbalances, or how they could expect to feel in the days after each infusion. Oncologists had heavy patient loads, were busy and tired from being on call, rushing from one hospital to another, coping with emergencies, and trying to keep up with their own documentation. Based on the questions they asked, it was apparent that treatment was interfering with their lifestyles, and I wondered what would happen after they completed treatment, what their lives would be like afterward, when we no longer saw them on a regular basis, after their ports were removed, their hair grew back, and they attempted to return to the life they had before the shock of a cancer diagnosis. Seeking and Resolving Unmet Needs They had navigators to assist them with some of their needs during treatment, but after treatment had ended, patients were on their own. I started attending a cancer support group in the hospital basement in the evenings, wanting to know if there was a better way to help them with unmet needs. Patients were happy with their doctors' care, but the lasting effects after treatment were interfering with their ability to return to their previous quality of life, activities, occupations, and relationships. Often, their entire lives had been upended, leaving them lost and unsure: "When will I feel better? Will I ever feel better?" Few had been given survivorship care plans, but even those who did receive them were at a loss for how to proceed. Unprepared for what life would be like after treatment, their coping skills were inadequate to face what would be an extended and unpredictable recovery period. Survivorship care plans were little more than a schedule for follow-up medical care: scans, labs and screenings, for lengthening intervals until the five-year mark, then they were on their own. The plans appeared to be designed for the doctor's convenience more than for the patient's benefit. They did provide some general guidelines that told patients to eat right, exercise, wear sunscreen, avoid stress, alcohol and tobacco, but they needed behavioral guidance. Fear and anxiety about cancer recurrence plagued them constantly, as well as fatigue and cognitive difficulties. They needed help restoring both their bodies and minds. Mental health guidance was all but absent. A Community Approach Doctors have neither the skill sets nor time to meet the needs of their newly created survivors, but patients came to them with problems they didn't know how to address. Patients fear being labeled hypochondriacs or sent away with antidepressants as the answer to their problems, without referrals to professionals in the community who might help them. A variety of mind-body therapies for functional restoration, such as physical and occupational therapists, exercise trainers, counseling, or other therapeutic modalities, can complement their medical needs during recovery. Having a background in health, recreation and wellness education before I went into nursing, I realized that I was in an ideal position to be able to start addressing these issues. The frustration at the healthcare system acting so slowly and being so unwilling to risk innovation or listen to nurses' input was additional motivation for me. My Own Innovation in Survivorship I started my own business coaching people through some of these needs, offered a class in the community to encourage movement and physical activity in a supportive setting for cancer survivors, and began to write educational materials. As a nurse entrepreneur, I cherished the freedom and creativity, though it was, and still is, a financial struggle. The Importance of Nurses What became even more apparent being outside of the system, was the degree to which physicians and patients need nurses. Nurses are underutilized. While physicians fail to engage in learning about community resources that can help their patients, it is because they cannot do everything, and no one should expect them to. However, they should be informed and aware of what services are available in their communities and make the referrals so their patients can benefit from all options available to them to continue their recovery and return to their optimal quality of life. Nurses see a whole person, and how their daily lives are impacted by medical intervention. It is long past time that nurses were listened to, and our input respected, valued and utilized. Just because insurance doesn't cover a service, or offered by a person with an MD, doesn't mean it has no merit. If physicians are so busy that they don't have time to learn about services to which they could refer patients, then they are doing patients a disservice. If it is a function of their work environment, then something needs to change and the onus is on physicians to alter the culture of medicine. It takes a nurse to see the bigger picture and identify needs for change, because we are really the referees. Medicine is only part of the picture of cancer treatment and survivorship. Being satisfied that your patient survived is not enough. The nurse sees around and beyond the specter of medicinal treatment, with its benefits and adversities, to the whole patient and the environment in which they must recover and truly return to living.
  4. SoldierNurse22

    Down to Sleep

    I remember one day when you were receiving blood. I went into the room with your primary nurse to double-verify. You were sitting on the couch, that same smile greeting us as we entered. "Let's get the good stuff running, sir." I said. "Is it good stuff?" You asked, the corner of your mouth pulling into a smile. "The last time I got blood, it was Air Force blood on my way over from Germany. I felt weaker immediately." I laughed. "The inhumanity to man." I empathized wryly. You smiled wider. "I think my H&H actually dropped, LT." You are clearly picking up on our medical lingo and using it well. I verify the blood, exchange a few more quips back and forth with you, and say farewell for now. The next few months pass quickly. I am rarely assigned as your nurse. It's the way the winds of fate blow, but I know you because I know your smile. I know you because of the way my techs, particularly my corpsmen, talk about you with fondness. You're the one who keeps a loaded squirtgun under your pillow and attacks without mercy when they enter your room for 0400 vitals. You're the one who tells one of my corpsmen, who continues to fail his physical fitness tests, that you're going to help him pass when you can run again. I know the sight of the top of your head passing the nurse's station, a tirade of sarcasm trailing behind you as transport wheels you to radiology, MRI or CT, your least favorite places in the world. You return to us with stories, aptly told in that fluently cynical manner, mere words weaving together a play-by-play of the chaos downstairs. Oh, it'll be a good day if you don't have to go back tomorrow. Chemotherapy begins. You're feeling good. It's the start of induction and you're invincible, like many I've seen before you. We push you through a few rounds of chemo, and overall, you're holding up well. Pain, aches, a few fevers. Everything we usually see. Antibiotics start. Your fevers subside. Looks like everything's even-keel here. Your optimism is waning with every ache and pain you develop, but we reassure those symptoms are normal. It's the first day you're assigned to me and my orientee, who is familiar with you as all of us are. We come in to see you, do your assessment, give your meds, tend to your needs. You're in one of those moods--you're not up for guests. We place the sign on your door and warn off all would-be visitors: not today. In the afternoon, you spike a fever. Shortly thereafter, we go into your room to hang an antibiotic. Your words are slurred. Your mentation is altered. Your mind is between our world and another we cannot see. Your wife looks at me and my orientee with worry in her young eyes. I page the Oncology team immediately. I update them on your status. As I'm on the phone, my orientee returns to the desk. You just...urinated in the bed? The worry in your wife's eyes has invaded my orientee's. Something is wrong. The team orders a fluid bolus. I argue with them. They need to assess you. Something isn't right. The "nursie hairs" on the back of my neck are standing on end. Something just isn't right. The physicians come down the hallway, all four of them in a little herd moving in your direction. I follow on their tails. They do an assessment, talk to you and your wife. Your mentation has improved, but your temper is short. You don't want anyone in your room. The doctors take some offense once we get outside. I know you're just a modest man and embarrassed at what has happened. But that lurking sense nags at me. Why are you suddenly so aggressive? That isn't like you,either. We continue your care and you apologize to my orientee and then, more broadly, everyone on the ward--nurses and corpsmen, that is. My orientee graciously assures you there's nothing to worry about. We all do. Life goes back to business as usual and the shift ends anticlimactically. Two days! Who knew paradise could be so simple? There's nothing like a little break from the hospital drag. I spend my time cooking, bike riding, buying groceries, packing for home. I have a four-day pass coming up for the holiday and the plane can't take off soon enough. All I have left are these two days off and three more days of work before I'm home again. When I return to work, I'm told almost instantly of your transfer to the ICU. Your condition is grim from what my coworkers tell me. I hear their words, their descriptions of what has happened registering logically in my mind, taking an observant seat in the part of my brain that computes the nursing and medical and physiological sides of my work. Your wife, crying comes to us, asking us to pray for you, encouraging us to come see you. You're not in good shape, but come, she asks. And we do because we know she needs us--she needs someone else--to see. So in waves, we come. We give a quick report to our fellow nurses with a grim tell-all at the end: "...and that's about it. I'll be back soon. I'm going to see the Major." For several days, I work on going to see you, but, just as when you were my patient, I am steadfast in my commitment to my assignment; the pain assessments, medications, and concerns of my patients come before my own desires. Days one and two of my three-day streak pass and I am unable to escape my ward long enough to make the trip. Your wife continues to migrate to our ward, to your old room, to sleep. She updates us, we reassure her that we're behind her, she goes back to you. Finally, today, day 3, I join Ms. Lewis and 1LT Torres, who are bound for the ICU to visit. Your wife is in the hallway, talking with some of your family members. We pause a moment, talk to your wife, and then myself and Torres take a few bold steps into your room. And then everything I heard from your wife, I see with my eyes. And now, I know. You're intubated, that smile interrupted by a life-saving tube that forces your chest to rise and fall unnaturally. You have an IJ, a femoral line,and a Hickman. The standard BP cuff, SpO2 sensor and cardiac monitor tell us about your heart, which, fatigued from some unknown antagonist, tried to stop working a few days back. The waves on the screen tell me a story about rising Troponin and the cath lab--the same story in your wife's eyes. You're unshaven, which would never have happened were you awake. You're laid out in bed, your heels buoyed by heel guards, pillows below your knees and elbows, turned off your back slightly to one side. Your skin is discolored and purple, bruised from IV failures. You're edematous throughout your body; your hands are a dusky purple. Torres talks, her words like a radio playing indistinctly in the background. She takes your hand on the other side of the bed. I reach for your hand. You're cold; most unlike you. I watch as the ventilator forces you to breathe, and instead of seeing a grotesque tube that most families see, I see the tube that's saving your life. I gaze over the mess of wires and IV lines and thank God for their presence, because as terrifying as they are, they're the reason you're still with us. Torres falls silent. I take the opportunity to tell you that I'm the other one here with you, that we're praying for you, that you're strong enough to come back to us. Torres adds quietly, "Everyone is praying for you." I take a breath as your ventilator pushes air into your lungs and exhale as you exhale. We linger a few moments, promise to return, and slip out of the room. We hug your wife again, repeat our promise, and retreat to our ward. I went home that night, finished packing for my 4-day pass and went to bed. As I fell asleep, I prayed that God would wake you up again. I prayed for your wife, for your family, for your tired, worn-down body. I prayed and thought about you and fell asleep just after midnight, your memory heavy on my mind. Home passed in a beautiful blur of family and friends. When I returned, I was told that just the night before, you had been declared brain dead and taken off of life support. This is the best eulogy I can write you. I could drone on about how you will be remembered, about how you will be missed, about how you were an example even in sickness to all of us who had the pleasure of knowing you. But none of this would do you justice. So I will remember you, I will miss you, and I will follow your example. When the time comes, I will be there with your wife, your family, and my fellow nurses at Arlington to lay you down to sleep for the final time. And one day, I trust that I will see you again when we all wake with the morning light.
  5. gsu8696

    Communication Chaos!

    I had been assured by my colleagues who had recruited me to the unit as well as the head nurse on our unit that the fact that I had no oncology experience and that I was not chemotherapy certified were only minor issues...unless I had the unfortunate opportunity of coming into contact with one of two primary oncologists who had reputations for being extremely demanding to the point of being able to throw some fairly impressive fits when they wanted something. These 'fits' were generally a result of them wanting their patients to have the best care, but also because they were 'typical' oncologists and wanted what they wanted when they wanted, where they wanted. I was reassured that it was extremely unlikely that either of these physicians would be causing me any issues on the evening shift because they rounded early in the mornings and again in the afternoon. My head nurse further reassured me that she had spoken with both physicians to let them know I was coming on board and that while I was not yet chemo certified, we had our IV therapy team that could provide the chemo until I was up and running. With all of these words of encouragement and phone numbers for every single person I knew (both home and beepers...I'm dating myself!), I felt like I was armed with enough knowledge and tools to handle whatever situation might arise in these first few evenings of uncertainty. While I had never met either oncologist that I was incessantly being warned about, I was certain that between my nursing courses and minor in psychology with my English degree, that I could no doubt handle whatever issues might come my way. Until that second night. Life had been going so well. Things were flowing smoothly. Then our unit secretary called me to the nurse's station to take a call from Dr. B (one of the notorious oncologists). As I approached the nurse's station, the unit secretary grabbed my hand before I could pick up the phone. Her words cut through me like a knife "he's admitting a patient to the floor. Tonight. And she needs chemotherapy." This wasn't supposed to happen--I didn't want to do this--I was just kidding when I said I would--I want my Momma!! Wait a minute. I could do this. Even if there was no empty bed on the floor. I picked up the phone and in my sweet, naive voice, said, "Good evening, Dr. B, how can I help you?" At that moment my brain went into one of those modes where it's trying to process something that's being thrown at it but it just can't process it and it can't figure out why until it hits you that perhaps someone neglected to tell you that one of those oncologists that demands perfection is from Pakistan and might have a thick Pakistani accent which might make it extremely difficult for you to understand over the phone especially if he's barking orders one after the other at you. Breathe! Oops! The physician had just rattled off a list of orders that I had not even begun to understand (although I was writing furiously). With every ounce of courage in my body, I finally said, "Excuse me, Dr. B. Could you please repeat what you just said?" Again the physician began to rattle off the admission and chemotherapy orders (which I had no clue about, although he would never know it!!). Still, I couldn't understand him. I was trying. And praying...hard, extremely hard. But it wasn't happening to me. Again I stopped the physician in mid-sentence, "Dr. B, I am so very sorry. Could you please repeat what you just said?" My brain was trying so hard to process the orders being thrown at me like darts through the phone. I contemplated either handing the phone to the unit secretary or just hanging up and leaving the unit--it was obvious my career here was over, but then I realized I couldn't do either. One more time I squeaked, "I am so sorry, Dr. B. I just do not understand what it is you are saying to me. I cannot tell you how sorry I am." Then it happened. Without warning, Dr. B began speaking loudly and so fast that I could only understand about every third word he said. Unfortunately this time, I did understand, "I can't believe you cannot understand what I'm saying! I don't know why you cannot understand me, no one else has a problem understanding me..." He continued. For an eternity. In a time that would have put an Olympic trial to shame, my ego had been deflated, my feelings had been annihilated and I had most certainly lost my job. I stood with the phone in my hand but away from the ear, although not far enough from my ear that I couldn't hear the laughter that began permeating through the phone line. There was a language I could understand! I put the phone to my ear in time for Dr. B to say, "It's ok. You'll learn how to understand me in time. But don't think I'll let you off the hook for very long!" At that point, he began to slowly repeat the orders to me. We then discussed the fact that I didn't have any empty beds on the unit, but I assured him I would work that out, even if I had to single-handedly build a room on myself! A couple of hours later Dr. B appeared on the floor to see the patient we had discussed...she was in her room, her IV accessed and her chemotherapy being administered by the IV therapist (I'm still paying all off all those people who helped make that happen, and it's been 20 years ago!). Dr. B and I had a great talk that night...it was the beginning of a long, strong relationship. He was right, it didn't take long at all for me to learn to understand him and what he wanted for his patients. And I delivered every time!
  6. SoldierNurse22

    Deep In The Dark

    "Mrs. R? Which room?" I asked in return. "Room four." Ms. O, a plump, pleasant woman of African origins, replied. Her thick accent and tendency to say things with a smile seemed to smooth a much-needed salve over my less-than-lovely evening. The oncology grind was getting to me, wearing on nerves that could snap at anytime, like an anvil held up by cheap dental floss. The loss of a 23-year-old newlywed to lung cancer the week before had hit hard. It was far from my first patient loss, but it had affected me more than any other. To make things harder, Little Brother was back with us, struggling after his last round of chemo. He was keeping his chin up, but watching him pace the wards at night made me anxious. Those factors combined with the cocky, "do-it-for-me" attitudes of a few of my coworkers and the against-odds hope for a permanent change of station (PCS) found me wishing myself anywhere but work. "Sure. I'll be right there." I replied. I pulled up the MAR, checked the orders and headed to the Pyxis. I drew up dilaudid, my old ally, almost robotically. Dose check, label, flush, heparin lock and alcohol swab. Ready to roll. I headed down the hall toward room 4. I was admittedly much more content on nights than I was on days, staffing issues aside. There's something I enjoy about tending midnight. Her concerns are about comfort, about sleep, about a patient's fears and hopes for the next day. I love it when the lights go down in the hallways, when patients finally get to lose themselves in much-deserved slumber, when my friends and I sit around the call bell answering machine and play Uno until the wee hours of the morning. And tonight, I'm the narcotics queen, I told myself wryly as I entered room 4. The pungent smell upon entering reminded me that Mrs. R had throat cancer and a trach. As I neared the bed, I took note of a small, frail woman who lay entrenched in bed as though she were a cork in a bottle. Blankets protected her from the cold of the hospital air, enveloping her in a sea of white. "Hi, Mrs. R." I said. The little lady smiled thinly. "Ms. O tells me you're having pain." Her little head, sparsely populated by white hairs, bobbed. "I've got some dilaudid for you." Relief flooded her dark brown eyes. "Can you rate your pain?" I asked. She held up six fingers, then seven. "Six to seven?" She nodded again. "All right. Let's see if we can knock that down." I replied. I deliver her dilaudid, flush, and was in the process of heparin-locking her port when Ms. O entered the room behind me. Mrs. R began to gesture, but Ms. O was at a loss as to how to interpret her needs. Looking a little frustrated, Mrs. R wrote down what she needed on her clipboard and Ms. O thanked me for giving the pain med. I asked if she needed help and she declined. "All right. Call if you need me." I offered on the way out. A few hours later, another push request comes in for Mrs. R. "Man, that poor lady." I told Ms. O. In the time between pushes, I had been fulfilling my charge nurse duties by reviewing every patient's history and plans of care, preparing for report in the morning. Mrs. R had metastaticc ancer that had spread to her larynx. The trach had been her only option to prolong her life as the tumor threatened to completely close off her airway. She was set to meet with hospice come morning to finalize her discharge plans and then head home. "I know." Ms. O sympathized. "She's a nice lady." She observed. "I think so, too." I drew up more dilaudid. By now, the lights were down, the halls were dim, and the rooms were dark. I tiptoed into Room 4, plunging into the dark. "Hi, Mrs. R. I've got some dilaudid for you again." I said as I reached reflexively for the string to turn on the over-bed light. It was at that point that I realized Room 4 was the only room that didn't have an over-bed light. The only light in the whole room was the harsh fluorescent controlled at the wall switch. "I'm going to have to turn on the overhead light, OK?" I asked, unable to see my patient but preferring to inform her before the lights blinded us both. "Here they come." I said as I switched them on. When the lights came on, I was relieved to see that Mrs. R had her eyes closed. She opened them slowly. I had already drawn off her heparin lock and was in the process of flushing her port. "Is that pain back up to where it was before?" I asked. She nodded, exhaustion in her eyes. "Still in your neck?" I asked. She nodded again, then motioned toward her face."Face, too?" I asked. She nodded, a smile back on her face telling me she was relieved that someone understood what she was trying to communicate. "Did the dilaudid work well the last time?" I asked. She nodded emphatically. "Good. We'll get this dose in and check on you in about 30 minutes, all right?" She smiled gently. I finished pushing the dilaudid. Before I left, she mouthed "thank you" from the bed. "You're welcome, ma'am. We'll be back in a little bit to check on you." She mouthed "OK" and I turned off the light. Midnight came and went. The witching hour slipped by. Before I knew it, it was nearly time for shift change. As I prepared the report sheets and the assignments, Ms. O joined me at the desk. "Mrs. R would like some dilaudid." Ms. O said, pulling her glasses down her nose and giving me a smile. "Not a problem." I replied. "I'll be right in." One more trip for the narcotics queen tonight, I told myself. In Room 4, Mrs. R sat up in her chair next to her bed. She leaned against a pillow, partially asleep. When she heard me approach, her eyes opened. "Up to the chair for a bit, Mrs. R?" I asked. She nodded groggily."Does it help the pain?" I asked. She shook her head and motioned for her clipboard. She wrote as I pushed dilaudid. "I can talk a little bit. The bed was wet." She had written. I glanced at the bed, which appeared dry. Noting my confusion, Mrs. R pointed to Kleenex in a pink bucket that sat on the bed. It was then that I saw the mucous draining from her trach, a stream of gooey brown dripping down her chest. "Oh, I see. Do you want me to change your sheets and clean you up? We can get you back to bed if you'd like." I offered. She shook her head no, looking away despondently. "I hear you may be going home today." I said, glancing up at her. She nodded distantly. "Are you ready to go home?" I asked. Mrs. R shrugged. She met my gaze with mournful eyes. "No one to go home to." She said in a low whisper. And at that minute, I forgot my PCS request. I forgot my lazy coworkers, the grouchy day shift that was just beginning to arrive, and the emotional trials of the past several weeks. The lonely little woman in front of me captured my full attention. She had no one to care for her at home. She was dying of a painful, ugly cancer. Her every whim was suddenly my only concern. "I'm sorry to hear that, Mrs. R." I replied, at a loss. When I first became a nurse, moments like that were incredibly awkward. I searched high and low for what to say to comfort patients that were ensnared deep in the depths of that deadening depression. Eventually, I realized that sometimes in moments like those, all a nurse can do is be there in the silence with their patient and hope that the knowledge that another person has heard and validated their suffering is enough to alleviate it, at least for a while. At least long enough for them to realize they aren't really alone. "It's cold." Mrs. R said, her voice a low whisper. Her quiet comment drew my attention to the cocoon of blankets around her. "I know. Unfortunately, our blanket warmer is broken." I empathized, my mind suddenly snapping into gear. "I can get you some hot packs, though. Would you like that?" I asked. Mrs. R's eyes lit up and met mine. "Yes." She replied. "Not a problem. I'll be right back." I said, hep-locking her port and heading across the hall to the storage room. I grabbed three hot packs and three pillowcases and hurried back to Room 4. At her bedside, I activated the hot packs, slipped them into their pillowcases and handed them to my patient. She closed her eyes as she took the first one, placing it in her lap. The second one went under an arm, the third under the other. "Better?" I asked. "Better." She nodded. I wasn't quite satisfied. Her blankets, which had previously been over her head, had slipped down behind her back and the chair. "You know, we have some knitted caps if you'd like them to keep your head warm." I offered. Her eyes lit up again and she nodded. "Sure. Any particular color?" I asked with a smile. She shook her head and smiled dimly. "All right." I cajoled. "I'll find one that I think you'll like and I'll be right back." Down the hallway, I slipped into the assistant manager's office and pulled out the bags of colorfully knit caps, donated from some saints who surely have no idea how much their contributions meant to our cold, bald oncology patients. One of the caps was baby blue and fuzzy, promising to warm the head that wore it. I took it immediately. I rifled through the bags a few times, trying to decide what colors she would like. Was she a fan of pink? That can be hit or miss. What about blue? Nope, already had a blue one. Green? Brown? Red? Yellow? When did picking the best cap become more complicated than taking the NCLEX? Finally, I came across a white, purple and light-purple striped cap. I smiled. It was bright and looked like spring blooming on yarn. Perfect. I returned to her room and held up her options. "Which one would you like, Mrs. R?" I asked. Instantly, her eyes jumped to the purple one. Her fingerpointed to her decision. "Purple it is." I said, sliding the cap over her head. "Anything else I can get you, ma'am?" I asked. She shook her head and gave me a smile as bright as her hat. "Thank you so much," she said. It was my honor to smile back into her eyes. "You're very welcome. We'll check on you soon and make sure your pain goes down. Get some sleep?" I half-suggested, half-asked. She nodded, resting her head on her pillow, that smile still on her lips. I gave report, finished my charting, checked my patients and headed down the hall. I had walked a few paces past Room 4 before I turned on my heel and took a few steps back. Mrs. R sat up in her chair, sleeping soundly, her purple cap jumping out against the clean white of her blankets. Nothing could change her diagnosis, her situation or her permanently ease her pain. But that purple cap, vibrant like Easter in the dimly lit room, reassured me that while I couldn't reach all the lost and lonely, one of them slept just a little bit warmer deep in the dark of my ward.
  7. SoldierNurse22

    The Fifteen

    I didn't ask to be an oncology nurse. I had no real interest in oncology at all, but a friend of mine who is a leukemia survivor was assigned to go initially, and when he requested a reassignment, I was sent in his stead. My experiences on my ward would soon prove unparalleled. The first day I worked on Ward 71 was sunny and bright. We were on the top floor and looking out the windows at the ground below was like looking out of a castle. I remember listening to report, receiving my assignment and my preceptor, and thinking to myself, this doesn't seem so bad. I was well aware that the mortality rate on the ward would likely be higher than usual, but my reasoning was that everyone was going to die at some point. I had seen patients die on other wards. Why should oncology be so different? My first patient was actively receiving chemotherapy. Being that I wasn't chemo-certified, I remember looking for my preceptor when the alarm on the IV pump started beeping. She dealt with the issue and I stood behind her, watched her gown and glove before pulling the air out of the tubing, and with it, a syringe full of chemotherapy. A few weeks later, I was given a patient who had lost her hair, her strength and near everything but the will to live. She was the first patient I ever cared for who looked like a cancer patient. Perhaps it's because she was female and her alopecia was more striking. It's interesting what we clinicians will tell our patients who are dealing with hair loss. She told me once that a few well-intentioned female nurses had told her, "Don't worry about it.It's just hair." Her reply was cutting and honest: "Really? Then why don't you shave your head?" As the weeks passed by, I began to notice a strange phenomenon when we were in report. Occasionally, we'd get a new admission and as soon as the reporting nurse stated the patient's name, the room would resound in moans and groans from my coworkers. They'd repeat the patient's name, passing it around the room to each other like a lost item rediscovered. But it wasn't a vocalization of exhaustion that one hears when it's announced that a frequent flier has returned. I slowly began to realize that when the room groaned like that, it was because every nurse in the room knew that patient, knew their families and was calculating how long it would be until that patient saw their last stay on our ward. And I didn't know it at the time, but it wouldn't be long until I joined that chorus. Just as the sun set on our time at Georgia Avenue, I found myself caring for a high-ranking officer who was dying of several types of cancer. GVHD had ravaged his formerly military-toned body. He was unable to move or speak, but he was one of my favorite patients. I spent my days hanging his IVPB medications, making sure he was clean, and helping to reposition him with my coworkers. He never complained, always smiled and tried to thank us as best he could with a mouth he could no longer control. I remember one dark night as I changed his IV meds, he sang along with "Roll Out the Barrel" while black and white figures sang on the classic movies channel. There's nothing like the moment you realize that the body in the bed is a person who used to live and move and enjoy life, much as you do. The merger with Bethesda happened in late August. Everyone, including my patient, transferred to the old Naval hospital. On my new ward, I found new coworkers, new patients and new challenges. But the greatest challenge was yet to come as my patient, exhausted from GVHD, slipped away one autumn night. About a month later, a longtime patient of Bethesda, well-loved by the Navy nurses, died while under my care. She was on comfort care, her pain and desperate respirations soothed away by a morphine drip. We all knew she was actively dying, but no one predicted that a few short hours after transferring to our ward that she'd slip away. I had very little to do with her assessment after she died as the Navy nurses stepped in immediately to bid farewell to an old friend in the only way that we nurses can. Together, we bathed her, showed her to her family one last time, and escorted her to the morgue. I remember being struck at how lifelike she felt an hour after her death. Were it not for the lack of movement,the complete absence of respiratory effort and the stillness in her wrist whenI felt for a pulse, I would've never thought her dead. Winter roared into our ward like a nightmare. Longtime patients of both the Army and Navy facilities were admitted in increasingly worse condition. In early December, the deaths of two beloved patients rocked the ward just in time for Christmas. In January, two more passed at the end of the month, including the woman I had cared for on Georgia Avenue who had taught me so much about how oncology patients are different from other med-surg patients. In February, I found myself frequently assigned to a young woman battling GVHD.Together, we braved my 12 hour shifts between IV pushes of morphine, zofran and conversation about anything and everything. We discussed food, politics, cats,her husband, my lack of husband, and whatever else came to mind. She was witty and observant and wise beyond her 30-some years. One day, the news on her TV reported that a handful of customers who had placed orders for their significant others for Valentine's Day were upset because their loved ones hadn't received the orders on time. A young man being interviewed said somewhat smugly, "Yeah, it's pretty devastating to order flowers for someone and have them come a day late. I mean, she was just standing there, waiting, and nothing came." My patient shook her head and smiled slightly. "You know what love is? It's your husband helping you back and forth to the toilet every couple of hours for two months.That's love." By March, she was discharged and we were on to other patients. No one was ready when our clinical nurse specialist told us the news: my patient from February had died 5 days after being discharged from our ward. April continued in similar fashion, only the mortality rate had increased significantly. I admitted a patient in late March who passed recently. When I first met him, he told me I looked like someone. Our CNS would encourage me to step to the front of the crowd in mid-April when we celebrated his birthday."He likes you. You remind him of his wife." Another patient whom I cared for over the weekend passed away when I returned to work a few days later. I listened to his apical pulse for a minute, all the while staring at his sleeping wife. There is nothing in the world, much less in nursing school, that can prepare you for the day you must wake up a spouse and tell them they are a widow. We had a total of six patients die in April. Six patients that we all knew well. Some died inpatient. Some died at home. Some died on our ward and some died in the ICU, but no matter where they died, their passing resounded on our ward. All in all, fifteen people I knew as both patients and human beings, who were unique and beautiful and entirely too young, passed away from cancer in my first year. I know now what I didn't know a year ago. The reason oncology patients are different from other patients is because they die from a disease that their own cells created. Sure, many people die from genetic disorders or pass away from abnormalities at the cellular level, but cancer is devastating because it isn'ta virus, bacteria or some sort of external pathology that's out to get you.It's your own body invading itself. It's the beautiful gift of cell division,the very process that gives us life, gone horribly wrong. For a year, I have worked on a ward where medicine frequently fails and death comes far too young and far too often. I have learned a vast many things over the past year about nursing, about what it is to be human, and about myself. But by and large, the most important thing I've learned is that it acceptable and right for me as a nurse to grieve the loss of my patients. I remembering learning in nursing school that it is important to keep myself emotionally distanced from my patients lest I burn out. I was told emphatically that allowing myself to become emotionally attached to my patients was not only bad for me emotionally, but it was unprofessional and set a bad example. But I have discovered that it is just that distanced, uninvolved approach that will send me running from nursing the fastest. There is, to be sure, a certain amount of professionalism to be maintained when dealing with patients, but that doesn't mean that professionals do not mourn the loss of their patients. Because patients aren't simply nameless, family-less,transient beings that we nurses give our time, our energy and our lives to caring for. They're people, too, and to do anything less than mourn them when their time comes is to dishonor the memory of a fellow human being. It is my sincere hope that others in the nursing profession will honor this sentiment and allow those of us who deal with death on a daily basis the right to grieve,for it is impossible to work sun up to sun down with other human beings and not find yourself becoming attached to them. So,with the end of my first year as a newly employed RN only a week away, I push on to a new year, to new patients, to new struggles. May God grant me the strength to care, the fortitude to act with knowledge, dignity and grace, and the beautiful memory of the fifteen who will forever guide my practice, my compassion and my hope.
  8. Oncology. When she first said those words I immediately had two feelings: excitement, and oh-my-gosh-I-think-I'm-gonna-crap-in-my-pants-what-did-she-just-say? But the more I thought about it, the more I realized that this would be an experience unlike any other. One that could, if I let it, become a stepping stone to becoming a compassionate person and nurse...in all life levels. First day. Five patients. Five cancers. As I woke up this morning complaining about my early clinical and how bad my makeup looked, these five people woke up not knowing what their future would be. As I get my breakfast of coffee and cold toast, these patients get drips through their NG tubes. While I stress about my presentation of hypercalcemia in pre-conference, their family members stress about hospice care. I get on the floor. I greet the patients with my cheerful greeting and smile, but I see that the emotional status of each patient is so very different than the run-of-the-mill right knee replacements of last semester. I assess the patients for hygiene needs, immediately noticing that two patients had no need of hair care, since they had none. I watch my nurse give meds that I had never heard of, speaking amiably with the patient who had been here for two months battling rectal cancer. I give my bed baths, I chart, I speak to the patients, and I even gave a Lovenox injection. It was looking like a good clinical day. But as I continue through the day, a nagging thought slowly pushed to the surface... These patients have cancer. Perhaps I had never truly realized it before, in my excitement of getting the "nursing experience" I forgot that these lives meant something, and these lives were slowly being eaten away by a horrible clump of cells that we call cancer. I forgot that this mother in room 35 who was, to me, the "lady who doesn't speak English" was an individual watching her daughter die of pancreatic cancer. I forgot that the lady in 34 not only had abdominal surgery, she was fighting a disease that was fighting for her life. I forgot that the husband of the patient in room 37 was not only talking to a "nice lady" in the hallway, he was arranging palliative care. But how can I not? How can I function as a nurse thinking that, when I come next week this patient might not be here? How can I continue smiling at this beautiful woman when I know that she has days to live? How can I not hope to forget that this woman who is screaming during a diaper change may be soon to pass into eternity? But I can't. These people lived lives, made friends, fell in love, ate, drank, and hopefully learned many lessons. I cannot, as a 19 year-old college student, ever realize the impact of that. I cannot, in my 7 hours on Fridays, hope to grasp the influence of this person's illness on others. Yes, we all die, many before we have had a chance to live. But this is not our choice. We don't plan it, and nothing that we do will ever change it. It is set by a Being who, even in our pain and suffering, loves and suffers with us. Let me never forget it. Let me never forget that God, in His infinite wisdom, has set me here for a time and a purpose. And let me never forget that I am blessed. This is a letter to myself, help me to remember that I never have the right to complain.
  9. A fungating (malignant) wound is a mass of cancerous tissue that is spreading under the skin and eventually infiltrates the outside layer of cells, breaking through the skin surface to create a wound. There is the potential for massive skin damage, with gross disfigurement and loss of function. As the cancerous tumor grows, it blocks the supporting blood and lymph supply, starving the area of oxygen. This causes the skin and underlying tissue to die due to lack of blood flow (necrosis). Fungating wounds present as either a raised nodule or as an ulcerated crater with a defined margin. The raised nodules often resemble a cauliflower or fungus protruding from the skin. The necrosis can lead to inflammation and infection. Usually there is a strong smelling discharge, bleeding, and pain. Thankfully, fungating wounds are rare, occurring in just 5 to 15 percent of cancers. These malignant lesions tend to develop in elderly patients, primarily those aged 70 or older, who are in the advanced stages of metastatic illness. They may develop during the last few months of life or be present for years. Fungating wounds rarely heal and often require palliative management. Nearly two-thirds of these wounds develop in the breast area and a quarter develop in the head and neck area. Other common sites are the kidney, ovary, vagina, colon, penis, and bladder. Head and neck fungating tumors can distort the face, while these growths in the genitourinary tract can cause fistulas involving the bladder, vagina, and bowel. Not surprisingly, these destructive wounds can have a devastating impact on the patient's overall quality of life. The most common symptoms of a fungating wound include copious exudate, an offensive smell, pain, bleeding, and itching. These symptoms can cause embarrassment, social withdrawal, and isolation. Wound bleeding is common in fungating wounds. This occurs because the cancerous cells damage the tiny blood vessels, making the tissue very fragile, and platelet function is impeded within the tumor as well. The profuse, spontaneous bleeding can be distressing to patients and families. Should bleeding occur, pressure to the area should be applied immediately with a moist or non-stick dressing to avoid damaging the tissue further. Meticulous skin care is imperative for comfort, cleanliness, and odor control. To avoid drying and irritating the skin, soaps should be avoided. A mild pH-balanced skin cleanser such as Aloe Vesta or Sensi-Care should be used instead. Dressings should facilitate maintenance of a moist wound bed, to prevent irritating delicate nerve endings. Hydrogels, hydrocolloids, foams, composite dressings, and calcium alginates are recommended. These type dressings also help control leakage or discharge. Wet-to-dry dressings are not recommended, as these can damage the periwound. A barrier cream such as Cavilon can be applied around the wound to protect surrounding skin. The dressings should be changed as often as necessary to control discharge and odor, but too frequent changes can exacerbate bleeding. Nonadherent dressings should be used to protect the fragile skin. Gentle irrigation of the wound with warm saline, as opposed to swabbing, can reduce pain and tissue damage with dressing changes. What have been your experiences with these types of wounds? References Fungating Wound What is a Fungating Wound?