Let’s Talk About Sex.

“Let’s talk about sex, baby
Let’s talk about you and me
Let’s talk about all the good things
And the bad things that may be
Let’s talk about sex
Let’s talk about sex
Let’s talk about sex
Let’s talk about sex

Let’s talk about sex for now to the people at home or in the crowd
It keeps coming up anyhow
Don’t decoy, avoid, or make void the topic
Cuz that ain’t gonna stop it
Now we talk about sex on the radio and video shows
Many will know anything goes
Let’s tell it how it is, and how it could be
How it was, and of course, how it should be
Those who think it’s dirty have a choice
Pick up the needle, press pause, or turn the radio off
Will that stop us, Pep? I doubt it
All right then, come on, Spin” ~Salt N Pepa

The second sheet of the Patient assessment can be daunting.  However, it is the part that I love best.  I love people and it’s important for me in my role as a student nurse to find out what is really going on with them on a personal and psychosocial level.  All the issues that concern them when they return home can hit like a freight train and returning to daily living can provide numerous challenges.  The second sheet can give them the opportunity to start thinking, marinating – if you will – about reentry into their roles and relationships after their hospital stay, procedures, and subsequent home care.  Sexuality is one of those issues.

We are all sexual beings.  That’s how we are created.  Our identity is tied into our intimate life whether with a partner, or with ourselves and physical and emotional trauma effect the way that we perceive ourselves and our roles in our relationships.  “I feel like I’m not whole.”  “Who would want me looking the way that I do?”  “I can’t even bear to look at myself, how is my partner ever going to find me attractive again?”  These are just the tip of the iceberg when it comes to the questions patients have about their sexual identities and their roles as a partner with whom they have an intimate relationship.

I love the second page.  Sometimes, I can nonchalantly ask very personal questions during the assessment.  Sometimes not.  Patients in a hospital setting can feel very vulnerable, but they can also feel a desperate need to talk with someone about their pressing and sometimes embarrassing questions.  Only a select few patients will initiate a conversation about intimacy, but gently developing a rapport and a feeling of mutual trust can powerfully influence their ability and willingness to open up about such deeply personal issues. 

Often, I introduce the subject when I am doing something else.  They don’t have to look me in the eye.  I gauge their receptiveness in their response.  I revisit the subject when we discuss their discharge from the hospital, again, gently.  I leave the conversation open for further discussion and I remind them that they can talk with me –confidentially- about anything that is on their minds, or hearts.  I follow-up late with an open-ended question about how they are feeling about resuming daily life activities and again state my willingness to talk about any concerns they may have and list a couple of pertinent topics, slipping intimate relationships into the conversation.

In my work in the cancer community, one of the topics I speak about and have participated in panels and radio programs about is sexuality.  In these settings, I have the benefit of creating a completely safe environment and offering myself up for additional time to share in their questions, or concerns after the session, via  facebook, by email, etc. 

I primarily work with young adult cancer survivors who have LOTS of questions about resuming sexual activity, psychosocial effects, partnering, parenting, fertility, the whole gambit.  Honoring that time together, listening to their concerns, reframing, and asking questions to gain more insight into their situations and deeper issues is important to me.  I think that this is one reason that I love the second sheet.  Co-creating a safe environment where a patient can offer up very personal and intimate concerns and have them listened to, addressed, and normalized is a gift to me.

Today, after clinical in post-conference I had a moment to reflect about why the second sheet comes so easily to me when so many students struggle with it.  I think the answer lies in that that I have done this, I have read and researched, I have had my own personal experiences where I wished that someone had discussed the myriad effects that a procedure, or treatment would have on my self-image, immediate effects on my body, long term psychosocial effects and late effects.  My nurses seemed so busy.  So unavailable.  I didn’t want to “bother” them with issues that were not applicable to their job, or care.  There were no bonds formed and certainly no place to think about, or discuss what might happen next.  The second sheet came as a complete surprise to me.  I would have never fathomed that we could, or should introduce these types of conversations.

So, I relish the opportunity to incorporate the second sheet.  To delve into a patient experience on a holistic level.  The reality of time constraints for RNs is becoming more real to me as clinicals progress.  Nurses are busy.  There is little, or no time –often- to ease into delicate, yet important subject matter.  I am relishing the opportunity to forge these relationships, to create a space for learning, understanding, teaching, and support that I hope to continue to create space for as a practicing RN.

Assessment Documentation Examples

Assessment Documentation Examples

Assessment                                                                 Thursday                                           Friday

General Appearance

Affect, facial expression, posture, gait

Speech

Affect and facial expression appropriate to situation.  Patient not observed OOB. Speech clear.  

Skin

Color, texture, hygiene, moisture

Braden score

Intactness, lesions, breakdown

Skin mostly warm and dry. Braden score- 20.  Catheter insertion site found with dried sanguineous urine around meatus.  Area cleaned thoroughly.  R midline dressing covered with Telfa cloth adhesive dressing soaked with dried blood inferior to incision, gauze covering changed, JP drain intact.  Midline and 2 groin incisions at top of each leg clean, dry and well approximated with derma bond.  No other skin lesions or breakdown  

Room and equipment

IV fluids, IV access

Tube feedings

Drains, Foley

D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV.  R wrist PIV medlocked.  Foley catheter.  JP drain from R midline incision drained 19 ml sanguineous fluid, drain reactivated.  (Drain later removed by MD, incision left clean, dry and intact).  

Neuro

LOC, pupils

Hand grips

Feet – flexion, extension

Oriented x4.  Grips, flexion, extension strong bilaterally.  
C-V: pulses  Heart: rhythm, S1, S2, extra sounds  Capillary refill  JVD, bruits  Edema S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 70. Radial 3+, R dorsalis pedis 2+ .  Cap refill ❤ sec. No JVD. Or bruit. No edema.  
Resp: rate, rhythm, depth, effort  Accessory muscle use  Chest expansion  Breath sounds Rate 20, even, unlabored respirations.   No accessory muscles used.  Breath sounds clear in all areas.  
GI:  abdominal shape, appearance bowel sounds x 4  tenderness  last BM, usual pattern Abdomen round and soft.  Bowel sounds x 4.Tenderness only in compromised areas.  No  BM since the day before operation (3/4/08).  
G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain on voiding Bladder tenderness or distention 180 ml clear amber urine drained from Foley catheter.  No pain or bladder tenderness reported.  No distention.  

Psy/ Soc

Family/ support systems

Lives with wife, who will be caregiver as needed upon discharge  

Pain

Intensity (specify tool)

Location, character

Associated signs/ symptoms

Pain interventions and effectiveness

Pain noted at 6 on the number scale.  Pain medication administered and pain noted at 3 on same scale 30 minutes later.  

Rest/ Sleep

Usual pattern/ changes since hospitalized

  Sleeping aids used

Pt reported no sleep problems other than hospital required interruptions.  
Other: specific to your patient, incl.  Dressings/ treatments    

General Appearance

Affect, facial expression, posture, gait

Speech

Flat affect.  Posture stupped. Gait unsteady and weak. Speech clear. Affect and facial expression appropriate to situation.  Posture erect. Gait weak. Speech clear.

Skin

Color, texture, hygiene, moisture

Braden score

Intactness, lesions, breakdown

Skin pink, cool and dry. Braden score- 18.  Abdominal sagittal midline well approximated incision with packed wound at inferior and superior ends, both approx 1 cm in circumference and 11-12 mm in depth, no site redness or swelling, scant sanguiness drainage.  Three puncture wounds from laparoscopic nephrectomy, well approximated, covered with steri-strips located right medial midline, inferior and superior left lateral abdominal area, no site swelling or redness.  No other skin lesions or breakdown found. Skin pink, cool and dry. Braden score- 17.  Abdominal sagittal midline well approximated incision with packed wound at inferior and superior ends, both approx 1 cm in circumference and 11-12 mm in depth, no site redness or swelling, scant serosanguiness drainage.  Three puncture wounds from laparoscopic nephrectomy, well approximated, covered with steri-strips located right medial midline, inferior and superior left lateral abdominal area, no site swelling or redness.  No other skin lesions or breakdown found.

Room and equipment

IV fluids, IV access

Tube feedings

Drains, Foley

NS at 50 ml/hr in 22 gauge LFA  IVAD, insertion date 6/1/08.  Dressing clean, dry, intact and reinforced with .  No other tubes, drains, or Foley. 22 gauge LFA S/L, insertion date 6/1/08. Dressing clean, dry intact, and reinforced with .  No other tubes, drains, or Foley.

Neuro

LOC, pupils

Hand grips

Feet – flexion, extension

Oriented x4.  Grips, flexion, extension strong bilaterally. Oriented x4.  PERRL. Grips, flexion, extension strong bilaterally.
C-V: pulses  Heart: rhythm, S1, S2, extra sounds  Capillary refill

JVD, bruits

Edema

S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 72. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally.  Cap refill <2 sec.  No JVD or bruit. Non-pitting edema in hands and feet bilaterally. S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 76. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally.  Cap refill <2 sec.  No JVD or bruit.
Resp: rate, rhythm, depth, effort  Accessory muscle use  Chest expansion

Breath sounds

Rate 20, even, unlabored respirations.   No accessory muscles used.  RLL wet, all other breath sounds clear. Rate 20, even, unlabored respirations.   No accessory muscles used.  Breath sounds clear in all areas.
GI:  abdominal shape, appearance bowel sounds x 4  tenderness

last BM, usual pattern

Abdomen firm and round.  Bowel sounds x 4. General abdominal tenderness reported.  Reported last BM was formed 5/31/08. Abdomen firm and round. Bowel sounds hyperactive x 4. Soft stool at approx 10:00 after administration of Ducolax suppository.
G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain on voiding

Bladder tenderness or distention

230 ml clear, yellow urine.  No pain, urgency, frequency or tenderness with voiding reported.  No bladder distention reported. Reported voiding x 2 this morning. No pain, urgency, frequency or tenderness with voiding reported.  No bladder distention reported.

Psy/ Soc

Feelings or concerns r/t hospitalization, illness.  Recent stressors, anxiety or depression. Family/ support systems

Pt transferred from rehab facility and expects to go back to another facility prior to going back home where wife is caregiver.  Wife has arthritis and back problems, so in-home assistance may be needed for a period of time.  Pt concerned about pet (Beauty) and not being able to take her on long walks which they both enjoy.  Not being able to do this and anticipating never being able to do this along with unrelieved pain and lack of sleep caused pt to say “if I had a gun, I would shoot myself”. Daughter (who is able to give some support for pt and caregiver) and wife are arranging placement for pt into a rehab facility upon expected discharge today.  Pt is please that he has been able to self ambulate today, but has concern of repeated evisceration.

Pain

Intensity (specify tool)

Location, character

Associated signs/ symptoms

Pain interventions and effectiveness

Pain noted at 5 on the number scale at incision site and radiating to right side.  PRN Oxycodone pain medication administered with no relief within 30 minutes.  PRN acetaminophen administered with pain decreased to a 3 with 30 minutes.  Patients report of consistent lack of pain relief reported to his nurse. Pain noted at 5 on the number scale at incision site and radiating to right side.  PRN Oxycodone pain medication administered with pain decrease to 3 within 30 minutes.

Rest/ Sleep

Usual pattern/ changes since hospitalized

  Sleeping aids used

Pt reported not being able to get any sleep due to unrelieved pain. Pt reported reduced pain and was able to get rest during the night.
Other: specific to your patient, incl.  Dressings/ treatments Abdominal incision site packed with NuGauze, covered with (2) 4×4, left untapped, then covered with binder. Two abdominal pads placed underneath top edge on binder to prevent chaffing.  Dressing changed by Dr. during rounds this morning.  Dressing found clean and intact with scant amount of sanguiness drainage during assessment.  Order for dressing change TID. Abdominal incision site dressed with approx. 4 inches NuGauze (both superiorly and inferiorly), covered with (2) 4×4, tapped, then covered with binder. Two abdominal pads placed underneath top edge on binder to prevent chaffing.  Dressing changed 11:00 and found scant amt of serosanguiness drainage on the both pieces of NuGauze.  Order for dressing change TID.