Sometimes the Best Thing You Can Say is Nothing

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Sometimes the Best Thing You Can Say is Nothing

We need to find God, and he cannot be found in noise and restlessness. God is the friend of silence. See how nature – trees, flowers, grass- grows in silence; see the stars, the moon and the sun, how they move in silence… We need silence to be able to touch souls.

~Mother Teresa

Being Teachable is the First Key to Learning

Be Willing to Admit Ignorance, So You Can Learn

Very few people seem to be comfortable with admitting that they don’t know something. Maybe they feel that admitting ignorance about a subject will make them seem stupid, so they’ll feign knowledge and attempt to go with the flow in any given situation. This is highly detrimental on many counts, from a person being seen as an insufferable know-it-all, to projects going awry because an employee claimed to know something they didn’t.

If you don’t know something, admit to your lack of knowledge, and then immerse yourself in the subject so that you familiarize yourself with it. The universe is full of things that we don’t know, but the only way to grow and change is to open ourselves to opportunities to learn… and those won’t come about if we don’t leave space for them by saying “I know” to everything.

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If We Could Look Inside Other People’s Hearts

My host hospital showed us this video  from the Cleveland Clinic in Ohio today… If you haven’t seen it, please take four minutes to watch. 

It’s a brilliant reminder that, on a daily basis, people lives shift and change as do their joys and burdens.  Whenever we encounter another, we see them through the lens of what is happening in our lives, through our “bubble.”  What if we took into account what other people are struggling with, or moving through?  As nursing students, I think that many of us are drawn to nursing because of our deep care and concern for what others are going through and how their life events impact physical and emotional health, but I thought that this video really drove that point home. 

I hope that you will watch and consider how much influence our care, ability to listen, to communicate therapeutically, and our empathy impact our patients, their families, our coworkers and our own perception of life. 

Be well.

 

“Could a greater miracle take place than for us to look through each other’s eyes for an instant?”

Henry David Thoreau

 

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.

[LEGISLATIVE UPDATE] Palliative Care and Hospice Education and Training Act

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H.R. 1339:To amend the Public Health Service Act to increase the number of permanent faculty in palliative care at accredited allopathic and osteopathic medical schools, nursing schools, and other programs, to promote education in palliative care and hospice, and to support the development of faculty careers in academic palliative medicine.

New Cosponsor: Rep. John Garamendi [D-CA3]

New Cosponsor: Rep. John Conyers [D-MI13]

New Cosponsor: Rep. Michael Grimm [R-NY11]

Thank you to our newest Cosponsors.  Please thank your legislators for supporting legislation that YOU believe in.  If they are not listed as Cosponsors, touch base with them and let you know what you support.  Your voice goes a long way towards creating change.

 

Explore the full text & track this bill:

https://www.govtrack.us/congress/bills/113/hr1339?utm_campaign=govtrack_email_update&utm_source=govtrack/email_update&utm_medium=email

Take time to thank our supporters, or voice your thoughts to your representatives.

Need help finding your legislators?

Find your representatives: http://www.opencongress.org/people/zipcodelookup

[LEGISLATIVE UPDATE] Palliative Care & Hospice Education Act Move Forward

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[LEGISLATIVE UPDATE]  S. 641: Palliative Care and Hospice Education and Training Act

A bill to amend the Public Health Service Act to increase the number of permanent faculty in palliative care at accredited allopathic and osteopathic medical schools, nursing schools, and other programs, to promote education in palliative care and hospice, and to support the development of faculty careers in academic palliative medicine.

New Cosponsor: Sen. Elizabeth Warren [D-MA]

Thank you to our newest Cosponsors.  Please thank your legislators for supporting legislation that YOU believe in.  If they are not listed as Cosponsors, touch base with them and let you know what you support.  Your voice goes a long way towards creating change.

Explore the full text:  https://www.govtrack.us/congress/bills/113/s641?utm_campaign=govtrack_email_update&utm_source=govtrack/email_update&utm_medium=email

Take time to thank our supporters, or voice your thoughts to your representatives.

Need help finding your legislators?

Find your representatives: http://www.opencongress.org/people/zipcodelookup

 

 

[LEGISLATIVE UPDATE]  H.R. 1339: Palliative Care and Hospice Education and Training Act

To amend the Public Health Service Act to increase the number of permanent faculty in palliative care at accredited allopathic and osteopathic medical schools, nursing schools, and other programs, to promote education in palliative care and hospice, and to support the development of faculty careers in academic palliative medicine.

New Cosponsor: Rep. Walter Jones [R-NC3]

New Cosponsor: Rep. Paul Tonko [D-NY20]

Thank you to our newest Cosponsors.  Please thank your legislators for supporting legislation that YOU believe in.  If they are not listed as Cosponsors, touch base with them and let you know what you support.  Your voice goes a long way towards creating change.

Explore the full text:  https://www.govtrack.us/congress/bills/113/hr1339?utm_campaign=govtrack_email_update&utm_source=govtrack/email_update&utm_medium=email

Take time to thank our supporters, or voice your thoughts to your representatives.

Need help finding your legislators?

Find your representatives: http://www.opencongress.org/people/zipcodelookup

U.S. Representative Lois Capps Introduces Safe Staffing for Nurses Legislation

Earlier this year, U.S. Representative Lois Capps (D-CA), a nurse, introduced bi-partisan legislation allowing nurses to have a safer work environment. Congresswoman Capps, along with U.S. Representative David Joyce (R-OH), introduced the “Registered Nurse Safe Staffing Act of 2013,” HR 1821. The bill is currently in discussion with the Committee on Energy and Commerce and is also being read at the Committee on Ways and Means. 

The primary goal of the bill is to provide for patient protection by establishing safe nurse staffing levels at certain Medicare providers. The bill enumerates many well known facts about workplace safety for nurses, patients, and hospitals. Some include

  • Research shows that patient safety in hospitals is directly proportionate to the number of RNs working in the hospital. Higher staffing levels by experienced RNs are related to lower rates of negative patient outcomes.
  • A 2011 study on nurse staffing and inpatient hospital mortality shows that sub-optimal nurse staffing is linked with a greater likelihood of patient death in the hospital. A 2012 study of serious patient events reported to the Joint Commission demonstrates that one of the leading causes of all hospital sentinel events is human factors, including staffing and staffing skill mix.
  • Healthcare worker fatigue has been identified as a major patient safety hazard, and appropriate staffing policies and practices are indicated as an effective strategy to reduce healthcare worker fatigue and to protect patients. A national survey of RNs found that 74% experience acute or chronic effects of stress and overwork.
  • A 2012 study of Pennsylvania hospitals shows that by reducing nurse burnout, which is attributed in part to poor nurse staffing, those hospitals could prevent an estimated 4,160 infections with an associated savings of $41,000,000. That study also found that for each additional patient assigned to an RN for care, there is an incidence of roughly one additional catheter-acquired urinary tract infection per 1,000 patients, or 1,351 infections per year, costing those hospitals as much as $1,100,000 annually.
  • When hospitals employ insufficient numbers of nursing staff, RNs are being required to perform professional services under conditions that do not support quality health care or a healthful work environment for RNs.

The bill also establishes certain levels of safety for nurse staffing at Medicare participating hospitals. Each participating hospital shall implement a hospital-wide staffing plan for nursing services furnished in the hospital, through which a nursing staff committee will help develop. 

The inclusive committee will “conduct regular, ongoing monitoring of the implementation of the hospital-wide staffing plan for nursing services furnished in the hospital; carry out evaluations of the hospital-wide staffing plan for nursing services at least annually; and make such modifications to the hospital-wide staffing plan for nursing services as may be appropriate.”

There is yet to be a companion bill in the U.S. Senate, but as the bill moves forward, ONS will keep its members apprised of the legislation.

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[TRANSFORMATION]

Transformation [ˌtrænsfəˈmeɪʃən]

n

1. a change or alteration, esp. a radical one

2. the act of transforming or the state of being transformed

 

One day I was a student.  A couple hundred days passed, seasons changed and changed again…  I changed and changed again, but one day, I opened my mailbox and I became [insert well-deserved drumroll] a nursing student. 

My friends had already received their acceptance letters.  Mine came two days later.  Two sleeps felt like an eternity.  Doubt crept in.  I congratulated my friends and was truly happy for them while coveting their correspondence and when mine arrived I was on-the-fence about what it contained.  I opened it gingerly.  I skimmed as fast as I could.  I was in.  Now what happens?

What happened for me was the rest of the semester, a trip abroad, an accident, life-support, and recovery.  I gathered my supplies as quickly as I could afford them.  I bought books in lieu of all else.  65 students stepped into a journey of unknowns together. 

Five days a week our 2015 cohort shares space, ideas, thoughts and concerns.  We talk in depth about readings, lectures and videos.  Articles we saw, or radio interviews we feel compelled to share are passed around, facebooked, and bulletin-boarded.  But we don’t end there…  We share candid discussions about personal experiences, family concerns, worries about washing out of the program.  Our conversations and shared experiences no longer hover on the surface.  We are becoming.  Each day as we learn more about each other, we have the opportunity to learn more about ourselves and how we can support each other.  Little by little, we are transforming. 

Over the next few weeks we will move from being newbies in the campus setting to ‘student nurses’ in the field.  We will be carrying all of our strengths and skills with us as we practice, learn, grow and continue to transform personally and professionally into the nurses that we will one day be.

New Beginnings

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First, let me say that I am thrilled to have been accepted into the nursing program.  It has been a long time coming for me.  I first applied to the program in 2000 and was accepted.

When I received my letter, I was beyond excited, however, I had two small children at home, I was a single mom working nights to be with the kids during the day.  I was recovering from treatment for ovarian cancer and I passed on the opportunity.  At the time, I had numerous credits that would have transferred.  I had no idea that child care was available on campus and my goal seemed temporarily out of reach.

I had developed a passion for expectant moms and birthing women prior to the birth of my own daughter.  My own pregnancy greatly heightened this passion and I began completing trainings to become a doula, a monitrice and then a lay-support midwife.  I read voraciously and felt like I couldn’t get enough.  I became a legislative advocate for the rights of women and for breastfeeding, both public and private.  I felt like brining my own child into the world had rebirthed me, had given me a cause to have a voice, and had made me love and appreciate my body in ways that I never had before.

At the time, I owned a restaurant and coffeehouse in Bowling Green, Ohio which my husband and I sold in 1997 after the birth of our son to move to Ithaca.  Once in town I aspired to become active in the birth community, but my husband and I separated within 6 months, I went to live with the kids and a family whom I barely knew with no car, no job, no money, and very little self-esteem left.  Two weeks later, I was diagnosed with ovarian cancer.

During and after treatment, I was amazed at the work of some of the nurses in surgery and oncology.  I knew who would be kind, who would laugh at my discomfort-inspired jokes, and who just wanted to knock out their hours.  I could tell who was there because they loved people and loved nursing, and who was there for a job.  The nurses who were filled with compassion, kindness, and caring in the face of a difficult job kept the flame on nursing alive in me.

Years later, after a subsequent diagnosis and treatment for breast cancer, a catastrophic spinal injury and myriad late effects; my kids are now teenagers and I am moving toward my dreams and goals of working as a nurse.  In the past 15 years, I have become a staunch patient and legislative advocate.  I have a passion for the young adult (AYA) cancer community and speak nationally and internationally about the special needs of AYA’s living with a cancer diagnosis.  I wish to develop the skills needed to be able to continue to serve my community in the most effective way possible.  I think that as a nurse, I have more to contribute to changing the conversation around cancer, cancer research, legislative policy, and community as well as global health.  I look forward to taking time to go abroad and work with populations who are disadvantaged due to lack of knowledge, lack access to appropriate health care/diagnosis/treatment/medications, cultural norms which prevent care and place an unbearable burden of stigma on individuals and families who are ill.  In my role as a nurse, I wish to serve and I look forward to the opportunities and the challenges which lie ahead and the recognition of self which changes and grows with every new challenge.  I am honored and humbled to be a part of the nursing community.

“The beginning is the most important part of the work.”
Plato, The Republic

[VOICES OF EXPERIENCE] Advice for Nursing Students From the Field

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Some words of experience from men and women who are working nurses in a variety of settings, with myriad skills, perspectives, and levels of education.  Thank you to all of the nurses who have been so forthcoming in sharing their views and experiences !

Be ready to eat, breathe & live for nursing school; even when you are on break. You really need to have a great support system. Your friends and family will have to realize that you won’t be around much because you are studying, preparing for clinicals, etc.
Don’t let all the madness of constantly having your head in the books get to you. Keep yourself focused because this is what you want and the road to get there is not easy. ~Jasmine

Realize that most places are requiring a BSN to get through the door. Also new grads tend to have a harder time finding a place to start as most hospitals do not want to put any money into training new nurses, i.e. using requirements that say 2 -3 years of recent acute care experience. The “recent” part of that means within the last year so, even nurses who have experience but were not working for over a year may tend to have difficulties as well. While it does not happen everywhere, you may run into nurses who still believe that males should not be in nursing. There are also patients who do not like male nurses, think labor and delivery. That being said I have had male patients who really wanted to have a male nurse because they were somewhat embarrassed to discuss some things with female nurses. Watch how much debt you build up just in case it takes a while to get a nursing job, very few creditors have much, if any, sympathy. ~Edward

Congratulations, you have to stay focus, and committed.  Some older nurses will try to discourage you, but if this is what you truly want then go for it. There are some many opportunities once you get over the honeymoon period the sky is the limit. I enjoyed nursing so much that I opened a nursing school and it is wonderful to see my students as colleagues. Good luck ~Mabel