Reflect, reflect, reflect

General Lessons

I have only spent 4 weeks in the urology ward and I can honestly  say that  I’ve never had a dull moment. Being student nurse so far as been amazing. I was initially very nervous of being on a ward with the responsibility others. However, I’ve grown to realise that as long as the staff nurses and sisters, were professional and supportive in what they do, I feel confident in finding ways to cope no matter how stressful the ward becomes. I can’t imagine doing anything else, I would definitely not want to work at any desk job or to sit in one place for a long period of time. Nursing is a demanding career, we are there 12.5 hours per shift, but there is always something that needs to be done. Whether it is emptying a catheter bag, rushing to obtain a controlled analgesic  for a patient, scrabbling around for a tool/medical equipment and cursing; only to discover tray storing said equipment/tool is empty, and scrabbling some more in the stock room to refill the supplies when a simple task that should only last a few minutes end up taking half an hour. But before I know it, the shift is nearing its end and I enter panic-mode to get the handover sheet updated in time.

Nursing is more than just “wanting to help people” or “being a people-person”. It is an art that requires time and experience to master.  You never know when someone would burst suddenly into tears or convulse violently in pain which requires you to show compassion to a complete stranger and being professional while maintaining their dignity. The vast majority of patients are an absolute pleasure to work with, despite some of them being in so much pain and suffering. Their general kindness and understanding towards me as a student, makes it all the more harder to see them suffer, which pushes me into provide the best service I possibly can (within my limitations as a student nurse). Occasionally,  patients can be spiteful and ungrateful, despite my best efforts to ease their discomfort they are still unsatisfied, but that should not be taken personally. It is easy to forget to see things from their perspective, when you are occupied with a million of things to be done promptly and accurately. Just imagine having lead a comfortable, healthy life and then being told you no longer have the function of your bladder or your kidneys. I cannot begin to visualise some of the psychological impact some might be going through. The feeling of injustice, despair, loss of independence which would destroy any shred of integrity and just generally not being in control of what is happening around you, it’s so traumatising to imagine. It is only during days off that I can  really a take a moment to pause and just think. With every shift I do, I’m starting to appreciate my own health more and more and not to take anything for granted. In reality, no one is really safe.

It would feel unfair to anyone, therefore, to become ill, especially if the condition is chronic and untreatable. Medications for many conditions such as diabetes, dementia, and COPD chronic obstructive pulmonary diseases only alleviate the symptoms but do not treat the underlying condition. Some people accept their situation and try their best to maintain their quality of life, “Do whatever you have to do, nurse. I don’t mind, honestly. I’d like to be a good patient.” Others act with spite, but it’s important to treat patients with unconditional respect, ” I’m sorry that you feel this way, please accept my apologies if I had upset you. Is there anything more I could do for you?’ Being unwell,  naturally makes most people feel entitled to become impatient, heighten their expectations or generally vent out their frustrations on staff. That is perfectly understandable as long as it doesn’t become verbally or physically aggressive. By behaving courteous and calm back to them, it could make them feel guilty for being rude in the first place.  It’s something I need to improve on because I get easily intimidated by them and flee asap, when patients become annoyed or irritated.

Nursing is definitely a career where you give more than you get back in return. It requires some degree of personal sacrifice, being flexible with your time by alternating between day and night shifts and working unsociable hours for a relatively moderate income.  Sometimes, you would be criticised by other staff nurses for getting things wrong but not be recognised or praised for getting things right. The fact that someone has bothered to point out flaws is a good sign, they actually want to push you to achieve, to not just be a nurse but a great nurse. It is paramount to be able to stomach dealing with bodily fluids; cleaning up diarrhoea, vomit, blood, oozing wound dressings, and not to feel sick when washing patients with offensive odours. Showing unconditional respect and humility towards patients, by ensuring that they are comfortable, hydrated and satiated, even if they are ungrateful is a challenge but not impossible to achieve. It really  helps to imagine every patient lying in the bed is your own mother/father, show the unconditional love! Lastly, the amount of effort you put in into treating and serving others is a reflection of you as a person.

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Complaints of Pain

Analgesics are used abundantly in the wards. They are essential to help patients recover and regain their independence. However it is not a permanent solution because according to pharmacokinetics, there are enzymes in the body that modifies the drugs into an inactive form or actively eliminates they from the system. The non-controlled analgesics can be bought over the counter, with or without prescription. On the wards, they are on the regular prescription chart, prescribed at certain intervals,  so are administered at specific times of the day by the nurse, once a day=OD, twice a day BD, three times a day TDS etc. Of course, patients are free  to decline painkillers but they cannot exceed their daily dose or before the next due time. It is safer to underdose on a drug than to have an overdose. In the case for the controlled narcotics, the opioid drugs: oramorph , oxycodon and fentanyl, they are given to the patient as and when they require. But, they would also have to wait for a certain time interval before they are permitted to take the next dose. If the patient do not feel the need to take any of the controlled narcotics then there is no need to remind them, whereas the  analgesics that are written on the regular prescription drug chart it is the nurses’s responsibility  to remind the patient if they would like that painkiller.

Depending on the patient, some of the non-controlled analgesics (paracetamol, ibuprofen and codeine, etc) would also appear on the “medication as required” list  in addition to appearing on the regular prescription list. However the the controlled narcotics, I have seen them only listed on the PRN, and never on the regular prescription chart (so far).  Additionally, there is also an order in which you offer the PRN (pro re nata= as required) medication from the weakest painkiller to the strongest, if patients are prescribed a range of analgesics. The order goes something like this: paracetamol, ibuprofen, codeine phosphate, tramadol and finally oramoph/oxynorm.  Also the doctor may prescribe a dose range, typically, for oramorph it is  10-20mg under PRN. If the patient is taking the PRN medication for the first time you would always start them on the lower dose, 10mg first in the case for the oramorph, and you can tell by their overall composure if they are in moderate or severe pain at the time they request for it.

Some patients in genuine pain are left in the dark 

These drugs only have a temporary effect on the body which means they must be taken at regular intervals or as required to control any severe pain. Furthermore, as analgesics, they do not resolve the underlying cause of the pain, rather, numbs the perception of pain. It is no surprise, therefore, that I have encountered two extreme types of patients, one that avoid pain medication at all costs and the other type relies on them so much so that they would counts down to the precise moment for the next shot of morphine. The former group of patients are fairly conservative; despite being in severe pain after a laparotomy or prostatectomy, they would rather endure it than ask for any pain relief. In many ways I can relate, I myself is the sort of person who likes to avoid taking medication as long as necessary.  If I experience a slight headache, I would try to sit through it rather than jumping straight to the medicine cabinet for some paracetamol. Patients who experience post-surgical pain however it can be severely debilitating, it prevents them from getting out of bed, going to the toilet and eating and drinking, all of which would delay their road to recovery. Patients who have had abdominal surgery should mobilise as soon as they regain their strength, as this to helps their bowels to contract in order to pass wind and defecate. Otherwise they would feel constipated and experience additional pain of distended bowels. Therefore the first step would be to address the pain, they should take the painkillers to feel comfortable enough to at least transfer themselves to a chair and then proceed to take a few steps into the bathroom etc. I have seen patients rolling and weeping in pain because; they were against taking painkillers, didn’t realise they were entitled to painkillers or feel embarrassed/ didn’t want to bother nurses for them.  But if it is obvious that if the pain they are having is absolutely intolerable, and is coming from a surgical site while waiting for the body to heal itself , there is no doubt that they are legitimately entitled, and should be actively encouraged to take painkillers. The underlying cause of pain is coming from the wound/surgical site and the only way it can be stopped permanently is to wait until the wound has completely healed. Taking the painkiller is a temporary measure until the healing process is completed. The healing process relies heavily having hearty appetite, and if patients are not debilitated by pain then they are free to eat more adequately.

Don’t jump straight into the med cupboard, do some digging

Conversely, there are some cases where the root cause of the pain can be identified and quickly resolved, rather than administering pain relief which would only mask the underlying problem and exacerbate their condition. As a nurse you cannot always rely on adhering to the plan left by the doctor, sometimes using initiative can pays off. I believe if the patient is complaining of pain then try to know as much about the pain as possible.

  • Where is the pain coming from?
  • When did it start?
  • What is the pain like? short and sharp? or sustained and chronic? or in irregular episode?

[This would be useful to report to the doctor if everything fails and the pain medication is clearly not working, the doctor would have to prescribe a stronger analgesic, increase the dose or increase the frequency or a mixture of both.]

Specific to urology, if the patient describes that the pain is originating from the groin area, more often than not, it may be due to voiding complications. If the patient is catheterised, check for signs of blockage and whether the patient was able to pass urine recently. I have had cases where the patient was crying out in pain and asked for some pain relief which worked for a while but then they were in pain again. When the ward sister lifted the patient’s gown to inspect the catheter, it was actually kinked all along. This stopped any urine from draining and it was accumulating inside the bladder, building pressure and causing the immense pain. So it was simply the case of first checking to see if the catheter is patent, after the catheter was unkinked, the patient sighed in relief. In fact almost, 1 litre of urine drained from the catheter. Alternatively, the catheter may not appear kinked but the patient is still complaining of pain in the groin, there is also the possibility that the catheter is blocked by debris (catheter is not patent due to internal obstruction). Giving the catheter a good flush if you notice that it was not been draining recently would either confirm or eliminate this as the source of the patients abdominal pain.

Additionally the patient may be complaining of groin pain but is not catheterised. On a more recent occasion, a patient was moaning in pain, and couldn’t express where the pain was coming from. If this should happen then a set of observations should be taken, paying careful attention to body temperature and blood pressure, in case they are developing sepsis or fever. Eventually, the patient was able to point to the groin area, he was not catheterised but had difficulty urinating. At this point the doctor arrived and gently felt around bladder (the lower abdominal area) and subsequently identified that it was a sign of bladder distension. Having realised that the patient was in excruciating pain combined with the fact that they had not been able to pass urine for a while suggests the hallmarks of  bladder retention. A bladder scan was quickly performed which showed the patient had a residual of 875ml. Without further delay the patient was quickly catheterised by the doctor. It was very hard to watch because the patient was screaming at the top of their lungs during the entire procedure, especially having  a urethral stricture previous injury made the urethra particularly tender. But the pain was resolved as soon as the bladder began voiding, with the catheter in situ, it provides the urethral sphincter support to remain open. I was just wondering if the entire thing could have been done by the nurses without calling for the doctor? From the moment  the patient complained of pain in the groin, their ability to pass urine should be checked. When it turns out the patient was unable to the next step of the protocol is to check the residual volume of the bladder and any outstanding volume (>50ml) is a classic sign of urinary retention and patient must be catheterised, to see if the pain can be resolved by draining out the bladder. In theory the entire process can be done by nurses, nurses are trained to catheterised. I just wished we were able to have take more proactive steps on that day. pass urine. In brief, there are some instances when, if  you see a patient in pain, it pays to try and identify the reason for the pain first before dishing out painkillers willy-nilly.

To another extreme: seeking for pain relief or seeking for the drug?

The reason why some analgesics are controlled (narcotics) is because if they are taken regularly, eventually it can lead to addiction, along with other side effects such as respiratory depression. Majority of these are opioid derivatives morphine (oramorph), diamorphine (heroin) if used for a long time they cause the body to become desensitised and you would have to increase the dose for the original effect.

There have been many instances  when I reported to the nurse that one of their patients has requested for some oramorph, they would mutter “Not again, they are not really in pain.” It was only after a few more patients did I begin to realise which patients really do need analgesic and which patients are questionable. Simply put, if the patient is prescribed a PRN medication and nothing has been altered by the doctor, and they request for the painkiller, they are inherently entitle to it. If the patient states that they are in pain then it is our duty to accept it without judgement and offer what is prescribed.

But still, I can’t help but wonder.

There have been some patients who asked ” Can I have some oramorph, please. I am due in a few minutes”, in a calm, normal tone of voice and with a completely neutral facial expression. During the first few weeks of my placement, those sorts of patients caught me out. I automatically turned to the nurse told her we should get the meds out right away. But when the nurse would raise an eyebrow towards me, “If the patient is in so much pain that they say they are, why are they still able to walk and talk normally?”  These are clearly not in agonising pain, perhaps they are experiencing moderate internal pain but not great enough to prevent them going about their business. The more meticulous nurses have explained that oramorph should really be reserved for patients rolling in agony. For sure, I have seen many patients screaming in pain, so much pain that they are unable to get out of bed and wrapping their arms around their abdomen, or wherever the pain is radiating from.  Some are in so much pain they are unable to vocalise their request for the on-demand medication. Apparently the rule of thumb is, if they are able to talk normally  to their relatives then they really should not be taking any of the stronger narcotics. Each time narcotics are given, a closer step towards addiction is taken, why make that risk if the patient is not in agonising pain?   

There will also be patients who are just addicted and will openly abuse the pain management system. The key thing is to get to know the patient. Pay attention to how they behave when they are in pain and when they are not in pain. When the patient is in actual pain they will act in a certain way, tone of voice, posture, they way they protect the area of the body that is in pain and  have some physiological changes that can’t be faked such as pyrexia and elevated blood pressure. While if the patient is just seeking out the drug, they may overact or underact. Being in pain is almost like an involuntary reflect, sometimes I could identify which patients are in obvious pain. Unfortunately, in reality this is only for my personal interests, and nurses had no choice but to fulfil the patients demands, even when it’s plainly a ruse. I believe it would just be detrimental towards the nurse-patient rapport to say “I can see straight through you and you are clearly not in pain”. Perhaps patients can be discouraged from taking analgesics, but ultimately the patient has the final say.

A day with the Urinary Diversion Nurses

I had the opportunity to spend some time with a pair of CNS clinical nurse specialists in urinary diversion. It was quite a nice change to arrive on ward at 9am in the morning instead of 7.15am! Within the urology department patients also get referred to urinary diversion nurses as part of their multi-disciplinary care team package if they present more complicated medical conditions. On my placement it is not mandatory to experience working alongside healthcare professionals other than other staff nurses or your mentor, but I realised, since I am working in urology it would be a good opportunity see what the clinical nurses in this division work on. I didn’t want to lose any of my regular time working on the wards, besides this is my first placement and I am still getting familiar with fundamental nursing care so I arranged to work with the urinary diversion nurses on my day off.

The urinary diversion nurses are responsible for overseeing the needs of patients with any urinary diversion operation, in which patient’s natural urinary tract has been altered or manipulated in anyway. Patients with bladder problems include:

  • Cystoplasty Patients born with small or inadequate capacity in their bladders, would mean they have to go to the toilet more frequently, a solution would be to have bladder augmentation or cystoplasty. You can graft a piece of the patient’s own small intestine and add it to their bladder to expand its size.
  • IDC indwelling catheters Sometimes patients cannot pass urine through their own urethras, and need intermittent self-catheterisation. This is required when the bladder has urinary retention, where the bladder muscle detrusor is unable to contract and eliminate urine, through self-catheterisation it allows the urine to drain artificially, thus relieves discomfort and distention of the bladder. Bladder retention may occur due to spinal injury, spina bidifa, diabetic neuropathy. In diabetic neuropathy the nerves to the bladder are damaged due to the high glucose levels (hyperglycaemia) that is the hallmark of diabetes mellitus. However, complications may arise and the individual is unable to catheterise independently, therefore patients are offered mitrofanoffs to resolve this problem. This involves taking the appendix and fashioning into a thin tube that connects the bladder to an artificial opening of the abdomen. This is usually the navel so patients pee through their belly-button, so its more discreet.
  • Ileal conduits Other patients with bladder cancer will have their bladder removed, cystectomy and will have either an ileal conduit or a neobladder.

Other urinary drains will be nephrostomies, suprapubic catheters.  as discussed in the  bladder cancer page.

Following the urinary diversion nurses was a weird experience, it felt weird not being responsible for only their urinary needs and not having to rush around ensuring everyone has had a wash etc. The CNS work within a tight frame but I felt it was much more relaxed because you work at your own pace and the tasks are not as physically demanding. The nurses on this day were working in a pair normally they would work independently but I am not sure why they needed to work on this occasion. In general they visited all the patients on my ward with a urinary diversion system so it was interesting to see the same patients but from a CNS perspective.

The first patient we visited recently had a cystectomy to remove a cancerous bladder and had opted for an ileal conduit. A piece of the ileum (last segment of the small intestine was removed and reshaped into a tube. The ureters that drain the urine from the kidneys were connected to the ileal conduit, instead of the old bladder, and the other end of the ileal conduit was connected an opening that the surgeons that have also made on the abdomen. In this urinary diversion system the kidneys made the urine, it goes down the ureters, down the ileal conduit (a piece of the small bowel shaped into a channel) and out through the opening of the tummy. Since it is only urine that comes out of this artificial opening it is called a urostomy. Stomy means artificial opening. There are also colostomy where the large intestine, the colon is diverted straight through an artificial opening in the abdomen, so faeces comes through the abdomen instead of the rectum and anus. Likewise there are ileostomies where the the entire large intestines are removed due to cancer and the ileum of the small intestine remains so surgeons create an artificial opening on the abdomen and connect the ileum to this creating an ileostomy. Although patients are under the urology team here they may have both ileal conduit-urostomy system and/or ileostomy or colostomy. However you cannot have an ileostomy and a colostomy, you can only have either one or the other. I hope the reason is obvious.

Anyway, back to the ileal conduit patient (strictly speaking its called an ileal conduit-urostomy because in order to have an ileal conduit you must have a urostomy) Patients like them will pee through their abdomens forever, instead of through their urethra. Unlike a bladder, the ileal conduit is just a conduit or a channel so urine will leave immediately so it must be contained in a bag called a stoma bag. This is where the CNS duties lie, they are responsible for educating the patients about caring for their stoma bag and monitoring the health of their  stoma.

When the CNS removed the stoma bag, it was the first time I had a proper look at a stoma. They come in all shapes and sizes according to the nurses and in this patient, theirs was rather like an oval shape, pale pink and the mucosal lining was roughly at the same level of the abdomen. The nurses agreed that the ‘ideal’ stoma should be more circular and the mucosal lining should be protruding slightly above the surface and brightly pink. I will not post any pictures of stomas because they are not for the faint hearted, I have a slight morbid fascination so I was intrigued rather than horrified when I first saw it, I even asked the patient if the stoma has any sensation, to which they replied no sensation at all. It is rather like seeing part of your innards protruding out from a hole in your tummy. Things to inspect the stoma for:

  • Moistness
  • bright pinkness or rich redness- not too pale which suggest poor circulation, if the stoma does not get adequate nutrients and oxygen it will die, tissue necrosis. Alternatively too red which is a sign of inflammation and infection.
  • warmth- body temperature
  • secretions

The stoma should really be protruding outwards because it helps with eliminating the urine straight into the stoma bag, also a washer ( a ring-shaped foam would be required to be fitted around the stoma to hold the bag in place- the more equipment the more complex the bag, the less likely for the patient to create a water tight seal for themselves). In other cases patients may have a very protruding stoma however this will gradually recede with time. The nurses visited the patient for a review to see if they could change the bag for themselves unassisted. However they had missed a couple of steps so the nurses will come back the next day to see if they can pass the test again.

Interestingly, this procedure is not available to bariatric patients, if they are above a certain waistline it is not possible to manipulate the ileum so that it stretches from the ends of the ureters to the surface of the abdomen. Patients who are morbidly obese have such thick layer of fatty tissue (subcutaneous tissue) that there is too much of a distance between the tummy and the ureters. Additionally, the ileum is live tissue and it must be nourished by a blood supply. Patients do not realise it but grafting the ileum to function as a channel for urine is essentially forcing the organ to perform something that is not ‘natural’ to its original function and the surgeons would have to connect it to a network of blood vessels to keep it alive in its new location. Excessive fatty tissues make this task impossible, so patients must lose weight somehow in order for the surgery to be a success.

Subsequently the nurses spent the majority of the time teaching the patients in other bed how to do their bladder wash outs. Some patients have both a catheter and a supra pubic catheter in place so it the same procedure I have outlines in my previous page on catheter care but with more clamps. Fortunately I managed to pick up a new piece of advice from the nurses, sometimes when urology patients that are catheterised are screaming out in pain it is not necessary to automatically give them oramorph or any other painkiller. Sometimes the catheter may simply be blocked with a blot clot or tissue debris from the bladder lining or even kinked at the end so urine is not draining from their catheter. As urine builds up they can feel the pain and you just have to see if they have been draining properly for the past few hours and give them a quick bladder wash out to remove any blockages.

According to the CNS they also noticed that there is a significant increase in the number of patients with bladder cancer under the age of 50, which is quite scary. They both classified themselves as “old school” and would reminisce back in the good ol’ days occasionally throughout the day. They said that their ward sister would be much more active on the wards, these days the wards sister have more office duties so their time spent on the wards have now been reduced. In fact, both of them were ward sisters before qualifying as clinical nurse specialists. As ward sisters they would randomly pick on a nurse and quiz them about their patients. They told me that although handover notes are useful, but as a nurse you should know your patients like the back of your hand and can recall at least the key procedures they had and about their current medical condition without referring to the handover notes. It does not look professional to be riffling through the notes anyway.

Also they were disappointed about the fluid balance record for one of the patients, nothing was recorded in terms of how much the patient drank from 5am for 7 hours! It was fortunate that the patient was not retaining water or in an excessively diuretic state, otherwise someone would be accounted for this lack of proper documentation.

After they had consulted all the patients with the urinary diversions on the ward, they also had out-patients to see. On this day there was only one out patient. These out patients have had the urinary diversion surgery and would visit if they noticed changes or developed complications, and would go straight to the urinary diversion team. Finally, in the afternoon the nurses have their office duties where they may ring up other out-patients to confirm their status and several things which I have forgotten now, but their clinical duties end around mid-afternoon.

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By eliselissa

Mid-placement Reflections

All “basic nursing skills” are essential nursing skills

I’d like to re-state something I had written earlier. There is no such thing as ‘basic nursing care’, making sure patients are fed and comfy, monitoring their appetites is absolutely fundamental for the patient’s road to recovery, and it is a duty and responsibility of the nurse in charge of the patient’s care for the day/shift. Ensuring that your patient maintains a good appetite suggests that they are responding well to the treatment, otherwise if they have poor appetite, it means they will not be getting enough nutrients and proteins to help their wound heal. During the healing process, although the patient may not be very active so it is not always obvious that they are burning many calories, the body does need to consume an incredible amount of calories to repair properly and if the patient is refusing food or is losing appetite then they are not or will not be recovering as expected. An empty stomach is just not healthy, they can feel frustrated, dizzy, lethargic and be in a bad mood in general. So it is important, from the nursing perspective, to encourage eating or, if they are not, you need to place them onto a food chart and/or start taking their daily weights and asa final measure you would have to refer them to a dietician so that a special diet can be implemented for them. If a patient’s appetite is not monitored properly, they are at risk of malnourishment and starvation. Without protein the plasma osmolarity will be low and water will diffuse into the tissue fluid via osmosis. This causes local oedema in the periphery such as the arms and the legs. Yes this “skill” does not require someone with a master’s degree or a PhD, it is simply a combination of common sense and intuition.

Additional fundamental things to look out for when caring for patients is their overall profile, age BMI and posture. According to the sister in charge I was told to order a dual mattress for this elderly patient who was 85 years old. I was only aware that people who were immobile and had a high waterlow score were automatically assigned a dual mattress. In this ward we have two types of mattresses, a foam mattress and a dual mattress. A dual mattress is an inflatable mattress that generates air currents within the mattress to alternate the pressure being applied on different areas of the body in contact with the mattress, that reduces the risk of forming pressure ulcers or further damage on existing ones. However that does not eliminate the chances, patient still have to be frequently repositioned if they have a high risk.

But apparently if you notice a fragile and over the age of 65 patient, who are are mobile, they are also entitled to dual mattresses.

Washing and ensuring that all pressure areas are in tact is not “basic nursing care”, as I had previously stated. I now realise how invaluable giving showers and bed baths myself with an HCA, incredibly important it is. If patients are refusing to mobilise, pressure ulcers can develop unexpectedly and progress rapidly through the grades. The only chance to really inspect the patient’s pressure areas is during the morning washes by providing personal hygiene for the patient, with an HCA or independently. Personally I would feel much more confident when it comes to documenting the pressure area status of my patients if I had inspected all the pressure areas that in tact or not of all my patients for myself. If patients are mobile enough to maintain their own personal hygiene then its not really necessary to inspect, although I have heard that patient have been walking around with pressure ulcers because the nurses assumed that if they are fully mobile there is absolutely no risk of them developing pressure ulcers. I would like to inspect all my patients just to confirm that all pressure areas are in tact but sometimes is not entirely practical to do so, for example on a busy morning some of my patients would have been washed and inspected by an HCA.

I feel like kicking myself

On one occasion I did something that I should not have and I have been reflecting back on this experience all the time. I feel very disappointed in myself. Although we are in an orthopaedic ward we still need to accommodate patients from other wards due to staffing levels and bed shortages. On this occasion we had an orthopaedic patient who had come in because of a fracture femur and was awaiting an operation in the afternoon. I did acknowledge it during the handover and it was clearly written on the handover but when the morning rolled on things had to be done. I was told to wash and prepare the patient for surgery. I did this millions of times now so I felt completely confident to work by myself. Half way through the wash she complained that she could not pee, she was catheterised and had a colostomy bag on so I calmly told her if she wanted to “go” she could just go because all the waste would be collected in the bags. After a while she complained that she still couldn’t go so I became worried that perhaps the catheter was blocked, I haven’t done a bladder washout myself yet so I called a nurse who happened to be free at the time to have a look at her. She did a bladder washout on her and showed me there was no blockage and anyway, urine started to flow down the tube. We again reassured her it was safe to pee. The nurse had a look at her diagnosis, she was also a dementia patient which explained why I had to remind her of the same thing several times and her anxiety over the catheter. Even though I had made notes during the handover I simply made assumptions that the patient was mentally stable, I should have had a quick glimpse at the notes again, so I would be more prepared in the future! After the wash I asked her if she was able to move to the chair. Being completely anal-retentive about pressure areas and sores I was determined to not let her lie in one position all day (by that time I had forgotten that she was due for an operation, having came to the resolution that she was also a dementia patent). Also I had heard great stories about how a nurse was able to act assertively and actively got patients out of bed, and I would be able to document that I managed to get the patient into a chair for the record. Before anything happened I asked for the patient’s consent if she would like to sit in the chair for a bit. She agreed and was able to transfer herself, although it caused her moderate pain to do so with some assistance from me.  I had felt so proud of myself that I didnt risk patient safety and move her into a chair, I reported the happy news to my mentor. Unfortunately she told me that I was not supposed to do this, the patient was advised to stay in bed for the operation. I always had the mindset that remaining in one position for too long was a bad thing; muscle weakness and pressure areas being compromised. However, that are occasions when this is necessary. Any orthopaedic patients that require surgery or awaiting for surgery from the waist or below should not be encouraged to mobilise as there would be risk of further injury. In retrospect, I was completely unaware of this and had wanted to show my mentor that I have initiative and in doing so, I had automatically treated her as a post-op urology patient. Post-op urology patients are encouraged to mobilise as soon as possible to help their bowels to open and prevent the formation of pressure ulcers. However as soon as I realised my mistake I was quick to rectify it first by apologising the patient that I should not have go her out of bed in the first place and helped her back into bed. Fortunately my mentor did point out that if I did do any permanent damage she would be screaming in pain. Also I didn’t force her to do anything, I asked her consent and held her arm to get onto the chair, she was able to bear most of the weight herself. But I know now in the future I must always refer to my handout what team the patient is under before taking any actions.

When patients cry

Dementia patients are never easy to work with, but so far I had some positive experiences from them. I suppose the experience also varies between different dementia patients, but I am never sure whether their consent is truly their consent. This is why relatives are called in to discuss with the doctor or surgeon before the patient has surgery. There was a patient with dementia who was getting ready for surgery, nurse have to ensure that their patients are washed, if they are MRSA positive we have to use a special solution called a ‘hibi’ scrub. I had got all the equipment ready, bowl of warm water, towels and liquid soap, just as I was about to give her a good scrub, she broke down in tears. I was deeply sadden by this but I knew I couldn’t just drop everything down now. This was the second time a patient ever cried in front of me and I felt slightly more prepared, the first time it was completely awkward for me:

{It was my 3rd or 4th day ever on placement and I was admitting this patient from PACU post-analgesic care unit, he had reacted badly from the oramorph and had vomited several times before taking anti-emetics and was prescribed tramadol. He had a prostatectomy, I sat down to do the waterlow score by his bedside and halfway through, he grabbed my hand and he started shaking. I thought, oh no I hope he is not going to throw up! but instead he broke down in tears.

”Hey, whats wrong, you can tell me,” I asked.

“I just feel so exhausted…..I,  I had a horrible time downstairs [PACU]. Im so tired but I just can sleep either. I just can’t take it anymore”.

Silence.  I didn’t know what to say I was stunned because he had appeared normal and kind a few minuted ago. I was too busy getting the order of things right to have thought about what the experience was like for him, having to move from one part of the hospital to another, being on medication to stop the pain but vomiting as a side effect, and feeling exhausted but not being about to sleep because of the noise and just being uncertain about things.

“I’m sorry you feel this way. Is there anything I can do?”

“No, no. its just good to get it off my chest.”

“Does your wife know you are here?”

“She is on her way now.” }

On the second occasion I felt a bit more prepared.

“I’m sick and tired of having operation after operation. Nothing is working and I am fed up with it all…..[sobs] I don’t have the strength at all. Why are you doing this to me? I wish I could clean myself ohhh I am so ashamed of myself!”

I put down the wet towel and held her hand and made direct eye contact with her.

“Listen to me. I know this must be very difficult for you. It’s so frustrating isn’t, to go through so many procedures and still not be certain of what will happen. I am so sorry you are in this situation. The fact that you are even here is a good sign, you are so strong and brave to have gone through these operations. I understand you have a daughter coming to visit you.”

” Yes, her name is ____. She will come and visit me before the operation.”

“Yes, let’s get you refreshened up and into a nice clean gown, so that you are ready when she get here. Does that sound good?”

“Yes, I’d like that very much.”

“Right then. I know it must be tough for you and I want you to know that you are not alone. You are in the right place so there is no need to feel scared, I am here for you and the nurses are here for you.”

I began to continue the wash and dressed her in a new gown. Later on, after she signed the documents with her daughter as the witness, the patient said to me before she left,

“Will you be with me after my operation?”

The fact that she had singled me out from the staff and asked if I would be there to meet her after the operation felt enduring. I said yes even though I know she would probably be in intensive care after the operation and be transferred to another ward because her operation was not  urology-related. I never saw here again, so i hope her operation had been successful and back at home now.

dementia

PR laxatives

On a more lighter note administering laxatives per rectum must be one of the most extraordinary things I have ever done. So far I have given enemas and suppositories. With suppositories, they are glycerine based and when glycerin is absorbed into the rectal walls it irritates the mucosal layer and stimulates smooth muscle contractions, then hopefully causes the bowel to open, it could take up to 48 hours to work, with some patients it may take a shorter time. The pack includes two bullet-shaped glycerin jellies. You would ask the patient to lie on their side and then apply aqueous (water-based) lubricant on the jelly and your little finger. Then push the jelly tip first into the anus and followed by the second jelly. Finally insert your lubricated little finger up the anus as well so that the two suppositories are inserted in the rectum as far and possible. Obviously for self-caring patient they can easily do this by themselves but you have to instruct them clearly what to do. One time a patient ask me if he could have another suppository, he was instructed by my mentor so I did not know whether she had explained very thing clearly to him/ whether he understood everything or if he had done it correctly himself. He felt that his bowels were going to open so he rushed to the toilet but what came out were the suppositories. He was adamant that he had inserted his little finger at the end. However he could not have another one after 3 hours, they are prescribed at strict intervals where patients may decline the medication but may not exceed their intake. Even if he was telling the truth there was no way of knowing, so making him wait 3 more hours would not be the end of the world. If you have given the medication but you have not seen the patient take it and says they have lost it you cannot administer another dose until the next time interval.

Phosphate enemas work by creaking more bulk in the colon, it is concentrated with electrolytes and causes water from the capillaries on the apical side of the bowels to enter the lumen down the osmotic gradient. It is in the liquid form inside a bottle with a pointy nozzle at the end. One patient was so desperate to have their phosphate enema that they had their feet on the ground, hands on the edge of the bed and backside up in the air. You would need to ask the patient to lie on their side on the bed and knees slightly bent almost like in the recovery position. It may be self administered but it is best for the nurses to perform this so that you know yourself that it was administered correctly and all the bottle was given. Lubricate the nozzle with the aqueous gel and ask the patient to take in deep breaths, as they breath out you insert the nozzle through the anus. The first time I had given an enema it was on a female patient and I was hoping that I really had inserted into the anus! Then you squeeze and squeeze until all the fluid has left the bottle. If you have time and you want to be extra considerate of your patients, you can run the bottle in warm water so that it is not so cold. Then you tell the patient to hold their cheeks together as tight as possible and for as long as possible so that the medication as a chance to work.

Ketamine abuser

This was my first experience of providing care for a drug abuser, I have never come across a SELF-CONFESSED drug abuser before and it was strange. Apart from the marijuana tattoo there were no obvious signs. I suppose if you are not on a withdrawal state, abusers act and appear like ordinary people. The patient was pleasant, was not verbally aggressive and agreed for me to perform the observations. Additionally the patient asked nicely for me to get a set of headphones. However once I had a chance to look the medical history I was horrified. Ketamine is a dissociate anaesthetic that is medically used to tranquillise large animals but can be obtained cheaply, compared to other drugs. Acute abusers may experience hallucinations, numbness, feel like floating and feel detached from the physical environment. However the chronic abusers experience irreversible urinary damage. The initial symptoms include, urinating becomes painful, haematuria, coagulants in the urine, the need to pass urine frequently, increases detrusor (bladder muscle) contractions and decreased capacity to store urine in the bladder. Abusers experience more pain so they are more prone to take more ketamine to numb the pain so furthering the damage to their bodies, in a vicious cycle. In the end chronic abusers will need to have a cystectomy which is normally a procedure reserved for elderly patients who have developed bladder cancer. This patient was under the age of 30 and was given a neobladder with a mitrofanoff so they would have to urinate through a catheter for the rest of their life and a degree of impaired liver function. The range of ketamine abuse was much wider than I first realised, as you may see in this article and this article.

I know it is my duty to treat all patients with an unconditional positive regard, but at the end of the day I am not a machine and I do have my own opinions. In the back of my mind abusers should face some sort of consequence from their use of the precious healthcare service. The surgery they have taken could have gone to some who really deserve it because of cancer which was not self-inflicted. It is a tough situation because you can argue that addicts eventually become unable to control their actions so that repeat abuse is not self-inflicted but is only a side effect of a bigger problem and the reason why their choose drugs in the first place is what needs to be tackled instead.

Pharmacology tips:

If patients are prescribed co-dydamol, you have to ensure that they are not given paracetamol at the same time or prescribed paracetamol at all because they are fairly similar. If they are given both they will be overdosing on acetaminophen (paracetamol).

If patients are NBM, then they are not entirely excluded from the medication rounds, they may have drugs given intravenously or intramuscularly. For example IV paracetamol however if patients weight less than 50 kg they should not be given IV paracetamol because it does cause hepatotoxicity.

Also I need to start learning the dosage ranges for each of the common drugs, as the doctors prescribe and the pharmacist administers, nurses are the last people to check before administering.

So many medical conditions

There are so many medical conditions I need to find a way to organise everything to keep up! Even within urology we get admitted patients under different departments due to bed shortage and as well as patient having multiple and complex medical histories along side renal complications.

I am trying to familiarise with them bit by bit so here goes….

Bilateral hip displasia this is usually a congenita defect if it occurs in children and young adults where the femur socket is not correctly aligned to the pelvis (hip bone). There are different classes depending on the level of severity of misalignment. No doubt this causes mobility issues and requires walking aids such as a zimmer frame. Bilateral hips are misaligned, displasia is the abnormal formation of.

Left PAO- periacetabular Osteotomy this is where it is used to correct the abnomral formality of the acetabulum displasia. Acetabulum is the socket that accomodates the head of the femur. This procedure is corrective surgery to enhance the curvature of the acetabulum to enable better mobility.

TURP– Transurethral resection of the prostate. This is done with a scope that is inserted of the urethra of the male patient. The instruments begin to shave off the disease cells of the prostate until the outer capsule remains, wash out of the patient. This is only suitable for small prostate cancers and begin tumours. Nursing aftercare, patients return to urology, with a catheter in situ, and connected to an irrigation system that runs fluids directly into the bladder and flushing it out. There will be haematuria but this is the consequence of the operation rather than the patient’s medical diagnosis. So the irrigation is in place to enforce the bladder and prostate to be cleared of tissue debris and clots, and discontinued when the catheter drains clear of blood. Bladder wash outs are required once a day to aid the elimination of embolisms that may stagnate or block the catheter.

Non-insulin dependent diabetic the patient has type 2 diabetes.

Arthritis this is an auto-immune disease where the body’s own lymphocytes attack the synovial membrane and fluids as well as the innate immune components (TNF, natural killer cells). This cause the jointed to erode and deteriorate, it is painful and difficult to move the joints.

CT KUB– computerised tomography (using X rays to see internal injuries) KUB-kidney, ureters and bladder.

DVT deep vein thrombosis

Pulmonary fibrosis– the loss of elasticity from the lungs due to asbestos or other carcinogens

Hiatus hernia, the hiatus is the opening in the diaphragm where the oesophagus enters the thoracic cavity. The hernia is where a segment of the GI tract prolapses through, in this case through the hiatus.

Dierticulosis is the formation of small pouches in the large intestine. As food moves along the large bowel they can become trapped inside and stagnate, this can being to decay attract bacteria and lead to infection and inflammation (dierticulitis). This can be prevented by having enough fibre eat day, fibre adds bulk to the faeces retains some water making the stools large and smooth, which enables faces to pass very easily. However low fibre diet forms small hard stools that causes the bowels to stress and strain that can generate dierticulosis.

Aortic stenosis is when the aortic valve (semilunar valve) opens but not completely. This reduces the full potential of cardiac output. This is an age-related disorder, older people have higher calcium that deposit in these valves.

Gout– this is build up of sodium urate in the joints and causes a type of arthritis. This is due to a high level of uric acid in the blood, this is a metabolic waste product that is usually excreted by the kidneys.- kidney disease is associated with gout.

Carotid endarterectomy, this is a procedure to widen the carotid artery, if someone has existing heart disease, atherosclerosis cause the arteries to narrow with plaque. This procedure prevents the event of a stroke. Ischaemia is the reduced blood supply to the heart while myocardial infarction is complete blockage of blood supply to the heart.

By eliselissa

Common Analgesics

Analgesics are painkillers, they are not to be confused with anaesthetics, analgesics inhibit the perception of pain only while anaesthetics causes a temporary loss of complete sensation.

We have a naturally in-built analgesia mechanism, when we are in pain and not too severely injured and running away from danger, there are neurones downstream in the periphery system that releases opioid-like peptide neurotransmitters that temporarily block pain sensation and enabling us to escape. Analgesics mimic and enhance this effect. Analgesics are roughly categorised into two main groups the NSAIDs, non-steroid anti-inflammatory drugs and the opioids. There are two types of pain, nociceptive and neuropathic pain. Here nociceptive pain will be discussed, this is initiated when there is damage to the tissues. It results in the production of a paracrine signalling molecule called prostaglandin, via an enzyme called cyclo-oxygenase (COX-1 and COX-2). Prostaglandin E stimulates the nociceptors and causes the pain sensation. So there are two mechanisms of action to prevent pain sensation, preventing the production of prostaglandin and activating the analgesic system in the body.

NSAIDs non-steriod anti-inflammatory drugs inhibit/reduces the production of prostaglandins. They are used for mild to moderate pain so they are NOT classified as controlled narcotics. In terms of nursing, would not need to be countersigned by a second nurse upon admission however they are not usually a PRN (as required drug), they can only be taken at the prescribed intervals. The NSAIDs work by inhibiting the action of the enzyme cyclo-oxygenase, without prostaglandin people feel pain relief for various diseases such as toothache, joint pain and cancer, as well as having anti-inflammatory  and anti-pyrexic properties because prostaglandins are released by mast cells to stimulate the local inflammatory response.

However a common side effect is increase gastric secretion, prostaglandins are responsible for various homeostatic effects, like temperature and filtration pressure in the kidneys. Prostaglandins are necessary because they also regulate the pressure of the kidneys for ultrafiltration, overdoses of NSAIDs can lead to renal failure.

Aspirin  

asprin

This is an age old medicine which existed back in ancient Greece. It should be taken with food because like any other NSAID it suppr

esses the production of prostaglandin, prostagland regulates the levels of stomach acid produced, without it the

stomach acid levels will increase. So to avoid rapid absorption of the drug, patients should take it during meal times and have food in the gut. It is also has a enteric coating to protect against rapid digestion in the stomach. Should be taken QDS 4 times a day which is every 6 hours over a 24 hour period, 300-600mg per dose. When prostaglandin levels are reduced the effects are also anti-pyrexic, lowers the body temperature. Contraindications- this should not be taken by anyone who is allergic to naproxen and ibuprofen. Additionally, anyone who has renal failure because it would exacerbate the problems. It should not be taken in combination with warfarin, a potent anti-coagulant, as this would increase the chances of gastrointestinal bleeding. Aspirin increases the gastric activity while the warfarin prevents the blood from clotting, this thinning the blood, would cause internal haemorrhages.

Aspirin is an NSAID because it prevents the production of prostaglandin so the nociceptors are not stimulated so pain is not perceived.

Ibuprofen This also an NSAID, it is a pink round tablet that must be taken during meal times because it is also upregulates the gastric activities. Dose prescribed would be every 4-6hours QDS, 200-400mg. If taken with lithium it reduces the kidneys abilities of eliminating lithium from the system, as well as the antibiotic gentamycin. Both the effects and side effects of lithium and gentamycin taken with Ibuprofen will increase significantly. Side effects include renal failure, heartburn dyspepsia so should not be prescribed to those patient who have heart failure or renal impairment.

Diclofenac

This has a rapid absorption rate so should be taken with meals and they are also encased with an enteric coat to make it more difficult for digestion and a slower release into the bloodstream. It is primarily used for joint, skeletal0muscular and tendon pain, however it is increasingly more widely used for post-operative pain relief because of its fast action mechanism. Sometimes in extreme cases where pain in intolerable diclofenac may be administered in the liquid form for rapid absorption and instant effect. However this can only be used acutely because there is risk of stomach damage. QDS?

Paracetamol 

Unlike the other NSAIDs, paracemtaol does not act along the cyclo-oxygenase pathaway, instead it is believed to stimulate the enzymes in the brain and spinal cord to relieve pain so the gastrointestinal tract is not affected. Thsi si why they are more widely available and therefore less potent. The dosage is higher too, 500mg to 1000mg QDS, however paracetamol is rapidly absorbed the serum levels peaks 30 mins after administration. It has a short half life because it is clear rapidly by the kidneys after 2 hours. At moderate quantities paracetamol has no side effects but overdose is dangerous. In order to metabolise the paracetamol, the liver breaks it down into a toxic by product and this must be neutralised with glutathione, a compound also synthesise by the liver. In the event of an overdose, the levels of toxic by-products exceeds the liver’s capacity to neutralise, so it begins to accumulate. Medical intervention is mandatory, this is done by intravenous infusion of N-acetylcysteine that helps the liver synthesis more glutathione.

Naproxen This is also an NSAIDs because it inhibits the COX1 and 2, cyclo-oxygenase enzyme for prostaglandin, it is associated with some cardiovascular failure. It is associated with heart burn, dyspepsia because the stomach acid production increases in the absence of prostaglandins.

morphine

The opioids, these work by stimulating the analgesic system in the body by binding to the opioid receptors in the neurone pathways, different opioids bind to different opioid receptors.

Morphine (oramorph- Oral route)

It is belived that morphine acts at the calcium channels and blocks its action. Calcium channels are present at the pre-synaptic region of the neurones, these are required to stimulate the release of the neurotransmitters across the synapse so that the next nervous impulse is initiated. Secondly morphine also opens the potassium levels to cause potassium to flow out of the neurone, down its concentration gradient, making the neurone hyperpolarised. This further suppresses the action potential propagation.

Morphine has multiple effects on the CNS and the GI tract

Analgesia- this is pain relief. By opening the potassium channels of the neurones, morphine causes hyperpolarisation, this means a higher threshold voltage is required to initiate an action potential, a greater amount of pain is required to stimulate the nociceptors so the patient feels no pain although their perception of other sense is still in tact.The patient also feels euphoria, a sudden rush of pleasure, this is noticeable in patients with acute pain, but patients with chronic pain will become normalised. It could lead to substance abuse, therefore oramorph is administer on specific intervals and requiring two nurses to check.

Respiratory failure. Morphine reduces the sensitivity towards Carbon dioxide, the hypoxic drive, the respirary centre instructs the lungs to inhale at specific level of carbon dioxide but morphine may disrupt this mechanism. This is a common cause of acute opioid poisoning.

Vomiting and nausea- 40% of patient will experience nausea because the morphine triggers the chemoreceptor trigger zone, as the patient uses the medication for longer, they will become less sensitive towards it.

Pupillary constriction

GI motility is reduced, this actually will increase the pain and it would cause bowel obstruction. patients having undertaken a major operation should be encouraged to mobilise as soon as possible to allow bowel movements, the side effect of morphine is also constipation, therefore.

Fentanyl – This is a powerful synthetic opioid used for very severe pain, usually after operations, it is 100 times more potent than morphine.

Codeine this is less potent of the opioids and is not a controlled drug. There are many variations such as codeine phosphate, hydrocodeine, oxynorm (oxycodon) the latter two are controlled.

By eliselissa
Quote

Somebody asked: “You’re a nurse? That’s cool, I wanted to do that when I was a kid. How much do you make?” The nurse replied: “HOW MUCH DO I MAKE?” … I can make holding your hand seem like the most important thing in the world when you’re scared. … I can make your child breathe when they stop. … I can help your father survive a heart attack. … I can make myself get up at 5 a.m. to make sure your mother has the medicine she needs to live. … I work all day to save the lives of strangers. … I make my family wait for dinner until I know your family member is taken care of. … I make myself skip lunch so that I can make sure that everything I did for your wife today is charted. … I make myself work weekends and holidays because people don’t just get sick Monday through Friday. … Today, I might save your life. … How much do I make? All I know is, I make a difference.

anon

By eliselissa