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Comprehensive Med- surg Reflections
As I reflect on my progress through this semester, I believe that I have learned and grown a lot from the beginning of the semester to compared to where I am now. I now approach each situation in the hospital with critical thinking by “putting the puzzle pieces together.” For example, I had a patient admitted for sepsis who had an EF of 75%, trending hypotensive BPs and presented with 4+ pitting edema. Upon finding the edema, I quickly thought of why this could have happened to the patient. I then assessed whether the patient was getting too much of the NG tube feeding solution or whether it was a result of CHF exacerbation. I then assessed for any other signs and symptoms of CHF exacerbation such as crackles, JVD and his current EF for that day, which I found out was 30%. Looking back at the situation, if I would have had this patient in my first semester, I wouldn’t have approached the situation as I did during that clinical day. I wouldn’t have gone into further assessing the edema and probably would just have focused on the patient’s over all general diagnosis and getting tasks done for the day. Based on my self assessment, I believe that I am ready to take on the role as a registered nurse. I now feel more confident with my assessment and interventions skills compared to when I was a first semester nursing student. As I get ready for my final semester, my concerns are passing all my final classes, networking with hospital employees that could get me a job at Cottage Hospital, applying and passing the NCLEX, and lastly getting a job as an RN. I have come such as long way and I have learned that nursing is more than just performing tasks, but a mixture of compassion, critical thinking, and task completion to steer patients back into optimal health.
Reflecting on nursing school
Reflecting on nursing school
The first semester feels like it is a life time ago. I remember my first clinical experience. The patient just had a hip replacement. I was with the patient from check in, then surgery, then PACU and then I was looking after her on the floor. I helped with assessment and pre –op check list, I gave her an extra blanket on the way to the surgery room. After the surgery I constantly monitored her vitals, alertness and comfort. Back in the room I brought her, her first drink of water and I could see how thankful she was. When my shift was over she took my hand and said, “thank you for your help, your presence made me less scared and it was nice to see a familiar face when I woke up”. And this again and again hammered home why I want to be a Nurse. I want to help and alleviate suffering in all its forms. There were times when I doubted if I could do it and in those times there was always someone extending a hand to help me up.
I feel competent with the education I received from CSU to work as a nurse. There is still a lot I need to learn but I feel prepared to enter the field. I look forward to the Leadership class in our last semester. I have realized the important role nurses have in facilitating change for the better. Nurses are first and foremost patient advocates. And the best advocating we can do is, changing policies and procedures. I look forward to learning how to a more effective leader and a team member who positively contributes rather than criticize.
As to what my concerns are. I would have to say the NCLEX exam. So much rides on the exam and it is so heavily weighed and it scares me that all my hard work comes down to a test. What have I learned? I have gained an extensive knowledge on Pathophysiology, Pharmacology, Nursing clinical practice, Patient education and implementing evidence base research in practice. But most of all I learned to think before I act. Take a second and go over my actions before I start doing things. This is the starting point of critical thinking and good patient care. I have also learned nurses make a big difference in the health care system and I want to be a part of that. I want to make a difference
Treating a Brain Tumor with “Ultrasonic screwdriver”
The new technological developments to diagnose and treat brain diseases is amazing! I am very interested in the high definition Fiber tracking and MR tracktology that Cottage Hospital is using to diagnose brain damage.
This article about treating brain tumors is extremely interesting. Scientists Have Breached The Blood-Brain Barrier For The First Time And Treated A Brain Tumor Using An “Ultrasonic Screwdriver” The technique allows the chemo to directly target the tumor behind the blood brain barrier. This is the first time it has been trialed on a human patient and it is a huge improvement over the technique trialed last year. It does require an invasive procedure of placing an ultra emitter into the brain.
Im sure there is a lot more to develop and perfect but it’s hopeful that technology is trying to pass the blood brain barrier to treat brain tumors.
SCI
I found a very interesting article about recent advances in SCI treatment from the American Academy of Physical Medicine and Rehabilitation (2015). One important change that heavily influences both ADLs and quality of life for many of these patients in the improvements in wheelchairs. Wheelchairs have become much lighter and easier to maneuver, providing better comfort and improving mobility. There are even wheelchairs under development that could climb stairs! This would be an incredible advance. I have spoken with several disabled people who use chairs that cited access difficulties as a major barrier to quality of life improvement. Though most basic buildings are wheelchair accessible, many are not. Additionally, those that are technically wheelchair accessible may not actually be conducive to chair use.
Another exciting new technology this article discussed is a type of electrical stimulation device. This device is implanted in the body and can help with hand movement, improving ADLs. Variations of this device can also help with bladder and bowel function. According to this article, ten year ago bladder and bowel related infections were the leading cause of death among people with SCIs. Today, the leading cause of death is the same as the general population: heart disease. I think this is an incredible milestone in a long road.
References
American Academy of Physical Medicine and Rehabilitation (2015). Advances Made in Treatment of Spinal Cord Injuries. Retrieved from https://www.aapmr.org/patients/conditions/neurologic/sci/Pages/sciadvance.asp
A Critical Window for Recovery After Stroke
A Critical Window for Recovery After Stroke
The BLAM (Brain, Learning, Animation, and Movement) lab at John Hopkins University is focusing research on promoting optimal recovery for patients suffering a stroke or TBI. Their Kata Project is a collaboration between neuroscientists, robotics, computer science, and animation.
Stroke is one of the leading causes of disability in the US. Scientists at John Hopkins University have identified that there is a period of endogenous hyperplasticity that occurs directly after an ischemic brain injury. During this period, motor coordination and movement improves at a much greater rate than later in the recovery period. They found that patients typically improve during the first month following a stroke and then plateau at a new level of functioning that is only a fraction of their baseline functioning.
Motor rehabilitation is often delayed immediately following a stroke. The first two weeks after a stroke is typically spent in an inpatient hospital environment focusing on medical stabilization. During much of this time the patient is alone and immobile. Unfortunately, by delaying rehabilitation efforts, there is concern that we are not optimizing recovery by taking advantage of the hyperplasticity period following ischemia.
John Hopkins University has been experimenting by looking at the level of functioning regained by mice that suffered a stroke. Immediately following a stroke, mice were placed in one of two environments. In the control environment the mice were primarily alone and immobile (similar to an inpatient hospital environment during medical stabilization). The experimental environment was an enriched environment filled with other mice, toys, and visual and physical challenges. Mice in the enriched environment recovered much more quickly and to a higher level of functioning than those in the control environment.
A pilot study is now being undertaken to see what gains can be made by placing a stroke patient in a more enriched and challenging environment immediately following a stroke. The BLAM lab developed an immersive gaming environment including 3D exoskeletal robotics and non-invasive brain stimulation.
In the “game” the patient manipulates the robotic arm to control a 3D dolphin and complete challenges. The hope is that this type of stimulation can be incorporated in the acute care setting immediately after a stroke and we can better take advantage of the hyperplasticity period. Per John Hopkins, pilot data has been promising. Regardless of the data on motor functioning, patients seem to be having a lot of fun playing the game. Being in a position of control seems to be very rewarding for patients after they have lost so much control through the disease process.
References:
Johns Hopkins Departments of Neurology and Neurosurgery. (2015). Funding a Lab of the Future. NeuroNow, Winter 2015, 1-4. Retrieved from http://www.hopkinsmedicine.org/news/publications/neuronow/files/sebindoc/m/r/4187BEB7CC3B446264EA2DD3CE8EBEDA.pdf.
Krakauer, J. (2015, March 7). A Critical Window for Recovery After Stroke [Video File]. Retrieved from http://tedxtalks.ted.com/video/A-Critical-Window-for-Recovery
Neuro Patients have Higher Rates of CAUTIs?
I decided to report on this article since it incorporates a bit of our NRS420 topic of sepsis (prevention) and current topic of neuro. As we know, preventing HAI is paramount in the hospital setting, and the neuro ICU seems to be no exception.
According to the CDC’s National Healthcare Safety Network which tracks national infection statistics, 30% of infections are UTIs and 75% of UTIs acquired from the hospital occur from catherization (CDC, 2015). Since 15%-20% of hospitalized patients receive catherization, this can amount to large numbers.
Due to the possible delicate nature/acuity of neuro-spine conditions, these patients are especially prone to longer ICU stays, increased needs for invasive devices (central lines, ventilators), limited mobility and urine retention. Reduction of CAUTIs (catheter-associated urinary tract infections) is especially difficult in the NSICU due to the neuro-spine patient’s debility which generally requires long-term foley-catheterization and longer stays. Topping the list of neuro conditions seen in neuro ICUs is the incidence of acute ischemic stroke, which averages a hospital stay of 5-14 days average (George et al,2013). Considering that occurrence of CAUTIs peaks at 12 days (plus) puts these particular stroke patients at high risk if catheterized with a foley-catheter (George et al,2013).
This article was written about a study done at one hospital’s neuro-spine ICU unit, as it represented that hospital’s unit with the greatest number of HAI/UTI. This is not unusual I surprisingly found, as neuro-spine ICUs have been found to nationally represent the unit with the most incidences of CAUTI, (Edwards, 2008).
Great concern has arisen for the neuro-spine patient population; the hospital cited in the study decided to utilize their in-house Infection Prevention team to assess and advise the neuro-spine ICU staff. Their conclusion was to implement a plan where either nursing leadership or Infection Prevention staff performed separate rounding to identify at-risk patients. Assessments and recommendations were made on the following gathered criteria: catheter presence, indication and possibility of removal. Their NSICU now includes an increased mindfulness when evaluating catheter necessity, care, and removal.
It is eye-opening that neuro-spine ICU units have been identified as the top needs-to-be-watched unit concerning catheter associated UTIs. I found no less than 5 studies about CAUTI concern conducted in neuro units during my research regarding infection. I originally began research on infection (general) and neuro topics, but found this one topping the list of searches…and it turned out to be enlightening and has served to increase my overall vigilance during my clinical rotations.
REFERENCES:
Center for Disease Control (2015, October 16). Catheter-associated Urinary Tract Infections (CAUTI). Retrieved November 10, 2015, fromhttp://www.cdc.gov/HAI/ca_uti/uti.html
Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA, Horan TC (2008). Center for Disease Control and Healthcare safety network (NHSN) report, data summary for 2006 through 2007. Retrieved November 10, 2015, from http://www.cdc.gov/nhsn/NationalAm J Infect Control. 2009 Jun;37(5):425.
George, A., Boehme, A., Siegler, J., Monlezun, D., Fowler, B., Shaban, A., Martin-Schild, S. (2013). Hospital-Acquired Infection Underlies Poor Functional Outcome in Patients with Prolonged Length of Stay. Am J Infect Control; 36:609-26.
Schelling, K., Palamone, J., Thomas, K., Naidech, A., Silkaitis, C., Henry, J., Zembower, T. (2015). Reducing catheter-associated urinary tract infections in a neuro–spine intensive care unit. American Journal of Infection Control, 83(1), 892-894.
