A year at U of R

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Monday, July 31, 2006

Weekend activities in Rochester

This past weekend was all about recovering from the first week of clinicals. Rochester has a surprising amount to offer for a tired nursing student.

On Friday night, I went with my neighbors to a bar called Lux. They have a huge outdoor beer garden with picnic tables. I hear that they show movies some nights projected on the outside wall of the building. There was a tarot card reading in the courtyard, and free pizza. On Monday nights, they have arts and crafts supplies set up. I imagine that the art gets better and better the more you consume.

Saturday, the Empire State games were going on. They are New York's own mini version of the Olympics, with all of the different events. Most of the athletes are the best high-school students from around the state, and there were master's categories as well. I watched some of the track and field and saw some judo and canoeing events.

Then it was dinner at an Ethiopian restaurant called "Abyssinia." I was surprised that Rochester has an inexpensive Ethiopian place. It was great ... lentil dishes and vegetable curries that you scoop up onto pancakes of Ethiopian bread to eat.

Finally, I went for a long bike ride Sunday morning through corn fields, past pastures with horses and dairy cows. Then, it was back to writing care plans for clients and doing reading.

Saturday, July 29, 2006

Someone's hero

By the end of our last day of our long-term care clinical experience (which lasted three days), I was getting a little frayed. I was exhausted from getting up at 5:50am, and pretty maxed out on new experiences. However I wasn't about to pass up on the chance to learn how to clean a tracheostomy.

To clean a tracheostomy, you need to maintain a sterile field while removing the long inner cannula (tubing that lines the inside of the tracheostomy tube) and cleaning it aseptically. I felt like a bumbling idiot as I tried to use sterile technique to get on my gloves. I got the trach tube out OK, but getting it in was another story. I thought to myself, "What's wrong with me? This is much easier than doing an oil change. All you have to do is stick the tube in the hole! Anyone who can baste a turkey can do that!"

However, imagine that you're tired, and you are sticking the tube down the throat of a person who is silently gagging and contorting, with the instructor looking over one shoulder saying "turn it, turn it!", while Spongebob blares out on the TV. A talking yellow sponge will now forever be ingrained in my head as linked to tracheostomies. It was just a little much. I could handle trach care or Spongebob, but I just couldn't take them both together.

Long term care has its good and bad points. The nurses in long term care are mainly the managers, who oversee a unit of nursing assistant. The CNA's provide most of the actual client care. Wound care specialists and respiratory therapists circulate through the unit each day as needed. The nurses manage the nursing assistants, write reports and distribute meds.

Much of what we saw was very sad. Some of it was end of life care, and some residents will be there for years. Some had limited or no cognitive awareness. Some were completely immobile. Some had very tragic stories. Some were comfortable, and some were not. The unit did an excellent job of caring for the residents and the hospital was an outstanding facility, but in some cases, we had to question the quality of life. It took only one day for me to personally feel very much in favor of assisted suicide. One classmate commented, "What kind of nurses are we??!! We want to kill our patients!" I think it was more that we very much wanted to relieve suffering, both physical and emotional.

There were very rewarding moments as well. I was able to take one client out for a walk in a wheelchair. Even if the client doesn't remember it the next day, for a few minutes the resident was outside in a garden. At one other point, another student was trying to understand what a client with a tracheostomy was saying. Finally she deciphered that the client was saying my name, asking for me. Wow. After only two days, I felt like someone's hero. I can see where if you worked there for a long time, you would know all of the residents very well.

Friday, July 28, 2006

Shaving a beard

Yesterday I shaved my first clients face. It's not quite the same as the female shaving experience, and it is very different than shaving your own legs or armpits. Basically, we completely botched the job.

I think we were both a little panicked at the idea that we were going to scrape a guys throat with a razor. It ought to be easy, but neither of us knew where to start. We forgot about applying a hot washcloth to the beard for 5 minutes to soften it. My partner started with the shaving cream, applying it like frosting on a cupcake. There was shaving cream everywhere ... in the nostrils, clothes, you name it. I think the finger-painting technique might have worked better than the frosting concept.

Next I took a razor and started out on one cheek, while my partner valiantly attacked the other. I quickly discovered that male beard hair isn't quite the soft stuff of women's legs. I had to make several passes with a razor to get any impact. But I was petrified I would scrape off skin if I made more than one pass. I was trying to figure out the grain of the hair to go with it, but it was impossible under all that shaving cream.

On the throat, I seemed to remember that the grain went from the chin to the neck. My partner whispered frantically, "NO! you're supposed to do it the other way!" So we each simulateously shaved in opposite directions on our respective sides.

Neither of us wanted to try the upper lip, but I did my best at it. Finally, I grabbed a washcloth to try to wipe away the remaining shaving cream. Patches of beard still stuck out here and there. At least there weren't any cuts. Neither of us even thought about aftershave.

Thursday, July 27, 2006

First Clinical Experience: Long term care

Wow, do I ever feel like I was thrown in at the deep end. The first two days of clinicals have been a great experience. I've had a chance to be exposed to many, MANY new things. I feel fortunate that my clinical group of eight students was assigned to a floor that has many clients with more complex care needs. I think many other groups have clients who are more able, but I was mainly with clients who need full care.

But it's been a little overwhelming. Today, I suctioned my first tracheostomy tube. I've seen more tracheostomies in the past two days than I ever wanted, plus some. I'd never even seen a tracheostomy before, much less cleansed, dressed and suctioned one. I never realized the vast quantities of colorful mucous that comes erupting, bubbling, spewing and projectile-launching out of them. It's not a pretty sight. Normally, our lungs make that much mucous, but we cough it up and swallow it, unaware. To suction a tracheostomy, you have to basically shove a vaccuum-cleaning suction catheter down the stoma (hole in the trachea) a LONG ways until the patient goes into violent gagging contorsions. Then using your thumb as a valve to apply suction, you slowly pull the catheter out. The entire procedure must be done with strict aseptic technique, sterile gloves and a sterile field. Mucous gets everywhere, so wear goggles or a full face mask.

Today, I watched as a wound care specialist dressed a decubitis ulcer (bedsore) that was so large and deep I could almost have put my fist in it. It was deeply undermined around the surrounding tissue. It was impressive that any pressure ulcer could get so large. It didn't bother me as much as the mucous from tracheosomies, though.

In the past two days, I've taken care of clients with tracheostomies, stomach tubes and urinary catheters. Some haven't been able to communicate at all, some have communicated vehemently that everything your are doing is wrong and some have been very pleasant and smiling. I shaved a guy for the first time (it is a very different experience!). I've dressed immobile clients, given bed baths, put on compression stockings and used hydrolic lifts to put clients in wheelchairs. I've emptied urine bags, brushed teeth, made beds, changed adult briefs (adult diapers) and combed hair. I assisted with a stretcher bath for a client today. We used a special stretcher lift to transport the client from the room to a spa tub in a bathing room. All of theses experiences were very hands-on. I was right there helping with the soaping and shampooing.

Communication has been a huge challenge. I've tried to understand the speach of clients with tracheostomies, and I've gotten better at lip reading. Some clients have really limited awareness. How do you communicate with them? How do you ask them permission to take a blood pressure or feel their pulses?

It's also brought to light some intense ethical considerations. How long do you maintain a client with no cognition on feeding tubes? At what point does quality of life deteriorate to a point where it shouldn't be maintained? If the individual still breaths independently, but needs supplemental oxygen, has no musculoskeletal movement, and has limited cognition, what then? The more I've seen, the more I know that I would never want to be maintained in this way. However, since they are not on ventilators, there is no easy switch to turn off.

To add to a veneer of the surreal to the experience, it has all been done with Chuck Norris in the background. Many residents listen endlessly to daytime TV. All of these experiences have been done to Martha Stewart Living and various reruns of Days of Our Lives playing endless in the background. Here I am, looking official about 5 minutes after my second clinical.

Saturday, July 22, 2006

Urinary catheters and restraints

Here I am with an instructor, learning how to insert a urinary catheter. Labs are becoming rapidly more involved. Our last two days of labs have involved giving oxygen via many different types of masks and systems, applying wet dressings to wounds, inserting urinary catheters into male and female manikins, applying restraints, and helping clients use bedpans.

The teaching is fantastic, though. For the catheter lab, we broke down into even smaller groups, with six students per instructor.

It's pretty amazing that this is week 9, and we're already learning to insert catheters. The scariest part is that next week, we may have to apply all that we've learned.

I've heard via word of mouth that after next week, when we have clinicals in a long-term care facility, my group will be in the urology department at Strong Memorial Hospital. Wow, lots of opportunities to insert catheters there!

Here, I've managed to subdue a combatant classmate. He was getting a little out of hand. How often do you get to fight with your classmates, and then pin them down?

Tuesday, July 18, 2006

Fake germs and toothpaste

The new quarter began yesterday with neon germs and toothpaste.

For the next five weeks, we have only one class, called "Inverventions I." It includes lectures, labs and clinical experiences all rolled into one. It should be a great experience.

Once again, the faculty seemed excellent. They've got a tough job, organizing all 100 or so of us into lab and clinical sections. We have three lab instructors for each lab of 25 people, so that's a 8:1 teacher/student ratio. Not bad. It also means that there are something on the order of 25 different instructors for this class.

The first lab was a lot of fun. We're learning basic care and hygiene for clients. We started with oral hygiene. I had my partner lie on his side and feign unconsciousness, while I propped his mouth open, donned gloves and brushed his teeth. It was a little strange at first ... sticking a gloved hand and toothbrush into my classmate's mouth while he drooled into an emesis basin. How often do you get to drool on your classmates? At least no one in lab had bad breath.

We then practiced putting pyjamas on and taking them off eachother. Of course, we all had several broken limbs to make the process interesting. We applied compression stockings to eachother, and gave sponge baths to a manikin.

Then came the germs. We rubbed hand cream from a dubious bottle labeled "fake germs" all over our hands, which made them flouresce under a UV light. We then had to use propper hand washing technique to see if we could get rid of them all, and have non-flourescing hands. Next time you need to entertain a 7- to 10- year old (or a bunch of college educated nursing students for that matter), I highly recommend fake germs.

Saturday, July 15, 2006

End of a quarter!

I've ignored my blog for the past two weeks or more, but for good reason. We had final exams, and all of the four classes from the first half of the summer are over. I've passed, and I'm certified, tested, and (according to them anyways), ready to start my clinical experience.

Next week is a full week of labs to prepare for it, and then we start our first clinical rotation. The clinical rotation is more than just being in the hospital from 7am to 4pm. We are each assigned a client and we have to pull their charts, review their records, prepare written nursing care plans and write papers on them. The didactic labs and lectures will also continue.

Am I nervous? You bet! I'm afraid I'll do something wrong, hurt the patient or let them fall. I secretly hope my patient will be in a coma so they won't be able to see me messing up. Stay tuned for more on the clinical experience...

Have textbook, will travel

School isn't all about studying... or is it? Some people travel around the world, taking photos of themselves at famous landmarks. Well, Rochester may not be a world-reknown destination, but I've decided to start my own travelogue. It's called "have textbook, will travel".

Here are my first shots of "Physical Assessment Techniques" in the gym at U of R.

A 28 hour daily schedule

Here's a little taste of what last Monday, July 10 was all about.

The day started with a bang at 9am, with a two hour review session for the upcoming pathophysiology class. Thank our lucky stars for the amazing assistants who run the sessions, or I think we'd all be sunk in pathophys.

Then from 11am-noon, there is a session on career advancement and electing class representatives to the student council. Many people skip out on this, and spend the time in the computer lab studying.

At noon, we go to our last genetics class. Actually, we don't really go anywhere, since all of our classes are held in the same dark, windowless auditorium. The teachers all come to us. Today, the genetics class is two lectures by guest speakers, one on genetics and psychiatric illness, and one on prenatal genetic testing.Very interesting, with lots of graphic pictures of neural tube defects... little babies with huge masses of tissue protruding from their backs.

Nursing science is next. We have a panel of guest speakers at the front of the auditorium, who represent all of the members who might be on a health care team. There is a nutritionist, a social worker, a physical therapist, etc. Two students go up and act out a family medical crisis, and the team of experts demonstrates how they would approach the problem.

3:30-6:45 (but we get out early, YES!)
We end with pathophysiology. We go through two case studies that the instructor puts on the overhead projector, and we raise our hands, and try to diagnose and treat the patients. One is a 42 year old man who is pretty clearly suffering from a heart attack. After 12 hours, we are still trying to treat him, but nothing is working. We won't give up. But alas, our patient dies. It's very frustrating. With a problem that the instructor puts on the board, you want an answer. It's hard to accept that there isn't an answer.

What next? A little fun? "Pirate of the Carribean" part II? Nope, it's back home to study for as many hours as I can for the test tomorrow!