Tuesday, November 14, 2017

Nursing Diagnosis - An Aimless Pursuit

Your patient suddenly loses consciousness, blows his pupils with a narrowing pulse pressure and
has the beginnings of decerebrate posturing.   What's your diagnosis nurse?

"This patient is experiencing hypovigilance secondary to disruption in the flow of energy resulting in a disharmony of the mind, body, and/or spirit." Say what nurse? Old time diploma students never dabbled in this high minded, academic  activity of  the modern  nurse diagnosticians, quite the contrary, we were sternly advised, "Nurses do not diagnose."  This resulted in many deferrals to "Ask your doctor."

We were well versed in acute clinical contingencies (Ha..Ha...I can talk just like you smarty pants nurse diagnosers) and knew exactly what to do if the patients under our care had problems.
Verigo on arising-back to bed...A hemorrhaging arm laceration-slap a blood cuff on while the resident scrambles for hemostats...Hypoglycemic..Have some orange juice...A sluggish chest tube-milk it.  It's really just plain old common sense.

A bona fide diagnosis is based on objective and measurable data, not the whim of a nurse wordsmith spouting off gobbledegook. The evidence supporting the diagnosis would enable different practitioners to come to the same conclusion. I think that those folks a lot smarter than I call it inter- rater reliability.

Nursing diagnoses grant objective status to subjective information. When subjectivity is confused with fact and treatments based on unfounded assumptions are implemented, bad things can happen such as that infamous 1-10 pain scale.

When nursing transitioned from a diploma based hands on education training to an academic setting, office sitter, nurse big shots had to come up with entities to differentiate themselves. They came up with three humdingers that are indeed, unique to nursing. Nursing research, which, more accurately should be called clinical research if the purpose is to improve clinical care. We don't have doctor research. Nursing theory of which I have written jabbered about in a previous post and finally nursing diagnosis.

These discursive disciplines have one thing in common. They are unique to nursing and difficult for other healthcare entities to understand. If the end game is to be a valuable, contributing member of a collaborative, team effort they fall short. Lots of nurses, especially old fools like me cannot comprehend them so maybe we should drop the nursing from nursing diagnosis and work toward a common goal. Diagnosis that is based on objective fact and guides healthcare workers toward effective treatment.

Nursing is all about common sense and using what you know to directly and appropriately helping patients. Having a nursing life that involves only intellectual and down right incomprehensible material is not a good way to live. Some folks think that mastering complex linguistic feats  and fancy talk is going to make them look smart and sophisticated. Truly smart nurses have a high sense of humility and plain talk that really does help patients overcome illness or mishaps.  .

Thursday, November 9, 2017

Poetic Artistry at it's Finest

Pretty please check out Underside of Nursing Blog (It's on my blogroll.) A poem dedicated to all the OldfoolRNs of the nursing world.

Thursday, November 2, 2017

Downey VA Introduces the Shoe Shine Nurse

 Downey VA Hospital, the agencies largest psychiatric facility, had an aloof contingent of highly
educated,  office-sitting nurses dedicated  to grinding  out an assortment of directives, memos, and program notes to lowly staff nurses for implementation.. These administrative hot shots even had their own building complete with plush Karastan carpeting, air conditioning and fancy  pictures on the walls. A far cry from the dingy, smoke filled  wards with cyclone fencing and bars on all  the windows where staff nurses practiced. These office bound nurses never ventured far from their comfortable habitats, but their word became law out on the wards.

Here is a real gem of a memorandum  from one of those office sitters with ample, well padded backsides that I recently  discovered in my basement junk pile  archives of old nursing paraphernalia, "Adjunctive therapy is utilized for phenomenologically promoting a patient's  self actualization when neutrality and anomia of traditional therapy are compromised. An  additional tool to augment the psychotherapeutic milieu." That one's a real head scratcher, but I guess, the general idea is to engage the patient in an activity program so he can find something to do.

Examples of adjunctive therapy include: psychodrama where the patient acts out a scripted scenario under  staff direction, token economy where the patient earns rewards and privliges as outlined by the staff, exercise group involving that old 1..2..bend and grunt routine, and work details such as the "spoon factory" where listless patients dutifully inserted plastic spoons in plastic bags for 8 hours at a stretch.

These adjunctive therapy all share a common thread and that's top/down delivery. A group leader instructed patients in a rigid, authoritarian manner.This did little to establish trust or facilitate communication.

Something different was needed here to demonstrate trust and caring. As I surveyed the ward, I noticed most of the patients were wearing scuffed and dull leather shoes. The ubiquitous athletic shoe was decades in the future. Low and behold, off in a distant corner, a little used and neglected  shoe shine bench sat gathering dust.

Suddenly an epiphany popped into my head. The next day on the way to work, I stopped by the local Ben Franklin store (remember those?) and purchased a few tins of Florshiem paste shoe polish. After gathering  a few worn out T-shirts, I was in the shoe shine business.  That evening after the head nurse departed I initiated my shoe shine therapy program. I pulled that old relic of a shoe shine bench away from the wall, dusted it off  and barked out, "OK fellas step right up. Let Nurse Fool shine your shoes. Let me buff them up to a brilliant shine in nothing flat."

Patients were reluctant at first, but after encouragement from the attendants,  a few disheveled  patients stepped forward and propped their lusterless shoes on the bench for an enthusiastic shine by my deft hands. At first I chatted with them about the condition of their shoes to get them talking. The role reversal and lateral delivery of care was off putting at first, but the shoe shine did help to build trust.

Caring and trust were in short supply at Downey VA, but at least I tried.

Thursday, October 26, 2017

One Flew Over the Cuckoo's Nest comes to Roost at Downey VA Hospital

Cuckoo's Nest Nurse Ratched on the silver screen at Downey VA
Downey VA Hospital, the 1600 bed psychiatric warehouse hospital in North Chicago, Illinois had it's very own movie theater showing first run movies that had been carefully screened by an assortment of know-it-all, busy body administrators. Disney Movies, feel-good musicals  and an assortment of cartoons were the typical fodder. Someone must have been asleep at the switch in the movie review detail  because one afternoon the head nurse approached me with an agitated look about her. "Can you believe it..One Flew Over the Cuckoo's Nest is being shown this afternoon at the theater on base." Hmm..I began thinking it might be an adventure to escort a group of our locked ward patients over to view this movie.

One Flew Over the Cuckoo's Nest, based on a Ken Kesey novel, was a movie filmed on the back wards of an Oregon State  Hospital for the Insane.  It featured a down right despicable Nurse Ratched character that was domineering and abusive to her patients. She controlled everything on the ward from the TV to determining candidates for lobotomy. The scenes of the patients' on the ward was a spitting image of Building 66AB at Downey where I was working. Downey nurses, for the most part, were too burned out to dominate anyone. The modus operandi was just getting by until that Civil Service Retirement kicked in. There were no Nurse Ratcheds at Downey.

Downey had a rule that any closed ward group of  patients must be accompanied by an RN on outings. I made it my personal mission to get these guys off that smoke filled, depressing  ward as much as possible and organized walks, picnics, and even ball games. So when I heard about Cuckoos Nest  being shown on movie night, I figured, what the heck? These guys are just about living the movie and I was curious how they would respond. I strolled onto the ward after supper and called out, "Movie night, who wants to go?"

Two dozen or so of the patients stepped up and we walked over to the theater. Sometime movies elicited shouting and bouts of unrestrained laughter, but during Cuckoo's Nest there was a strange silence from the crowd. The experience of sitting in a long term psychiatric hospital watching a movie filmed in such a location reminded me of watching a war movie in the middle of an active battlefield. Today one of the most overused words that pops up in contemporary banter is surreal.

Watching Cuckoo's nest at Downey VA with a group of schizophrenics was way beyond surreal. It was one of the most unusual experiences I've had as a nurse except perhaps for the time a patient filled his prosthetic leg with urine and asked for help putting it on. When I placed his stump in the prosthesis urine splashed everywhere to the delight of the young amputee.

After the movie ended, about half of the patients had no reaction what so ever, because the long term use of drugs like Thorazine had wiped out any trace of individual personality. A chemical lobotomy of sorts. Another group of patients had trouble separating reality from the movie characters and asked me to speak with Nurse Ratched to "straighten her out."  The other small group identified with the characters and  was delighted that someone had made a movie about them.

On the commute home, I kept thinking that I'm going to write about  that Downey VA movie night experience down some day. I knew my lackluster writing skills would fail to communicate the bizarre nature of watching a movie imitating a mental hospital in a genuine metal hospital. At least I tried.

Thursday, October 19, 2017

Curved Surgical Instruments - What's the Deal?

One of the liberties of being "just a  scrub nurse" was the privilege of asking dumb, foolish questions. When there was a lull in surgical action such as waiting for a phone call from pathology or passing  time until an esoteric instrument was flashed,  the time was ripe to pose philosophical queries to the attending surgeon. Surgeons could come up with some convoluted answers to foolish  questions when they were caught off guard. Timing and delivery of the question was the key to obtaining an offbeat answer.

Here is a sampling of some questions I asked in a foolish attempt to resolve the greatest mysteries of the operating room; "Why do cloth shoe covers track blood on the floor a greater distance than new-fangled plastic disposable covers?...  How normal is 0.9 saline?... Can you sleep on a mattress suture?... and perhaps the ultimate question... "Why is the working end of many surgical instruments curved?"
Four lovely curved clamps in the foreground with the tips arching forward. A pair of straight Allis forceps, straight  hemostats, and a lone, proud Babcock sitting in the background. An obscure visual treasure of glimmering stainless steel enhanced with graceful arching curves, glowing in the brilliant overhead light of the tiled temple. The astounding beauty of those gracefully curved clamps surrounded by the deep sky blue surgical  towel is so easy to overlook while we live out our remaining days craving the cheap balm of a glowing screen. Hmm.. Maybe I could scrub for just one more case.😃

Here are some candid responses straight from the surgeon's masked mouth: "Instruments are curved to match the curve of the human hand....Because that is the way it's done Fool, now hand me a sponge stick and get back to work...There are no straight lines to be found in nature; that's why instruments are curved... Curved instruments have greater utility and are more useful."  That last answer probably made the most sense, but it's still not an elaborate rationale for instrument curves.

With the luxury of time to think about it and lots of experience watching curved instruments in action here is  my foolish explanation. When cutting with a straight bladed scissors the operators hand is directly in-line with the direction of the cut. This can obscure the view of the cutting activity. Curved scissors place the operating hand at a 30-45 degree angle (depending on the acuteness of the curve) to the area being cut, providing an unobscured view. Curved needle holders drivers as you whippersnapperrns call them, follow the same principle.

When using just about any hinged surgical instrument the opposable thumb is moved away from the index finger when spreading the jaws or blades, in the case of scissors.  It takes physical space to accommodate this thumb/index finger span. Curved instruments create an angle to move the hand above the area of work providing room for the necessary finger span. A long handled, curved instrument allows the surgeon to work in some very deep wounds such as encountered with obese patients.

Retractors have gracefully curved blades to distribute pressure over a wide area to minimize trauma. Wrapping those blades with saline soaked lap sponges helps too.  I believed that aggressive retraction caused as much trauma as any blade. Whenever a resident was pulling back so hard on a retractor that he assumed the position of a water skier, tissues were being stretched to the limit. Aggressive retraction always bugged me. Surgery should not resemble a taffy pull.

Old school nurses had the responsibility to ensure surgical instruments were in proper working order. If a surgeon encountered a  hemostat or needle driver with misaligned jaws, it was his prerogative to "fix" the offending instrument by opening it up and bending one arm up and the other down. Instruments that had been curved via this "repair" were rendered useless and thrown into the trash where they belonged. Curves, in this case, served to identify a non-functioning piece of equipment.

Friday, October 13, 2017

A Friday the 13th Foreign Body Mishap??

What does this X-ray reveal?  Looks like the scrub
nurse was preoccupied by counting sponges and over-
looked keeping track of the instruments. That looks
just like a straight Mayo scissors at waist level

Foreign body false alarm. That's just an x-ray of a student
nurse in uniform toting scissors in the standard location.
When a snip was needed, student nurses could pull those
scissors out faster than an outlaw cowboy could draw a
six shooter.

Tuesday, October 10, 2017

Thorazine - An Old Fashioned Cure-All

Thorazine was thought of as a revolutionary breakthrough medication similar to Penicillin when the FDA approved it's use in the early 1950's. It was the very first psychiatric medication useful in the treatment of schizophrenia. Before Thorazine,  institutions used leather restraints, alternating cold and hot body packs and of course crude psychosurgery such as lobotomy.

In a bizzare side note Freud never received the Nobel prize for his work, but the fellow with that ice pick brain surgery  got the call from Sweeden to come pick up his Nobel prize for lobotomy. Efforts to recall this Nobel have been unsuccessful.

Thorazine was discovered while searching for a cure for malaria and worked by blocking dopamine receptors  in the brain - a chemical lobotomy. After Thorazine disables the dopamine receptors all sorts of bad things happen. Blocking dopamine does blunt the psychosis, but fooling around with neurotransmitters never has a happy ending. Akathesia (constant uncontrolled restlessness,) sustained muscle sasms leading to a debilitating constant muscle activity called tardive dyskinesia. I always thought of Thorazine as the equivalent of weeding a garden with a hand grenade. Sure the psychosis was blunted, but so was everything else that made the person an individual. These people were mere shells of human beings. The reeks and wrecks found on the backward of any long term psych hospital were not there only for their psychosis. The institutionalization and side effects of long term phenothiazine therapy were at fault too.

Thorazine was supplied in a wide range of dosage forms including;  syrup,  concentrate, injectable vials and even suppositories.  On my first medication passing adventure at Downey VA I had a med card that indicated the patient was to receive 2000mg of Thorazine concentrate. I was taught the maximum dose was around 200 mg. How could a patient receive 2 grams of this potent tranquilizer and survive? I was told this was the correct dose and the patient acquired a tolerance over the decades and to go ahead and give it. The patient shuffled up to the med room, gulped it down and went about his business. Simply amazing.

Some of the long term Thorazine concentrate consumers requested the nasty tasting substance "straight."  This meant giving the drug in a small medicine cup diluted with just a splash of tap water. The concentrate turned a brilliant shade of pink when the water was added and this was long before the color was associated with cancer survivors. Thorazine concentrate was just plain nasty smelling. Cracking that big brown tinted bottle unleashed a scent not unlike the Testors glue that I used as a youngster to assemble plastic model kits. We usually diluted it in a thick sugary substance called simply "citric." I doubted this tactic made it any more palatable, but at least it knocked some of the unpleasant smell down.

There is ample truth to the old adage that when there are 3 or more treatments for the same condition, none of them are effective. The pharmacologic corollary- If one drug is used to treat multiple divergent illnesses; it's not an effective drug. Here is an interesting hodge-podge of ailments that Thorazine was purported to cure in 1950s ads. A foolish panacea if I do say so.

Hmm.. this might just work. Snow him on Thorazine and see if he makes it to the bar.

I wonder if her "serene detachment" persisted through the muscle spasms of tardive dyskinesia.

In my experience, Thorazine induced rapid, shallow respirations-not sure how well this would play out for asthmatics.

Thorazine was known for it's hypotensive actions. Throw in an old time general
anesthetic with a Thorazine pre-op and watch the B/P drop like a lead balloon.

Wow.. never realized Thorazine was such a miracle drug with an assortment of therapeutic applications. It did work well for nausea in small doses of 25mg, but patients never asked for a repeat dose. I always asked post-op patients if their nausea was relieved by the small dose of Thorazine and their reply was always something to the effect that it worked but made their mouth very dry and induced a profound malaise and general feeling of unwellness. "Don't give that to me again!" was a frequent request.

When drugs are touted as having so many uses I suspect it's because they don't work too well for anything. Of course this lesson has been well learned and would never happen today. HeHe.