nursing-101

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Hügel, and a Fruit Tree Canopy ☑

It doesn’t look it, but this hügelkultur berm is 1 metre high, and 1.5 metres wide. It’s been coming together with yard waste since last Autumn.

I have just finished planting my main fruiting trees in this area, doing my best to break up species and cultivars that share diseases. Many of my grafting projects this year took place in this area, as I top-worked diverse scions on to established and wild trees.

I am now installing leguminous nurse trees, multiple fruiting shrubs, and a ground layer with gourds.

I’ve also planted a Dawn Redwood behind the mound, which I plan to pollard; It is intended to aggressively take up excess water while generating timber resources.

In building the mound, I dug a rain garden, which I will be planting with semi-aquatic irises. The whole surrounding area will soon be covered in a sheet mulch, and begin to look more cohesive: but there is no way around the fact that curb appeal takes time when using low-impact permacultural processes.

It’s a relatively small area of the total forest garden, but by the time I’m finished planting and grafting, it will be home to 25+ different fruit cultivars, from about 10 different species!

Barium Enema

Barium enema, otherwise called Lower Gastrointestinal Series (LGIS), is a diagnostic test wherein a solution (contrast) which is called BARIUM is put inside the colon (large intestines) of the patient and then an x-ray is taken.

There are two types of barium enema: single contrast and double contrast. In single contrast, only the barium is injected. With double contrast, barium and air in injected into the colon.

Purpose:

  • Barium enema is done when the case of the patient asks for a possible pathologic condition in the lower gastrointestinal tract and a view of the anatomy of the lower GI of the patient is needed. This guides physicians into diagnosing the possible or even the real cause of the signs seen in the patient and the symptoms s/he is experiencing.
  • There could be a lot of cases where barium enema is ordered. Some signs and symptoms that could prompt a doctor are GI bleeding, abdominal pain and absence of bowel movement. History taking is very important because it has to be made sure first that the condition of the patient really needs a view of the anatomy of the GI’s patient.
Some conditions that may need barium enema:
  • Appendicitis 
  • Celiac sprue 
  • Colorectal adenoma (harmless tumors) 
  • Colonic diverticula (pouches or sacs in the colon) 
  • Colonic polyps 
  • Crohn disease 
  • Diarrhea 
  • Diverticulitis of the colon 
  • Chronic intestinal pseudo-obstruction 
  • Lower gastrointestinal bleeding 
  • Ulcerative colitis\
  • Colorectal cancer

Preparations:

  • The patient has to undergo fasting which means s/he should no longer eat by 12 midnight before the examination.
  • Sometimes, physicians orders the patient to take castor oil or dulcolax. These are used to make the bowel clean or to make the colon free of fecal material.
  • If there is a condition that the patient needs continuous nutrition, the patient maybe given an IV fluid to make sure the patient doesn’t go into hypoglycemia once s/he starts fasting.

Nursing Responsibilities:

  • Before
  1. Instruct the patient about fasting.
  2. Administer medicines as ordered.
  3. Assist in IV insertion.
  4. Regulate IV fluids as prescribed.
  5. Reassure the patient.
  6. Educate the patient about barium enema.
  • During
  1. Read physician’s order.
  2. Confirm bowel preparation if done.
  3. Promote safety by staying with the patient.
  4. Instruct the patient to hold the barium as long as possible.
  5. Provide and promote privacy of the patient.
  6. Assist in position changes that may be ask of the patient to do.
  • After
  1. Instruct the patient to take plenty of fluid to promote excretion of the barium.
  2. Inform the patient that s/he can take laxatives to promote faster excretion as prescribed by the doctor.
  3. Educate the patient that white stools for two to three days is normal.

Possible complications:

  • Complications can occur with patients who have perforation or possible blockage in the intestines.
Patient 3301

This was one of the most unforgettable experience I have so far and one of the most frightening to the fact that I’m dealing with a patient who is dying.  

It was the last day of our second clinical rotation at Bethany Hospital [mid-day shift]. I arrived at the usual time of  2:30 pm at Bethany. As my other group mates arrives, we chatted a bit and I found out that there is this one patient in our area who just came from the Intensive Care Unit. I ask what is her condition. My classmate told me that she have a stage 3 colon cancer and ask if she needs close monitoring… my classmate told me that the order was every-hour vital sign monitoring. I was praying again to God not to be assigned in this toxic patient… but fate has a way of playing a game… I was assigned in this patient. But to consider what my [new] Clinical Instructor gave me [patient assignments] previously in the same rotation , which mostly no one in my group wants to handle, I was not surprised.

When the staff nurse gave us the go signal to read the charts, I immediately read the doctor’s order and the nurses’ progress notes to found out that she has been admitted in Bethany since April of the same year with just a complain of difficulty of breathing and cough for several days. She has an indwelling Foley catheter, in O2 therapy, has anasarca and she has a colostomy etc… I continued reading 

Before going inside the room… i wear my mask… I was reprimanded about this by my Clinical Instructor  about wearing a mask… I told her that the reason I am wearing a mask is for the principle of Reverse Isolation, I was only protecting the client from any infection that I may transfer since Cancer Patients are immunusuppressed because of the corticosteroid therapies that they are receiving. After that she argued no more. [We’ll the real reason why I’m wearing mask was Im a Paranoid Person… a clean freak person]

After knocking at the door, I opened it and before I greeted the patient and the family members a different odor enters my nostril. it was unpleasant and it was a good idea really to wear a mask. As I greeted the patient and the family I took a quick look at my patient, actually my patient and louella’s since there were not much patient in the unit that day so we were teamed up… I observed how pitiful her condition was.. I tried to talk to her but I can not understand he speech. Her husband assisted us in taking her vital signs, in changing positions and others since we can’t hide the fact that our little hands cannot do much things considering the condition of our patient. she can barely move, even her extremities. 

After taking her vital sign and regulating the IVF hooked on her and even her O2 inhalation, draining her urine bag and recording the fluid output… we reported to the staff nurse that she has a fever… it was above 38.5 if my memory serves me right. So the immediate action is to give her PRN med- Aeknil IV so to lower her temperature immediately so it will not reach 40C above to prevent permanent brain tissue damage because of brain cells begins to die if the core body temperature gets too high [according to what I have read in my books]. However she had already received an Aeknil earlier [2:00 pm] and it was only 4 pm so we cannot administer the next dose of Aeknil yet. 

So I implemented my independent nursing intervention for hyperthermia… I if its okay to adjust the air conditioner since it was really hot in the room. I encourage the husband of the patient to let her sip water… we even change her gown since it was soaking in sweat and we did TSB. Tepid Sponge Bath. Louella and I did everything we could to lower her temperature.

As we are busy doing TSB with our patient, another knock was heard, the door opened and it was our clinical instructor checking on us. maybe she was wondering where we were since most of our group mates are lounging at the nurses station doing nothing…maybe writing already their sample charting. She entered and said “Kumusta kayo diyan?” [How are you?] I answered “Okay lang ma’am TSB lang kasi mataas ang temperature ni ma’am at kabibigay lang ng Aeknil sa kanya ma’am kaninang 2:00 pm.” [We are doing fine, we are just providing TSB to lower the temperature of our patient since she was just given Aeknil about 2:00 pm] She said “Okay sige” [Okay, carry on]..

So Louella and I continued providing TSB and constantly checking her temp… a second know was heard and a girl entered… it was the patient’s daughter. I can’t help but eves drop a little. I found out that the daughter is hesitant to come actually in the hospital since she had exams and assignments to think off. she and her father continues to talk and it was like her father requests if she could stay at least since her mother is very sick and might no longer live and stuff… like they want to be complete when her mother dies… and stuff again. and As we continue to provide TSB to our patient another knock was heard it was again the other daughter of our patient.

After I guess 2 hours or maybe 1 and a half hour of providing nursing intervention… her temperature goes down a bit and increases again. we decided to check if it was okay now to give Aeknil but before that we clean up the materials we used…then we left the room. The husband said thank you on us. He always smile at us and thanked us every time we check on our patient.  we rested a bit at the nurses station as we report to our CI and to the Staff. The staff told us that she will be giving Aeknil later. So as we are sitting at the benches near the Nurses’ Station, I was already making my nurses notes so that my CI can check and later I will just write additional nursing interventions I did to my patient.

As Louella and I are browsing the internet via our phones since our Clinical Instructor asked questions regarding some medications and at the same time we are reviewing for our quiz, a number of people are approaching the nurses station… Louella had a hunched that they may be the relatives of our patient since her husband said that some of their relatives will be arriving… One of them approached the nurses station to ask and the nurse pointed room 3301… they all entered… and greeted the patient.

Louella and I looked at our watch and it was already time to get her vital signs. At first we are hesistant to enter since we heard some moans/cries inside… we dont want to disturb them… sow e waited for 15 minutes I guess and entered… after assessing her vital sign she still have hyperthermia so we reported to the staff that she still has fever… so the staff looked at the time, It was already pass 6:00p pm, prepared her medication and administered it. 

At the same time that we are done Dr. [I forgot the surgeon’s name! Oh My!] and told the nurse that he will be changing the patient’s colostomy bag. The staff asked us if we had seen one before and would like to assist  we said we haven’t seen one yet and we would really like to assist. so there we knock at the door, the doctor entered and greeted the patient and the family and I get the tray where the needed equipment and materials are and Louella was with the staff nurse beside the doctor. So a the doctor opened the colostomy sight a foul smelling odor came out and it even penetrates in my mask which has already two layers and I really stared and observed the sight… it was edematous, the color of the surrounding tissue is dark red… and there was no bag placed but instead a diaper is placed and it has fecal matter on it. so the doctor just wiped the site, cleaned it, put some sterile dressing/ gauze and placed a new diaper and secured it with plasters. it was a quick one. Ooh I forgot to tell you, the doctor isn’t wearing any mask at all… maybe he was alraedy used to it.

After we provide colostomy care, the doctor talked to the family inside the patient’s room and the next thing we know is the doctor opened up regarding signing a DNR consent/order. [Do Not Resuscitate] we are sitting at the bench and  heard the doctor say to the husband “Anong magagawa natin? Diyan din naman pupunta” the husband called some family members and went to the corner of the ward and I guess they are discussing about the DNR order/ consent. they they began crying. The sound of their moans and their feeling of anguish echoed and covered the place. Waves of emotions are flow in the place. and I felt extremely depressed and sympathetic. I can’t do anything since that time I don’t no knowledge yet regarding dealing with persons who are experiencing grief and loss. They comforted one another and the doctor went to them and talk to them. I even heard a young boy say “Wala na akong mama?” [I no longer have a mother?] I really felt sad for the young boy…

few minutes later, the family was escorted by the doctor to the nurses’ station and signed the DNR order/consent. Then they all go inside the room… And we are going to check again the patient that time.. we decided not to enter and just wait again for a bit.

We entered our patient room again. asked what the patient needs… re-positioned the patient, offer some fluids, wipe off her perspiration, drained her urine bag, check her O2 inhalation, her IVF, and assessed her vital signs… she still have fever. we leave the room and the husband thanked us again and smiles..

we asked the new staff nurse what can we do the staff nurse told us that in the case of our patient, she is having a terminal fever since she is nearing the last hours of her life. So in the next hours we just provided maximum comfort to our patient… we continued monitoring her every hour, assessing vital signs and etc.

after our clinical duty that day… we had just learned [louella and I] our patient died around 1:00 am, 2 hours after we leave the area… the time that her O2 tank is already empty…

I forgot to mention she was only around 45 years old and she already have a stage three colon cancer

Nursing 101, The Georgia Way | Georgia and Dean

It was common knowledge to people in the house, that when you went for sympathy, you went to someone like Cassie or Josie, maybe even Izzy. The last person in the world you go to for friendly caring advice and cuddles, was Georgia. Her idea of nursing people to health was less than kind, and normally ended up in the ill person being traumatized. Last time she’d ever tried to cheer anyone up, they’d ended up drunk and giggly in Paris, with no idea where they were. It worked for her, but not for everyone. In her defense, Georgia had never been the sympathetic sort, it wasn’t in her nature. Mainly because her nature was always, get on and look forward. It was the reason she never held grudges and kept her arguments to the minimum.

Dean was interesting. Mainly because he had a volatile nature about him. He could switch in a minute, and that was exciting. Things weren’t dull with him. People couldn’t be dull around Georgia or she just got bored and wandered off. She moved on the fast lane, no slowing down for anyone. But no, Dean was interesting. Like with Marco, he had a spark, and they got on. Not in the way she did with other girls, though really, much of the time, Georgia was “one of the lads”. Knocking on Dean’s door, Georgia opened it and poked her head around the door. “Nurse Rae reporting for duty” she joked, closing the door behind her

Annex Medical Services

June 23-24 2011

It was the first month of the 1st semester of the school year 2011-2012. We are all excited to have our clinical duty that time. We always check the Bulletin Board outside the faculty to check our assigned area. A week before our 1st rotation the schedules were already posted and we were assigned to Bethany Hospital AMS ward or the Annex Medical Services.

Bethany is one of the hospital that we are affiliated. It was not my first time to be assigned in Bethany even in AMS since when I was a second year nursing student I was was already assigned to AMS and 4th SAB building [we were the 1st batch of the new nursing curriculum]. Since I am not new to the environment I don’t feel any more the “Fear of the Unknown”. What I am anxious about is the condition of my patients. I am afraid to come into contact, patients with communicable diseases like Pulmonary Tuberculosis and the like. So when we are at the Nursing Station, I immediately look at the board for any AFP culture tests.AFP stands for Acid-Fast Bacillus, the test used to identify PTB cases. So I am scanning the board, I saw one so I begun praying that I will not be assigned to that patient.

As my clinical instructor is listing our assigned patients, I try to observe the condition of some patients in the ward. The ward has relatively few patients that time since there were a lot of vacant beds and even rooms. Afterwards, our Clinical Instructor Ma’am Tessie Labanar calls our attention, she was already telling our assignment and I am waiting my name to be called. Unfortunately the number of patients is not proportion to our number that’s why I have no patient yet. Ma’am Labanar told me to join one of my classmate since I will be the first to admit a patient if ever one will be admitted. 

So I help my friend Louella in taking care of a patient who experiences dizziness. I help her assess her[the patient is a female] vital sign, change the bed covers, administer prescribed medicine and other nursing care. The patient of Louella seems fine until later that afternoon the patient feels sever headache and vomiting. the staff nurse ask the patient’s husband if they like to have a CT scan so to further diagnose the condition of the patient . Later on the patient was diagnosed to have Cerebral Edema.

Before we take our lunch, the emergency department, just below us, called the nursing station for a patient will be admitted in the ward. After hearing the order, my ma’am Labanar called me and ordered me to make create a complete patient chart. I pulled out several sheets of paper from a folder put them in the chart and completed all necessary information. I was asked to do it quickly for I can be used to it according to ma’am Labanar. She instructed me what to do so that I will know it if I will be a staff nurse already. So I completed all the information, listed all the lab tests to be done, order to the nutrition department, drug prescriptions, and others. So after several minutes, here comes my patient in stretcher.

He was already old and frail. I forgot to tell you he has stroke or Cerebrovascular Accident or CVA[click to learn more about cerebral edema.]. Some of his lab exams are not yet available so I just wear my mask and implemented Universal Precaution. He has a side-drip of Nicardipine which is an emergency drug for hypertension so I was nervous that time since it was my first time to handle stroke patient. He was my patient for two days and caring him was not that difficult since after the first day, I read about Stroke and proper nursing interventions for clients with cerebrovascular accident. 

On the second day, as i mentioned earlier, He was still my patient and the lab results are already placed in the chart. i found out that in his Chest X Ray result, the radiologist found out that he has PTB. I was shocked and I feel scared since PTB is one of the diseases I am scared off. But fortunately I am wearing a mask on our first meeting. I just practice proper hygiene and took my vitamins… His CT Scan shows that he have a Hemorrhagic Stroke Left Thalamus so the affected part of his brain is the left hemisphere. So as I ask him several question he can answers me however his speech is slurred which is one of the conditions ween in a stroke patient. He can not also move his right extremities which is congruent with the CT Scan result. 

I interviewed his wife on what happened before the incident. The wife is very friendly she answers my questions, told stories, and even assisted me when I needed help. 

One of the challenging part in caring patients with stroke is assessing their Blood Pressure accurately so to be sure I ask my classmate’s second reading and whenever i get an extremely high reading, I endorsed it to my CI and even to the CI of the other group [there are two groups assigned in AMS that time, they were my classmates too] if my CI is busy. There was a time when the Bp of my patient was 160/100 that we need to endorse it to the resident physician. she ordered an increase in the flow of Nicardipine IV so I sdjusted the flow rate. Their is also a side-drip of Mannitol on the IVF of my patient to remove excess fluid and help decrease his BP.

All in all taking care of a stroke patient is a first to me. And I enjoyed this experience! in the future when I will be assigned to another stroke patient I will be more confident and will be able to take care of them properly.