Teach back

Get your patients to “teach back” what you have taught them. Get them to repeat what you have taught them. You may be surprised at how little information your patient has absorbed from the education you have given. Using the “teach back” or “repeat back” method can help you gauge just how much information your patient is retaining.

With the “teach back” method, it’s exactly as it sounds. You get your patient to teach you what you taught them. This method is really effective for education that involves hands on training. Things like changing a colostomy bag at home, changing a wound dressing, giving tube feeds, doing peritoneal dialysis, etc all require a lot of teaching. These are thing you want to make sure your patient understands before they return home. When you get them to teach it back to you then you know that they have an understanding of the information they have received. As they are teaching it back, you can correct them if necessary and give them little hints to help them with the process.

“Repeat back” works well with information that may not require as much hands-on work. I found that it works well with my patients that are being sent home with multiple prescriptions, especially different inhalers. I had a patient with COPD and asthma (and yes, she still smoked, how did you know?) that had both Symbicort and an albuterol inhaler. She ended up on our unit from a bad asthma attack. When she started to get wheezy I took her the albuterol inhaler to help open her up and she refused. I couldn’t understand why. She said “that’s not the one I need for my asthma, I need the other one”. Confused, I asked her if she was referring to her Symbicort. She said yes, that’s the one she takes when her asthma flares up. She took her Symbicort whenever she felt tight or wheezy and took her albuterol twice a day. OH, nooooooow I know why you’re in here. I tried explaining to her that the Symbicort is for her COPD, not asthma. She argued with me for a good 10 minutes that I was wrong. I had to not only print out information on Symbicort but also have the doctor talk to her before she accepted that she has been using her meds wrong this whole time and that is why she was in the hospital. Upon discharge I made her repeat the education I had given her and show me which inhaler was her twice daily inhaler for COPD and which inhaler was for her asthma. I felt comfortable that she understood her meds upon discharge.

I think this teaching our patients about their health is where the medical system is lacking. Often, we are in such a rush to get people out so we can get people in that we just assume the patient understands because they didn’t ask any questions. Often, it’s the opposite. Some are embarrassed to say they don’t understand. Some can tell we are in a rush and don’t want to bother us by asking us to repeat what we have told them. It is up to us to make sure our patients are leaving with a full understanding of their health and their medications.

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Holier than thou

Hello holier that thou nurse and/or doctor on med Twitter.

We are so glad you came to join us and tell us how wrong we are for sharing our experiences when they aren’t all “rainbow and unicorny”. Let me see if I can explain something to you:

Sometimes it can suck being a nurse. Sometimes it sucks being a doctor. Sometimes it sucks being a CNA. Sometimes, the medical field just sucks.

I know this is shocker for you since your days are only sunshine and blue skies. For the rest of us, however, we deal with patients every day. We see death, abuse, addiction, cancer, and disease progression on a daily basis. We see tears, we get hit, we get verbally abused, we witness (and then somehow get involved in) family drama, we get spit on, we get called racial slurs, we go THOUGH it. Sometimes, we take to “med Twitter” to vent to those that understand us. We don’t do this because we get a kick out of bashing patients. Majority of us in the medical field are in this field because it’s what we love and we couldn’t see ourselves doing anything else. We love what we do but sometimes it’s a bad day and we need to talk about it to other people that have been through what we are going through. We get encouragement. We get advice. We get a picture of a puppy to melt away the stress. It’s our own little online bar where we get to sit and talk to the bartender. We need an outlet.

What we don’t need is your pretend internet holiness and your pretentious “I’m more of a patient advocate than you are” attitude. We would never do or say anything to harm or patients. We are, contrary to your belief, compassionate and caring medical professionals. We use these outlets to keep from losing our minds. So how about you hop on down from atop that high horse, ok?

Vitamin C and sepsis

You may or may not have heard about some new studies coming out that show some positive results adding vitamin C to sepsis treatment.

If you haven’t heard anything about it, don’t worry, you will.

This is what really kind of started it all. It was a retrospective study, not one you could really take back to your ICU and make evidence based changes on, but it provides some interesting factors to think about. This study gives some information about some of the preliminary findings. So far, (cautiously) it looks positive.

However, don’t think doctors around the world are ready to jump on the vitamin C boat just yet. There hasn’t really been a what I would call a “large scale” scientifically sound study completed just yet. It’s safe to say the idea remains controversial. Here is a really good article addressing the controversy surrounding the treatment. I did notice one thing when I read this article: while doctors may not be ready to jump on board do to a lack of evidence, most of them really hope vitamin C treatment does turn out to be beneficial. The health care field as a whole really wants a better treatment for sepsis, especially since what we are doing now is only partially successful.

I am hoping someone decides to do a large scale study and really put vitamin C to the test. I would love to know if this could potentially be an adjunct sepsis treatment or if it is time for medicine to go back to the drawing board. Trying new things is what helped the medical field advance this far, let’s not stop now!

Motivated?

I’m strangely motivated to do a lot of nursing related things that I had no desire to do before. All of a sudden I want to go back to school to get my Master’s. I want to join our shared governance committee. I want to advance on the clinical ladder up to a Clin III. I want to cross train in other parts of our department.

What the hell is happening?

Where did I get all of this motivation from?!

Is… Is this what happens when you’re happy at your job?

I mean, honestly, these are all things I know I can do if I put forth the energy to do it. I’m still (relatively) young, unmarried, no children… I have the time so why not?

I need to sit down and prioritize all of these new goals. Time for me to become Super Nurse!

Wish me luck!

Real nurse?

In a conversation I had someone ask me if I was a “real nurse”.

Yeah, let that sink in for a moment.

Here’s what happened:

I was having a conversation with an individual and they asked me what I do, I told them I’m a nurse. Their response: “so are you a real nurse?”

This was my exact face:

I had to ask what they meant by “real nurse”. Their answer? “You know, a real nurse like ones that work in a hospital and not in a nursing home or doc in the box.”

Of course you know this means war…

I ask why those nurses aren’t real nurses. Apparently (according to this person) those nurses don’t really do anything but take vitals and give meds.

Oh really?

OH REALLY?

To people who think like this I have a question, CAN YOU DO IT? Can you be responsible for the safety and welfare of multiple patients, often at the same damn time? It was a real nurse that took care of you at Patient First when you caught the flu. It was a real nurse that got punched in the face by your demented Nana. It was a real nurse that handled your kid’s GI bug that you brought him to the doc in the box for. It was a real nurse that has been the only person some of these elderly assisted living patients get to talk to since you haven’t visited Grandpa in 3 years.

WE ARE ALL REAL NURSES.

Needless to say, I am an advocate for my nurses.

On my own

This was my last week of orientation in MRI nursing. Starting Monday I’ll be on my own.

I’m nervous.

It’s not that I don’t think I can do the job. Compared to getting my ass handed to me in the STICU, this is going to be somewhat less stressful. It’s the fact that procedural nursing is new for me. I’ve been bedside for 8 years now. I’ve always been in charge of the patient because they were “mine”. Now I’m dealing mostly with outpatients. I also deal with kids. As you all know, I don’t do kids, they make me uncomfortable. I will still have inpatient contact but while I am responsible for their safety while in MRI, they aren’t mine. I have to remember that my contact with them is as a MRI nurse and not as their primary nurse.

That’s a little weird for me.

It’s also kind of nice. Patient being a douche? I can send them on their way. Patient too confused to hold still for the MRI? Back to the unit for you buddy.

Not going to lie, it’s fabulous not going home with back pain everyday.

I think I’m going to like finally being on my own, you know, once I get over the initial shock of it.

PALS is not my pal…

I took PALS this week. If you aren’t familiar with that acronym it stands for Pediatric Advanced Life Support. It’s ACLS for kids.

I don’t like kids.

I don’t want to work with kids.

Thanks to my new job, I occasionally work with kids.

I’m in MRI now and I have contact with individuals of all ages from one week old to 99 year olds. This is new to me. I’ve worked with adults my entire career. That’s been on purpose. I don’t like kids and I don’t know what to do with them. Everything dealing with pediatrics is intimidating to me and I commend all of you pediatric nurses.

Honestly, it’s the math. I SUCK AT MATH!

EVERYTHING with kids is weight based and that just throws me off. Everything I’ve learned in PALS involves the weight of the child as a basis for how to treat. With adults it’s typically a general dose. Don’t get me wrong, there are some weight based meds for adults but typically a miscalculation isn’t going to kill them quite as quickly as it could a child. Children are so much more fragile and I’m afraid I’m going to do far more damage to a sick child. I couldn’t live with myself if my poor math skills resulted in the death of a child. I’m just going to keep my hands off.

So why was I sitting in a PALS class?

It’s mandatory for me. Radiology nursing is considered “progressive care” and we are required to have PALS and ACLS since I come in contact with all ages. We do sedation on our claustrophobic patients and recover them afterwards so the potential for an emergency is absolutely there. I mean, I needed the class. I learned quite a bit. I had no idea just how different it is caring for a child when compared to adults. I now feel a little more prepared to handle a pediatric emergency. I will probably still freak out completely but at least I will know what to do if someone can calm me down.

PALS made me realize I will never be a pediatric nurse. Rock on pediatric nurses, rock on!

That’s so gross

You would think the grossest thing that I have seen as a nurse would involve the patient.

Oddly enough, no.

I can say for sure the grossest thing I have seen is the patient’s family member(s) sleeping on the floor of the room.

DO YOU KNOW WHAT HAS BEEN ON THAT FLOOR?!?!?

I have walked into the room and nearly tripped over a family member sleeping peacefully on the floor. I was immediately freaked out. Like, what makes someone think sleeping on a hospital floor is safe or sanitary?

Oh, you have to get up off that floor honey.

There have been soiled linens, blood, body fluids that I can’t describe, EVERYTHING on that floor. Glare all you want but I’m not leaving you down there.

People think hospitals are far cleaner than they actually are…

Consent and ethics

Nursing is fully aware of consent. We know that we need to have documentation that the patient accepts this treatment. It’s a no brainer. But, what if the patient doesn’t want treatment and the power of attorney does?

Prime example, you have an elderly patient that is obviously letting the family talk them into surgery. To no one’s surprise, it doesn’t go well. They end up sick. They have to remain intubated. They need an art line, central line, pressors, the works. Even on the ventilator they are adamantly shaking their head no to all the things you’re trying to do. They are fighting. They keep trying to pull away. They don’t want this.

Their family does.

The POA is who the doctors decide to ask for consent to treat. They completely bypass the patient. They’re intubated, they can’t answer for themselves right? If course the family wants everything done… So, everything is done. Is that fair to the patient?

Shouldn’t the patient be allowed to say no without having someone else choose otherwise? What is the fine line that decides when a patient no longer has the capacity to make their own decisions? Does intubation automatically take away that right? Does having a POA take away that right? If a patient is clearly communicating, even in the vent, shouldn’t we respect their wishes?

The nurse in me says yes. The nurse in me says to respect my patient’s dignity.

The nurse that’s been at the bedside for almost 8 years knows that that is normally not the case.

I have seen advanced directives ignored because the patient is unconscious and the family isn’t ready to let go. I’ve seen cases like the one mentioned above. I’ve seen doctors watch as the family is almost forcing a patient to go along with treatment and the doc just goes along with it as well. I’ve had to be a part of “moral distress” meetings because nurses were stressed over the ethical dilemmas involved in certain cases. When do we stop?

PJP and HIV

Most of us are aware of HIV and how it affects the body. We have been taught how the virus attacks and destroys the immune system. It is not the attack on the immune system that directly kills a person.  It’s all those opportunistic infections that eventually weaken and often times finally kill HIV/AIDS patients.

PJP, “pneumocystis jirovecii pneumonia”, is one of the most common opportunistic infections to befall an HIV positive patient. This particular type of pneumonia (or as one of my patients pronounced it “ammonia”) is caused by a fungus commonly found in the environment. For those of us with a normal immune system, it does us no harm. For the immunosuppressed patient, however, it can be dangerous and possibly deadly. For a patient with severe PJP, it can lead to ARDS which has a high mortality rate. Having HIV does not mean a patient will automatically become infected with PJP. The infection typically manifests when the CD4 count is low. This is a really good article describing PJP and its relationship to HIV/AIDS. Here is another good article by Medscape that talks about the fungal pneumonia and how it functions.

You are probably wondering what made me write a blog on a type of pneumonia that you may not have heard of before. Well, I am a nurse and also a state certified HIV tester. HIV is becoming a passion for me. However, that’s not the only reason. See, back when I was a med-surg nurse, we had a patient that I can’t forget. He was a 22-year-old young man that was in and out of the hospital with chest pain, complaints of difficulty breathing, fever, and other rather generic symptoms. His chest CT showed the opacities in the lung. The doctors were sure he had pneumonia but he didn’t respond to most therapies. Furthermore, he’s a young guy, he shouldn’t have a recurrent pneumonia presentation like this. Enter our infectious disease doctor. He decides this guy needs a bronch. We are done guessing, he wants to get a bronchial sample so we can figure out what is going on. They began testing the sample for what type of pneumonia it was and it came back as PJP. He immediately asked for the patient to be tested for HIV. The resident nor I really understood why. Of course, I had to ask. His response? “When I see PJP I think HIV.” I asked him what he meant by that. That’s when he began to tell me about the fungal infection and its relation to immunosuppressed patients. In his words, “you just don’t really see it in people with a healthy immune system. Our guy wasn’t a transplant patient. He wasn’t on chemotherapy. So, what other reason would a man his age possibly be immunosuppressed?”  Turns out, he was HIV positive and did not know. His CD4 count was terribly low. I witnessed this man’s life change in the blink of an eye. He didn’t take the news well, but I couldn’t blame him. That was not the last time I saw him. He was in and out of our unit with pneumonia or thrush. He wasn’t really compliant with his meds. No one in his family knew what was going on with him. He wouldn’t allow visitors while he was in the hospital and would sit in his room all alone. It was heartbreaking. Then he stopped coming into the hospital. I held out hope that he had finally started taking his meds and got better. Deep down, I knew that wasn’t the case. Turns out he did come back into the hospital, just not to our unit. This time he was intubated in the ICU. He didn’t make it. He was just too sick and had been sick for far too long. Because of him, because of his case, I will forever remember an obscure pneumonia that I haven’t treated since.

So, I thought I would share a little bit of obscure information because… well… why not?

Are there any cases that stand out to you? Leave a comment and let me know.