Systolic v Diastolic Heart Failure
Systolic Heart Failure: Canāt Squeeze
Diastolic Heart Failure: Doesnāt Relax
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Systolic v Diastolic Heart Failure
Systolic Heart Failure: Canāt Squeeze
Diastolic Heart Failure: Doesnāt Relax
child handling for the childless nurse
My current job has me working with children, which is kind of a weird shock after years in environments where aĀ āyoungā patient is 40 years old. Ā Hereās my impressions so far:
Birth - 1 year: Essentially a small cute animal. Ā Handle accordingly; gently and affectionately, but relying heavily on the caregivers and with no real expectation of cooperation.
Age 1 - 2: Hates you. Ā Hates you so much. Ā You can smile, you can coo, you can attempt to soothe; they hate you anyway, because youāre a stranger and youāre scary and youāre touching them. Ā Thereās no winning this so just get it over with as quickly and non-traumatically as possible.
Age 3 - 5: Nervous around medical things, but possible to soothe. Ā Easily upset, but also easily distracted from the thing that upset them. Ā Smartphone cartoons andĀ āwho wants a sticker?!!?!?ā are key management techniques.
Age 6 - 10: Really cool, actually. Ā I did not realize kids were this cool. Ā Around this age they tend to be fairly outgoing, and super curious and eager to learn. Ā Absolutely do not babytalk; instead, flatter them with how grown-up they are, teach them some Fun Gross Medical Facts, and introduce potentially frightening experiences withĀ āhey, you want to see something really cool?ā
Age 11 - 14: Extremely variable.  Can be very childish or very mature, or rapidly switch from one mode to the other.  At this point you can almost treat them as an adult, just⦠a really sensitive and unpredictable adult.  Do not, under any circumstances, offer stickers.  (But they might grab one out of the bin anyway.)
Age 15 - 18: Basically an adult with severely limited life experience. Ā Treat as an adult who needs a little extra education with their care. Ā Keep parents out of the room as much as possible, unless the kid wants them there. Ā At this point you can go ahead and offer stickers again, because theyāll probably think itās funny. Ā And theyāll want one. Ā Deep down, everyone wants a sticker.
This is adorable and true. Also for age 1-2: get the correct flavour of medication or suffer the consequences.
This maps quite closely onto my pediatrics experience. Especially the part about getting medication falvors right. GOD but have I been spraypainted too many times withĀ āstrawberryā-flabored ampicillin. (And is it ever a pain in the butt to get out of a white uniform.)Ā
Did you know that exercising every hour while working the night shift can help you stay more awake and focused? http://ht.ly/XAjg30kzoWE Ā What tips do you have for working the night shift?
Going into a room when I was first learning to start IVsā¦
Going into a room now to start IVsā¦
My patientās blood cultures come back positive...
So every week our ANM does a discharge instruction ā hall of fameā and thereās one doctor who has no shameā¦..
These are so much more amusing than my wordy, wordy discharge summariesā¦
Stop running around naked at night.
Tag yourself.
Iām āCharm School Recommendedā
Iām āfired so fast if I actually wrote this and gave it to a patientā ā
But it just might be worth it.
IāmĀ āFor nausea if it occurs, I recommend life saving zofranā
I wish I worked somewhere that didnāt put so much emphasis on patient satisfaction so I could write discharge instructions like thisā¦
We had a patient coming off who knows what, they came in and got zofran and like 15 warm blankets, 2 crackers and a cup of water and decided he wanted to go home, and the discharge notes were likeĀ ārecommend sweaters prior to seeking out emergency room careā
Oh man. These are the best.Ā
Youāve remembered the necessities: phone, laptop, toothbrush. But the hospital still doesnāt feel all that comfortable. There are little ways to make your hospital stay a bit warmer. Set up some framed pictures of your family, friends, or pets. Pack your favorite pillow and hang up a poster. Though it might seem little, even the tiniest personalization will make your hospital stay a bit better.Ā
This guy comes in to the ER with chest pain and you wonāt believe what happens
Full cardiac workup plus full PMH and PSH. Trop and 2hr trop negative. EKGs show NSR. Turns out they have an inherited disorder that predisposes them to develop blood clots. They take Coumadin, or rather theyāre supposed to take it. The significant other rats them out and says the patient stopped taking it.
So naturally they get a CT scan and guess what? Go ahead. Youāll never guess.
The scan reveals a dissected aortic aneurysm. DISSECTED. AORTIC. ANEURYSM.
Oh. But it gets better. Name two things that donāt go well together. Here, Iāll help: dissected aortic aneurysm and Coumadin. Yeah. Bad. Not good. But remember, this patient stopped taking their Coumadin.
I know what youāre thinking: how is this patient living if their aorta dissected? A clot. This patient had a massive clot sitting at the dissected section of the aorta, preventing them from bleeding out.
And they wanted to go home and follow up with their cardiologist on Monday. To which I repliedā¦
We donāt have cardio-thoracic coverage, so we ended up transferring this patient. But, damn, what a hell of a case.
What does your steth say about you?
P.S. if anyone helps me turn the digital cardio deluxe into reality that would be awesomeā¦
Journal of a New Graduate:
Day 1:
Iām a new grad, I went to a great school, didnāt miss a clinical, a good study group, focused prep for NCLEX, passed with relief at only 75 questions, accepted into the first position applied for - the position Iād dreamed of all through nursing school. It just seemed too good to be true. Iām excited to be here in nursing orientation, excited but nervous about what the next twelve weeks will bring.
Day 7:
Iām a bit confused with what Iām supposed to be doing. My educator seems to be disorganized, giving me the wrong packet, one thatās supposed to be for another nurse, and vaguely waving her hand sheāll get it to me āat some pointā. That was two days ago, Iām in the Library, doing some online learning that I happened to find out about from a fellow new graduate. I hope thatās what I am supposed to be doing. My educator waved me off again, saying she would catch up with me at some point. Sure.
Day 12:
Iām on the unit. Gulp. I completed the online learning, mostly in my own time, since the modules I was doing wasnāt actually what I was supposed to be doing. I completed the work on my own, as my educator emailed me a packet late Friday, stating it needed to be completed by Monday. I was two days late, despite staying up late every night to do it. Today Iām on the unit, Iām shadowing my preceptor, who wasnāt told I was coming. Iām beginning to think I chose the wrong place. My Preceptor seems really annoyed, muttering to another nurse that she was tired of orienting new nurses. I feel like I donāt belong.
Day 18: Iām tired, and It hasnāt even been a month yet. My preceptor yelled at me for fumbling with an arterial line set up, saying I would have to do this on my own someday, and I shouldnāt be expecting her to be right next to me every time. I sat in my car on my lunch and cried, so no one would see. Fine. I can take the yelling, except I havenāt ever actually seen an arterial line before, just on the computerized learning module. I havenāt practiced with one yet. I donāt belong here.
Day 24: I saw my educator today. Iād forgotten what she looked like. She pulled me into a mid point evaluation with the nurse manager and preceptor. They all looked grim. I wasnāt progressing in the way theyād hoped, or expected by this point. They wrote up my error in levelling the EVD, when I had never seen one before, despite my asking my preceptor for help, only to hear the same, āYou have to learn to do these things on your own.ā They wrote a verbal warning that I wouldnāt make it through orientation with my slow time management skills, and I just sat there and nodded. They didnāt ask me how I was feeling, and I didnāt want to tell them. They already wrote me off a long time ago.
Day 30: I asked my preceptor today what her experience was like as a new graduate. She said I had it easier than her, then she turned away. Whatever.
Day 40, last day orientation: Today, I met a patient who probably saved me (even though weāre supposed to be saving them, I suppose). She was young, maybe 21, s/p cardiac arrest r/t overdose on red bull, Her family and friends perched on seats at her bedside, praying. āGet them out,ā barked my preceptor, āyou always spend too much time talking to the families. Just another young punk overdose.ā So, after 40 days of following her instructions, today I did the opposite. Today I closed the curtains in the little corner room of the ICU, and I sat with the family, and asked them to tell me about her; tell me about your daughter, tell me about your sister, tell me about your friend. Tell me about how sheās been feeling, tell me about what she did the night before the ER. āShe was quiet, she wanted to be a nurse, but she just kept failing all her exams. We think she might have tried to take her own life, but the doctors breezed through all that. They just assumed she was some wasted teen on a Saturday night trying to get high.ā And I knew, it wouldnāt matter what my preceptor had said about taking too long with patients, some day I would speed that up, it wouldnāt matter that I had fumbling hands with A-line, someday I would get it, someday I wouldnāt be so nervous. It wouldnāt matter that every day I felt abandoned by my educator or preceptor, or apologetic for the disappointment they thought I was, as one day I would have the confidence to not look for that validation. It would matter only that I could listen, and maybe use what little skill I had, not learned from any textbook, not garnered from any preceptor, something that would remind me to keep fighting for the patients who couldnāt fight for themselves. Someday I would be faster at that, too. And so, on the very day I planned to quit, the very day I āgraduatedā from my preceptorship, I survived. I survived orientation, and it wasnāt because anyone had fought for me. It was because I fought for myself, alone.
~ As told by a graduate nurse, 6 years before she became a preceptor, a mentor, and a charge nurse who remembered what it was like to walk in a new orienteeās shoes.
Hereās to all the nurses, doctors, and first responders out there who are spending the day today with their family because tomorrow theyāll be spending the day with their work family. Merry Christmas!
donāt forget the feet
Today I had a patient who was a littleā¦off. She couldnāt tell me what year it is. She didnāt even know how to count backwards from 10.
I thought to myself,Ā āSheās 70. Maybe thereās a history of cognitive decline?ā
So while she sat and wondered about which day of the week it is, I quickly looked through her chart. But I found nothing. Nothing about memory lapses. Nothing about disorientation. Nothing about short-term memory issues. Nothing.
I preceded to do a full head-to-toe physical. When all I had left to do was the feet, I hesitated. I usually donāt skip the feet. But for this poor woman who sat there mumbling to herself and nodding off, I wondered if I should make an exception. The woman had enough trouble getting out of a chair, let alone pulling on socks and lacing her shoes.Ā
But I knelt down and placed my hands on her shoes.Ā āMaāam, is it okay if I take off your shoes and check the bloodflow in your feet?ā
She nodded and returned to mumbling to herself.
After I got the laces undone and the shoes off, I carefully pulled back the socks.Ā
Then when I examined the soles of her feet, I found this:
Few rashes appear on the soles of the feet. Syphilis is one of them.
Syphilis can lie dormant for decades. Sometimes when it reappears, it can affect the eyes (occular syphilis). Other times, it can affect the brain (neurosyphilis), leading to dementia and behavioral disturbances.
I helped the woman put on her socks, and I tied her shoelaces. Then I left the room and reported to my preceptor. Once I mentioned the sudden cognitive decline and rash on the feet, my preceptor immediately searched the patientās records at all local hospitals for bloodwork.
Then we found it. A positive RPR dating back a few decades, indicating that at some point the woman tested positive for syphilis. Looking through her records, she never received treatment.
We spent most of the following hour scrambling for an emergency infectious disease consult, and it did create some chaos for the remainder of our scheduled patients. But we managed, and now the poor woman is receiving treatment.
So, friendly reminder:
Donāt. Forget. The Feet.
On the blog now, Podcast Show Notes.Ā Season 1, episode 1 is ready to view or download.Ā https://www.freshrn.com/2017/05/02/nurse-orientation-show-notes/
Prevent Alzheimerās
8 Ways To prevent Alzheimerās
Eat more fruit and veggies.
A population-based cohort study of 1,836 older Japanese-Americans found that consumption of fruit and vegetable juices was associated with decreased incidence of Alzheimerās over seven to nine years of follow-up
2.Eat fatty fish.In the Framingham study, individuals with the top quartile levels of docosahexaenoic acid (DHA) found in fatty fish like salmon, mackerel, and tuna, measured at baseline had lower rates of Alzheimerās over nine years of follow-up. These fish are all rich in omega-3 fatty acids.
3.Eat like a Greek.Two studies that used dietary questionnaires to assess and quantify adherence to the diet in different populations found that patients who were most adherent to the Mediterranean style diet had a lower incidence of Alzheimerās, compared with those who did not follow this diet.
4.Have a glass of red wine.Drink a glass of red wine or purple grape juice with your evening meal. Components in grape skins protect brain cells from the toxic effect of oxidative stress and beta amyloid.
5.Control your blood pressure.Hypertension appears to be associated with an increased risk of both vascular dementia and Alzheimerās disease.
6.Eat berries.Berries contain high levels of biologically active components, including a class of compounds called anthocyanosides, which fight memory impairment associated with free radicals and beta-amyloid plaques in the brain. Eat berries each day for maximum benefit.
7.Make friends.Findings indicate that an active social life and strong network of friends may help prevent Alzheimerās in later life.
8. Control inflammation.Once thought to be a by-product of Alzheimerās it has been found to be one of the causes of this and many other chronic illnesses.
The word you're looking for is "patient."
I will *not* call the people I care for āclients.ā
Iām not doing a project for them.
Iām caring for them through their illness. Iām nurturing and teaching and supporting them. Iām feeding, washing, medicating, ambulating and encouraging them. Iām making sure theyāre warm enough and that they can rest.
And Iām giving a damn about them. Oftentimes, though not nearly to the extent they are, Iām suffering with them. Also fairly often Iām pissing them off by not giving them what they want because itās not what they need.
Iām determined to get them better, not make them happy customers.
Asking me to call them āclientsā is an insult to both of us.
The vision of medicine as big business has to go.
Coagulation cascade made simple.
Someone shared this with me on my surgery clerkship and I wanted to pass it forward.Ā
1) Everything centers around the perfect 10
2) 7 is a lucky number so I keep it to myself
3) 8 and 5 are cofactors
4) 3, 4, 6 do not exist
5) When you draw it out, it looks like a gun, and your trigger finger (TF) would go by the 7. so TF (tissue factor) goes by 7
6) You use guns and trigger fingers in war, so thatās the part effected by warfarin. The other one is heparin
7) The shorter path has the test with fewer letters (PT). The longer path has the test with more letters (PTT).
The last āruleā was told to me by someone else, but it helps me every time, so Iāll include it here:
8) PET is WET (PT, extrinsic, warfarin) and [Brad] PITT is a HIT (PTT, intrinsic, heparin)
After 2 decades, finally a coag mnemonic that I might be able to remember!
If only I had this when I studied haematology
Patient died from a myocardial infarction that lead to a rupture then tamponade.
That large dark mass to the right of the dissected heart is one huge blood clot.
Crazy.