DREAMS.

Why do we dream?

Is dream mystery?

Or does it have scientific, Philosophical, religious meaning?

Please I need your responses.

We all dream dreams.

Have you ever dreamt that you are married and was getting engaged to be married again?

Funny,very funny.

I want to dream that I am driving Lamborghini or Ferrari?

I know that it can never happen .

Because it is like a hen trying to reproduce a cow.

So is dream part of what we are thinking in our subconscious mind?

What do you think?

PROCEDURES. WHY?

Why do we undergo surgeries or procedures?

So many people undergo surgery or procedure without asking questions.

Surgery is the use of instrument to create incisions so that injuries or disorders in

the body is treated.It is usually done under general anesthesia.

Some people ask questions before the procedure or surgery.

@Amazon.com

But some people don’t ask questions.They just trust their surgeons.

You should be aware of not only the Name of the Procedure or Surgery

but Why do you need it.

Ask questions and make sure that you are answered correctly.

Do not be shy or ashamed to ask for clarifications.

Your surgeon should  explain to you what he/she intend to do before you sign

the consent form.After the doctor and the Anesthesiologist talked to you then

you can sign the consent form.

The anesthesiologist is the doctor that will put you to sleep.

Don’t you think that you need to know?

The informed consent means that you got the information and that you totally agreed.

PERSISTENT/SCD/LOVENOX by Philomena N Okeke.(My little poem)

I like to stick to

what I believe in.

I persisted on my speech.

I must persist

To persist you must know

He said NO.

But I persisted .

Where is NO?

I t does not fit.

I have no time to waste.

Push ,push on.

In Nursing School you persist.

No is not an answer.

It pushes you back.

Revisit NO and make it YES.

Persistent is the answer.

To persist is to press on.

Give to Cesar what is his.

I got what is mine.

Presumption does not mean right.

Nurse persisted on the need for

ambulation based on doctor’s order.

Walking decreases hospitalization.

The Nurse was right.

There should be no presumption

that patient does not want to ambulate.

Ambulation is good for me.

Ambulation is good for you.

If immobile.

Where is SCD?

Where is lovenox?

Is it contraindicated?

Why is patient not ambulating?

Per doctor’s order (Ambulate patient TID)

Who wants DVT/PE?

Nobody.

Does patient need pain medication before ambulation?

Nurse medicated patient for pain.

Patient felt better and ambulated.

Does patient need assistive device to ambulate?

Nurse ,thanks I feel better.

Nurse persisted everyone won.

Efforts were planned and coordinated .

There is no fear when you persist.

It is good to persist.

Determination is to persist.

To persist is to insist and press on.

Push,push on.

I pursue.

He perseveres.

I endured and ride on.

I strive.

Jesus persist that he

should wash his eyes in the pool.

He washed and received his sight.


NURSES BURNOUT by Philomena N Okeke,Author.

Burnout can be defined as depletion of your physical and emotional energy

for over a long period of time due to unrelieved pressure from your job.

So many nurses have been burned out in the past.Some of them changed jobs,relocated,

got married,develop health issues, but so many are still hanging in,doing it differently

with smile on their faces,coffee in the hands,friendly environment and doing what they love.

The ball is your hand.Nursing is a very beautiful ,fantastic,lovely but challenging profession.

You make the best of it.I love it and so will you.

I have been burnt out in the past without realizing it until someone pointed it out.

Over fourteen years ago ,it all started when I told one of the doctors that I worked with, that I saw him ,the managers and everyone working in our unit in my dream .And that we were preparing for JCAHO(Joint Commission on Accreditation of Health Care Organization) visit.(JCAHO came to our hospital that year and we scored 93%,I was one of the coordinators in my unit)He replied,” if you saw us in your dream then you are definitely burnt out.So please evaluate the jobs that you have and see which one is giving you stress the most.If it is this job or any other job .Whatever it is, you must leave it immediately.”I did not like the doctor’s suggestion.I thought that he hated me. Two days later my manager called me into her office to tell me that my Primary doctor called and said that I needed emergency surgery.And that I must go for the surgery immediately.I told my manager “NO” the doctor just wanted to make extra cash.I do not want to go.I do not need any surgery.She replied,”YOU MUST GO BECAUSE IF ANYTHING HAPPEN TO YOU ,WE WILL NOT BE LIABLE”. So I left very uncertain of what will be my faith.I had my surgery done.It was the removal of cyst .I returned to work immediately.I love working .Working was my only language that I speak.One year later I decided to move on and left that hospital but never stopped working.But drastically reduced my hours,learned to speak up ,make friends and then learn to educate and delegate.Also learn to listen to my body.

TEN FACTORS THAT CAUSES BURNOUT.

(1)Unrelieved pressure from work.You work in a hostile and unconducive environment.You are constantly harassed ,rather than encourage and support you.Or Charge nurses give you the worst assignment and bully you all the the time. The other nurses do not like you because you are inexperience or not one of “them” or from the Registry.You come to work tortured,ridicule and relegated to the background.That is working in a stressful,dangerous environment

(2) Lack of support : You are single or divorced and has no support,friends or families to help you.

(3) Difficult Co-workers: You have difficult co-workers that are not supportive.

Their main agenda is to see you fail.They are not happy if you sit down to review

your work or chart. And their popular language is that “she does not belong here”

(4)Having a lower degree: BSN rather than associate degree is much better.

You have more respect. And the doctors want to communicate with a BSN

than associate degree.There is a proverb that says,”If you want to eat a toad get

the juicy one”.

Nursing profession have so many specialty ,bedside Nursing is one of them.

(5) Bedside :Bedside Nursing can be emotionally draining.You see so many trauma on a daily basis.You watch people of your age ,your dad age ,your son’s age your brother age die of various diseases from gunshot wound to cancer, car accident. Nurses experience death,and complication lost of limb can be so emotional and can affect the ability to continue.

(6) New Nurse: Lack of knowledge and inexperience can make it difficult for new nurses.

There is the unrealistically high aspirations in Nursing Program that teaches “the perfect patient situations”,which most often does not exist.It is surprising to the new nurses when the those situations in nursing  schools does not apply in the real world.They start to feel incompetent and lack of resources at the beginning of their career.

Rome was not built in a day so new nurses should learn to ask questions rather than development attitude.What attitude do you want to show when you are inexperience?.And the experience nurses should learn to support their own.The doctors knows when we have new nurses and they (doctors) react to their inexperience. Who is that nurse that called me? She does not know anything.Doctor :she is new ,please be gentle ,we want them to stay I replied.Do not chase them away please.

(7) Lack of Respect among the healthcare Team.Respect is reciprocal.Please give me some.

(8) Under staffing: Sometimes there is not enough staffing ,so we have to manage the limited

staff that we have.With long hours of work,and maintaining a high quality standard of care.

(9) Delegation: Most Nurses do not know how to delegate or they believe that it will not be delivered the way they want it.In an attempt to do it all without seeking help could contribute to burnt-out.

(10) Lack of Emotional intelligent: It is very important to know how to deal with people.It is always good to understand people that you work with before dealing with them.Because we have the individual differences.If you do not know how to fit in,it can be very deterimental, frustrating and can contribute to burn out.

3 SIGNS AND SYMPTOMS OF BURNT OUT.

(1) Emotionally exhausted.This is much more than tiredness after working eight

hours and you want to go home and rest.This is complete fatigue.

Asking you to do one more problem will upset you or too much to ask.

(2)Depersonalization: This is a situation where the nurse has no feelings for the patients

that he/she is taking care of.All the patients are the same in her/his eyes.

There is no individualized plan of care.He/she became a slective listener.

The nurse does not have feelings for the patients that he/she is taking care of.

(3)Decreased in Personal Accomplishment:In this situation a competent nurse becomes

the nurse that barely provide minimal patient care.

Patients are dissatisfied with Nurse care.This is a situation where

there is unhappy outcome.The nurse in this stage feels other nurses

are better so my effort will not yield any difference or a better positive outcome.

Nurses experience death,and complication lost of

limb can be so emotional and can affect their ability to continue.

7 WAYS ON HOW TO PREVENT BURNOUT.

(1)ACKNOWLEDGEMENT: Identify when you feel burnout.

Provide an equitable assignment.Work should be assigned

effectively.Please do not overload the highly competent nurses.

(2)SELF CARE: Take time to care for yourself.Exercise,meditate.Take your

PTO ,have time for you.You earned the PTO is yours,use it but do not abuse it.

(3)STRONG TEAM :Find time to develop strong ,and compassionate

co-workers who are supportive. I can tell you that they do not need to

speak the same language with you,but they are great team players.

(4)RESILENCE : Develop a coping mechanism in other to alleviate burnout.

Preserve Nursing morale,and avoid role confusion.Salary most often is not the number one factor but if the physical enviroment is not conducive.The salary becomes a serious issue.Is the environment clean,safe?What is the organizational climate? Is the establishment friendly?Is it difficult to interact or communicate with other nurses.

(5)EDUCATION: Educate yourself,subscribe to Nurses Journal.Stay current in Nursing practice.

The ANA Ethical Code for Nurses is that Nurses must maintain competency in Nursing profession.

(6) SAFE TIME: Delegation could be the fundamental key to successful management of your time.

Delegate correctly to the right professional.Understand the roles of the Nurse,Case manager,the CNA,Manger,PT so that your needs will be met.

(7)Realistically look at your environment Do you have any control?But you can control yourself,your mood,and your behavor.Do not be too apologetic.Prevent defensive mechanism.Acknowlege your limitations.

TOOLS FOR WOUND ASSESSMENT AND MEASUREMENT.( The way I understand it as an RN).

To measure your wounds you need measuring Tapes,Gloves, Cotton Swab,digital camera,and clock.

Have all your supplies ready because you do not want to be going back and forth for supplies.

Provide privacy.

Wash your hands and wear your glove.

Get the measuring tools ready.(Write patient initial ,date,time and your name and title).

Patient initial and room number is good enough for this situation,because we are trying

to protect the patient as much as we can.Please follow your Facility policies and procedures .

Position your patient properly for the camera.

Remember do not take a picture of your patient face or his/her tattoos.

Position the measuring tape correctly and take your picture.

Use the tape to measure length and width ,and the cotton swab to measure the

depth by sticking it into the wound to find the depth,undermining and tunneling.

Place the cotton swab on the measuring tape to get and document the depth of the wound.

L x W x D =Length x Width x Depth

If the wound is round find the diameter.

Is there a tunneling.

Check for undermining?

What did you see?

Do not alter what you saw.And do not use personal phone to take pictures.

Remember that the head is always 12oclock and the tail 6oclock.

Discard the measuring tapes with patient initial in patient’s room ,inside the trash can,

after tearing it.

Wash your hands before leaving patient room.

cotton swab


Measuring tape

Print the pictures ,write a brief description and place it in patient chart.

Thanks ,you have done well.

THE OTHER WOUND.

We Do have the other types of wounds that are not related to

pressure ulcer, bedsores or debicutes ulcer.You do not Need to be bedridden or wheelchair bound to have this wound.

Anyone can have this wound anytime in their life.

The most important thing is taking proper care of it.

*Remember that wound is not part of your body,so it Must heal and go away.*

Educate your patients to take care of their wound (s):

To prevent infection. (Signs of infection can be fever,increase drainge,swelling(edema) ,pus,smell,change in color of the surrounding tissues.)

To follow doctors orders.

And should not allow their wound to adhiscence.

(That is the seperation of the skin from tissue layers).

Wound can adhiscence few days after surgery.(3-11days).

I am talking about the following wounds below.

Surgical wounds/Surgical incision.

Vascular Ulcer.

Diabetic Ulcers.

Wounds due to Trauma for example bruises and contusions.

Cancer related wounds.

Dermatitis.

Rashes.

Skin tear due to adhesive tapes.

Burns.

Abrasions.

These Other wounds can be Classified as:

Closed wound.

Superficial

Partial thickness.

Full Thickness.

The wound is bumpy red granulation,scar formation.

Fat known as adipose.

Muscles,tendon,or bone are exposed.

Rolled edges.(Epibole )

The skin is maroon or purple.

Firm to touch and non blanchable such as bruises .

Wounds due to trauma such as car accidents.

Blood filled blisters.

There could be slough,yellow ,tan or eschar.

Whereas Pressure Ulcer can be Classified as:

Closed.

Pre stage 1 : This is known as blanchable.

Stage 1 :Non blanchable erythema (redness)

Stage 11.partial thickness of the loss of the dermis showing wound without slough.

Stage 111. This is the fullness tissue loss in which the subcutaneous fat may be exposed

but not the bones,tendon or muscles.Slough ,undermining and tunneling may be present.

But you can still see and able to measure the wound.The staging of stage 111

depends on the location of the wound.Please read more on that.

Stage IV. This is full thickness skin loss in which you can see the bones,

tendon and muscles.

DTPI: Deep Tissue pressure Injury. Area will be boggy,firm,painful,warm or

cooler than the adjacent skin.It is marooned or purple localized discolored

intact skin.You do not know what is in the injury,it is warm,painful,different

but the skin is intact.

Unstageable.It is named unstageable because we do not know the depth.

It is a full thickness skin loss in which the wound base is covered

with yellow slough,tan,black or eschar.We do not know the dept.

The only way we could know the depth of the wound is if all the

soughs are removed.Which might involve Sharp debridement or any other

types of debridement.

The doctor or trained physical Therapist can do Sharp debridement.

Again please follow doctors orders, and your hospital protocols,

policies and procedures.

PRESSURE ULCER.WHAT IS IT?(In my understanding as a Registered Nurse)

Pressure ulcer in a simple term is known as bedsores or decubitous ulcers.

They are localized damages to the skin.They are very expensive to treat,

so the best thing is not to develop pressure ulcer.The hallmark sign of pressure

ulcer is that they usually develop over Bony Prominence due to unrelieved pressure

such as the back of the head,sacrum,coccyx,hips,ankles,elbows, occipital,shoulder,

ischium,ilac crest,medial malleolus,lateral malleolus etc.Development of pressure

ulcer around the ears is due to equipment.

Pressure ulcer could be a combination of pressure and friction.

If you are alert and oriented x4,walking,able to comprehend,not incontinent.

Will you develop pressure ulcer?The answer is “NO”.

So if you are compromised,you stayed in bed for too long or in one position

for too long.And you are not able to repostion yourself because

you are bed ridden or wheelchair bound.Then pressure ulcer will develop.

due to unrelieved pressure.

When there is a limitation in the flow of blood in the area where there is pressure

bedsore will develop. Pressure ulcer or bedsore is categorized in stages.

You cannot talk about pressure ulcer without understanding the BRADEN SCALES.

Please look up on Braden scales.It is a scale for predicting pressure ulcer risks.

Braden Scales is great predicting indicator for developing Pressure Ulcer.

And understanding who are at risk for developing pressure ulcer.

The Braden Scales for Pressure ulcer is as follows:

Lowest risk 15-18

Moderate risk 13-14.

High risk 10-12

Highest risk 9.9 and below.

When you think about Braden Scales think about the following.

Is the patient able to respond to pressure?.

To what degree is the skin expose to moisture?

Is the patient active?

What about their nutritional intake?

Can patient reposition self in bed or can patient ambulate(That is walk).

How to prevent Pressure Ulcer:

To prevent pressure ulcer is to understand the skin,nutritional intake, the Braden scales,

immobility,various types of wound including their origin, wound care.

These are very important as an healthcare professional.

The right equipment should be in place for bariatric patients.

According to the National Center for Health Statistics report shows that 30% of

American adults are obese-over six million Americans.

Reposition patient every two hours while in bed,and evry one hour while in the wheelchair.

(PT/OT ) Physical and Occupation therapists should be ordered for all patients.

Physical therapist should evaluate who need therapy and who need treatment.

Physical and occupational theraist clearance sould be done before discharge

home or SNF or REHAB transfer.Each patient situation is different.

Nurses should encourage and assist in early ambulation and other activities

of their patients.

Nurses are to medicate patients for pain thirty minutes prior to physical activities.

Unnecessary immobility should be discouraged by the nurses.

The GOLD STANDARD will be getting the patient ready for physical activities as

long as it is NOT against doctor orders.

Is there an OVERHEAD TRAPEZE for the patient to turn and

reposition self while in bed?

Avoid Electrical blanket under an immobilized patient with very low Braden Scales.
During repositioning ,watch out for bony prominent areas.Protect bony prominent areas.

NUTRITION:

Nutrition Assessment.

Can the patient eat independently?

Does patient have adequate nutrtion.

Is there a recent weight loss >5% in 30days.

What is the prealbumin level?

WNL > 16 mg/dl

What is Albumin level?

WNL >3.5g/dl

But if the patient is trauma patient,inflammation or has infection.Plasm prealbumin level can be false result since the prealbumin level has been affected due to trauma,or infection or inflammation.Then the C-reactive protein test can be use instead.It is the doctor decision if he/she wants to do that.

The importance of adequate nutrition cannot be overemphasized.

Evaluate PO intake that is can the patient tolerate food by mouth very well ?.

Eating 80-100%. Is patient getting enough nutrient?

If NO can the patient swallow?

Does patient need swallow evaluation?can your patient chew?

If NO Speech therapist and nutrition consult will be ordered by the doctor.

Speech therapist will evaluate for swallow and make recommendation.

Registered Nutritionist will make recommendation on type of feeding.

Tube feeding type for example Glucerna.1.0,1.5, jevity 1.0 or 1.5,Suplena

based on patient disease process and notify the doctor

on their recommendations.

And the doctor will write the orders.

Does the patient need Tube feeding,TPNor PPN ?

If your patient is not getting adequate nutrion,notify your doctor so that

he or she can order Nutrition Consult.

And the Nurse will execute the orders.

Next concern do the hospital beds have moisture control assistive device?

Is redistribution of pressure and comfort provided for patient?.

Are the patient feet off -loading from the mattress?.

Understanding of the wound that you are dealing with is very important because

successful treatment involves not just the wound but a complete knowledge of the

patient with the wound.

For example who is this patient?

Does the patient have diabetes,vascular disorder,anemia,hypothyroidism,

obese,COPD,or CHF?.

Is he/she a cigarette smoker?

In order words, good assessment of the comorbidities

are very important for adequate wound healing.

HOW DO I HEAL THE WOUND.

Assess location of wound,type of tissues,etiology of the wound,wound

suroundings, amount of exudate,odor,pain, signs and symptoms of infection.

Is the wound viable?

What are the factors affecting the wound?.

(A) Maintain moist environment for the wound to heal.

(B)Keep the wound surrounding clean.

(C)Avoid early closure of the wound that is not ready to be closed.

Why? Because it will be back to SQUARE ONE.

When it becomes clear that the drainage from the wound is winding

down,then the wound is getting ready to be closed.

(D)Excess exudate should be removed.

(E) Understand skin condition,products,products adherence

, and absorption and quality of products when making selection.

(F) Understand various ulcers such venous,arterial ulcer,lymphatic ulcer

and diabetic wounds and the types of dressings.

When do you use a negative pressure wound therapy or

any other type of wound therapy?.What are the indication and special

reasons or rational for using Hyperbaric Oxygen Therapy?.

One simple thing that I will say to you is please assess your

patient,his/her lab values and check the blood sugar.

If the blood sugar is low take action.Follow doctor’s order.

Please Note: “NO DEBRIDEMENT NEEDED ON A DRY

NECROTIC WOUND ON THE FEET”

QUESTIONS:

(1 )Bedridden patient position should be repositioned.While in bed—————————and

while in wheelchair—–———————————–

(2) Partial thickness wound can be classify as:

(a) Stage IV

(b) Stage 111

(c) Stage 11

(d) Stage 1

(3) Full thickness wound without exposed bony areas ,tendonor

slough should be classified as.:

(a) Stage 11

(b) Unstageable.

(c) Stage IV

(D) Stage III

Answers 1.Every two hours and every one hour.
2. C.

3. D.

REFERENCES:

SCOTTSDALE WOUND MANAGEMENT GUIDE.

A comprehensive Guide for the Wound Care Clinician.

2ND EDITION Pages 13 -123.

Black J,Clark M,Dealey C,et al.Dressings as an adjunct to pressure Ulcer prevention:

consensus panel recommendations.Intwoundj.2015;12(4)480 -485.

Washington,DC: National Pressure ulcerAdvisory Panel,2009.

Lippincott William&Wilkins: Wound care Incredibly Visual. 2nd Edition. Pages 3-26.

Diane L. Krasner,PhD,RN,FAAN . Chronic Wound Care.A Clinical Source Book for

Healthcare Professionals. Pages 1-20.



MESSAGE TO MY PARTNER.(POEM by Philomena N Okeke)

Where are you my love? You stood like you evolved. You are my sweet dove. If you are sweet candy.
Then I crave for  sweet candy.
I am ready to eat up the candy.
And worry about tooth
decay later.
We giggle with each other. Holding hands on the street. You rebuilt and organized me. We jump up together. Happy and sad together. You lifted me up. And now I can fly. We play with each other. Dive into the Ocean with each other. Peaceful and divine. Our eyes spark at each other. “The world can stop turning, the Sun can stop burning, Who can tell me that love is not worth going through?. If it falls apart,I will understand deep down in my heart ,the only dream that meant a lot to me, has come true. In this life,I was loved by you”Bette Midler. You held my hands. And I held your hands. When I see you I behave. I have lots of curves. I feel like a new me. “What the heart gives cannot go away,it is kept in the hearts of others”Robin St. John. Now I am alive . I am your beloved. And you are my beloved. “I have learned not to worry about love,but to honor , its coming with all my heart”. -Alice Walker. Love me in the light and in darkness. I promise to do the same.

ELECTROCONVULSIVE THERAPY(THE WAY I UNDERSTAND IT AS A NURSE).

FOR DEPRESSION?

Electroconvulsive Therapy (ECT) is an effective treatment for major depression with an eficacy rate of 80% or more,which is equal to or better than response rates to ANTIDEPRESSANT medications in some patients.
It is particularly useful for people who cannot tolerate or fail to respond to the use of medication treatment.

There  are various Reseaches from MAYO CLINIC ,JOHN HOPKIN’S University,and others but they did not allow to download for your references.You  can reference them .Also talk to your doctor or healthcare provider for educated information.

NURSING CARE.

Provide educational support to patient and family.

Assess pretreatment protocols to ensure that it was according to hospital procedures.

Assess the patient behavior ,memory and functioning ability before the ECT.

Patient should remove prothesis before treatment to prevent damages or loss.

The Nurse should prepare and monitor patient during the actual ECT procedure.

Patient should use the bathroom before procedure to prevent incontinent.

THE TARGETED BEHAVIOR OF ECT/EFFECTIVENESS.

1.Hyperemotionality.

2.Hypermotility.

3.Catatonia.

4. Severe psychosis with acute onset,life threatening psychiatric conditions.

Rigidity of parkinsonism or the neuroleptic

malignant syndrome.

NURSING INTERVENTIONS.

1.Education on procedure and expected effects to patient and family.

2. Encourage expression of feelings by patient and family.

3. Reinforce teaching after treatment.

4. Check emergency equipment before treatment/procedure.

5. Maintain NPO(Nothing by mouth) Status for 4-8hours

before treatment.

6. Remove harmful objects such as denture,jewlry before treatment.

7. Check vital signs ,maintain airway,assist to ambulate,

offer analgesia or antiemetic as needed.

8.Remain with patient before and during treatment.

9. provide support.Your focus should be on that patient only during treatment.Do not combine with other assignment.

10.Reorient patient and assist family members after procdure.