The Psychiatric Hospital

December, 1998 – New England, USA

I have now completed my first six months as a Nurse Practitioner in a 120 bed psychiatric hospital. I thank God for my boss, Dr. T., who is a Family Practice Physician and an excellent teacher. The hospital has an adult unit for acute psychiatric problems, a second adult unit for detoxification of patients from alcohol and opioids (heroin and oxycontin mainly), a teen psychiatric unit, and a pediatric unit for ages 5-12. I thank the Lord that He closed the door four years ago to the Adult Nurse Practitioner (ANP) program and redirected me to a Family Nurse Practitioner (FNP) program. Otherwise,  I would not be qualified for this job since I need to treat the medical problems of the children and teens.

When patients are admitted here, Dr. T. or I must do their admission physical examination and record it in their chart within twelve hours. We have a full time MD who works all night and does the exams of patients who are admitted after we leave. I am becoming an expert at doing a neurological exam of the twelve cranial nerves. I am also improving in my examination of ears and eyes with the otoscope and opthalmoscope.

Image result for nurse using otoscope

I developed my skill in using an otoscope for ear, nose, and mouth exams.

In addition to being certified in cardiopulmonary resuscitation (CPR), I also had to be certified in handling violent patients without hurting them (Nonviolent Crisis Intervention). I learned how to break a strangle hold in case a patient tries to choke me. I never wear a necklace or scarf to work since a patient could use it to strangle me. If I feel uncomfortable about being alone with a patient in the exam room, I request one of the aides to be present with me for safety. I always keep myself between the patient and the door so I can escape the room if I feel threatened.

The hospital is under investigation from the state because a child died last year. The staff did a face down restraint when the child came violent, and he suffocated. Tragically, they were unable to revive the child. So the state investigators come every day and read each providers’ progress notes, including mine. How I ask God for wisdom in my job! It is sometimes difficult to work under such scrutiny.

“If any of you lacks wisdom, let him ask of God, who gives generously to all without reproach, and it will be given him.” James 1:5

Dr. T. and I write the admission orders for the patients going through alcohol and opioid detoxification. The nurses use a scale to measure the patient’s withdrawal symptoms which guides them to administer the correct amount of medications to prevent the patient from having a seizure or dying.

It is so sad to see patients’ lives wrecked by alcohol and drugs. Only the person who receives Jesus Christ as his Savior can truly be delivered from these deadly addictions.  I pray for each of them to look unto Jesus Christ and be saved. How I thank God that He has put a song in my heart and prevented me from ever using alcohol or drugs by His grace. By following Him, He has spared me so much heartache and grief.

“And be not drunk with wine, in which is excess, but be filled with the Spirit, Speaking to yourselves in psalms and hymns and spiritual songs, singing and making melody in your heart to the Lord.” Ephesians 5:18-19

Reflection

I thank the Lord for all I learned while working in psychiatry for those four years. It was sometimes difficult to see lives so broken. But my experience with psychiatric assessments was  extremely helpful in every other job I had the remainder of my nursing career. A person’s mental condition often strongly impacts his physical condition.

 

Homework on Thanksgiving Day

October, 1994

I have been enjoying my first semester in graduate school tremendously as I study Nursing Issues. It feels like my brain is coming out of mothballs, and the group discussions are very enlightening. Our professor is excellent and gives interesting lectures. I just went to the hospital library to do some literature searches on my ethical dilemma for my paper. I have chosen to write about Euthanasia. I was surprised to learn that euthanasia (ending a person’s life) is legal in the Netherlands. We need to use the American Psychological Association (APA) format to write all our papers. I have a large textbook with all the writing rules for this format which is a bit overwhelming to learn. I also decided to invest in a personal computer to help me write my papers, so I am trying to learn this also. During my lunch break at work one day, I stopped at the local library and the librarian showed me how to use this pointer called a “mouse” to find my place on the screen. I am not very good at it yet, so I will have to keep practicing.

The "mouse" was difficult for me to use at first!

The “mouse” was difficult for me to use at first!

Thanksgiving Day, November, 1994

I turned in my paper on Euthanasia and my professor handed it back to me without a grade. She said I totally missed the point, so I have to rewrite it before she can grade it. She said I did a report rather than addressing both sides of the ethical dilemma and stating my viewpoint clearly. I am so disappointed and feel very discouraged. I also have to finish writing my final paper on Prescriptive Authority for Nurse Practitioners. This is interesting because the laws are different in each state. Some states allow NPs to prescribe all medications including narcotics independently without a physician on site, while others require a MD co-signature, and still others don’t allow NPs to write for any prescriptions.

No one at church  invited me to Thanksgiving dinner this year, and I live too far away from my family in the Midwest to go home. One of the single fellows in the career group, George, does not have any where to go on Thanksgiving day either. He asked if we could eat together at my house? I said I could take a three hour break from writing my two papers, so he is bringing the turkey and pie, and I am making the side dishes.

We had a pleasant meal together, sharing what the Lord has been teaching us lately.

My 3 hour break from homework for Thanksgiving dinner.

I took a three hour break from homework for Thanksgiving dinner.

I was able to finish both papers by Saturday night after working on them the rest of Thursday, all day Friday, and all day Saturday. Thank You, Lord, for helping me finish on time!

If any of you lack wisdom, let him ask of God that giveth to all men liberally, and upbraideth not (ungrudgingly); and it shall be given him. James 1:5

Reflection

I was so thankful that my professor accepted both my papers and I received an A- for my first course in graduate school. It was quite a stretch for me to get back into the study mode, learn how to write in APA format, and learn how to work a computer while working full time as a visiting nurse.

George and I sometimes laugh about our Thanksgiving dinner together when I gave him three hours of my time! He later married a dear friend of mine from church, and they are both growing faithfully in the Lord.

Graduate Nurse Orientation

April, 1977 – Midwest, USA

After one week of vacation visiting friends, I began orientation on the diabetes unit on day shift. The nurses have been very friendly and encouraging as they teach me about diabetes and how to care for the patients. This new hospital is a circular tower with 10 floors of 30 private patient rooms on each floor. It was designed with nurses in mind since the nurse’s station and elevators are in the center. This way, each patient room is equally close to the nurse’s station. Since no one has a roommate, it also eliminates roommate problems, and it is easy to put someone in isolation when they have an infection.

I stand in front of the new hospital tower where I worked as a new graduate nurse.

I stand in front of the new hospital tower where I worked as a new graduate nurse.

I quickly learned the day shift routine. After clocking in with our badge, we began by listening to the cassette taped report from the night shift nurse in the conference room. Then we made walking rounds with the night shift nurse and checked how much fluid was remaining in each IV (intravenous) glass bottle and marked the tape on the side of the bottle with the hour. Next we counted narcotics with the night shift nurse, both signed the book, and she handed me the keys. Then I mixed all my IV antibiotics for my shift in 50 cc bottles of normal saline. This could be quite time consuming if I had to mix 10 to 15 bottles. First I wrote out all the labels with the patient’s name, medication, time, date, and my initials. Then I gathered the glass bottles of dry medication from their tray in the medication cart and  enough 10 cc syringes from the supply cart. Next I withdrew 10 cc of saline, injected it into the bottle with powdered medication, rolled it between my hands until it dissolved, withdrew it from the small bottle, injected it into the 50 cc bottle of normal saline, and pasted on the label.

By that time it was breakfast. The aides checked each patient’s urine sample for sugar and handed us the list of results: negative, trace, 1+, 2+, 3+, or 4+.  Then I checked he patient’s insulin dose, drew up NPH or Lente, and added enough Regular Insulin (short acting insulin) to cover the amount of sugar the patient spilled in his urine. Then I went to the patient’s room and watched him inject himself while giving him further instruction.

After the patients finished breakfast, the aides started baths and bed changes while the nurses passed the 9 a.m. meds. After meds, we did treatments such as dressing changes. In between all this, we made rounds with the chart rack whenever the doctors appeared, and then processed the orders. After the MD wrote the orders on carbon paper, the unit clerk tore off the extra copies and sent them in the pneumatic tube to the correct department (lab, pharmacy, dietary, etc.) Then the nurse cosigned the order after checking their work for accuracy.

On day shift, there are 3 nurses, so each cares for 10 patients and there is one nursing assistant for each block of patients. On evenings, there are only 2 nurses so each cares for 15 patients with 1 nursing assistant on each block. On night shift, there is usually only 1 RN and 1 nursing assistant for the entire floor. This is really challenging trying to manage 15-20 IVs alone with antibiotics, hypoglycemia, etc.  It is quite a shock to me to take care of so many patients after only having 2 patients in nursing school! Probably my best preparation was the summer I worked as a nursing assistant on night shift in the nursing home and was in charge of 50 patients at night. But the nursing home patients only needed custodial care; they were not acutely ill such as these complex diabetic patients.

All patients who are diagnosed with diabetes come to our floor whether they have a medical or surgical problem. We can closely monitor their blood sugars and adjust their insulin or tablets appropriately. We also are taught to quickly recognize and treat low blood sugar with 50 cc intravenous injection of glucose if they are unconscious.

When a patient is newly diagnosed with diabetes, they are admitted to the hospital for an entire week of classes. We have a new diabetes classroom and have class every day after lunch. On Monday, we teach them about diabetes in general by showing a short 8 track film and using posters. On Tuesdays, the dietician teaches them about the diabetic diet and counting exchanges of the different food groups. Wednesdays, we teach them about the 3 different oral medications (Diabenese, Orinase, Tolinase) and the 4 types on insulin (Regular, NPH, Lente, Ultralente) and they learn how to inject insulin into a sponge for practice. Thursdays we review exercise and how to travel with diabetes. Fridays we teach them about foot care and skin care since they are prone to ulcers on their feet, and what to do when they become sick. We also encourage them to walk around the unit to get their exercise. I really enjoy teaching the classes!

I have completed 4 weeks of orientation on day shift. Next week I go to evening shift for 2 more weeks of orientation, and then I’m in charge of the whole unit. I have to admit, it sounds rather scary… Every day before I go to work, I ask the Lord to give me wisdom in making the right decision and to help me learn all this new information. I am definitely on information overload!

If any of you lack wisdom, let him ask of God, who giveth to all men liberally, and upbraideth not, and it shall be given him. James 1:5

Reflection – 2014

As I think back over the workload on that very busy diabetes unit, I can recall so vividly my feelings of inadequacy and struggles with time management and making the right decisions, especially in emergencies as a new graduate. I quickly became much more comfortable with patients with diabetes which had been a weak area for me in nursing school. There are now so many medications available to treat diabetes, that it is hard to keep up with them!

I am so thankful we now have plastic IV bags and that the antibiotics are mixed in pharmacy before they are delivered to the floor. I recall dropping a glass bottle on occasion which shattered and made a big mess!

The advent of the blood glucometer so each patient can check their own blood sugar numerous times daily has made patient management much easier. As a result, the urine dipsticks for sugar have become obsolete. Our unit piloted one of the first glucometers which cost $500, needed to be plugged into an electrical outlet, and was about 4 inches by 6 inches in size. But it was much better than calling the lab for a stat blood sugar before giving the patient orange juice loaded with 3 packets of sugar while we waited for the results.

 

International Travel Tips – Part III

“If any of you lack wisdom, let him ask of God…” James 1:5

Packing Hints

After my trip to Europe in 1978 with my three outfits as suggested by Arthur Frommer, I decided that was just a little too light to travel comfortably. I’m afraid I could not bear to look at those outfits after I returned and gave them away! All the photos looked like I seldom changed my clothes in 3 weeks. So here goes…

I start with prayer and ask God to bring to my remembrance what I should I take and wisdom to know what to leave behind. I then type a packing list and save it in my computer.  About 1 week before my trip, I copy my previous list into a new file, delete and add things that are appropriate for the country I am visiting, and print it out. I divide it into Purse, Carry-on Bag, Checked Bag, and the outfit I will wear. Then if I need to buy anything, I’m not rushing around at the last minute. I get out my suitcase a few days before and line it with a plastic garbage bag in the bottom and inside the top pocket to protect it from rain and mud puddles. (Once they unloaded my suticase from the plane in a downpour and everything was soaked including a couple books.)  Then I simply check things off as I put them inside.

LL Bean bathroom bag hanging

LL Bean bathroom bag hanging

I leave my LL Bean Bathroom bag hanging in my closet  packed and ready to go at all times. That way I just throw in a few last minute things. I like to use my bathroom bag the day before I depart as if I’m in the hotel so I discover anything I have forgotten. I always carry these items in my bathroom bag: electronic thermometer, extra foam ear plugs, immodium, chewable pepto bismol (prevents traveler’s diarrhea), Char-coal caps (to remove toxins if you get diarrhea), tylenol, ibuprofen, bacitracin, Qtips, cuticle scissors, tweezers, nail file, bandaids, shampoo, conditioner, small bar soap, Sambucol lozenges (anti-viral cures sore throat if taken first 24 hours), small sewing kit.

LL Bean bathroom bag zipped up for travel

LL Bean bathroom bag zipped up for travel

Pack light! (I still struggle with this.) Check the airline’s baggage limits. Usually the international trips still let you check a 50 lb. bag free. Leave room for souvenirs. I take my oldest underwear and nightgown so I can toss them at the end to make room for things I want to bring home. I weigh myself first on my bathroom scale, then hold my suitcase and weigh again and subtract the difference. I aim for 40-45 lb. checked bag going over. They now even weigh your carry on bag and limit it to 8 Kg (17 lb) on the last two airlines I took.

Take your PASSPORT! Show it to your traveling companion BEFORE you leave for the airport. Make 3 copies. Leave 1 at home, give 1 to your traveling companion, and put 1 somewhere in your carry-on bag. One lady drove 5 hours to the airport to go on a mission trip and discovered she forgot her passport. She missed the entire trip and lost all the money for her airfare. Expensive mistake! Enter your passport number in your cell phone contact list.

Print out your email airline ticket and hand it to the ticket agent with your passport. Email a copy to your family who stays behind. Keep both of them handy until you are in your airline seat and then put your passport in the SAME PLACE every time in your purse so it is easy to find. (My friend kept putting it in a different place and wasted lots of time looking for it.)

My travel vest with inside pockets, money belt, shoulder purse to prevent pickpockets.

My Magellan travel vest with inside pockets, money belt, shoulder purse to prevent pickpockets.

Wear a money belt and take 50 single US dollars. They are good around the world! Don’t change any money at the airport before you leave the USA as they have terrible exchange rates. Notify your ATM bank and credit card company before you go or they will shut down your card when you use it overseas because they will think it was stolen. Make copies of the front and back of them and store a copy in your carry-on bag. Put the 1-800 numbers in your cell phone contact list in case they are stolen so they are easy to call.

When you arrive at your destination, go to the ATM before you leave the airport and take out enough cash to last you a week. Your bank will charge you $5-10 every time you use your ATM so don’t take out small amounts. Stuff it in your inside pocket of your travel vest as fast as possible, then go to the restroom and put it in your money belt when you are inside the stall. Also put your passport inside your money belt at this time. Only keep about $50 in your wallet or enough to cover the taxi to your hotel. Some people carry a “dummy wallet” with about $20 and an expired gift card to give a thief if you are accosted.

Items I carry in my purse: Colgate disposable toothbrush  (doesn’t need water & has paste on it), Sea-Bands (prevents motion sickness-CVS), Zofran (by prescription) or Bonine (over the counter) for when the motion is severe, Ear plugs on a string so I don’t lose them (Walmart hunting/camping section-$3), gospel tracts in English and the language of my destination country, 2 or 3 teabags.

Items for my carry-on bag: tablet (great for checking emails and taking videos), Kindle (good for reading-battery lasts longer than the tablet), charging cords, batteries, language phrase book, small Bible, flashlight,  3 pair underwear, 1 or 2 tops, swim suit (impossible for me to find in another country if my checked bag doesn’t make it), personal medicine, collapsible water pouch ($1 Walmart). After you go through security, fill it up at the drinking fountain in the USA to save a few dollars. You can’t do this after you leave the USA because the tap water is not potable.

I carry an airbed (Coleman slim twin- Walmart $20 in the camping section) in my checked suitcase.  I put it on top of the hotel mattress after inflating it since I am most comfortable on a soft mattress. It really makes each new bed feel like my airbed at home and I sleep so much better without a backache. If you take a battery pump with you, put the batteries in your carry on bag. I forgot to do this when I went to Israel, so they leaked all over and ruined the pump. I couldn’t find any D size batteries in Israel, so blew it up by mouth the entire trip! My lungs had a good workout:)

Coleman slim twin airbed

Coleman slim twin airbed

If I am going to a hilly country, I put my collapsible LL Bean walking poles which fit perfectly diagonally in the bottom of my checked bag. They were great in Israel! The others on the tour group said they wished they had brought theirs along. They have many steps without handrails and few elevators in many countries. No country I have visited is as handicap accessible as the USA.

Jet lag prevention: Nothing works very well for me, but this is what the experts say. Set your watch to the new time zone when you board the plane. Eat a healthy dinner at the airport after you go through security. If it’s an overnight flight, skip dinner on the plane, put in your earplugs, throw the blanket over your head, and try to sleep all night.  Eat breakfast when they serve it. If you land in the morning, try to stay out in the sun all day to reset your internal body clock and don’t nap! Go to bed at the normal time in the new time zone. Take melatonin or a prescription sleep aide the first couple nights to help sleep. It takes 1 day to recover for every hour of time change. My best flight with the least amount of jet lag was when I flew all day to England, landed at midnight and went to bed immediately. I’m a very light sleeper, so I only catnap on the plane no matter what I have tried. I have to admit, I envy people who can sleep on a plane!

Stay hydrated since you lose 8 oz. of fluid for every hour you fly. Also, do leg exercises and stand up and walk hourly  to prevent blood clots. I’m high risk for clots, so I also take a baby aspirin and wear Jobst compression knee socks. I like to walk to the rear of the plane and ask the flight attendant for a glass of water in between their service times.

Ask God to bless your trip, use you for His glory and honor, trust in Him, rest in Him,  enjoy meeting people and making new friends! Remember He is the good shepherd and goes before you. “My sheep hear My voice, and I know them, and they follow Me.” John 10:27