Febrile children Oh NO!

Went to bed last night and checked on the kids before getting in myself - to find out that my eldest - kiddo had a temp. I KNEW he did, just by touching him. When I finally found a thermometer (don't know where they all went, we own like 8 of them!) and checked his temp, it was 102.9 F (39.1 C) - poor kid felt like crud. Said he had a headache and his legs were hurting and he just felt crummy. Gave him some tylenol and tucked him back into bed.

Gave him tylenol and tucked him in for the night. Thankfully in the AM it was normal again. I was also thankfully that he wasn't feeling nauseous since he has a SUPER finicky/sensitive stomach and vomits VERY easily.

When he was young, I couldn't force him to eat because if I did he would vomit it all up and then I would be further away from my goal than I would have been if I had let him stop eating when he wanted to.

I also know that when kiddo says "mom, I don't feel so good" I need to find him a container to vomit in IMMEDIATELY or else it's going all over me or right in front of him, and that could mean on the floor or all over the car! Such was the last time I did drop off for visitation.

He has hockey tomorrow, hope he's feeling all together better. I hate seeing the kids sick.

Steven Johnson Syndrome

I don't know about those who read the blog, but this is something that I have seen several times. When I first learned about it, I thought it was a rare occurance. However, we have someone on our unit who I SWEAR has it! Not that he's been diagnosed with it - doctors just think of it as a toxicity to one of the meds that he WAS on. That being said, when I started to peruse the internet about it, I learned that it IS indeed a side effect of one of the medications the pt was on.... dilantin. Prior to my perusing, I was under the impression that those who experience this VERY PAINFUL condition, that it's mainly due to a reaction to antibiotics or NSAIDs.

When I found this I had an "a ha" moment. I honestly don't think that the doctors on our unit managed this pt's condition well because he wasn't diagnosed with this.

This is the sort of things that the pt was experiencing....

Now his appearance wasn't as severe as the flank picture, and his oral mucosa wasn't this severe - but you can see how bad it can actually get. It can LITERALLY affect EVERY part of your body - and it's just like a SUPER SEVERE sunburn, and therefore you see blisters, weeping skin, peeling, etc. And they treat this condition as they would burns - preserving the airway because sloughing can occur in/on ANY part of the GI system - from the mouth to the anus, and the respiratory system as swelling can occur and these two things can compromise the airway. It's something that should be monitored closely.

Our poor patient blew up like a balloon, he was soooo sick. And because of restraints, blisters tended to form right under those and were so painful for him. Unfortunately he needed the restraints so you often felt bad having to go into his room to do personal care because you would have to fiddle with the restraints and turn him from side to side. VERY painful.

So be cognizant of seeing something like this and that it can become WAAAAY worse in a VERY short period of time. I wish that I was around when our guy was acutely ill because I think that he would have gotten the care he deserved. But I think that if the doctors had never seen anyone diagnosed with it previously, it's hard to connect the dots and come up with the correct diagnosis and therefore the correct treatment. I just wanted to share this so that anyone who reads this blog, will know that this is possible. My patient had this occur because he was on Dilantin - for seizures, but the docs didn't recognize his symptoms as SJS but treated it like it was an adverse effect - ya it SURE was but they certainly didn't treat it as SJS. Poor guy either way.

Manager's should leave well enough alone!

I'm an RPN (LVN/LPN for those US ppl) and at my hospital we get to practice to FULL scope - which means that we can do ANYTHING an RN can, minus take care of unstable patients.

So on one of my evening shifts I had the privlege of carrying 5 pt's - one where the family is over bearing and there looks like there's going to be legal action taken against the hospital as the family feels that the hospital has caused their mother's stroke (for another post); one pt that is a total care, but she turns really well, and she's a diabetic which means glucose testing and insulin; another pt is independent and only requires 1800 meds. Then I was supposed to get TWO admissions! Now one is enough but two REALLY sucks! And this I knew was going to be the case as soon as I started my shift. CRAP, CRAP, CRAP!!! At least that's what I said in my head.

The ONLY saving grace was that one of the new grad RPN's was going to be shadowing me for 4 hrs. GREAT! And good thing I had her or else I would have been screwed!!! Before the newest patient came up, I took report on the second patient. This is the report for patient number one...

Female in with confusion NYD (not yet diagnosed) and diarrhea. But she was in FOUR POINT RESTRAINT!!! Ok flag number one! Ok, on with report.... aggressive with staff and that's why she has the restraints on. She's on 40% oxygen by mask.... flag number two!! Then I get given her VS - temp normal, pulse in the 90's (okies... sorta), BP normal, O2 of 96% on said oxygen.... but flag number three and probably most worrisome was that her respirations were 40!!!! Yeah this doesn't sound normal... I was told that pt was stable and that there was a referral for a Dr - one that I've mentioned before I had to call in the middle of the night (refer back to my post about my pt with seizures and a back compression fracture). Another issue I had while I took report was that this pt was a diabetic, NPO but only on NS (normal saline) TKVO (to keep vein open)... which didn't make ANY sense because you would think that critically thinking that this pt would become dehydrated since she had diarrhea, was NPO and was a diabetic... ok whatever, I'll bring it up with our MRP (most responsible physician) who would be responsible for this pt - and get her started on D5W at 50cc/hr or something like that. At least that way you are addressing the dehydration possibility AND the diabetic sugar levels.

WELL, when this lady came to our unit, she looked and more importantly SOUNDED terrible!!! I don't know if any of you have ever heard of the "death rattle"... the sound that the chest makes when a person is close to death and aren't swallowing their saliva and these secretions go into the chest and make it sound all congested.... well that's what this lady sounded like. It was crazy - and all of us nurses were like, "why is this patient even coming to our unit, she should be going to ICU"....

The porter, RPN shadow girl and I transferred this patient onto our unit bed and away we went with our assessments. I had the other RPN take the respirations and I would get her BP, pulse and O2 sats.... Again BP was fine, pulse was elevated and O2 sat was 80%!!!!!!!!!!!!! And that was on 40% Oxygen - 8L per minute... MRP was on the unit and I went and grabbed her and had our unit clerk page support (part of our code blue team - which in essense is like me calling a silent code blue) - put the patient in high fowlers and went to grab ventolin and atrovent as well as suctioning equipment. RPN gave us a 40 resp rate and I gave her the suctioning equipment while I set up the breathing treatment. While she was on 100% O2 - during the breathing treatment - her level stayed above 92% - but once we put her back on the 40% she would bounce between 67%-94% sats... the 67% happened often because she was also having periods of apnea and would only breath once you verbally stimulated her.

Once she was stabilized a bit - where she was sitting above 80% sats for more than 5 minutes - I spoke with my UL (unit leader) about what this patient looked like clinically. She asked me whether I wanted someone else to take over. I told her no - that although she was unstable, she was stably unstable and that I felt that I was supported by many people on the unit. I had the MRP there, that if things changed that I have SEVERAL RN's on the unit that could take over, and that support was already paged and I knew what threshold to initiate calling a code. I also indicated that since I had the other RPN, I could stay with this stable patient in a closer fashion than is normal, for our unit.

Therefore I kept this patient... Thankfully I had the other nurse, who then took the initiative to take the blood sugars on the other people, as well as this new pt... and give meds, while I was caring for this new patient pretty much on a 1:1 basis.

About an hour later support came and assessed the patient and then got the other referring doctor to come see the patient and made the decision to put this patient in the ICU - all the while we are ALL in agreement that this patient should NEVER have come to our unit! The support nurse thankfully found a spot in the ICU and put that stuff all in place - without having to go through many hoops that would generally have had to occur and instead it was going to be a trade off. When this patient went to ICU, that I in turn would get an ICU patient back to me (one that was ready to be D/C'd from ICU though). By the time that that happened, I had this patient for almost 3 hours... it was craziness!!!! My lady patient was so unstable that we sent her, not by stretcher, by left her in our bed and wheeled her down the hallway to ICU. With me in tow, ensuring that she breathed.

It was funny bringing her to the ICU because when I gave the nurse taking over, report, she asked me if I would ever consider working in ICU... when I told her yes, she told me to apply for a job. I had to tell her I had to wait another year and a half until I finish my RN, and then maybe I would. I think that this shocked her. LOL

Thankfully I didn't end up getting ICU guy, even though I took report, because I was told that he was quite a handful (had him my next shift and yes he was!!!). Just as I transferred my lady to the ICU, I got my second admit, who although not unstable, was still pretty sick. She was septic and the poor lady had chronic liver cirrhosis and her belly was BIGGER than a lady at 9 mos pregnant - and anyone who reads this and has been to that point - you can totally empathize with her.... sooooooo uncomfortable!!! And her poor legs looked like tree trunks they were sooooo edematous.

Much to my surprise, half way through my shift, when my RPN pal went home, another nurse on my unit helped me by unloading one of my patients - which was UNBELIEVABLY helpful!!! When she did that, she lightened up my load tremendously and allowed me to focus on the unstable patient, but still touch base with my other patients since they were all in the same area and the patient she took was in a TOTALLY different part of unit. Bless her heart!!!

Such a crazy shift! Hope I don't have one of those for a long, long, long time to come! I guess it serves me right since I've had such quiet, easy going shifts before this... I just had a feeling that it was the calm before the storm, and WHAT a storm it was! But I guess it made for a fast and interesting shift and an interesting story for here.

Also - this is being investigated because if the nurse had done her assessments thoroughly, she would have noticed the respiratory distress, should have realized that this patient was NOT suitable for my medical unit, and SHOULD have contacted the physician to indicate this. ALSO, IF the manager of the ER hadn't gotten involved and MADE the nurse call my unit to send this patient to MY unit, the patient could have been given enough time to be assessed by the referred doctor and wouldn't have been sent to my unit in the first place (IMO!). Interesting all the way around!

The Business of being born

Today I watched the documentary "The business of being born" and it's something that I feel strongly about... I don't necessarily think that every woman should have a home birth - but I certainly think that less intervention during labor and birth should be done.

Birth is a natural process IMO - and though I believe in a woman's choice to pain control - I also believe that birth takes time and as shown in this documentary, many hospitals don't give women the time it takes to have a baby. I agree with the documentary that hospitals have time lines, and if laboring women don't stick to them, interventions occur.

I know that in this day and age, we want immediate results and as such this has affected how labor and delivery occurs. What is too often seen is a pt getting pitocin or being brought back for a c-section, which isn't always necessary. That's not to say that c-sections aren't required for some circumstances, but I often think that these are being done too often because establishments (hospital policies, doctors, etc) are saying that it's unsafe for a woman to be in labor without change on a regular basis (cervix dilation, baby dropping into pelvis, etc).

I postulate this - approx. 20-30 yrs ago - my mother's generation, how likely was it to hear that women had labor that existed for DAYS???!!! And this was alright with physicians!!! I think that a page from yesteryear should be brought back. That's not to say that babies should be let to go a month without delivery - as my mother did with me!

It's ALRIGHT to let women labor, and to deliver without interventions like vaccums and pitocin augmentation. There is a time and place for these things but it shouldn't be a majority like it is currently.

I also think that doctors need to move over and give space to midwives. Physicians have a place in labor and delivery but they don't provide the same kind of care that midwives do, plain and simple. How many OB's do you know that stay the entire length of a woman's labor AND deliver them??? Probably less than 5% if there were stats done on this! Physicians mainly come in to provide interventions, whether that be epidurals, breaking of the water, etc and at the VERY end, just prior to crowning and simply deliver the baby (on most occasions).

I have had two children - with my son I used an OB. At that time, there were NO midwives in my city (that I knew of anyways), and I'm thankful that I had an OB because my water was meconium stained, we had difficulty with pushing (managed it without vaccum OR forceps) which caused oxygen issues with my son and I required an episiotomy in order to help get him out fast enough. His APGAR scores at birth was 3!!! At one minute it was 5, and at five minutes it was 7! Pathetic really! He required resuscitation. Little did I know (at that time, I learned this later) that a code pink was called for my son!

For my daughter, I used a midwife. I LOOOOOOVEDDDDDD the entire experience.... UNTIL I developed PIH (Pregnancy Induced Hypertension) and was on the verge of developing HELLP which is a DANGEROUS form of preeclampsia. I was hospitalized for 5 days for close monitorring and almost delivered my daughter at 30 weeks. YEEKS! (For those interested in reading all about my crazy whirlwind pregnancy I have another blog for that - just ask and I'll give you the site). Now because this happened, I lost the ability to use JUST a midwife - instead, my midwife and OB developed a relationship - for MY benefit where I could go for appointments with my midwife unless there were issues, and my OB was simply her back up. That worked for a couple of weeks until things changed on the home front and we decided that we were going to move south - figuring that we were going to move there eventually and that's where all the NICU (neonatal intensive care unit) level III & IV were found - because I was told the likelihood of me making it to full term were NIL (HA, little did they know!!!).

I think OB's rrreeeeeaaaaalllllllyyyyyy should ONLY be used for higher risk or complicated pregnancies. There is a shortage of OB's and I think that they should be utilized in the best possible way - NOT for low risk pregnancies. Keep them for the people who actually DO need them. Thus in turn, utilize the available resources out there - MIDWIVES!!! They go to school for a reason, and it's not for a short period either.

Something funny the little tyke said...

So lately my darling daughter has been cursing, like a truck driver, or a sailor. Either one is a fitting description. And she will do it at the ODDEST times! And it has us giggling up a storm.... which doesn't help to curb it but seeing it from such a cutie is difficult to stifle oneself from laughing.

Take this evening for instance....

I was sitting on the couch, and I've been trying to potty train the dear darling for the past week. Some success I might add. And today happened to be a trying day as far as peeing on the potty goes. So when she had told me that she had peed NOT on the toilet but in her pull up I told her (in no uncertain terms) that she HAD to go sit on the potty.

And WHAT is the responsible from my not even three year old???..... "that's BULLSHIT mommy"

OMG!!!! I couldn't believe she had said it (she's only said it once before - cuz it's not something she hears of much). And the fact that she had said it in a manner that would totally apply to this situation. Oh yeah, the whole room of ppl started giggling as mommy tried to be stern (with not much luck) and mutter "little tyke that's not nice, we don't say those things and you HAVE to still sit on the potty" and of course I included the "mommy" look for good measure and off she went to sit on the potty.

WOW - what am I going to do with this one?!

More on her growing antics another day tho! I shall leave you with a couple of pics of her....

She was telling me that she was going to go "bye bye" - in her PJ's with sandles on and it was snowing outside - oh and it was like 11pm at night!!!! YA NO!

My little sassy girl - quite the diva she is... hope it's not indicative of what I should expect in 10+ yrs!

I need to live somewhere else!!!

Living in this house is starting to make me depressed. Can you believe that I actually escape TO the gym???!!!! I thought that THAT would never happen but alas it does! I wish I could have tonight but unfortunately, today is "family day" for those of you Canadians - "President's day" for those American folk who read this blog, and with that comes early closure times or not open at all.... and my gym closed aat 3pm today. And of course when I wanted to escape, it was after that time.

The next best thing... a bubble bath, BY MYSELF!!!! I locked myself in my in-law's bathroom for an hour and a half and caught up on Pan Am and just enjoyed the quietness. The awesome thing about their bath tub is that it has jets... which is UBER fun with a bit of bubble bath.... INSTANT bubbles. And when the bubbles get too high, you turn off the jets for a bit and the bubbles go down. When they get a little too low, turn the jets back on and voila bubbles again!

Now of COURSE hubby tried to come into the bathroom.... which I wouldn't let him - he'd just interfere with my serenity. Then came little tyke- who OF COURSE insisted that SHE needed a bath. And I mean, who could blame her. So I let her in after listening to her bang on the door and whine for about three minutes. She LOVES baths now so it was fun watching her enjoy the bubbles. Of course hubby could hear that I let the billa (nickname for her) into the bathroom so he had to come and bug us. It was fun while it lasted and seemed to poop out the little tyke .and once bathtime was done I put lotion on her (with her help and insistence of course) and pajamas then off to bed she went.... without much of a fight either I might add!!!

Sometimes I just hate being in such a small house with sooo many ppl in here. It's cramped and we don't have a viable living area for just us. It sucks!!! It makes me frustrated and angry and depressed many times. It also sucks that when stuff happens around this house that I am not included in ANY of the communications because it's done in Urdu and I certainly don't understand enough of it. Of course none of his family (incl. hubby anymore) takes this into account because they're selfish (IMO) and could care less that I don't understand.

Many times I wish that I could fast forward a year and a half and be in Texas already!!! I want to be finished school, I want my RN degree to be completed and I want my OWN house with hubby SOMEWHERE ELSE!!!!!!!!!!!! Where it's JUST US (and kids of course).

I know this is probably not the lightest of posts but there it is... my REAL life!

My dinner BLEW UP!!!!

Last night when I was at work, I brought my dinner with me. My MIL had made palau - a rice dish with chicken. VERY yummy. Was VERY VERY much looking forward to eating it. So when I went on break I put my dish in the microwave, as I've done a million times!

I put it in for TWO minutes, and when the microwave said ONE second, I heard it go KABOOM. When I opened the microwave I saw this.....................

OH MY GOODNESS!!! I could barely imagine it so I took a picture - cause WHO would actually BELIEVE that this happened?!

Thankfully the cafeteria was still open, UNFORTUNATELY I ONLY had my credit card available and at the cafeteria you HAVE to buy $10 or more in order to be able to even USE it!!! Crappy part is that I'm on a diet and so it's not like I can buy pop, or chips or dessert.... they have unhealthy stuff there. So I had to buy two soups (delicious tho- butternut squash) and two vitamin waters (at $3 each which SUCKS!). I had my dinner and then went back to work.