Managing The Moderately Unstable Patient: The Challenge of Ambulatory Care Nursing

When a nurse educator makes the bold statement, “The moderately unstable patient is at the highest risk,” I’m interested in knowing why. I’ve thought about this statement ever since.

Wild Card by jparadisi

Wild Card by jparadisi

She explained that the task-oriented nature of ambulatory care units (ACU) is a contributing factor. While patients in the ACU are assessed by their physician or nurse practitioner for treatment readiness, and again assessed by the infusion RN during treatment, the primary goal of these appointments for patients and providers is to administer treatment, complete the appointment, and, for the providers, to move on to the next patient. The ACU patient then goes home to fend for his or herself until the next appointment.

If you spend only a small length of time at the triage nurse’s desk answering phones, the high risks faced by these moderately unstable patients are clear:

Pain
Chemotherapy-induced nausea and vomiting (CINV)
Blood clots
Febrile neutropenia
Depression
Herpes zoster shingles
Malnutrition
This list is not comprehensive. Individual risk factors such as living alone or comorbidities also play a role in overall risk factors.

Some risk factors that might occur during the ACU appointment:

Patient falls
Adverse drug reactions
Syncope
Patient and nurse are unaware that patient is unexpectedly unfit to drive after the appointment
The above factors often occur because the nurse caring for a particular patient is unfamiliar with that patient’s baseline functioning. This puts first-time patients, and nurses new to an established patient, at an increased risk for an unfortunate event.

So, how can ACU nurses protect patients and their nursing license in this fast paced, and rapidly expanding nursing specialty?

First, stop calling your place of work a clinic. The ACU is a specialty care area requiring its own unique set of nursing skills, and should be recognized as such.

Maintain a high level of suspicion. Asking the right question is more important than having all the answers. What you don’t know will harm your patient. One of the most common examples is explaining to a patient how to care for their back pain, only to later discover that the pain is shingles, which were missed because no one asked to see the patient’s back. Other important questions are: “When did you take your (fill in the blank) medication last?” If they haven’t recently, ask, “Why?” because the answer may surprise you. Asking the right questions is an essential part of a solid assessment.

Continuing education is critical to quality patient care. While ACU nursing may seem less demanding than inpatient nursing, it requires the same level of skill and vigilance.

Sins of Omission: Latest Episode of The Adventures of Nurse Niki Has Posted

The Adventures of Nurse Niki
The Adventures of Nurse Niki

Sins of Omission, The Adventures of Nurse Niki Chapter 28, posted today. Corey describes a typical litany of ER patients, while Niki ponders who to tell what about her and Corey’s new relationship.

The Adventures of Nurse Niki is a work of serial fiction. The blog is formatted so the most recent episodes appear at the top. New readers not wanting spoilers of The Adventures of Nurse Niki may begin at Chapter 1 and scroll up from there.  Chapters are archived by month (click on the lined square icon on the home page). New chapters post weekly on Thursdays.

Off the Charts has this to say about The Adventures of Nurse Niki:

This blog is made up entirely of first-person episodes told by a fictional nurse named Niki. Each episode is short, detailed, and engaging, and it’s easy to keep up with it on a regular basis, or quickly catch up if you haven’t yet read any episodes. Jacob Molyneux, AJN senior editor/blog editor

Kevin Ross, aka @InnovativeNurse wrote a review of The Adventures of Nurse Niki, with this highlight:

Julianna has embarked on something special for the nursing community. The Adventures Of Nurse Niki is one of the most intelligent perspectives of life as a nurse. These are the experiences of a “real nurse” if you ask me. Nurse Niki is a smart and dynamic character who works night shift in the PICU at a California hospital. A good television show or fiction novel could certainly draw out the sexiness of working in the ICU, but with Niki’s story we quickly discover that this dynamic character is also struggling to cope with life at the bedside, and as a mother and wife. Hidden within each chapter the discovery is that Nurse Niki is in fact you. She’s me. Well that is of course if I was a woman.

You can interact with Niki on The Adventures of Nurse Niki’s  Facebook page. Please don’t forget to “Like” it too. Show Niki some love! Thank YOU!! to the readers following The Adventures of Nurse Niki, the retweets of  @NurseNikiAdven (Hashtag #NurseNiki) and those who Like Nurse Niki’s Facebook Fan Page. The support is very much appreciated!

Close Encounters at The Grocery Store: Thanksgiving

It’s the weekend before Thanksgiving, and I’m grocery shopping. Pushing a cart through throngs of people looking for that special can of yams, I wish I’d pinned a sign reading, “Don’t follow, Makes frequent stops,” to my rear, so people might stop running into me.

photo: jparadisi 2012

photo: jparadisi 2012

Surprisingly, most of the shoppers are in good moods. I hear the words, “Excuse me,” “After you,” over and over. Only the very young adults, shopping for holiday meal preparations for the first time, I presume, express out loud their bewilderment at the crowds. Suddenly, their attention to space and time is required. This means they have to get out of the way while text messaging, instead of stopping abruptly in the middle of an aisle where more seasoned shoppers will trample them.

In the produce section I pull a thin plastic bag from a dwindling roll to fill with Brussels sprouts. Another woman poises to do the same. I’m sure she’s a nurse, like me, although I will never know. Simultaneously, we pause at the large bin of loose sprouts, realizing we have to gather them with our bare hands, because there is not even a rudimentary tool for the task. We eye each other, smile, then I say, “Wow, how many pairs of dirty hands have been in this bin before mine?”

She laughs. “I know,” she says, “I’m thinking the same thing. I’m going to have to scrub these well, and remove the outer leaves.”

“Me too,” I say.

I’m sure she’s a nurse.

Happy Thanksgiving from JParadisiRN

*This post was originally published on JParadisiRN in November 2012. 

Why Nurses Need to Make Art

The first thing people usually say to me when they find out I’m an artist is, “Gosh, I can’t even draw a straight line.” My response to that statement is, “Nobody can. That’s what straight edges are for.”

Detail of oil painting by jparadisi

Detail of oil painting by jparadisi

When these same people discover I am also an oncology nurse, the second thing they say is, “Painting must be so therapeutic, after dealing with so much death.” My response to this statement is more complex than the first.

First, there’s not really “so much death” in oncology, as treatments improve and many cancers are managed as chronic conditions, which is great. There is still sad sorrow, however. Ironically, when I’m most engaged in a real life human drama, that’s when I find it the most difficult to unleash my creativity. On those days, I’m more likely to calm myself by going for a long run, or knitting, which I consider hobbies.

For me, the creative act of painting is often as uncomfortable as a difficult day of patient care. This is because, I believe the difference between art as therapy, and art as art, is that art as art usually begins with a question or inquiry, and most importantly, results in an insight. Art as therapy requires neither. However, if art as therapy results in an insight, it can also meet the status of art as art. Simply speaking, strong works of art, like strong nursing, involves critical thinking, not simply performing rote skills.

Attaining insight is the reason I believe it is so important for nurses to open up to creativity. Insight leads to an understanding of motivation, our own, and that of others. When we understand our motivations, we are better able to communicate with others. In this dynamic time of The Affordable Health Care Act, nurses need to publicly communicate our role in health care now more than ever.

For instance, the nurse blogosphere is full of posts championing Advanced Practice Nurses as primary care providers. Proponents focus on filling the gap created by a shortage of Family Practice physicians, and reducing the cost of care. While these goals are admirable, the time is now to take creative control of the Nurse Practitioner image by promoting the characteristics differentiating medical science from nursing science: an emphasis on preventive care, in-depth patient teaching, and patient-centered care, which are in some ways superior to that offered by medical science. By creating an image, or branding, if you will, for APRNs, they are appreciated as a unique profession, not as a watered down brand of medicine, or “doctor lite.”

Unflattering, and inaccurate images of nurses are created through tradition, novelists, and outside observers, but rarely by nurses themselves. In order to dispel the nursing stereotypes we despise, nurses will need to rise up and create new ones through visual art, novels, screenplays, and films of such quality that our vision of ourselves transcends into mainstream culture.

Note: This post originally appeared in March 14 2013 on RNFM Radio: Nursing Unleashed!

Limited Edition Giclee Prints of Love You to Death

   

October 2009 cover of The American Journal of Nursing

  In response to  numerous inquiriesthe painting, Love You to Death, featured on the October cover of the American Journal of Nursing, ( click On the Cover in the table of contents) is now available as a limited edition of 200 giclee prints. The original painting,  hand drawn and painted in oil, charcoal, and graphite on paper, translates well as a fine art print.  Print size is 17″ x 22″ with an image size of 14″ x 20″. Each print is professionally printed ( in Oregon), on premium Epson paper, using archival inks. Each print is proofed, numbered and signed by the artist.  For more information, click on tab below this blog’s header.

The Acorn Contains the Tree Images Are on My Website

Installation from The Acorn Contains the Tree. artist: J.Paradisi

Installation from The Acorn Contains the Tree at PNCA's 214 Gallery. artist: J.Paradisi

Visit my Visual Art website  http://juliannaparadisi.googlepages.com/

to see images from The Acorn Contains the Tree and read the artist’s statement.