The Red Thread of Nursing Experience

An invisible red thread connects those destined to meet, regardless of time, place, or circumstances. The thread may stretch or tangle, but will never break. ~ Chinese Proverb

Calligraphy by Julianna ParadisiI’m headed for Seattle. Making the experience surreal is that I’m traveling without David for first time since we married. I’m attending the West Coast Regional Meeting of the AONN (Academy of Oncology Nurse Navigators). It’s been years since I’ve attended an out of town nursing conference. Truth be told, I’m pretty much a homebody. Home is my happy place. Yazzie (detail) by Julianna Paradisi

Yesterday, in preparation for this trip I had a mani/pedi, and Bree, my manicurist, mentioned the Chinese proverb above. I hadn’t heard of it before, but it immediately resonated. I’m sure there’s a red thread connecting David and me, and he agrees. I believe I’m bound in a similar way to my family, and a few friends too.

This trip is about forming connections. In my new role of oncology nurse navigator, it’s important not only to close gaps in my knowledge base, but to form relationships with other nurse and patient navigators. Textbooks and continuing education can only advance a nurse’s education so far: Experience is vital to competent decisions, and critical thinking. The fastest way to gain experience is from other nurses. Conferences are about nurses creating red threads of connection between ourselves by collectively sharing our knowledge and experiences.

My hope for this conference is to learn to be a better nurse navigator, and maybe find some nurse red threads.

The Nursing Dilemma of Medical Marijuana

Medical marijuana is legal in Oregon, where I practice. In one sense, this seems to be an enlightened act of legislation for patients who cannot tolerate conventional medications or simply prefer an herbal approach to managing pain and/or nausea. Its use is particularly prevalent in among oncology patients, and those with chronic pain.

Still, it’s a nursing conundrum. The issue is that marijuana remains illegal at the federal level. Because of this, many hospitals are reluctant to allow prescription marijuana on their campuses. Although a 2009 Justice Department memo recommends that drug enforcement agents focus their investigations away from “clear and unambiguous” use of prescription marijuana, it also says users claiming legal use but not adhering to regulations may be prosecuted.

In light of this, hospitals take the conservative approach: Attending licensed medical practitioners are prevented from prescribing medical marijuana for hospitalized patients, and create policies prohibiting the use of medical marijuana on their campuses.

For pharmacists and nurses the problem is this:

  • Pharmacists can only dispense medications prescribed by licensed medical practitioners. The federal government classifies marijuana as a Schedule I drug, which means licensed medical practitioners cannot prescribe it.
  • Nurses administer medications only with an order obtained from licensed medical practitioners.

Nurses may have run-ins with patients and caregivers unfamiliar with this policy, and a patient’s home medication routine may be disrupted.

Though it does not happen often, I had the experience of treating a chemotherapy patient expecting to smoke marijuana between infusions to control nausea and vomiting. Initially caught off guard, I struggled to find a way to manage the situation.

The campus did not permit smoking, tobacco or otherwise. When I reviewed the hospital policy, it confirmed that the medical marijuana was not an exception. I explained this to the patient, who was understanding, but skeptical.

Reviewing the premedication orders, the oncologist had done a good job of covering nausea and vomiting with conventional medications. I asked the patient to give it a try. Always having a plan B, I promised that if the medications didn’t work, I’d call the oncologist and, if necessary, the department manager.

Fortunately, the conventional medications worked. The patient enjoyed a hearty lunch and held it down. For the future, I recommended the patient smoke marijuana at home before appointments, and afterwards if indicated.

Several states have enacted medical marijuana laws. Do you work in one of them? How does this affect your nursing practice?

 

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.

Fast Food Nation: When Customer Service Competes with Patient Safety

by jparadisi

Drive-Thru Health Care by jparadisi

Calculating chemotherapy doses by surface area (m2) or kilograms was a smooth transition for me, a former pediatric intensive care nurse. In pediatrics, every medication, even acetaminophen, is dosed by weight. Tailoring chemotherapy doses to a patient’s weight was already a familiar concept; likewise dose reduction or withholding treatment altogether based on the patient’s lab values and assessment.

It’s a rare patient, however, who understands that her chemotherapy is prepared to order, not mixed ahead of time and awaiting her arrival, as if it’s fast-food made for the masses, preserved under a warming lamp.

This doesn’t matter as much if the patient receives his or her care in the hospital, but sometimes it creates unrealistic expectations in ambulatory oncology clinics. Somewhere along the line, good customer service has become confused with fast service, resulting in more and more patients with unrealistic expectations for their appointments.

It was one of those shifts when appointments backed up. Several factors contributed: Harsh weather conditions meant some patients arrived either late or too early for their appointments. The rapidly approaching holidays caused schedule changes for some patients. Of course, there were the normal, garden-variety delays: lab values requiring attention and patient veins that refused to accommodate IV catheters, etc.

Throughout the shift patients asked, “What’s the holdup?” Each time I thanked them for their patience, and validated the importance of their time. All shift long I explained, “One of the difficulties is that administering chemotherapy is not like making fast-food. Each treatment is made to order, measured against your lab values and tolerance. Our most important service is guarding your safety.” The explanation was received well, refocusing expectations on patient safety. Patients expressed appreciation for their nurses, oncologists, and pharmacists watching out for them.

The shift reminded me of a statement made by my husband, “Health care is neither inexpensive nor convenient,” and another one I heard a celebrity say on TV, “There’s never enough time to do things right the first time, but there always seems to be time to fix the mistakes later.”

Delivering prompt care is part of customer service, and as nurses, we should endeavor to keep appointments on schedule. However, our most important responsibility is patient safety.

How do you help patients keep their expectations regarding their care realistic?

Switching to Oncology From Another Nursing Specialty

illustration by julianna paradisi

illustration by julianna paradisi

One of the most enjoyable aspects of my recent job transition is meeting new colleagues. Not only are they a great group of nurses, but for the opportunity to exchange information.

During one such discussion, the topic was how we learned oncology. Unlike myself, a former PICU nurse, some had started out in oncology as new grads. We all agreed that nursing school does not provide much preparation for oncology nursing. The conversation then turned to “how I became an oncology nurse.” 

It occurred to me that other nurses might be seeking information about how to break into oncology nursing.

I offer this advice:

  • If you want to transition from another nursing specialty into oncology, do some research about the skills the two have in common. For instance, skills carrying over from the ICU to an oncology unit are the use and maintenance of central lines (although you’ll probably need to learn accessing implanted ports), and whole body assessments. The interpretation of lab values, and acting on them is as important in oncology as the ICU. Conditions such as SIAH, SVC syndrome, and more are common to both specialties, as is pain management. Highlight these similar skills during a job interview.
  • Consider outpatient oncology. Much of cancer treatment is now done on an outpatient basis. While outpatient nursing is very different than inpatient, it is as rewarding and challenging.
  • In the beginning, focus on one or two common cancers (breast cancer and colon cancer for instance). Develop a familiarity with their treatments, particularly the chemo regimens. From there, expand your knowledge base while gaining experience.
  • Earn oncology CE. This provides two benefits: First, it guides your focus on one or two cancers. Second, it provides certificates you can add to a resume for an oncology job interview. You can find oncology related CE at the Oncology Nursing Society (ONS.org) and The Oncology Nurse Community (TheONC.org) website offers a library tab, which is a great resource for nurses seeking oncology CE.
  • Immerse yourself in oncology culture. Become a national member of the ONS. Sign up for electronic newsletters.
  • Cultivated local networking. Join the local ONS chapter, and participate. I meet nurses seeking oncology positions all the time at these meetings, which are often attended by oncology unit managers too. Sign up as a member of a cancer department’s team for fundraising events, another way to meet and network with oncology nurses and managers while helping others.

What advice do you have for nurses, new or experienced, desiring to break into oncology nursing?

Surviving The Realities of Nursing

Adriamycin by jparadisi

Adriamycin by jparadisi

One of the things I love about blogging is conversation through comments on posts with people I may not otherwise meet. I learn as much from the comments as I do writing the posts.

I received a comment from a nursing student, quoted in part:

I am finishing up my RN degree and so want to go into oncology, but I fear that it will turn into nothing more than a loosing battle. A battle that I lose almost every day. Do you ever feel this way and do you ever wonder if the chemo is worth the pain your patients suffer through sometimes?

I think this sensitivity makes her an excellent candidate for oncology nursing. I wanted to answer her honestly. After taking a few days to consider, I responded:

You must have done some clinical rotations in oncology if you have interest in it. I’m wondering what experiences led you to believe it will turn into a losing battle? As a cancer survivor, and a nurse, I would answer, “Yes, the chemo was worth it.”
I suspect the question you might really be asking is,
“When should curative treatment be withheld or stopped?” and that is the big question in any nursing or medical specialty. I’m sure you are aware that some chemo, surgery, and radiation are done to control cancer symptoms when cure is not possible, and that is different.
Doctors and nurses do not have crystal balls. The best we can do is listen to our patients, offer advice when asked, and respect the decisions they make. Nurses are patient advocates. We cannot control outcomes, only do our best for each. Every nurse must find a way to reconcile this.

Perhaps I could have/should have added at the end, “in order to survive our profession.”

I thought about this nursing student’s question while sitting on the rolly stool gently pushing chemotherapy into the side arm of IV tubing connected to a patient. She asked how long it would be before her hair fell out.

There and then, I wanted to apologize for being the nurse dealing this blow to her self-image, but I did not. Instead, I reminded myself that the chemo might very well save her life. The blow I administered was to her tumor. Her hair will grow back.

This is how I have to look at oncology nursing for my patient’s survivorship — and my own.

Do you feel nurses face a losing battle? How have you reconciled the harsh realities of treatment with your desire to help others? How would you advise this student?

Recognizing Febrile Neutropenia in Oncology Patients

Send Help, We're Languishing (Febrile Neutropenia) by JParadisi 2013

Send Help, We’re Languishing (Febrile Neutropenia) by JParadisi  2013

Has this ever happened to you?

A patient arrives for supportive care. On examination, they describe flu-like symptoms, and general malaise. Their blood pressure is low, but since their prescribed treatment is IV fluids for dehydration, you are not surprised. Perhaps they have a fever, but just as likely, they do not. You note that they received chemotherapy earlier in the week. What is your assessment? Do you consider febrile neutropenia?

I remember taking a patient with febrile neutropenia to the emergency department. Besides malaise, one extremity was red, swollen, and hot to touch. The patient’s blood pressure was low, but still within normal limits, and the temperature was normal for age. I had a difficult time convincing the triage nurse that this patient was experiencing an oncological emergency. Fortunately, the emergency room doctor recognized febrile neutropenia, and the patient received appropriate treatment.

The presentation of febrile neutropenia is often insidious, particularly in the outpatient setting during supportive treatment. However, according to the British Journal of Cancer, not only can it quickly escalate into a medical emergency, but can also lead to a reduction of chemotherapy dosage, resulting in decreased survival rates, particularly for breast cancer patients.

Symptoms of febrile neutropenia can be subtle. Often, the only symptom is a fever in a patient at risk, but in severe cases, the patient may be unable to mount a febrile response. Fever is defined as a single temperature of 38.0°C (100.5°F) or a sustained temperature of 38.0°C for over an hour.

So, when should a nurse suspect that an oncology patient has febrile neutropenia?

Common signs and symptoms of infection are:

  • Fever over 38.0°C (100.5°F)
  • Red, swollen areas of skin, especially on the legs and arms
  • Chills or rigor
  • Sweating
  • Cough or shortness of breath
  • Sore throat or sores in mouth
  • Loose or liquid stools
  • Increased urinary frequency, burning sensation, or bloody urine
  • Unusual vaginal drainage or itching
  • Flu-like symptoms, such as head and/or body aches, and general fatigue

Any of the above symptoms presenting in an oncology patient require immediate notification of the oncologist or oncology nurse practitioner for laboratory tests, and prophylactic, broad spectrum antibiotics, or antifungals. Hospital admission should be considered based on the patient’s presentation, and risk factors.

Patients and their caregivers must be instructed to call their oncology office immediately, day or night, if these symptoms occur at home.

What barriers have you experienced in recognition or treatment of febrile neutropenia?

Nurses & Doctors: Make Appreciation Reciprocal

artist: jparadisi

artist: jparadisi

Few life-threatening or terminal diseases present themselves in otherwise healthy, alert, and charming hosts the way cancer does.

From the get-go, oncologists are not only captain of the ship; they hoist life preservers in the form of treatment to patients drowning in waves of shock after a cancer diagnosis.

In my opinion, oncologists’ hearts closely resemble those of nurses. This is attributed to the fact that although oncologists do not spend the same quantity of time with patients as nurses do, the quality of the time they spend is intense. They often form relationships with patients over years. It’s common for an oncologist to know close members of their patient’s family, also like nurses.

During my last episode of possible (it wasn’t) recurrence, I experienced this truth.

My oncologist and I share a professional relationship. One of the reasons he’s my oncologist is because I know he’s good at what he does. My husband likes him, too. They share an easy communication, which is another reason for my choice. If/when cancer recurs, I know they will cooperate on my care, freeing me to be the patient, not the nurse. This arrangement brings me peace of mind.

Anyway, I had suspicious symptoms, which landed me face down in an MRI. My appointment to receive the MRI results was scheduled at end of a workday for my oncologist.

David accompanied me. Dr. My Choice entered the exam room holding the films, clipping them to the light box.

“I haven’t looked at these yet,” he explained. “I thought we could see them at the same time.”

It hit me in a flash: Dr. My Choice likes us too. He is about to find out if he will tell a nurse he enjoys working with, and her husband, whether or not her cancer has recurred.

Snap! What have I done to him?

Fortunately, the films revealed I am still cancer free. The look of relief on Dr. My Choice’s face nearly equaled David’s.

Oncologists, (doctors) have feelings, too. This knowledge affects the professional relationships of nursing practice in the following ways:

  • When questioning an order, assume the doctor has good intentions toward his or her patient, same as you.
  • Avoid framing questions to a doctor with your personal inferences, such as opinions of whether or not the physician is “good” or “bad.”
  • Consider that doctors suffer from work overload, and burn out, as do nurses.
  • Remember: Being part of a team is catching one another when we fall. No one is on top of his or her game every time.
  • Protect the Rock Star Doctor (every unit has one) by double-checking their orders the same as you do for any other physician. Don’t let them fall to earth because you were not diligent in providing a safety net for their patients.

Education is the tool of our trade. It is our demeanor, which makes us professionals.

Helping Families Manage End of Life Pain at Home

In the oncology infusion clinic, sometimes I provide care for patients whose pain medication management is not under their control.

Typically, this patient has rapid disease progression, almost always with metastasis to the spine. They are easily identified by their need of mobility assistance. They are in pain even while lying in bed. Often they talk to you with their eyes closed. They are too sick to speak for themselves.

Also typically, a family member accompanies them. That person can recite by rote not only the name of all the patient’s prescribed medications, but the doses, and when they were last given. The caregiver provides a detailed report of the patient’s diet, stools, and urinary output. Glancing at the patient, I see he or she is freshly bathed, and dressed in clean clothes. Obviously they are well cared for.

Next, I assess for the fifth vital sign: pain. The patient’s body language prepares me for a high number. I am not surprised when they report an eight out of 10 or greater. I see on the home medication list that their oncologist has prescribed both a long-acting pain medication and a short-acting one for breakthrough pain.

I ask, “When did the patient last have pain medication?” The caregiver answers, “Last night.” I ask,  “Why didn’t patient didn’t have a dose in the morning before their appointment?” The answer is something like, “He needs to walk more.” “He doesn’t eat enough when he takes pain meds.” “I didn’t think he needed it,” and a long list more. Family members withholding a cancer patient’s pain medication are a common problem confronting hospice nurses.¹

It is my experience that when pointing out to this archetypical caregiver that their loved one is in pain, they begin crying. They almost always have the vial of long-acting pain medication in their purse or pocket. I get an order from the oncologist, and together, we treat our patient for pain.

I explain that the bone pain will not go away, it will only worsen. The patient will need more pain medication, not less. Then we discuss loss and grief, and how painful the feelings are. The caregiver sees their loved one floating away on a cloud of analgesics, and illogically thinks that withholding narcotics will keep them here longer. There may be other reasons the caregiver withholds pain medication, as well.²

How can an oncology nurse help this caregiver?

  • Provide a safe environment for the caregiver to talk about their grief.
  • Use the word “medications” when describing opioids and narcotics, instead of the word “drugs,” which has a negative connotation when associated with these necessary tools of pain management.
  • Is the patient eligible for home hospice care, which provides support and respite for the caregiver? If yes, provide the necessary referrals.

Encourage the caregiver to be brave. Appropriately treating their loved one’s cancer pain is a declaration of love.

And I say a little prayer for all of us.

Have you had similar experiences in your practice?

References:

http://www.medscape.com/viewarticle/557072
http://www.cancer.org/cancer/news/expertvoices/post/2012/05/07/just-say-no-to-pain-drugs.aspx

Nurses Can Offer Reassurance When Cancer Changes Relationship Roles

Many relationships thrive after cancer, but how?

painting by jparadisi

Self Portrait by jparadisi

I think they transcend.

In a way, a patient is lost to loved ones during cancer treatment. Roles within the relationship change. The big, powerful husband adored by his wife of many years is now too weak to get in or out of their car without assistance, let alone do his longtime chores around the house. The wife and mother who makes Martha Stewart look like an amateur has not only stopped preparing gourmet meals, but can’t tolerate the smell of cooking food either, forcing Dad to pick up deli stuff, or order pizza to feed their hungry children.

Everyone has to adjust when a family member has cancer. The roles have changed.

  • There’s a new chapter in the family medical history. The cancer patient is the unwilling author of a family cancer history. Genetic counseling is an option, but family members may not want to know the results. It depends on their comfort level with the sword of Damocles dangling above them.
  • Partners become caregivers. Suddenly, there are extra duties around the house. Some learn to help with ostomy appliances or continuous infusion pumps. It’s common to teach spouses to flush PICCs. I often assess my patient’s status by the level of distress expressed by the spouse.
  • There is an uninvited guest who never leaves: fear of recurrence. David and I married after my cancer treatment. It’s a cute story; maybe I’ll post it one day. A few years ago, my surveillance labs came back with abnormal liver function results. My doctor ordered an ultrasound. Watching the monitor while the tech swabbed my belly with a wand, I said to David, “Look, Honey, I’m not pregnant!” I laughed, the tech laughed, but I will never forget the look of pain in my husband’s eyes as he uncharacteristically admonished me, “This isn’t funny.” I felt guilty for his fear, for letting someone fall in love with me when the cancer could come back. It turned out, an antibiotic I had taken a few weeks before caused the elevated LFT results. There was no cancer, but our uninvited guest remains.

Nurses cannot make these things disappear for our patients. We can, however, be sensitive to their needs, and reassure that they’re on a well-traveled path. Remind them that the most important thing they can do to help themselves is to talk about the pressures they feel as the cancer patient, or as the partner with increased responsibilities. We can also encourage them to develop strategies against their common enemy as a couple. Finally, we can be prepared to provide information about community resources available to support them.

And hope for the best.

How do you help patients and their families adapt to changing roles during cancer treatment?