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student nurse

Focussed Clinical Question (part 2)

29 Jul, 09 | by John Offen

I have a focussed clinical question!  Whilst working on the pain list, I note that patients receiving epidural steroid injections in their spine have to lie down for 20 minutes after their injection.  I am told that this is to reduce the chances of them developing a headache following their procedure and that they used to lie down for much longer.  I decide to look to see if there is any evidence to back this up.  My question is “For patients undergoing lumbar puncture does bed rest result in reduced incidence of headache compared with no bed rest?”.  Searching for “lumbar puncture and bed rest and headache” in Evidence Based Nursing (http://ebn.bmj.com/search.dtl), I find an article that seemed to answer the question “McArthur J (2002) Longer bed rest does not prevent more postpuncture headaches than immediate mobilisation or short bed rest. Evidence Based Nursing. 5;87”.  I am pleased to find this article because I know that only quality research is summarised in this journal.  In addition, the title of the piece answers the question immediately, and the article itself consists of an easily read synopsis of the relevant research (in this case a systematic review of randomised controlled trials) without too much unnecessary detail.  The article also includes a commentary which provides a simple explanation of the research and its application to practice.  The conclusion appears to be that contrary to the previously perceived wisdom on the subject, there is no evidence to suggest that bed rest after lumbar puncture reduces incidence of headaches.  Flushed with success I print both this article and the longer systematic review to which it refers in order to examine them more carefully, and resolve to search for further more recent evidence perhaps in some of the bibliographic databases (for example Medline). 

Young Lives Cut Short

6 Jul, 09 | by John Offen

An ex-colleague died of a sore throat today.  It was an apparently innocuous infection that eventually affected his heart and lungs, and despite intravenous antibiotics he died.  I did not think that people died of infections any more in our medically sophisticated western world.  He was a talented and intelligent man, had just been promoted, he loved his wife and his dogs, and was younger than me.  The same day I hear that an 11 year old in my son’s year at school has died of a brain haemorrhage.  Life can be very cruel.  I start reflecting on my own mortality and end up feeling melancholy.

Focussed Clinical Questions

29 Jun, 09 | by John Offen

Today I have a day off, and enthusiastically start to look for a ‘revolutionary’ piece of evidence to introduce into the day unit.  I know that Evidence Based Nursing (http://ebn.bmj.com) and The Cochrane Library of Systematic Reviews (www.cochrane.org) are good places to look for quality evidence, but I don’t really know what I am looking for.  I notice that the majority of the reviews concern drug treatments, or the efficacy of certain surgical procedures and that as a student nurse I am not in a position to influence either.  I find an article about knee surgery.  For one awful moment I have visions of trying to confront Mr Shetland the orthopaedic surgeon with my piece of evidence.  Mr Shetland is not an easy man to work with.  He is an excellent surgeon I have no doubt, but I have watched him reduce his theatre staff to tears as he bombarded them with a sustained barrage of criticism.  Rumour has it that his reg walked out on him.  Trying to discuss my piece of evidence with him is unthinkable.  This is an ignominious start to my aspirations to spread the word of evidence based practice.  I have fallen before leaving the starting blocks.  I spend another hour scanning through endless articles about the merits of using indigenous health care workers in treating indigenous children with asthma and other esoteric topics before realising I am wasting my time.  I remember being taught at university about the necessity of a focussed clinical question, and realise that that is what I need.

Mature Students

18 Jun, 09 | by John Offen

‘Played centurion again last night with the medical students,’ comments fellow student Dave during a quickly snatched tea break.  I have to admit to him that I need further explanation.  ‘Oh you have to drink 100 shots in 100 minutes,’ he explains cheerfully, ‘and the last one to throw up wins’.  ‘Sounds like a good laugh,’ I comment hoping that my horror at the idea does not show.  Clearly Dave is a man who embraces all that student life has to offer.  I realise how different my outlook is as a mature student with a family than when I was Dave’s age and centurion might have struck me as being a fun sort of thing to do instead of a wet form of Russian Roulette.  We nursing students are a diverse bunch but united by the trials of juggling the academic, time and financial pressures of studying nursing.  Not only do we have to fulfil our placements hours, and cope with university lectures and assignments, the vast majority of us also hold down jobs to stave off financial ruin.  Add to this that many of my fellow students are mothers running a household and it is no wonder that nursing courses have such a high drop out rate.  My next assignment is on health promotion, and I make a mental note that Dave could be a good subject.

Breathing

10 Jun, 09 | by John Offen

“He’s on the throne,” called Mrs Tonks from within the small cottage.  “On the phone.  How long will he be?” queried my mentor?”. “Not the phone, the throne.  He’s on the commode” she laughing good naturedly.  By the time we reached the living room, Mr Tonks was ensconced in his threadbare easy chair puffing like a steam train.  His blue tinged hands reached anxiously for his nasal cannula, and he sucked deeply at the meagre 2 litres of domiciliary oxygen which oozed from the concentrator behind his chair.  It was minutes before he was able to utter a word.  He looked deadbeat, like he had just finished a marathon, rather than moved a few feet from the commode to his chair.  I found this man’s desperate struggle to breath after so little excursion shocking, and resolved to find out more about oxygen therapy.  I started with  a recent article in Nursing Standard about the use of domiciliary oxygen.  I also found a Cochrane review that summarised the evidence base for domiciliary oxygen use.

 

The following day we visited another couple afflicted by respiratory failure.  Mr Little and his wife lived in a beautiful village house overlooking a lake, but Mr Little had pulmonary fibrosis, a serious disease where the alveoli and lung tissues become damaged and scarred.  Whilst we took a blood sample from Mr Little, his wife wheezed and coughed distressingly.  “I have emphysema,” she gasped.  Mr little was getting used to using a permanent oxygen supply, and clear plastic pipes snaked across the plush carpets.  He started telling me that he had been given conflicting advice on how long to use his oxygen each day.  One nurse had thought that it should not be used for more than 15 hours per day, whilst the GP had suggested using it 24 hours per day.  Did I know which was right?  Pre-armed with my recent reading, I prepared to explain that research had shown that mortality in patients with severe hypoxaemia was reduced if oxygen was used for more than 15 hours per day, but Mrs Little was to quick. “He won’t know – he’s only a student,” she scolded her husband abruptly.  I felt slighted.  OK I was only a student, but I had been taught to read and appraise evidence, and to try to apply it in the real world, and here I was at last doing it for real, only to be told that knowledge was the preserve of the experienced.  I felt pleased that I had looked at the research, and this empowered me to promote best practice, but was reminded that sometimes it is not what you know, but who you are that carries weight.

 

Notes on evidence base

 

The Nursing Standard Article was:-

Lynes D and Kelly C (2009) Domiciliary oxygen therapy: assessment and management. Nursing Standard. 23 (20) 50-56

 

The 15 hours guideline emanates from the following research paper:

Medical Research Council (1981) Report of the Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981 (1) 681–5.

 

A broader review of the evidence base can be found in:-

Cranston JM, Crockett A,Moss J, Alpers JH. (2005) Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001744.

Dignity

5 Jun, 09 | by John Offen

Dignity in practice is a hot topic at present.  The media regularly publish horror stories of poor care, and it is drummed into us students that we must put dignity first when dealing with patients.  Furthermore, the community practice where I am working is undertaking a dignity survey, canvassing patient’s experiences of the district nursing service, so when my mentor and I visited elderly Mrs Potts, dignity in care was ringing in our ears.  Mrs Potts had a sore bottom, and we had been asked to visit to assess it, and plan the care needed.  We introduced ourselves, and explained why we had come.  Mrs Potts was a little upset.  Nurses from another practice had already visited that morning to take some blood, had not said who they were, and had left the back door open when they left.  She had made a complaint about them.  Ah we thought, how lax of them.  We would have expected better things from our fellow nurses.  Perhaps we secretly felt slightly smug that our team were more professional.  Mrs Potts was initially anxious about baring her bottom, so I discretely left the room whilst my mentor, after seeking permission, gently inspected the offending buttock.  When we got up to go, Mrs Potts became distressed about some family issues, so we stayed and chatted to her for a while.  I was impressed by my mentor’s quiet caring attitude.  We left promising to come again to check on her, and she thanked us for our efforts. As we departed, we were surprised to find that the door latch was jammed, and only some deft work with a pen allowed us to secure the door. “What a lovely lady,” we commented to each other as we drove back to the office.   A shock awaited us.  Mrs Potts had just rung in to complain about a nurse and a student who had marched into her house, and pulled down her pants without a word about who they were or why they were there.  I was stunned.  I could not imagine how my mentor could have treated her with more respect or kindness.  It was fortunate that I was there to witness the good quality care that actually took place.

My First Crash Call

27 May, 09 | by John Offen

Today I witnessed my first crash call.  To be honest I did not actually realise what was happening till I saw nurses running around shouting ‘where is it?’.  I followed the general stampede, and with a move worthy of a rugby forward about to score a try, dodged past two health care assistants trying to stop me adding to the numbers in the already crowded room.  I was not going to miss this, perhaps my one opportunity to attend a crash call during my training.  Doctors and nurses swarmed around the unfortunate patient who had suffered a massive MI on returning from surgery.  I was alarmed at how disturbed I felt about the experience.  This was real exciting medicine, but somehow it did not feel like that.  I felt sad for the old man in obvious pain and distress amongst a room of strangers who did not even know his name.  They fought to save his life, but in a strange way he, the man, was forgotten in the process.  I knew it was important for my training, but I felt slightly ashamed to be a spectator intruding on this private tragedy.

Day Surgery – my first week

21 May, 09 | by John Offen

Sunday

Tomorrow I start my new placement at the local hospital.  For the next eight weeks I will be nursing student in residence in the ‘Day Unit’, and am looking forward to getting stuck in to some practical nursing after all the essays and course work.  I am also planning to try to put into practice some of what we have been learning about evidence based practice at university.  I feel a little aggrieved that once more I do not have a ward placement.  Half way through my course, and my tally is two nursing homes, an outpatient department, and one seven week placement on a surgical ward.  I know that nursing is becoming less and less about hospital wards, but I am starting to dread meeting my fellow students and hearing them talk so knowledgeably about things I have barely heard of.  I console myself with the thought that we probably all feel the same, each suspecting that others are getting better experience than we are.  Still it’s scary to imagine qualifying and being let loose as a ‘real’ nurse any time soon!  I have heard nurses saying that it all comes together in the third year – I hope so.

Monday

I must say I enjoyed my first day.  It involved managing a list which consisted of three gentlemen for vascular surgery.  I struck up a good relationship with all three, relieved after my previous placement in outpatients to spend more than a few moments with each patient.  Managing the list seems to involve admitting the patients, taking them down to the day theatre when called for, collecting them afterwards, and monitoring them during their recovery through to discharge.  It does not seem too difficult.

Wednesday

My first clinic was not representative.  This is hard work.  I fondly remember the coffee breaks and business meetings of my previous career in IT as I shift my weight from one aching foot to the other.  What possessed me to throw away a good salary and a nine to five job for this?

Friday

I had my initial interview with my mentor today.  She oozes calmness and experience, and tells me I am doing well.  I am not so sure.  I am in awe of the staff nurses’ multitasking abilities.  In my previous career I kept a ‘to do’ list which I reckoned was a pretty reliable and efficient way of organising myself, but this is different; there are hundreds of things to do every day, and they all seem important.  I realise that you are not remembered for the ninety nine things you remember to do, but for the one that you plain forgot about.  I have had decent results in my exams and assignments at university, but sometimes I just don’t feel clever enough to be a nurse.  The experienced nurses manage it all so effortlessly.  How will I ever be able to do that?

Evidence based confessions of a student nurse

Evidence based confessions of a student nurse

John Offen on evidence, ignorance, triumph and tragedy in student nursing. Visit site

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