Introduction

Hi! I am currently a nursing student in Singapore. This blog is mainly for me to remember things. Or if I can't, to store and retrieve nursing-related information when I need them: some nursing procedures, the common medications that are being used in Singapore and mostly importantly, my clinical life as a nursing student. IT IS NOT AN EDUCATIONAL WEBSITE. THUS, PLEASE TAKE EVERYTHING YOU READ HERE WITH A PINCH OF SALT AND CONSULT A PROFESSIONAL BEFORE YOU DO ANYTHING STUPID! I WILL NOT BE RESPONSIBLE! 

Like I have mentioned above, this blog contains the steps of some common nursing procedures and medications that you may also be interested to know. You can read my experiences as a nursing student to learn more about this "helping profession" too. Hopefully, you gain a little knowledge about nursing and respect it more after reading my blog! If you find anything that is questionable, please bring it up to me too, so I can clarify them with my teachers in school before I graduate and IT'S TOO LATE! Lastly, thank you for taking your precious time to read my crazy ramblings! =)

Aged Care Posting

When I first saw  Mdm K, I realised, like Ah Gong (my grandfather), she had many bruises and skin breakdown on both her arms, in varying colours too! (ranging from red to different shades of purple). She looked old and frail. 

I thought she was demented because when I asked her for her name, she told me a four-syllabus name. However, I couldn't make out the exact words and spelling of what she said but I thought it was a Japanese name and since she could really be a Japanese or demented, I thought she was the latter. Moreover, she told me her age was 35 when she obviously looked much older than that.

I realised my mistake when I turned around to look at the place and saw that the name outside Room 1 was exactly what she told me! Omg! I totally didn't expect that! First, she was still lucid enough to remember her name and second, I just assumed she wasn't and that a four-syllabus name could only be a Japanese!

I have a "natural inclination" to sayang the elderly especially when they have bruises on their arms and thus, I kept sayang-ing her while talking to her. I tried feeding her lunch too but she insisted on feeding herself with no assistance needed. Afraid that she would drop her food while bringing it from her plate to her mouth, like most elderly with dementia, I tried to use her plate to follow her spoon but she became irritated after that. She scolded me for grabbing her plate and for explaining to her my reasons. Lol. She insisted that she would not drip her food and refused to let me feed her or hold her plate. Elderly can be so stubborn. She even said I was "kpo". Haha. So fierce.

After I read her case notes, I learnt two important points about her. 1) her  2 sons "disowned" her 2) she had scabies =.= the first fact was saddening especially as it was written that she still misses one of them (if she forgets then at least it is less painful for her) the second fact was =.= omg! I just sayang-ed her everywhere sia. And how does scabies spread? Via direct contact. There are no difference whether you're a healthy young girl or a frail old lady with weaker immune system. Shit! This means my stronger immune system could not even protect me! Omg!!! I became sian after that. I should have read the case notes before touching any patient. However, the only consolation was that if she really had active scabies, the staff won't touch her too, without protecting themselves and they would inform us about her. The fact that they don't and the fact that the last report about her having scabies was in September this year probably meant that she was cured (?). I was still unconvinced and quite sian about touching or even going too near her.

The next day though, I still couldn't resist myself and kept going to her. This time round, I tried to keep my hands to myself and really did touch her LESS (instead of totally not touching her like what I should actually be doing=.=). I even told myself numerous times that if I get scabies, it's ooo..kkk.. la. If I do get it, I get it lo. Bo bian. She's worth it.

Sometimes, she felt so itchy that she asked the nurses to take out the board (in front of her chair) so that she could scratch herself properly. Of course, that wasn't attended to at all. Personally, I feel that the nurses there are quite free sometimes and they can actually just take out the board, sit with the residents and ensure that they do not fall out of their chair. However, I don't think they would ever be so nice to do this. Once, she signaled to me to help her remove the board; I explained my reasons for not being able to do so and she signaled Hui Ping to help her. When Hui Ping didn't understand her, she turned to the nurses who just brushed her aside and eventually, the resident beside her to ask for help! Sadly, that resident is slightly mentally unstable and didn't even respond to her. I think it's very sad that these people, having to live there for long periods of time, only talk to the nurses (who cannot even speak their tongue) rather than make friends with their neighbours. Just picture an old lady feeling itchy all over and failing to get help to allow her to scratch herself and relieve her itchiness. She must be feeling so terrible.. Haiz.. I tried to soothe her by talking and hoping to distracting her but to little success. I even wore gloves and helped her apply moisturizer. She also asked me to help her scratch. Lol.

I liked this lady so much that I actually went to re-read her case notes again and again to find out more about her. I specifically read the part about her skin condition because I could not bear to see her keep scratching herself and complaining about being itchy..</3 I wanted to find out what condition did she suffer from to give her so much pain (I didn't manage to figure that out). However, to my relief, I found out that she was cleared of scabies during her last dermatitis appointment! I was so happy! Mainly because I could now sayang her without fears! It is her other skin conditions (and the post-scabies) that are making her feel itchy. I feel so heart-pained for her. Poor lady.

After that, I became more willing to touch her again! I helped scratch her lightly when she complained of itchiness. She even told me not to do so because helping her scratch is dirty! Omg! Didn't expect that. Haha. I continued this on my third and last day there. I even sayang-ed her head and watched her sleep on the last day. I kind of hope all these elderly whom we interacted with would not remember us because they would then keep hoping that someone else would talk to them (?). They would then miss having us around to talk to them (?). *sigh*

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Paedatrics Posting

Even before I met H, I had already heard about him. My friends were "complaining" about him, saying he had a "bad record" with the other patients and their parents. His misdeeds were also recorded in his case notes. I also heard him using swear words freely. Though this is common, to hear it coming from a 12 year old is really quite shocking for me.

Thus, when he came over to my cubicle to find my patient, I was not too happy about it. Even when he tried to interact with me by asking me to play cards with him, I would find excuses to reject him. As I felt guilty, I agreed to play with him eventually. However, throughout the game, I was uneasy as he kept using swear words AND asking my patient to do the same. He even scolded other patients who were in the play area as well. I tried my best to steer clear of him and also hoped that he would leave my patients alone. I know I was wrong to be prejudiced against him and this is not how a nurse should behave.

Later, I found out that he is actually quite pitiful. His mother was non-existent and his father beat him frequently. This was what caused him to be hospitalized in the first place. I also heard his aunt intended to bring him overseas after he was discharged.

On my last day there, I realized that I actually cared about what happened to him. We would definitely never meet again but I hoped he would (and I told him this too) take care of himself. If no one cares for him, then all the more he should treat himself better and stay away from the "bad side"...

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Cadiopulmonary Arrest (Hospital Settings)

If you suspect a patient has collapsed,

1. Try to rouse the patient by calling his name and tapping him (eg. "Mr Tan, are you ok?" while tapping his shoulders)

2. If there is no response, take his pillow away and lie his head supine (ie. flat) on his bed.

3. Open airway by doing "head tilt, chin lift". If the patient has a cervical injury, perform jaw thrush instead. Inspect for any loose teeth, dentures or other foreign objects that may obstruct airway and remove these obstructions.

4. Check for presence of breathing by doing "look, listen & feel". Look for signs of breathing like chest rising; listen for breath sounds; feel for air exhaled from the patient.

5. Check for presence of circulation by feeling for the carotid pulse. If there is no pulse, activate "CODE BLUE" immediately.  

If there is pulse, provide oxygen to the patient at a rate of 12 breaths/ min using a bag-valve-mask (BVM). ie. provide oxygen (by squeezing the bag), 2-a-thousand, 3-a-thousand, 4-a-thousand, 5-a-thousand, provide oxygen...

6. If the patient is pulseless, lock and pull the bed out a little before locking it back, set the height of the bed to the level of your thigh, remove the headboard and screen the patient for privacy.

7. Bring the cord side down, shift the patient more to his other side to allow more room for yourself and commence cardiopulmonary rescue (CPR).

8. When the e-trolley is pushed in by another nurse B, get her to attach the 3 leads electrocardiogram (ECG) and stop CPR to obtain the heart's rhythm. Once obtained, continue CPR. The doctor would prepare to "shock" the patient if it is a "shock-able" rhythm; either ventricular fibrillation (VF) or pulseless ventricular tachycardia (pulseless VT).

If sinus rhythm resumes after "shocking" the patient, continue CPR for a minute before checking for pulse unless patient shows signs of circulation eg. moving.

9. If patient's heart rhythm remains the same, nurse B would then insert oropharyngeal airway of suitable size (it should measure from the tragus of the ear to the tip of the mouth on the same side of the patient) to maintain patient's airway. Wear clean plastic gloves as there is a risk of contact with patient's body fluids (ie. saliva, in this case).

10. Nurse B would also assemble the BVM and provide 100% oxygen (15litres) to the patient at a rate of 30 compressions: 2 breaths if pulse is still absent. If pulse is present, continue providing 100% oxygen to the patient at a rate of 12 breaths/ min.

11. If the patient has an IV access, another nurse, C, would check for its patency by withdrawing any blood clots (if any) and then injecting 3-5ml of normal saline; "flushing". Maintain this IV access by running normal saline at a slow rate. If there is no IV plug in situ, prepare for the insertion of an IV plug.

12. Nurse C would also prepare for drugs to be administered when the doctor requests for it (usually, it is 1ml of adrenaline in 9ml of normal saline/ water for injection). If intubation is required, nurse C would prepare the requisites for intubation and suctioning equipment as well.

13. Once intubated, the patient's breathing would be taken over by the ventilator. If pulse returns, prepare to send patient to intensive care unit (ICU). Maintain therapeutic hypothermia for the patient. If pulse has not return, the doctor may administer more drugs/ shock the patient again, depending on the condition.

14. Nurse C should then document all the events/ procedures that happened during the resuscitation eg. the amount and type of drugs infused to the patient at ____ hours and the patient's response to that particular intervention etc.

Back to Procedures

Haloperidol

Brand Name: Haldol

Class of Drug: Typical anti-psychotic

Mode of Action: For people with psychotic illnesses like acute psychosis, schizophrenia, there is an overactive / over-secretion of neurotransmitters in their brain. Thus, depending on which areas of nerves are constantly/ excessively triggered, they may see, hear, smell, feel or taste "excessive" things that others do not experience. Haloperidol blocks the receptors for the neurotransmitter, dopamine. Thus, excessive stimulation of the nerves are prevented, resulting in a decrease in the symptoms experienced by the patient.

Used For: Psychotic disorders, Controlling motor and verbal tics of those with Tourette's disorder

Side Effects: Extra-pyramidal side effects (various motor disturbances including inability to initiate movement, inability to stop movements, jerky and sudden movements etc), dizziness, dry mouth, lethargy, muscle stiffness or cramps, tremors, lactation, increased libido, decreased sexual functioning in males, difficulty urinating etc
Serious Side Effects: Neuroleptic Malignant Syndrome (muscle cramps, fever, unstable vital signs, tremors, change in cognition), difficulty breathing or swallowing, seizures, neck cramps etc

If you missed a dosage, just take it as soon as when you remember it. However, if it is almost time for the next dose, take only 1 dose and ignore the missed dose.

http://www.medicinenet.com/haloperidol/article.htm
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682180.html

Back to Medications

Amlodipine

Brand Name: Norvasc

Class of Drug: Calcium channel blocker (CCB)

Mode of Action: A CCB prevents calcium from being transported into smooth muscle cells found along arteries, especially the coronary arteries. Without sufficient calcium, the smooth muscles cannot contract the artery muscles are relaxed. This dilates the arteries and lowers the blood pressure. The heart gets a larger supply of blood and this helps prevent chest pain (angina) which may result if there is insufficient blood flow to the heart and coronary artery spasm.

Used For: Preventing chest pain (angina) and for high blood pressure treatment

Side Effects: Swelling (edema of the lower extremities, headache, feeling faint, fatigue, drowsiness

Serious side effects: Palpitations (rapid, pounding heartbeats) or fainting

If you missed a dosage, just take it as soon as when you remember it. However, if it is almost time for the next dose, take only 1 dose and ignore the missed dose.

http://www.medicinenet.com/amlodipine-oral/article.htm

http://www.nlm.nih.gov/medlineplus/druginfo/meds/a692044.html

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Rehabilitation Posting II

When I first fed a real patient via a nasogastric tube (NGT), I was feeling a little nervous and I even dropped one of the connecting tubes right at the start! It was quite embarrassing especially with a nurse staring at a clumsy me. Other times during lab practices, I "fed" at most 50ml of plain water. However, this time round, I had to feed 200ml of thicker fluid which flowed much much slower. Thus, the entire process was quite draggy. I lost concentration and as a result, forgot to kink the tube immediately when needed. Luckily, the enrolled nurse (EN) and a fellow nursing student saw it and alerted me! Thankfully, Mr K., my patient, did not cough and appeared fine/ normal. I made a mental note never to lose focus on my task at hand again.

The second time I fed Mr K., I was constantly reminding myself to remember to kink the tube. This time, with the experience of my first NGT feeding, everything was much better and the process was smoother-- I did not drop anything and I kept my eyes constantly on Mr K., his tube and my equipment.

I learnt that besides aspiration of fluid from the NGT to test for its acidity, there are two other methods of testing the placement of the tube. They are auscultation, the pumping of air into the tube and hearing its sound in the stomach and putting the tube into a cup of water to check for presence of any air bubbles, which may mean that the tube is displaced into the lungs. However, the best method to check for tube placement is to send patient for an X-ray. Having said that though, it is not feasible to send patient for an X-ray everytime the patient is about to be fed as there are not only manpower and costs issues, exposing patient to constant radiation, no matter how low, is harmful for the patient too. Thus, the most practical and reliable method is the aspiration method.

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