It seems some things come in waves. A few weeks ago every time I got an admit it was a GI bleed, in the last 2 weeks it's been kidney/renal problems.
For some reason I find kidneys to be mysterious organs - maybe it's because it seems like they are hiding back behind the rest of the organs like they have a secret? Or the fact that you have 2 of them, but can live with 1? Anyway, I thought it was a great opportunity to review the basics.
First, this short 45 second video is a great big overview of the kidney (plus the English accent is funny- especially the word for capillaries):
All right, so we know the kidneys produce urine. But that's not the only thing you kidneys do!
Here are some of the other very important and necessary functions of kidneys:
Excretion of waste:
Kidneys remove waste produced by your body's metabolism. Major waste products would be urea (that makes up uric acid) and nitrogenous wastes. To much of either of these waste products does intense damage to the body and brain. Often times in renal failure people will present with altered mental statuses because of the build up of waste products that starts to affect their level of consciousness or even personality.
Acid/base balance:
Our body tries to maintain a neutral pH. Carbon dioxide (CO2) and hydrogen ions (H-) are both acidic substance in our bodies. Bicarbonate (HCO3) is a basic substance in our bodies. Our lungs regulate the CO2 through breathing. Our kidneys can regulate HCO3 by not filtering it out of the blood and into the urine. The kidneys can also regulate acid by filtering out H- from our blood and into the urine.
Fluid volume regulation:
The entire goal of the human body is to reach homeostasis. With everything. Really, your body is like Goldilocks, it doesn't want things too hot or too cold, too acidic or too basic, too full or too empty. Fluid volume is another one of these markers.
The body- more specifically the hypothalamus in the brain- is constantly monitoring your fluid volume and telling the kidneys through hormones messages - "okay - we are too full, take more fluid off " or "we haven't had a drink of water all day - get rid of waste, but hang on to the water!!!"
Blood pressure:
This is related to fluid volume, but also to your body's needs. If you go for a run, your blood pressure is going to go up because your heart is pumping and your muscles are demanding more oxygen and want to get rid of waste. Blood pressure at the kidney level has to do with the retention of sodium. When we need our blood pressure to increase, the kidneys get a signal to retain sodium, because water follows salt. When you keep your sodium, you keep your fluids and your blood pressure increases.
In cases where someone has high blood pressure because they are unhealthy or sick, one medication that is often prescribed is a diuretic. These medications often cause the kidneys to release the sodium into the urine. Again- water follows salt - the salt leaves, so does the extra fluid, and voila - your high blood pressure patient's blood pressure decreases and they have to urinate fairly frequently.
Production of red blood cells:
So far we have talked about hormonal messages traveling to the kidneys to activate a response. However, kidneys are responsible for releasing their own messenger called erythropoietin. When the kidneys sense they are not getting adequate perfusion (meaning their own red blood cell/oxygen supply is not sufficient) this hormone is released and sent to the bone marrow to stimulate the production of more red blood cells. In patients with renal damage, they tend to be anemic because this function is damaged and the bone marrow never gets the message to make more red blood cells.
Now go drink some water and appreciate everything your 2 kidneys do!
I live a blessed life where I see both sunrises and sunsets every day that I work because I am awake for both. My last night at work this week was crazy busy and I came off my 12 hour shift with a big dose of adrenaline, so on my drive home I stopped and snapped some photos along the way.
sunrise in the side view
sunshine in color, review mirror
sage brush sunrise
"Keep your face always towards the sunshine- and shadows will fall behind you" -Walt Whitman
Denial is a big river that meanders and has no real direction. Some people cross this river in a speed boat. Others are on tubes that get caught in the eddies spinning around and around. It is one of the many stages of grief, but one of the hardest to watch in my opinion.
Sometimes patients are not going to get better and the discussion to change care from aggressive treatment to comfort care is a difficult one to have to begin with. It's even more challenging when family members of a patient cannot acknowledge the end is inevitable and the nurse or doctor's message falls on deaf ears. This leaves a patient in a "no man's land" where we continue treatment and delay hospice.
I also personally think this is forcing the patient to have quantity over quality when it comes to last days of their life. I think it should be the inverse - quality over quantity. If my terminal patients could all go home on hospice and enjoy their families and be at home to die peacefully and comfortably with their cat on their bed, death would be a much gentler experience in our culture.
Acceptance is not something that can be forced, but taking care of a patient that is suffering and not going to get better is an emotional burden that I did not expect. I've spoken to other nurses on my unit and all of them have stories of feeling like they were torturing their patient while waiting for a family member to finally make the decision to change to comfort care. Some even told me of asking for switching patients because they could no longer handle the emotional toll of going in for another shift.
Having had my own experience with this now in my own job I sought comfort in knowing this has happened to other nurses that have come before me. The commonality of this experience, however, is a huge cause of chagrin. It has made me a bigger advocate for advanced directives/living wills as well as encouraging families to have these difficult discussions BEFORE anyone ends up in the hospital. No family member wants to feel responsible for "pulling the plug" or "giving up" - this is why these unfortunate situations happen.
In Idaho the state website offers a wealth of information on Living Wills including:
During my 2 days off I decided to enjoy some southern Idaho sunshine - that is warm right now- and take my road bike out for a spin since the rubber hasn't met the asphalt since PDX. It was glorious to be back in the saddle. On my first bicycling adventure of 13 miles through farmland, I experienced 13 things:
Dogs- both in town and on the farm- will chase you. It's good for cardio.
Entire pastures of livestock will stop what they are doing- cattle, horses, or farm raised elk- and will do one of two things when they see you. A) Stop chewing their cud simultaneously at the same time or B) Run away.
Kestrels (little hawks) will stop flying and sit on the telephone lines to stare at you as you go by.
Trucks and cars will honk at you while driving by because they think that's helpful.
Trucks and cars will not stop to help you if you are pulled over on the side of the road and lost.
Each time you reach a stop sign you have gone 1 mile. Makes calculating distance a cinch!
Wind at your back is awesome. My first 6.5 miles were done in 20 minutes.
Wind at your head is the opposite of awesome. My last 6.5 miles took 45 minutes. It's even worse when dogs - see #1- are chasing you.
Someone has a giant dinosaur and a giant sturgeon sculpture in their front yard.
I saw a farmer out tilling the land with his draft horses. It was rustic and he even waved at me!
Bicycling through farm land is not good for your new location based allergies.
Bicycling to avoid goat heads makes you look crazy.
You should not forget a water bottle. Especially for biking into a head wind. Oops. :(
I knew my first year of nursing would be tough. I had a night recently where I barely kept it together until morning when I got to my car and just burst into tears and drove home through a fog of blurry red eyes feeling both overwhelmed and terrified that I wasn't cut out to be a nurse. It was a combination of adrenaline let down and having a moment to process what had just happened.
I had a very sick patient and our ICU was full so I got this patient in the IMCU. I hung more meds that I knew what to do with and I felt under supported by the charge nurse that night that was kicking back on the computer instead of coming to help me after several phone calls. My patient was a bucket full of anxiety which was not helping either of us and I felt really bad later because I told them they would have to wait to get an anti-anxiety medication while I sorted out the more pressing/life saving medications. I am tremendously grateful to 2 experienced nurses that came by and helped me sort out my med lines and prevented me from making any mistakes, as well as get blood products up and running before I had to rush my patient to the OR 40 minutes after arrival.
The worset feeling was the fear that I could have hurt my patient with all those medications and that feeling of never being fast enough or feeling compassionate enough. The MD I worked is also young and nervous and together we made a good team, but later that morning we confided in one another that is was a very rough night for both of us. I was touched that he acknowledged that he threw me into the deep end and that he was glad I didn't drown (his words, not mine! On the inside I very much felt like I had ridden the Titanic to the bottom of the ocean). I barely slept the following day just replaying the scene in my mind.
Some days just suck.
The following night though I got that patient back. Some charge nurses are wise and know when to make you get back on the horse that bucked you off, even if it's the very last thing you want to do.
The patient and I had a good conversation about the night before. They told me about how scared they were when they arrived and that they had never seen someone work so fast and efficiently (meaning me- good thing I fooled them!). I told the patient that I had felt bad about coming across as not compassionate when they arrived because I had been so worried about their well being and getting them ready for the OR where they could fix the patient up properly. It was really therapeutic for both parties and opportunity that would have been missed had I been reassigned a different set of patients.
And so it goes: this job has a steep learning curve that is unrelenting, but I wouldn't trade it for any other profession.
It is a rare day in the IMCU or ICU that someone says no to pain medication. In fact it's usually the opposite where we have patients hitting their call light as soon as they know they can have another dose. The patients under our care have usually had something traumatic happen to them compounded by surgery or other uncomfortable procedures that were done to treat them. Their pain is a force to behold and reckon with as nurses as we try to keep people comfortable so they can focus on the journey of healing.
However, every once in awhile one encounters what I call the 'cowboy' mentality in patients. These are typically men (sorry to pick on you) who refuse to admit that they are in pain and continue to refuse any sort of help with their pain, even ice or heat packs. The flip side to these patients is that they are stoic or even down right mean. Sometimes I get so caught up in my other cares for them that it takes me awhile to connect the dots that them being grumpy is really just a side effect of their pain.
The conversation usually goes something like this:
"Just checking in on you for my midnight assessment. Are you in pain?" "No" "Have you slept at all tonight?" "No" "Has there been a position you've been able to fall asleep in since your stay?" "No" "Would you like some pain medication to help with your comfort? You did have major surgery." "No, I'm not in pain. Just leave me alone." "Here is my concern: if you are in pain your body is activating a stress response in your body. This causes more inflammation and more pain and your body will be spending resources focusing on the pain instead of focusing on healing, which is why you are here. It is okay to use pain medication." "Oh, well, okay....maybe just a little bit." "Alright sounds good."
10 minutes later they are sleeping for the first time since their hospital stay.
And the best medication for healing: sleep!
This week our hospital just incorporated aromatherapy strips and added them into our supply machine. I was so excited to use these on my little confused patients who try to get out of bed at night due to agitation from things like dementia, kidney failure, or annoying family members.
We currently stock two types: lavender sandalwood for anxiety and orange/ginger for nausea. These strips are about the size of a small sticky note and have a plastic colored ribbon attached.You remove the backing and stick the strip to your patient's gown or pillow case or somewhere in their room. You then tear the plastic ribbon part for the intensity of the fragrance for mild or maximum aroma.
I had to chuckle because the other night myself and one of my favorite coworkers in the IMCU were approached for getting certified in therapeutic touch. The person told me that I was approached because I am "adventurous and from Portland." Anyway, I won't know more about that certification process until later this spring but now am looking forward to adding that to my repertoire soon!
This week's new nurse forum was all about stokes. I previously touched upon tPA, a clot busting drug given to stroke patients in my posting Week 4: one month of nursing!!!. This post I want to focus briefly on the 2 types of strokes, the parts of the brain, and some neat information I learned from our stroke nurse education.
First off: ischemic versus hemorrhagic stroke. My conceptualization of blood vessels that I always return to is thinking of blood vessels as gardens hoses. It's not a perfect simile, but it works for me.
In ischemic stroke a blood vessel in the brain gets blocked, something essentially is stuck in the garden hose preventing it from flowing. Things that can cause blockages: blood clots, cancer cells, clumps of bacteria, and even clumps of fat cells can get lodged inside one of the brain's blood vessels. Everything downstream of that clot is not receiving blood/oxygen/nutrients and the tissue becomes ischemic (ischemic is a fancy pants way of saying the tissue is not getting adequate blood supply and is starting to die). Ischemic strokes are candidates for tPA because the goal is to break up the clot and restart blood flow to that tissue.
Hemorrhagic strokes are more like a garden hose that springs a leak. Instead of a clot that stops blood flow to brain tissue, instead the blood vessels is leaking or bursts such as in an aneurysm (a blood vessel with a weak pouched out wall that eventually breaks). Blood is kept inside blood vessels for a reason: it is a great transporter of nutrients/waste/oxygen/and carbon dioxide, but it is caustic on tissue. As one of my nursing instructors would always say, "Too much of a good thing is always bad." When the blood gets out of the vessels and into the tissue it causes swelling, cell death, and everything downstream of that leak (much like ischemic stroke) is also not getting adequate blood supply.
Again, I think a video does a better job providing a visualization to these different strokes. The first stroke is ischemic and the second is hemorrhagic.
One of our speakers this week is our stroke nurse educator who is spear heading our transition to becoming a certified stroke center. She recently attended an international convention on strokes where some really interesting research is going on.
Some of the preliminary findings she shared were pretty neat including:
Strokes seem to occur more frequently when there is a change to cold weather. Something about the body vasoconstricting (making the garden hoses smaller) to conserve heat may increase the occurrence of strokes in these transitional weather periods.
The majority of strokes occur from 6am to noon. This is when the body's cortisol level is the highest (unless you are a night shift worker). Cortisol is produced by the adrenal glands and helps manage metabolism, blood glucose levels, and is the hormone that helps the body manage stress. Additionally, it increases the coagulation of the blood, thereby making the chance of blood clots to the brain a higher risk.
One problematic group of patients has been those that wake up from sleep with a stroke. The clot busting drug tPA has a four and a half hour window that it can be given from a patient's last known well time. The previous bullet helps narrow down when a possible stroke start time could have occurred. Research is also showing that is seems patients are waking up on average about an hour or so after the stroke has started (I wish I had the paper this was from because I would like to know how they determined this). This allows physicians to be more aggressive with tPA and this segment of patients are now having better outcomes.
I will try to post more educational information over the next month as I will be working weekends for the month of March, but still have Wednesday classes.
