RH had multiple systems effected by the syncope episode. As of May 13, 2009, the origin of the episode had not been determined. However, that episode ended up causing RH problems after he aspirated his stomach contents. As described previously, the cascade of events that followed aspiration included pneumonia, acute respiratory distress syndrome, acute renal failure, and ileus. Each system in the body directly or indirectly effects another.

There can be long-term complications for RH from the resulting cascade of events. Acute respiratory distress syndrome can leave RH with a cough, excess sputum production, dyspnea, oxygenation abnormalities, and abnormal diffusing capacity. Acute renal failure can leave mild to moderate damage to the kidneys. The damage to the kidney may effect the glomerular filtration rate. These symptoms may or may not improve over time.

RH was intubated and put on mechanical ventilation to ensure adequate ventilation. Mechanical ventilation helps to rest the respiratory muscles and provide adequate oxygenation. Positive end expiratory pressure (PEEP) was set at 10. PEEP was used to improve RH’s oxygenation and help reverse the collapse of the alveoli. The ventilator was set to administer 16 breaths per minute. It also delivered 700cc in inspiratory volume to RH with each breath. The ventilator also set to deliver forty- percent oxygen to RH to help keep his PaO2 above ninety percent.

RH had two main medications to assist in his care while ventilated. The first was Propofol. Propofol was the sedative that helped the ventilator provide ventilation, decreased anxiety and ‘bucking’ the ventilator, and also helped decrease oxygen consumption due to immobilization. Chlorhexidine was used to promote oral health, mucous membrane breakdown, and help prevent additional nosocomial respiratory infections (Mathews, 2000).

Writing Strengths and Weakness

Tammy Larsen

Lower Columbia College

English 102

July 5, 2009

Over the years, you may find that you are a fairly effective writer…with only a few little hang-ups. You must have excellent research skills and pay attention to details. Being able to get your point across in papers and other works is another great assest to have. You must also appreciate what the reader wants to know or read. Nevertheless, as a writer just getting started may become a barrier in and of itself. Then once you get started, you may find that spelling and grammar can become a hang-up for you as well. However, all of these things—from research skills to grammar—are what makes for effective writing.

The research skills that you employ will allow you to see your subject through a multifaceted light. Research allows you to add a little sparkle to your papers by allowing you to back up what you are saying with facts from experts on your subject matter. You should also use a multimedia approach to research, because you can get a more clear representation of your subject matter. If you read something in a book, you get a glimpse of your subject. However, if you see a picture, graph, or animation in addition to what you have read, then you get the full view of your subject. This enables you to give your readers a fuller understanding of your subject matter, because you have a fuller understand of the subject matter.

Being detail oriented allows you to give the reader exactly what you want them to know or understand. Details can also allow you to show your own knowledge of the subject. If you wrote that the grass is green, your reader’s mind would fill in whatever green their mind chose. However, if you said the grass is an emerald green that glistens in the morning sun, you are able to narrow down that grass color in their mind to exactly what you want the reader to see in their mind. Adding those little details, shows the reader that you know exactly what that grass color is in the morning sun.

The ability to make your point known and understood can sometimes be tricky when you are writing a paper. You really need to give the positives and negatives with any subject that you write about. The trick is to make your point sound and feel like the most obvious choice or way to go. Whether you are writing for or against something, you must take your reader down the path that you want them to travel. That is the tricky part about writing. You have to have a clear view of what you want your readers to get from your writing, and you also have to take the reader with you on your journey down the path that you want them to take.

When writing about a specific subject matter that a reader wants to know more about, it is important to stay on tract. You want to give the details in an orderly fashion and keep the reader interested in what you are writing about. Give the reader enough information to allow them the understanding that they need. If you want to give them a feeling about something, be descriptive with your wording. If you want them to have an understanding of something then tell them the facts and follow it up with great explanations. You do have to avoid getting sidetracked with useless information or descriptions, because this may make the subject become vague or uninteresting.

The hardest thing about writing is really just getting started. Writer’s block can set in and make an easy task become a monster. Take this paper for example. At first a seven hundred and fifty-word essay seems harmless, but where do you begin? How can you make the writing process fit into your ideas of what you want to write about once you narrow down what you are going to write about? What does the reader really want from the essay? All of these questions pop into your mind. Before you know it, the easy and harmless task has truly become that ‘monster’ of a paper.

Things can really start looking bad when you stop and think about adding in the elements of spelling, grammar, and proper writing etiquette. These elements can make writing a daunting task all by itself. Knowing what you want to say and being able to make it look right on paper are two different things. If you say ‘there dog’ versus ‘their dog’, there is a completely different meaning to each. You may have meant one thing but you wrote the other. This can complicate the writing process. Even though that is a simplistic example, the reality is that it really can happen just like that. Furthermore, when you proofread you may not catch those little idiosyncrasies, because you know what you meant to write from the start.

You must take each task, whether its research or writing etiquette, slowly and as an individual element of writing in order to be successful as a writer. As you can see, writing has its pros and cons, but writing is an important part of your life. You use writing to express yourself in letters, on applications, and in just about all aspects of life. Practice using your strengths to help offset your weaknesses and effective writing may just be within your grasp.

My name is Tammy Larsen. I am currently a nursing student here at Lower Columbia College. I am also a pediatric nurse. I work for Pediatric Services of America as a LPN. My specialty is patients with tracheotomies and ventilators. However, I do have a patient with only a tracheotomy.

I think the most interesting part of my job is the patients themselves. Most of these children have some extremely limiting disabilities. Some are paralyzed from accidents and some were born with their diseases. All of these children, however, have personalities that are phenomenal. They are usually upbeat and so happy to see me. How could I not just love giving them the care they need?

I just can’t imagine how I could have chosen any other career, but there have been a few other blips on my career screen. I was an electrician in my late teens and early twenties. I have been the manager of a million-dollar jewelry store. There have been other little jobs along the way, but really those mentioned have been the bulk of my life with regards to work life.

Now…lets talk about my home life. I am married and live on a farm. We have cows--of course—and we have our pride and joy...Sady. Sady is our little miniature schnauzer doggie. She has personality plus so much more. I really think she thinks she is as big as a Saint Bernard. For the most part, she is fearless. On those rare occasions that she gets scared, she runs and hides behind me. She is always happy to see me when I get home, she always showers me with love, and she is just a joy to have in our lives.

Busy is the name of the game in my life. There is never any shortage of things to do. Going to work, fixing fences, fishing, tending the garden and many lots more keeps us busy and our lives full. If you add in school to that mix, you can see there is really never any down time. The good news is that there is a light at the end of the tunnel. In the fall, I will be finished with my RN schooling and will be moving on to my bachelor’s degree. The future is looking bright.

My ultimate goal is to be a nurse practitioner. With this class…the end is within reach.

Preoperative Care

On January 20, 2009 patient MW came into surgery to undergo a radical cystectomy with an ileal conduit urinary diversion due to BCG (Bacillus Calmette-Guerin) resistant bladder cancer (Smelter, 2008). When she arrived for admission, the patient expressed a positive attitude in regards to the surgery. Her general condition was fairly good. All of her vital signs were within normal range (blood pressure 111/59, pulse 84, temperature 97F, and respirations 22). However, MW did have some wheezing in her lungs for which the nurse administered albuterol in a nebulized treatment.

The admitting nurse checked all previously performed preoperative tests for completeness. She checked her wristbands—and added one for her allergies—and assessed the patient. She also noted that MW was at high risk for postoperative complications given her history (see appendix A). She verified that the consent forms were all signed and had MW sign a blood consent form. She answered all of the patient’s questions to ease anxiety. Then we did the patient surgical teaching (see appendix C for the list of surgical teaching). She put in an IV on the left hand (2 attempts). She put a warm air-inflated blanket on the patient for comfort. She reviewed all of MW’s medications with her and asked about the colon-cleansing drink mix prescribed for her surgery. The nurse also asked MW about her pain level and when she last took the pain medication in order to establish a baseline. The nurse then administered the prescribed preoperative medications (see Appendix B for a list of medications used both pre- and intra-operative).

Intra-Operative Care

This was a six and a half-hour surgery and a very intensive surgery. This surgery was different than most because the surgical nurse was training a new nurse, the doctors were testing/‘trialing’ a new piece of surgical equipment (called LigaSure), and the representative from the company of the new equipment was there to answer any questions the doctors had. There were a lot of different aspects to the surgery that were very compelling and interesting.

The nurses put MW in a modified low lithotomy position (Smelter, 2008). They did a vaginal prep leaving the iodine soaked gauze in the vagina. The nurse put in a Foley catheter, put on cardiac monitoring electrodes, and sequential compression devices. They charted the ‘counts’ for sponges, scissors, needles, and various other surgical tools. They charted the time they started and prepared the surgical suite by making sure any supplies the doctor might need was available.

The anesthesiologist made MW unconscious (using general anesthetic) and intubated her. Then he put in a right subclavian central line (a chest x-ray to confirm placement was not performed until after the surgery). He used this central line throughout the rest of the surgery. He also monitored her blood loss and vital signs throughout the surgery. He administered the anesthesia, fluids and electrolytes (6700ml lactated ringer with normal saline), blood (700ml), and plasma volume expansion agents (500ml) throughout the surgery. The total blood loss and output during the surgery was 1100ml.

The surgeons (the main surgeon was Doctor Lesson) dawned their surgical attire with the help of the surgery tech. Doctor Lesson then made an incision from the top of the pubic area to above the umbilicus. He called me over and identified many structures in the abdominal cavity. Doctor Lesson had to first deal with an abundance of scar tissue to ‘free up’ the viscera and bowels (lysis of adhesions). He, again, called me over to point out the aorta, vena cava, and femoral nerves running through the area.

Once the bowels were free from adhesions, Doctor Lesson removed the bladder and sent sections of the ureters with the nurse to the lab to ensure there was a clean margin. Doctor Lesson then removed the pelvic lymph nodes and performed an appendectomy. Doctor Lesson stated, "I do this because in six months when she presents with abdominal pain we will know that it is not appendicitis". He then explained the use of the stints, and I watched him insert them into the ureters. Doctor Lesson then dissected a piece of the ileal. He attached the ureters, made a hole for the stoma, and then brought the dissected piece out of the stoma hole. He applied the urine collection device around the stoma. He inserted a drainage tube, attached Jackson Pratt drainage device, and sutured and stapled everything back in place. There was a final count performed prior to the final closing of the wound. The anesthesiologist extubated MW and made his final checks. The surgery was complete.

Immediate Postoperative Care

After the surgery was complete, MW was transferred to a hospital bed and transported to the recovery area. The surgical nurse identified the patient and gave a brief overview of the surgery to the recovery nurse. The recovery nurses then busied themselves getting vital signs, giving oxygen at 2 liters per minute, and assessing MW. The nurse determined from the assessment that MW’s vital signs were all within normal limits. However, MW’s still had the wheeze in her lungs and she needed another nebulized treatment of albuterol. MW got a chest x-ray shortly after the treatment was complete.

There was a little confusion about whether MW would go to the surgical floor or intensive care unit, because there was no directive from the surgeon about going to the intensive care unit. The nurse spoke with the anesthesiologist and Doctor Lesson. It was determined that it would be the intensive care unit due to MW’s high risk for complications. The nurse called up and made arrangements for the transfer to the intensive care unit. The nurses in the recovery area never left MW’s side. Finally MW opened her eyes—briefly—about fifteen to twenty minutes after arriving in recovery. With her vital signs stable, MW was transported—a little over an hour later—to the intensive care unit.

Post-op Care

January 21, 2009 MW said that she remembered me in the holding area but not in the recovery area. She said that she had no problem with me being there, and my presents did not affect her in a bad way. When asked if she remembered the teaching that was done in the holding area she said, "I don’t remember a whole lot of it". However, it was evident that she either did remember some of it or that someone had reinforced the teaching. She told me she was splinting her incision area and using the incentive spirometer. She said she did remember how to use the patient controlled analgesia. I thanked her for allowing me to follow her through her surgical procedure. She thanked me for being with her and appreciated me coming to check on her.

Appendix A

MW is a 56 year old obese female. She has extended tobacco use (80-pack year) and 8+ caffeine beverages per day. Previous surgeries include knee surgery, cholecystectomy, hysterectomy, cervical band, carpal tunnel, transurethral resection, and bladder biopsies. However, this patient was most noted for her extensive medical conditions. They include diabetes, renal microalbuminuria, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, gastroesophogeal reflux disease, irritable bowel, arthritis, neuropathy, depression, degenerative disk disease, and chronic back pain.

Appendix B

Citric acid/Na citrate 15ml (to buffer the stomach), (Deglin, 2007)

Dexamethasone 20mg (anti-inflammatory)

Famotidine 20mg (GERD)

Albuterol (bronchodilator)

Bupivacaine HCl/Epinephrine 30ml (local anesthesia), (Deglin, 2007)

Cefoxitin Na/dextrose 1 gram (antibiotic)

Gentamicin sulfate 90mg (antibiotic)

Fentanyl citrate 100mg (analgesic), (Deglin, 2007)

Glycopyrrolate 5ml (reduce secretions), (Deglin, 2007)

Hetastarch/NS 500ml (plasma volume expansion), (Deglin, 2007)

Hydromorphone 10mg (centrally acting analgesic)

Meperidine 250mg (analgesic), (Deglin, 2007)

Midazolam 2mg (sedative, anxiolytic, skeletal muscle relaxant), (Deglin, 2007)

Morphine Sulfate 8mg (analgesic)

Odansteron 4mg (nausea and vomiting)

Pancuronium bromide 2mg (muscle relaxant), (Deglin, 2007)

Appendix C

Surgical Teaching Plan

References

Deglin, Judith Hopfer, and April Hazard Vallerand. Davis's Drug Guide for
Nurses. Philadelphia: F. A. Davis Company, 2007.

Smelter, Suzanne C., et al. Textbook of Medical-Surgical Nursing. Philadelphia:
Lippincott Williams &Wilkins, 2008.

February 10, 2009

Biological Development

JM was shorter (by about one to two inches) in height in comparison to his classmates. He was not as slender as some of his classmates, but he was not the overweight child either. His bowel and bladder control was unremarkable in comparison to his classmates. They all had full control over their bowel and bladder in addition to regularly scheduled ‘potty’ breaks (Ball & Binder 2006).

Although JM’s gross motor development was unremarkable. He ran, jumped, and climbed just like his classmates. However, JM differed from his classmates in his fine motor skills (Ball & Binder 2006). His fine motor skills were slightly above the developmental stage for his age group as depicted in Ball & Binder. He seemed to really enjoy craft time (Ball & Binder 2006). He was meticulous in his cutting and pasting. He took the time to cut out the project perfectly. He glued each individual popcorn kernel to the paper. For his classmates, this was more an exercise in getting to know the scissors and paintbrush. He held the scissors and paintbrush correctly without being shown. According to the National Network for Child Care, these activities are more apt to be found in school-age children than in the preschooler (Eller & Mulroy).

His sensory development was also remarkable. He had the ability to concentrate on activities longer than his fellow classmates did. Even after his classmates had moved on to other things, he filtered out his surroundings and continued to do the project at hand. This ability is more indicative of a school-aged child (Ball & Binder 2006).

Psychosocial Development

JM’s psychosocial development was unremarkable. According to Kohlberg’s Theory of Moral Development, JM fit into his age appropriate category (Ball & Binder 2006), because JM’s decisions were based on pleasing others and not being punished. JM assumed his role as a boy and embraced this role with no obvious body image issues (Hunt 2005). JM initiated play with his classmates and displayed independence throughout the day (during play, activities, and group time). In Erikson’s Theory of Psychosocial Development, these attributes put JM squarely into his appropriate developmental age group (Ball & Binder).

Cognitive Development

JM’s cognitive development was unremarkable, because he fit into Piaget’s preoperational developmental category. Piaget’s Theory of Cognitive Development mentions egocentrism in school-aged children (Ball & Binder 2006). He did not relate his experiences to his friend’s (or anyone else’s) perspective. He thought that since he saw something happen, that everyone else saw it happen as well.

Piaget’s Theory of Cognitive Development also mentions that a developmental task for this age group is make-believe play (Ball & Binder 2006). JM has accomplished this task because he participated in make-believe play. He took hats and made them represent other objects. He put one of the hats on his head and said it was his crown. He said, "I’m the king." This behavior is indicative of his age group.

Social Development

JM’s language was unremarkable for his developmental age. He used many words. At one point, a teacher left the room and instead of good-bye JM said "good-riddance". When asked, he didn’t realize that what he was not nice. He didn’t fully comprehend the meaning of the words he used. This is indicative of his stage of communicational development (Ball & Binder 2006). JM’s personal social behavior was also unremarkable because—much like his classmates—he could dress and feed himself.

JM’s play development was remarkable. Associative and cooperative play are the hallmarks of preschool-aged children, and JM had not fully acquired this developmental task (Ball & Binder 2006). JM preferred to play in a parallel way and he could play in a group as long as he played his own thing. There was some associative play observed, but there was no cooperative play observed. For example, he would play with the bugs with other classmates for short periods, but he soon ventured off to play by himself with the bugs or other things.

Safety Issues

One safety issue observed is that JM often roamed away from the other children. In the controlled setting at HOFL this was not a big issue. However, outside in the real world he might be susceptible to stranger’s advances. He also plays in his own world enough and concentrates so hard that he may not see a stranger (or even a car) coming.

Another safety concern is that JM is full of energy and runs full speed. This makes him susceptible to falls. JM did actually fall once while running and playing outside. He also fell once inside the classroom. However, many of his classmates were the same way. This is not abnormal for his developmental age.

Perceived Developmental Concerns

The only developmental concern for JM was in his play skills. Higher levels of play (such as associative and cooperative play) helps children exchange ideas. It fosters their emotional and social development. JM may need some attention in this area. Encouragement of JM to participate in games with other classmates may be useful in providing proper growth and development in this area. However, children do develop differently in different areas. This may just be an area that JM is still slowly developing (Ramseyer).

Hypothetical Acute Care Setting Scenario

JM had an appendectomy and needs a dressing change while in the hospital. Explain that the bandage on his abdomen (or stomach) needs to be taken off, the incision area needs to be looked at and cleaned with water, and a new bandage need to be put on in the place of the old bandage. If available, use a pictorial of the procedure and ask him to make up a story about the pictorial. It might also be helpful to let him put a bandage on his teddy bear. It would be important to allow him time to ask questions and talk about the procedure. Give JM choices about what color bandage he would like if available. Allow him to express fears. Also if he brought a favorite musical CD with him, play it to help relieve stress. Perform the dressing change and answer questions that may come up. Make JM as comfortable as possible.

References

Ball, Jane W, and Ruth C Binder. Child Health Nursing . Upper Saddle River:   
	Pearson Prentice Hall, 2006. 
Eller, Carol L, and Maureen Mulroy. "Developmentally Appropriate Programming
	for School-Aged Children." National Network for Child Care. National 
	Network for Child Care. 13 Feb. 2009  
	<http://www.nncc.org/SACC/dev.approp.sac.html>. 
Hunt, Roberta. Introduction to Community-Based Nursing. Philadelphia: 
	Lippincott Williams & Wilkins, 2005. 
Ramseyer, Viola. "Stages of Play." Enzinarticles. 13 Feb. 2009
	<http://ezinearticles.com/?Stages-of-Play&id=900253>.