Death and Grief

I think that this quote sums up nicely the role of a community nurse in palliative care. However difficult it is we cannot change the outcome but hopefully we can make a difference to the patients comfort and also provide support to the family as they go through such a difficult time.

I lost a patient during my weekend shift yesterday and I am not going to lie, it was a hard day. Even though I'm a nurse I am also human and have emotions and sometimes nursing is just emotionally hard. You sometimes see those posts floating about of nurses outside the patient room crying on shift, well yesterday that was me. Nothing can teach you or prepare you for death and as a nurse you need to find a way to cope with it by yourself as everyone experiences emotion differently.

As a team we had been seeing the patient daily for a number of weeks and had gotten to know them and the family well so when the patient declined very rapidly from telling me jokes on the Saturday to dying on Sunday it came as a bit of a shock. When I left the patients house on Sunday morning I knew the patient didn't have long left and not long after getting back to my base I got the call to say they had died.

I was so privileged to have been part of the patients journey and to have been able to go back and give final care and support his family for one last visit. On leaving, the patients partner gave me a big hug and asked me to thank the team for all we done which was lovely when they were going through so much grief. I just hope that we were able to provide some relief and comfort on that final part of the journey for the patient and their family.

When I came home that night I had a good cry, reflected/debriefed with my husband (who is a paramedic so unfortunately has to deal with death a lot more frequently than I do) and realised that I could have done nothing more: the patient was comfortable and the family happy that the patient had been able to die at home as wished; I don't think anything will ever make death easier!

Importance of Listening

Last week I experienced first hand how quickly an infection can deteriorate into something more serious and thought I would write a little about how important it is to listen to your patient as well as looking at their clinical presentation as not everyone is the same.

About 3 weeks ago now a few of my colleagues at work came down with a nasty cold which for most of them lasted around a week. As we all share a small office it quickly spread and I caught it also. I am asthmatic and after just a few days the symptoms quickly spread to my chest causing me to have an audible wheeze, however I am used to this happening and contacted my GP to ask if I could increase my steroid inhalers. I continued to work through it and although I felt rubbish I didn't think it was serious. After a week of wheezing I contacted the GP again by phone as I didn't want to take time off work and asked for a course of prednisolone hoping that would clear it and the GP was happy to give this during the phone consultation as I had given him my observations and although my sats and peak flow were slightly reduced they were not unacceptable.

Then last weekend, I went to my kids swimming class and maybe it was the humidity in the room but all of a sudden I felt awful and could barely catch my breath, I used my rescue inhaler and it helped but I decided that I should probably see the GP the next day as it had now been going on a little too long at almost two weeks. I called and booked off work, fully expecting that I would be seen by the GP and back to work the next day (I have never taken more than two days off in my life before!).

That wasn't to be, the GP saw me and took some observations, at this point my sats were down to 94, my peak flow less than half of my normal and I had a raised heart rate, resp rate and a slight temperature although I had taken paracetamol a few hours before. The gp sounded my chest and couldn't hear anything, told me that my peak flow was still in normal limits, even though I told him more than once that mine is normally a lot higher as I swim a lot and said that my temperature wasn't significant even though it was likely being masked by paracetamol at that stage. He thought that it was an exacerbation of my asthma causing the reduced sats and raised heart rate and he gave me another weeks worth of steroids with instructions to call back for another course if they didn't help by the end of the week. I trusted his judgement and gave the steroids another chance.

Over the course of the week, I felt more and more rubbish and ended up not going back to work as I could barely pull myself up of the couch to get a drink let alone climb stairs to my patients houses. It peaked on Thursday morning when my husband came home from his nighshift as a paramedic and took my temperature, it was sitting at 39 even though I had taken paracetamol about an hour before. I felt really awful but really didnt want to end up in hospital and so I called the GP again and this time saw a lovely young Dr who took all my observations and listened carefully to what I was telling her in regards to my normal levels. My sats were down to 90 after walking to her office but again when she sounded my chest she could hear nothing. She decided that as I was completely against a hospital admission that based on my observations and that she felt that I knew my asthma symptoms better than she could, she was going to give me a week's worth of antibiotics and trust that my husband would monitor and take me to hospital at any sign of deterioration.

I am pleased to say that two days later other than a slight temperature and a small decrease in my peak flow, all of my observations are back to normal and I am feeling 99% better after what has felt like a very long 3 weeks. Had that Dr not listened to me and what my normal levels are as opposed to perceived normal I would probably be in hospital by now and could have had a lot worse outcome.

Observations on Monday

After one day of antibiotics!

So I suppose that the lesson to be learnt is that as a healthcare practitioner it is really really important to listen to your patient...they know themselves and what is normal or abnormal better than you, their physical presentations or any textbook can tell you. 

And from a personal perspective...I will definitely be taking more time to self care if I am ill in future! I've had to have a week off work after pushing myself for two weeks of feeling awful at work and had I seen about it quicker then it may have meant that my body had a chance to rest and recover quicker.

Lynsay x

24 hour nursing in the community

It often comes as a bit of surprise when people find out that the district nursing service is 24 hours and 7 days a week.

Recently my husband (a paramedic) was called out to a patient requiring a catheter change that the out of hours doctor had booked to be seen at hospital, luckily my husband is aware of our service workings due to my shifts and was able to have the patient redirected and seen within their own home, stopping an unnecessary hospital admission.  However not everyone is so lucky and it pays to have an idea of what each service can do and when to make the most of the NHS services.

I thought I would take a few minutes to talk about how our service operates 24 hour cover and what kind of things we would normally do.

Within our area, and this may be different for other areas and trusts, we have a day team based within an area who generally cover the day shift 8am-4:30pm Monday to Friday. Each member of the cluster, along with a few nurses who are specifically employed for evening working take a turn usually once a month to work the evening shift from 4pm -midnight. This is followed by a night service who work the intern shift from midnight until 8am. The day team also work a weekend day or evening shift once a month to allow cover on Saturday and Sunday.

However the work varies considerably depending on what shift is being covered.

Day shifts can cover anything from diabetic care, to wound dressing, to catheter care or even social issues. Whereas the evening and weekend services cover essential visits only, this may be later diabetic care or daily visits for wound dressing and often includes call outs for blocked catheters or breakthrough pain medication and even verifying patient deaths.

I done a weekend shift just a few weeks ago and my day went something like this:

8am start and text to cluster band 6 to let them know that I am about to start lone working. Set up my identicom which gives us emergency help if required and go to my first patient who required diabetic support.

Between 8am and 9:30am I visited another 6 patients for diabetic care, then I returned to the GP practice where our base is for a quick toilet break, filled up my water bottle and gathered stock for my remaining visits.

As we do essential visits only at the weekend, I had a look at my list and went to my next patients home who also required diabetic support at a later time, on arrival they did not answer the door. I was not overly concerned as I know the patient well and it is a common occurrence for them to be out but I contacted the band 6 to make them aware and to let them know I would return later.

I continued to my next two patients, bilateral leg dressings and a medication administration and returned to try and reach my patient again. I still had no answer and was starting to become concerned so contacted the band 6 again and let them know I would contact the patients next of kin. I left a message and moved on to my next two patients, both a daily wound dressing.

After these visits I returned and was still unable to reach the patient or their next of kin so I contacted the band 6 and we discussed what options we had. It was decided that I would try again in half an hour and if there was still no answer I should contact the police to break in to the property just incase the patient was unwell. This is understandably a difficult decision as if the patient was found well then there would be damages caused to the property to gain entry but there is the risk that the patient could be unable to answer the door due to being unwell.

I visited my final scheduled patient for wound care and returned...and after the first knock the patient answered the door! I was so happy to find them well and explained that we had been ready to contact the police...the patient had simply been out shopping.

As my scheduled visits were completed I returned to the office and had my lunch break. After lunch I had plenty paperwork and referrals to do and chase up so I settled down to do those for the few hours before I had to leave to do the afternoon diabetic care visits. During this time we are 'oncall' with the NHS24 service who can ask us to attend to patients for call outs. That day I did not get called out but often we can have a number of visits to go to in the afternoon.

At 4pm I locked up the GP surgery and headed out to the afternoon visits I only had three visits to do as a neighbouring member of staff had offered to go to one of my patients as they were near to one of hers, so at 4:30pm I was able to text the band 6 to let them know that I was finished and heading home for the night.

So there is an idea of what kind of things we do at the weekend, generally call outs from NHS 24 are for a mixture of catheter problems, breakthrough or palliative medication administration or wound care where the dressings have not stayed in place or are wet through and these can happen throughout the weekend or evening shifts.

So next time you need a community nurse you will know that we are always around even if you don't always see or hear from us!

Lynsay x

5 Tips

5 top tips in nursing...

1. Self care - take time for yourself whether that is a 10 minute break or a two week holiday. Make sure you nourish yourself, especially hydration! And talk to someone if you have a bad day or experience. You can't look after others without first looking after yourself.

2. Never stop learning - There is new cpd and evidence published all the time, make sure you keep up to date and learn new things, it's what makes us a great profession!

3. Always treat other staff as you would want to be treated - HCA's, students and all other staff are amazing, take care of them and they will be your back bone in this work.

4. Never dismiss a patient's worries - they know their own body better than you do, often they can pick up that something is wrong long before it clinically shows.

5. Enjoy nursing - despite all of the negative press, it is a great career and you can change so many lives in your job.

Lynsay x

Proud Nursing Moment

My proudest moment is actually nothing to do with nursing and everything to do with my kids, but I do have a nursing moment which sticks out as something that I am proud of...

In my first placement of first year I undertook a 12 week placement on an orthopaedic ward, I had been there for 9 weeks and had progressively seen one of the patients improve after surgery to the point that she was able to mobilize well and was due for discharge the next day. That morning when I came on shift she refused to get out of bed and asked if she could sleep a little longer, so I returned after helping the rest of the bay get washed and dressed and helped her to get up. I was surprised to see her flinching when she tried to sit up and after helping her stand up I promptly put her back into the bed as she was in obvious pain even though she said that she was fine.

I went done a set of observations which were fine except a very slight hypoxia and explained to my mentor that I was worried about the patient. At that time the nursing staff were in the process of making up IV medication so she asked me to contact the doctor and explain my concerns. As a brand new student this was terrifying but I explained to the doctor and he came straight away. However this is where I am proud to have advocated for my patient.

The doctor came and checked her over and found nothing visible that he was concerned about. I explained that she had been fully mobile without pain the day before and that something had changed. He then indicated that he didn't think there was anything wrong but that he would prescribe pain killers and take some bloods. He left the ward at that point but just a few hours later my patient asked for help to the bathroom and by the time I helped her to return to bed I could see that she was visibly paler and in a lot of pain, I done a further set of observations and saw that her saturations had dropped again so I contacted the doctor again and told them that I was still concerned and that the pain medication hadn't worked.

He visited the patient again and asked me to tell him why I was so concerned, I told him that I knew her and had seen her every shift for 9 weeks and that something was not right, she had not displayed pain like this even post operatively. This time he listened and ordered a scan.

I went home at the end of my shift before the scan had been completed but received a message from my co-mentor that evening who had came on shift to say that they had diagnosed a Pulmonary Embolism and that by sticking with my intuition had potentially saved the patients life by ensuring that something further was done.

I was really proud to be able to have advocated for my patient and it made me realize that if we don't, then who will?

5 Words to Describe Nurses

5 words that describe nursing...
In the current climate I am sure that there are many negative words that could be used but I am going to keep away from them.

1. Decision Makers- Nurses are often required to make important and sometimes life or death decisions and need to be able to decide what is most important from the list of tasks all day every day.

2. Educators - Whether it is a student, another member of staff or a patient we are always educating others, this can be through health education or as simply as leading by example.

3. Advocates - We advocate for each and every one of our patients daily.

4. Learners - We are constantly learning, updating our practice and using the evidence base to improve patient care.

And lastly
5. Human - We are still human, we get things wrong, we don't understand, we get tired and burnt out so need to make sure that while we care for others we also care for ourselves.

Lynsay x

Nurses in the family

There are no nurses in my immediate family, most of them are engineers including my uncles and brother and both of my parents are self employed: www.paperlace.co.uk and IM Plumbing Edinburgh

However in my extended family we have my great gran (who is now 100) who was an old nursing auxiliary, my dads cousin who is a HCA in mental health, his wife who is a nurse in our community hospital, their niece (who I think of as a cousin) who is a carer in learning disabilities.

Then from my husbands side, my husband himself is a paramedic and his cousin is a HCA in respiratory.

On top of this, my best friend from school is a cardiac nurse, and my daughter's best friends mum is a student child nurse.

So I suppose that although I didn't grow up with much nursing influence as a child, I do have plenty around me as an adult!

Lynsay x