Hi there everybody! (Hi Dr. Nick LOLOL) I'm BACK! I know, I know, I did a very bad job updating you on my nursing school progress, but yes, I DID graduate in Dec, and I passed NCLEX in Jan. My license number was posted in Feb, and I'm still looking for that elusive first new grad job. Its a TOUGH market out there right now for new grad RN's. Lots of openings for experienced nurses, but because of the economy, many hospitals would rather not put in all that extra money (and it can be upwards of $80,000) to orient a new nurse. I have interviewed with 2 agencies. The first was at the hospital I did almost all my clinical at. For budgetary reasons, the unit was unable to hire ANYONE for the position right now. The second I actually got called back for a second interview, but the position was most decidedly NOT a new grad position. It was a position with a local mental health organization going out into the community to work with severely mentally ill clients (think Schizophrenia and Bipolar, many of the clients are homeless or near homeless, have substance abuse problems, criminal records, etc). I would have LOVED that job but there was a lot of case management involved, which I have never done before. So yeah, still looking.
ANYWAY, since it is getting nice and warm and people are out and about, I thought I'd take the time to post a public health message here, and its all about dog safety! According to the ASPCA, 50% of all children will sustain a dog bite before their twelfth birthday, so this is of special importance to children. Small children are many times bitten more severely. Because of their stature, they are at eye level with many dogs and as a result sustain more facial injuries than adults do. So what can we do to keep our children and ourselves safe with dogs? Visit this link for an informative dog safety quiz!
1) If you have a dog, learn and teach your kids about dog body language and never approach a dog that is showing signs of dominance, stress, or fear
2) Do not "stare down" a dog, hug them, or get in their faces. These are all VERY threatening gestures to a dog
3) Do not approach a dog that is eating, has a toy (mostly for children. Adults, you need to TRAIN your dog to give up any item in his/her mouth. If you see any resource guarding behavior, seek professional advice!), is sleeping, or is caring for puppies
4) All children must be supervised 100% of the time around dogs. I don't care WHAT the dog's breed is, NEVER leave a child alone with a dog. I know many parents who like the cute photo op with their small children or babies, but NEVER place a child on or in the front paws of a dog. A dog needs to be trained to give small children and babies plenty of space
5) If you see a dog outside with its owner, ask the owner first before you pet the dog
6) If you see a loose dog, don't approach it, (even you adults!) find a parent and report the loose dog to the proper authorities. If you know who the owner is, you may let them know, if you wish
7) If a loose dog comes up to you, do not scream and run away. Stay very still with your head held high, arms crossed in front of you
8) If you are knocked down by a dog, curl into a ball and protect your neck with hands, stay still and quiet
9) Never tease a dog
10) Do not approach a dog behind a fence or tied up in a yard. NEVER climb into a yard with a dog.
11) If you are given permission to pet a dog, present your closed hand first to let the dog sniff you. Pet under the chin, never over the head. This could be seen as a threat by a dog.
12) Do not touch a dog that is hurt or sick. Get an adult.
ADULT DOG OWNERS (especially if you own a large breed dog)
1) Socialize, socialize, socialize! If you are getting a puppy, it is recommended that the puppy meet 100 new people in the first 100 days. The critical socialization window ends starting at about 16 weeks of age. The dog needs to meet every type of person you can think of, and be exposed to as many new environments as possible. Puppies should also meet other puppies and friendly adult dogs. Remember that not all adult dogs readily accept the wild and energetic antics of a puppy, especially if its a senior dog
2) Training. With a puppy, a great first step is to enroll in a Puppy Kindergarten class that uses non-aversive methods. Training needs to continue throughout the dog's life. The dog should be able to sit, down, stay with distractions, should have a foolproof recall, should be taught how to "drop it" and "leave it". The dog should be taught to walk nicely on a leash and focus on you during walks. This can prevent a LOT of problems.
3) Do not baby your dog. Take a look at the Nothing in Life is Free (NILIF) method. This is a great way to handle your dog. It will teach him that you control all aspects of his life, and if he wants something, he is going to have to work for it.
4) Containment. Never leave your dog alone outside. No matter how good you think your fence is, dogs have been known to escape from all of them. The backyard fence I have is not the greatest, hence whenever my two dogs go out, I am ALWAYS with them, and they are on either the 6 ft or 20 ft lead. I do all my fetch games on the 20 ft lead. ALWAYS leash your dog in public. If you have more than one dog, never leave them together unsupervised, and if you can't be there, crate.
5) Common sense in public. Learn body language. If your dog seems dominant or anxious, don't allow anyone to pet him/her. I let LOTS of people pet my puppy when he was little (he is 5 mos now) but at this point I am teaching him to ignore and only allow those people that approach him CALMLY pet him. He is a very friendly pup, but excites easily and I do not want him jumping up on people, which he has a tendancy to do if someone approaches excitedly. Ask the person petting to pet him under his chin. Only allow dog/dog interactions if you KNOW the other dog and the other dog's owner. Strange dogs can be aggressive, not vaccinated, etc. Under no cicumstances allow an off leash dog near your dog. If play between two or more dogs starts looking too intense, end it. Your dog should understand that the party is over when YOU say it is.
6) Dog fights. If one breaks out, STAY CALM. Screaming will only make the situation worse. If you own a bully breed, have and know how to use a break stick. Do not use a break stick with other breeds, you will probably get bit in the process. Check out this article about how to break up a fight without getting hurt. Many dog bite injuries occur in the course of breaking up a fight.
7) Dog parks. I think they are a bad, bad idea in general. You don't know the health status of other dogs there, most often people are not really watching their dogs and you have no idea if another dog is going to be aggressive. I wouldn't take any breed of dog there, but this is especially important if you have a bully breed or a dog you know has a history of animal aggression.
8) Human aggression. If a dog appears to be aggressive towards people, get it evaluated immediately by a vet and a behaviorist. Dogs that are sick or in pain can become aggressive. In the same light, take extreme care in handling a dog that is injured. Even if it is your own dog, he may not understand you are trying to help him. Once your dog is cleared by a vet, its time to get the dog evaluated by a behaviorist. Take care in who you choose for this task, not every behaviorist or trainer is all they claim. Check on credentials and ask what methods they use. If you are advised the aggression is fear based, you can choose to work with the dog or have it euthanized. Understand that if the behavior is fear-motivated (and they have no real reason to be afraid) you likely will never be able to "fix" that problem, only manage it. I have dealt with it in the past, and I would have to say I don't think I'd ever do it again. I would likely PTS.
9) Husbandry. Make sure your dog gets plenty of exercise. A tired dog is a good dog :) Plus the more exercise he gets, the less energy he will have to engage in obsessive or over-excited behaviors. Make sure he gets enough food and water and make sure he is on a high quality diet. No grocery store crap, please. The number one allergen in dogs is corn. Read labels. I would stay away from anything with corn, soy, gluten, or byproducts of any kind. A named meat source should be the first listed ingredient. Finally, make sure your dog is up to date on his yearly physical, vaccination, and flea/heartworm preventative. Last year, two dogs were found not 5 miles down the road from me that were rabid. Scary, scary stuff. Not to mention that heartworm is SO preventable, yet the treatment for it is painful, very involved, and sometimes fatal to the animal. Do not leave your dog to languish outside on a chain. Not only can it make him more aggressive, its just downright cruel. Your dog belongs with you! Finally, get your dog spayed or neutered. Doing it before sexual maturity can help cut down on territorial and dominance behavior. Plus there is an overpopulation of pets in this country right now. Leave the breeding to experts.
And I will say it one final time: ALL CHILDREN UNDER THE AGE OF 18 MUST BE SUPERVISED AT ALL TIMES WITH DOGS! No matter what the breed. There is no such thing as a "nanny dog". Of any breed.
Thursday, April 26, 2012
Monday, November 21, 2011
An open response to CravenDesires/Pitbull Chatter/ etc, etc, etc and dogsbite.org
For anyone who actually reads this thing LOL-this is not about nursing, its about one of my other passions: dogs. And yeah, yeah, yeah, I know I haven't updated this is a good long while. Nursing school is like that :)
I am writing this to give you the answers to the real pit bull problem and to dispel some of your more fallacious arguments. I am a pit bull advocate. I have in the past owned an American Bulldog/pit bull mix and am expecting in January to acquire an APBT puppy from a breeder that is reputable and I have done my homework on, checked references, and personally know someone who has gotten 3 dogs from this kennel and are the furthest things from “frankenmaulers” on the planet. And before you call me a “nutter” or “white trash” or whatever you want to call me, please know that I am a middle class, suburban married female and I have obtained an undergraduate degree and will be completing my second degree within the next few weeks in health care.
What we have today is not a pit bull problem. Its a dog problem. All dogs in general, and because of this powerful breeds are becoming a casualty. The first problem is breeders who have no business breeding dogs, putting two dogs together just because they are of the opposite sex, or the “right” color/size/etc. Many of these so called “backyard breeders” don't have the first clue about temperament and aren't evaluating the temperaments of their breeding stock or the puppies they produce. Hence we get into trouble with injuries and even deaths, which of course are always tragic. I would argue that most dogs who bite and do serious damage do so not because of their breed, but because of their temperament. All dogs, like people inherit their temperament to a certain degree. Please see the following article from a German Shepherd site about drives and temperament (which are common to ALL members of the species Canis familiaris regardless of breed, a concept so many of you hopelessly fail to understand-ALL dogs are born with the drives mentioned in this article. They are essential for survival):
This is an excellent article for anyone wanting to learn more about why dogs do the things they do. In the article, the author discusses “weak nerves” which to put it a little more succinctly than the article does is basically a dog that has a tendency to be skittish, shy, or have a low tolerance for excessive stimuli. This is where your fear biters come into play, and unfortunately this has become a big problem with our breed: the over breeding, and breeding by people who have absolutely no business doing it. Its also become a problem with many other large, powerful breeds like GSD's, Rottweilers, and their ilk. If I would have to venture a guess, most of the tragic injuries are resultant from dogs with genetically weak nerves that came from parents who should never have been bred in the first place. Which is why as an advocate of the breed, and an advocate of dogs in general, I feel there should be strict regulations in place about who gets to breed ANY breed of dog, and those people should be required to become experts in evaluating temperaments and drive in adults as well as puppies, and of course do all the required health testing. Its also become a problem in shelters and rescues who are not doing a very good job of temperament testings these dogs, not that a shelter is a great environment for doing temperament testing anyway. All of you anti-APBT people love to decry ATTS but it is probably one of the best tools we have to evaluate the likelihood that a dog will fatally maul a person. Yes, ATTS IS based on Shutzhund, and yes, a dog that passes the ATTS test would be considered a confident, strong nerved (I would not use the word assertive here, the test does not measure rank drive) dog. That is EXACTLY what you want in one of the strong breeds. A dog that is not going to be rattled by ANYTHING. A dog that has strong nerves is not going to fear bite, period.
The second problem is a people problem, although many of the people I am going to talk about DO have good intentions. I don't know when we stopped treating dogs like dogs in this country and started treating them like people. The fact is that they AREN'T people and what you or I might find soothing or comforting can be threatening to a dog. Such behaviors as hugging a dog, getting in your dog's face, sweet talking a dog when he is unsure all contribute further to making a dog unstable. You want a fear biter? Take a shy puppy who is unsure of something, pet him and say “Shhh, shhhh its ok baby” To a dog, that display of affection is a reward so what you are basically telling him is “Good boy for being afraid.” You are setting that dog up for failure for the rest of his life. If you want to engage in this kind of stuff, have a human baby, don't get a dog. We need to treat dogs like dogs. Dogs are pack animals and they have to know their place in the pecking order or they become anxious and unstable. If you are a thugged out ghetto gangsta with low self confidence getting a pit bull because its going to make you look “tough” you are setting that dog up to become anxious and unstable. Your dog should respect you and be under your control 100% of the time. Too often you see people adopting a pit bull from a shelter because “Awww poor little baby was abused, lets take him home and love on him” That dog may like you, but he sure doesn't respect you. If however, you take him home, teach him to respect the rules of your home, teach him that he looks to you for all of his needs (including protection) chances are you are not going to have a problem. If you cannot do these things, and you cannot commit the sufficient time to provide exercise to the animal, you do not need to own a pit bull. Get one of those little ankle biters instead. Another disturbing trend I have seen with dogs is highly aggressive toy breeds who are allowed to continue with this behavior because its “cute”. Its not. Its aggression and should not be tolerated. My brother was bitten by a snack sized dog and nearly lost his entire index finger due to the bite and subsequent infection. His crime? Reaching over to hand his friend a drink who had this dog in his lap. I was similarly terrorized and bitten repeatedly in the legs by a neighbors cocker spaniels when I was a very young girl, causing a lifelong fear of dogs, until I met my first pit bull, a friend's dog called Remy.
I'm not naive to the breeds history. I know that a certain amount of dog aggression can be inherent. Pit bulls are not for dog parks. Only the most ignorant continue this trend, and they have no business owning a pit bull. However, if you treat your dog LIKE A DOG and not as a human child, your dog will look to you enough on a walk that you can teach him to focus on you and to ignore other dogs. Its a good practice to begin teaching on walks with young pups. Not to say that socialization is not important, it is, but you never know how dog tolerant your dog will be. An adequately exercised dog with an owner he understands is the “boss” can easily ignore other dogs on a walk and never become a problem. If you are not willing to do this, you should not own a pit bull. If you are not willing to supervise your dog in your fenced yard, you have no business owning a pit bull, and if you are not willing to supervise your CHILDREN with a dog, you have no business owning a dog PERIOD. I have seen many, many pictures of idiot parents letting their huge dogs lick up their baby, or put their sleeping baby in their sleeping dogs paws..................that really, really scares me. A dog should know that an infant or small child belongs to YOU and he is not to mess with it. Then as the child becomes older should take part in the training routine so dog knows child is higher in rank than he. But lets not mince words. Any other breed of dog can be dog aggressive. My in laws yellow lab is terribly dog aggressive, yet they are in total denial about it. He is 95 lbs and very strong, and could do some serious damage given the right opportunity.
You also relish in talking about “unprovoked” attacks. Very, very few dog attacks are actually unprovoked and just because a dog did not growl or nip or raise his hackles first does not mean that he did not give a warning. As human beings, 70% of our communication is non verbal. That's more like 90% for dogs. Much of their non verbal communication is very subtle, but if you know what you are looking for, you will be able to see signs that a dog is uncomfortable in a situation. Please do some research on calming signals in dogs. That would be a good place to start. If you don't want to learn about dog body language, you have no business owning a dog, period. A dog behaviorist I have had the pleasure of working with told me some very wise words once. “All dogs WILL bite, given the proper motivation.” Those very, very few “unprovoked” attacks likely come from dogs that are ill, old and senile (yes, dogs do go senile) or have a neurologic issue similar to bipolar disorder or psychosis in people. I had this situation happen to me. Our AB/APBT mix bit me last April after I startled him awake. At the time, he was riddled with lymphoma, we just didn't know it yet. Four months later, it was so bad that his chest was filling with fluid. We had him put to sleep, and it was the worst day of my life.
Finally, you enjoy fallaciously claiming that BSL and racism or discrimination are far afield from each other. On your Pit Bull Chatter blog, you made some comparison to the Remington 700 misfiring with the number of pit bull attacks. Well to use your same logic the US DOJ found that blacks were seven times more likely than whites to commit homicide. These statistics were collected between 1980 and 2010. See the article from DOJ http://www.bjs.gov/content/pub/press/htus8008pr.cfm. By this same logic, should we then assume that all African Americans are killers and preemptively put them behind bars? By your own argument, comparing a pit bull to a gun, your OWN argument logically shows that BSL IS discrimination along the same lines as racism.
I don't know what happened to you to hate these dogs so much. I personally have never met a vicious one. Yes, I was bit by a very sick dog, but that didn't stop me from consulting a veterinarian and a behaviorist and doing what I needed to do for my dog. I have never met a pit bull that fits the description of “frankenmauler” you so love to bandy about. What I have seen are dogs with heart and courage. Dogs that no matter what you ask them to do, they excel at. Most sanctioned dogs sports were not created with pit bulls in mind, but they excel at all of them: weight pulling, agility, flyball, dock diving, I've even seen a few with herding titles. They are exceptional working dogs, having assisted law enforcement in seizing an untold amount of drugs, helping gain control of the dangerous feral hog population in the south, and serving as good listeners for children that are unconfident in reading aloud. What we have in this country is a dog problem and a human problem, not a pit bull problem. If we cannot have adequate, reasonable discourse on this topic, the problem will never be solved.
Thursday, December 2, 2010
Last lecture of Med/Surg 1, plus your disease factoid of the week!
So, last night was my last lecture of Med/Surg 1. I can't believe how FAST this semester has flown by. I mean I feel like it literally started yesterday. Maybe because we packed all our clinical hours into the first part of the semester, I don't know, but wow, next week I will be DONE with my first year of nursing school. I'm thrilled but terrified at the same time. I have heard that next semester is the hardest out of everything. I go from taking one class to 2. That will be interesting. I've never taken more than 1 class at a time before since I started at FCC 2 1/2 years ago. Its Med/Surg 2 and Psych. We will have clinical pretty much every weekend the entire semester, so I better enjoy having my weekends to myself while I still can! We do half the semester clinical wise in Med/Surg 2, then the other half Psych. I kind of hope to get Med/Surg 2 out of the way first. I feel like that is going to be far more challenging to me. We start taking 2 patients next semester and I'm kind of worried about that. Mostly how I'm going to prioritize their care and such. We shall see. So far I have had REALLY wonderful clinical instructors, hopefully that trend continues. We also get to go to the OR next semester. I'm sort of leery about that. I can watch trauma shows on Discovery Health without a problem, but when its a REAL person, right in your face that's getting cut open, I imagine its quite different LOL!
OK so on to disease factoid of the week. Now remember, I am just writing this to enlighten the general populace, so if you are a health care person reading this, I know this is going to seem way oversimplified, but please bear with me and remember my audience, ok? Yesterday, we covered the liver, gallbladder, and spleen. We spent a LOT of time discussing cirrhosis and liver failure, so I am going to talk about that. I also took care of a liver patient this semester, so it was cool learning how everything fits together. So, what do you need to know about cirrhosis of the liver? Well mainly that the liver does A LOT of things in your body. There's really not a system of the body that the liver doesn't do SOMETHING for. It plays a big role in protien and carbohydrate metabolism, stores carbohydrates, stores iron and copper and many of your fat soluble vitamins, detoxifies your blood (most medications you take are metabolized in your liver, and Tylenol can really do a number on it. The MAX dosage of Tylenol a day is 4 grams. So be careful when you have a cold with aches and a fever. A LOT of cold medicines have Tylenol in them, so if your taking a cold med AND Tylenol for pain or a fever, you are getting a double dose right there.), makes bile which you need to be able to break down the fats that you eat, helps with the breakdown of old red blood cells, makes clotting factors, and makes a protien that is found in your bloodstream called albumin. Albumin helps keep the water contained in your blood in your blood vessels instead of leaking out into your body. So you can see that if your liver is screwed up, well, everything goes wrong.
So cirrhosis. The number one cause of cirrhosis is alcohol abuse. The number 2 cause is chronic hepatitis from infection with Hep B or Hep C, with Hep C really being the worst. As far as alcoholism is concerned, scientists don't know whether it is the actual alcohol or the malnutrition that results from being an alcoholic that causes cirrhosis. They are still looking in to that relationship. Cirrhosis happens when your liver cells (called hepatocytes) and the cells that make up the many vessels in your liver die and try to regenerate. Your liver CAN regenerate. That is why they can take liver transplants from living donors. You could lose part of your liver and it will grow back. Neat huh? Anyway, the different cells in your liver come together in a VERY organized structure. In cirrhosis, when the cells regenerate, they do so in a very unorganized way, essentially making your liver not able to function properly anymore. There are A LOT of complications and signs and symptoms of this disease, but I only really want to tell you about a few of the major ones that I saw with the patient I took care of. Her disease was caused by a combination of alcohol abuse AND Hep C.
1) Jaundice: This is a yellowing of the skin and the sclera (whites) of the eyes because of a build up of bilirubin. Bilirubin is a waste product from the breakdown of red blood cells. There are 3 types of jaundice, but I'm not going to get into that here. That's a little complicated for our purposes :) Your red blood cells have a lifespan of about 120 days. After that, they are broken down. Normally, the liver takes in the bilirubin and breaks it down into less toxic substances that are then excreted from your body in the urine and feces. If your liver isn't working, obviously you can't break the bilirubin down, and it deposits in your skin, giving it that yellow color. So the patient I took care of had end-stage liver disease, so she was pretty jaundiced. I noticed it most in the whites of her eyes. They were quite yellow.
2) Ascites: This is basically a fancy term for build up of fluid in the belly. Patients with ascites are those patients that look 7 months pregnant but aren't. The skin of the abdomen becomes stretched and shiny, and if the fluid buildup is bad enough, the skin can actually start to weep fluid. You can have a build up of fluid anywhere in the body, and that is called edema, but when its massive and in the abdomen, its ascites. There are MANY reasons a person could have edema or ascites, but I am just going to discuss why people with cirrhosis get both edema and ascites here. Normally your body maintains a VERY strict fluid balance and there are many mechanisms within the body that keep your fluid balance where it's supposed to be. So without getting into a lot of complicated concepts, the reason people with cirrhosis have problems with fluid balance are 3. 1) The liver is not making albumin anymore. Remember I said albumin was the protien that keeps the water in your blood inside your blood vessels and not out in your body? Well if you don't have enough of that albumin, the water is going to leave your blood vessels and enter your tissues, causing swelling 2) Malfunctioning of the capillaries in your liver: Remember from bio that the capillaries are the smallest blood vessels in your body? Well the liver has them too and they are called sinusoids. Capillaries are permeable, because they work in the tissues releasing nutrients and oxygen and taking up waste products. Now normally, the openings in the capillaries are NOT big enough to let albumin through, because it is a pretty big molecule. In cirrhosis, the sinusoids are no longer normal, and they allow the albumin to escape. So now we have low albumin because the liver can't make it anymore, and even LOWER albumin in circulation of the liver, because it is being lost. Water is going to follow the albumin out, so we get fluid in the tissues. THIS part is important for the actual ascites because of the location of the liver. If you are losing water from the capillaries of the liver, where is it going to go? Think about the area where your liver is located. There is a good bit of space inside your belly, so the fluid is going to build up there, but you might get swelling elsewhere too, and finally 3) Aldosterone: Aldosterone is a hormone that is made in your adrenal glands, and it tells the kidneys to retain sodium. In the human body, water follows sodium. The liver is the organ that breaks aldosterone down. So now you have high levels of aldosterone telling the kidneys to conserve all this sodium, and you retain water. That is why salty foods make you bloated! Because water follows sodium. I found it kind of strange that my patient didn't really have ascites, since she was end-stage. She did have edema down her legs and feet though. You can imagine why ascites would be bad though? First, having all that fluid in your belly makes it difficult to breathe. Second, you run into a lot of problems because of fluid overload that are too complicated to get into here. Third, all that fluid is nice and warm, and contains nutrients, a perfect breeding ground for bacteria, and you wind up with an infection called peritonitis, which can be fatal.
3) Hepatic Encephalopathy: This is a really end-stage complication, and eventually IS fatal. It's a neurological condition that starts as more of a psychiatric problem (confusion, agitation, mood disturbances) and ends with coma and death. People with this also have a characteristic "hand flapping" tremor called asterixis. My patient definitely had this. She was in the beginning phases of it. She had the confusion, she would often forget where she was, what she was saying, or forget words for things, had flights of ideas, and definitely had mood disturbances. One minute she was in a good mood talking to me, the next she was crying, and the next she was yelling at me because she didn't get any toast on her breakfast tray. She had that tremor too. Its only really noticeable when the person puts their hands out in front of them. So here's its cause. When your body breaks down proteins, one of the waste products is ammonia. A lot of that is done by the bacteria that live in your large intestine. I am sure that you know that ammonia is VERY toxic. Well guess what breaks down ammonia? If you guessed the liver, pat yourself on the back! It converts the ammonia into urea, which is excreted by your kidneys in your urine. So if your liver is not breaking down the ammonia, it starts building up in the blood, and ammonia can cross over your bloodstream into your brain. Most chemicals can't do this because the barrier between your blood and brain is so tight (the blood brain barrier) but ammonia can, and it is also quite toxic to your brain. So that is what causes hepatic encephalopathy. The treatment for it is lactulose, which is essentially a laxative. The special property of lactulose is that it binds up the ammonia in your large intestine, and then you eliminate it. My patient was on this, and I am guess that that was why her condition wasn't worse, although after a while, there isn't anything else that can be done.
So wow. This was long! Thanks for reading, and I hope it was educational :)
OK so on to disease factoid of the week. Now remember, I am just writing this to enlighten the general populace, so if you are a health care person reading this, I know this is going to seem way oversimplified, but please bear with me and remember my audience, ok? Yesterday, we covered the liver, gallbladder, and spleen. We spent a LOT of time discussing cirrhosis and liver failure, so I am going to talk about that. I also took care of a liver patient this semester, so it was cool learning how everything fits together. So, what do you need to know about cirrhosis of the liver? Well mainly that the liver does A LOT of things in your body. There's really not a system of the body that the liver doesn't do SOMETHING for. It plays a big role in protien and carbohydrate metabolism, stores carbohydrates, stores iron and copper and many of your fat soluble vitamins, detoxifies your blood (most medications you take are metabolized in your liver, and Tylenol can really do a number on it. The MAX dosage of Tylenol a day is 4 grams. So be careful when you have a cold with aches and a fever. A LOT of cold medicines have Tylenol in them, so if your taking a cold med AND Tylenol for pain or a fever, you are getting a double dose right there.), makes bile which you need to be able to break down the fats that you eat, helps with the breakdown of old red blood cells, makes clotting factors, and makes a protien that is found in your bloodstream called albumin. Albumin helps keep the water contained in your blood in your blood vessels instead of leaking out into your body. So you can see that if your liver is screwed up, well, everything goes wrong.
So cirrhosis. The number one cause of cirrhosis is alcohol abuse. The number 2 cause is chronic hepatitis from infection with Hep B or Hep C, with Hep C really being the worst. As far as alcoholism is concerned, scientists don't know whether it is the actual alcohol or the malnutrition that results from being an alcoholic that causes cirrhosis. They are still looking in to that relationship. Cirrhosis happens when your liver cells (called hepatocytes) and the cells that make up the many vessels in your liver die and try to regenerate. Your liver CAN regenerate. That is why they can take liver transplants from living donors. You could lose part of your liver and it will grow back. Neat huh? Anyway, the different cells in your liver come together in a VERY organized structure. In cirrhosis, when the cells regenerate, they do so in a very unorganized way, essentially making your liver not able to function properly anymore. There are A LOT of complications and signs and symptoms of this disease, but I only really want to tell you about a few of the major ones that I saw with the patient I took care of. Her disease was caused by a combination of alcohol abuse AND Hep C.
1) Jaundice: This is a yellowing of the skin and the sclera (whites) of the eyes because of a build up of bilirubin. Bilirubin is a waste product from the breakdown of red blood cells. There are 3 types of jaundice, but I'm not going to get into that here. That's a little complicated for our purposes :) Your red blood cells have a lifespan of about 120 days. After that, they are broken down. Normally, the liver takes in the bilirubin and breaks it down into less toxic substances that are then excreted from your body in the urine and feces. If your liver isn't working, obviously you can't break the bilirubin down, and it deposits in your skin, giving it that yellow color. So the patient I took care of had end-stage liver disease, so she was pretty jaundiced. I noticed it most in the whites of her eyes. They were quite yellow.
2) Ascites: This is basically a fancy term for build up of fluid in the belly. Patients with ascites are those patients that look 7 months pregnant but aren't. The skin of the abdomen becomes stretched and shiny, and if the fluid buildup is bad enough, the skin can actually start to weep fluid. You can have a build up of fluid anywhere in the body, and that is called edema, but when its massive and in the abdomen, its ascites. There are MANY reasons a person could have edema or ascites, but I am just going to discuss why people with cirrhosis get both edema and ascites here. Normally your body maintains a VERY strict fluid balance and there are many mechanisms within the body that keep your fluid balance where it's supposed to be. So without getting into a lot of complicated concepts, the reason people with cirrhosis have problems with fluid balance are 3. 1) The liver is not making albumin anymore. Remember I said albumin was the protien that keeps the water in your blood inside your blood vessels and not out in your body? Well if you don't have enough of that albumin, the water is going to leave your blood vessels and enter your tissues, causing swelling 2) Malfunctioning of the capillaries in your liver: Remember from bio that the capillaries are the smallest blood vessels in your body? Well the liver has them too and they are called sinusoids. Capillaries are permeable, because they work in the tissues releasing nutrients and oxygen and taking up waste products. Now normally, the openings in the capillaries are NOT big enough to let albumin through, because it is a pretty big molecule. In cirrhosis, the sinusoids are no longer normal, and they allow the albumin to escape. So now we have low albumin because the liver can't make it anymore, and even LOWER albumin in circulation of the liver, because it is being lost. Water is going to follow the albumin out, so we get fluid in the tissues. THIS part is important for the actual ascites because of the location of the liver. If you are losing water from the capillaries of the liver, where is it going to go? Think about the area where your liver is located. There is a good bit of space inside your belly, so the fluid is going to build up there, but you might get swelling elsewhere too, and finally 3) Aldosterone: Aldosterone is a hormone that is made in your adrenal glands, and it tells the kidneys to retain sodium. In the human body, water follows sodium. The liver is the organ that breaks aldosterone down. So now you have high levels of aldosterone telling the kidneys to conserve all this sodium, and you retain water. That is why salty foods make you bloated! Because water follows sodium. I found it kind of strange that my patient didn't really have ascites, since she was end-stage. She did have edema down her legs and feet though. You can imagine why ascites would be bad though? First, having all that fluid in your belly makes it difficult to breathe. Second, you run into a lot of problems because of fluid overload that are too complicated to get into here. Third, all that fluid is nice and warm, and contains nutrients, a perfect breeding ground for bacteria, and you wind up with an infection called peritonitis, which can be fatal.
3) Hepatic Encephalopathy: This is a really end-stage complication, and eventually IS fatal. It's a neurological condition that starts as more of a psychiatric problem (confusion, agitation, mood disturbances) and ends with coma and death. People with this also have a characteristic "hand flapping" tremor called asterixis. My patient definitely had this. She was in the beginning phases of it. She had the confusion, she would often forget where she was, what she was saying, or forget words for things, had flights of ideas, and definitely had mood disturbances. One minute she was in a good mood talking to me, the next she was crying, and the next she was yelling at me because she didn't get any toast on her breakfast tray. She had that tremor too. Its only really noticeable when the person puts their hands out in front of them. So here's its cause. When your body breaks down proteins, one of the waste products is ammonia. A lot of that is done by the bacteria that live in your large intestine. I am sure that you know that ammonia is VERY toxic. Well guess what breaks down ammonia? If you guessed the liver, pat yourself on the back! It converts the ammonia into urea, which is excreted by your kidneys in your urine. So if your liver is not breaking down the ammonia, it starts building up in the blood, and ammonia can cross over your bloodstream into your brain. Most chemicals can't do this because the barrier between your blood and brain is so tight (the blood brain barrier) but ammonia can, and it is also quite toxic to your brain. So that is what causes hepatic encephalopathy. The treatment for it is lactulose, which is essentially a laxative. The special property of lactulose is that it binds up the ammonia in your large intestine, and then you eliminate it. My patient was on this, and I am guess that that was why her condition wasn't worse, although after a while, there isn't anything else that can be done.
So wow. This was long! Thanks for reading, and I hope it was educational :)
Monday, November 29, 2010
Bit of a rant
Ok, so here's the deal. I am jobless right now. I have been jobless since last New Year's Eve when the temp agency I was working for so kindly let me know the position was over. With no notice. On New Years. THANKS GUYS! If you ever need a temp job, stay far away from Sparks Personnel Services. Anyway, with that out of the way.........
As a nursing student, you can apply for your CNA after you complete your first semester. Which I have. After that, you can work as a nurse's assistant pretty much anywhere. Here's the rub though. To work in a HOSPITAL as a CNA, I am finding, you have to have experience. Nursing homes usually not so much. BUT many (if not most) nursing homes require you to have a GNA (Geriatric Nursing Assistant) which requires you to take an additional test and whatnot. But here's the REAL kicker. With my program, I can't APPLY for a GNA. Yes, that's right, I would have to take an additional 6-12 month course, WITH more clinical time to learn skills that I have already been taught and have used umpteen million times already. Its MADDENING! Same thing for anything clerical. EVERYONE wants 1-2 years of experience in a doctor's office. WELL HOW THE FRIKITY FRAK do you get the experience when NO ONE WILL HIRE YOU? Bottom line is, I need a job. I'd LIKE to get a job somewhat healthcare related, but that doesn't seem to be in the cards for me.
Who knows, I might be unemployed until graduation. My primary field is insurance, and God knows THAT isn't hiring right now. Plus I've been out of the industry so long...................so yeah. Huge vent. But at least you were warned!
As a nursing student, you can apply for your CNA after you complete your first semester. Which I have. After that, you can work as a nurse's assistant pretty much anywhere. Here's the rub though. To work in a HOSPITAL as a CNA, I am finding, you have to have experience. Nursing homes usually not so much. BUT many (if not most) nursing homes require you to have a GNA (Geriatric Nursing Assistant) which requires you to take an additional test and whatnot. But here's the REAL kicker. With my program, I can't APPLY for a GNA. Yes, that's right, I would have to take an additional 6-12 month course, WITH more clinical time to learn skills that I have already been taught and have used umpteen million times already. Its MADDENING! Same thing for anything clerical. EVERYONE wants 1-2 years of experience in a doctor's office. WELL HOW THE FRIKITY FRAK do you get the experience when NO ONE WILL HIRE YOU? Bottom line is, I need a job. I'd LIKE to get a job somewhat healthcare related, but that doesn't seem to be in the cards for me.
Who knows, I might be unemployed until graduation. My primary field is insurance, and God knows THAT isn't hiring right now. Plus I've been out of the industry so long...................so yeah. Huge vent. But at least you were warned!
Wednesday, November 24, 2010
Thanksgiving break, weird dreams and such
Well normally I would have lecture tonight and be able to come back here and post scintillating information about whatever diseases we learned about that night, but alas, that is not to be! Its the day before Thanksgiving, so no class tonight! Whee!!!!!!!! And clinicals are over for this semester too, so my weekends are my own once again until the end of Jan.
Anyway, what I really wanted to post up about tonight is this really crazy dream I had last night. I dreamed that I was in the hospital, during clinical. I was on the same unit that I have been on all semester, except that it wasn't that unit. You know how in dreams you might be at your friend's house but the actual building around you is NOT your friend's house? That type of deal. I was also with my same instructor from this semester, as well as all of the same group members I was with. Anyway, I was in my patient's room getting ready for the day. Now in real life, we are assigned to one patient for both Saturday and Sunday, and we are expected to attend to all of their needs, including bathing, helping them eat, helping them walk around, etc, and we also administer medications one of those days. In this dream the patient that I had in the beginning was a woman I had never seen before, and she was what we in the nursing community call a "walkie-talkie". A "walkie-talkie" is a patient that is alert and oriented (ie not confused), can walk around without worry that they will fall on you, and is independant with all their self care needs (ie bathing, eating, toileting). Basically a nursing student's dream patient.
So, getting back to the dream. I was in this patient's room, and my instructor walks in with a few other students, including one of my friends that was in my group in the dream, but not in the program anymore in real life. My instructor tells me there is a patient on the unit that is dying, and she wants me in there with this patient today because all of my other classmates have already seen someone die. (Which is not the case at all, only one person in my group was actually with someone when they died this semester). I started FREAKING OUT that I did not want to see anyone die, and that I was afraid to touch a dead person. I really am terrified of touching dead people. I am scared I'm going to touch them and they'll pop up and be like, "BLLLAARRRRGGGGHHH" or something. I guess I have watched one too many zombie movies.
In the dream, my friend demonstrates to me how a person screams just before they die, and that made me get even more upset, but my instructor told me it was just something I would have to do.
So I get to the patient's room and the room is HUGE, probably close to 5 regular hospital rooms put together, but its what you would imagine a 1950's hospital room would look like. There are 3 CNA's in there taking care of this woman who is elderly and morbidly, morbidly obese. She was wearing an oxygen mask, breathing very fast. The CNA's keep trying to raise the head of her bed, and end up raising it to the point where the bed is perpendicular to the floor and the woman slides down the bed onto the floor, so they pick her up and put her back in the bed and lower it so she is laying flat on her back. At this point she starts seizing, so they raise the head of the bed to about a 45 degree angle and she takes off her mask, looks at me, and asks me to please pray with her. There is a rosary on her side table and she hands it to me and I start saying the rosary. After a while, it looks like she's not going to die yet, so my instructor has me leave the room. Finally, another of my classmates comes running in the room saying it looks like she's going to die at any minute. I walk back in and instead of this morbidly obese elderly woman in the bed, it is the same woman, but she now she is very thin and fragile looking. There is a priest in the room and everyone is singing, "Amazing Grace." For some reason, only the priest and I know the words because we are the only two Catholics in the room, but I know that's ridiculous because pretty much all Christian denominations sing that song. Anyway, that's how the dream ended. I never actually saw her die.
So now I'm wondering what does this mean? I mean, I know that actually seeing someone die is probably one of my biggest fears. So is having to touch a dead body. Nurses do BOTH of those things on a pretty regular basis, so I'm going to have to get over that. I don't know. Any ideas?
Anyway, what I really wanted to post up about tonight is this really crazy dream I had last night. I dreamed that I was in the hospital, during clinical. I was on the same unit that I have been on all semester, except that it wasn't that unit. You know how in dreams you might be at your friend's house but the actual building around you is NOT your friend's house? That type of deal. I was also with my same instructor from this semester, as well as all of the same group members I was with. Anyway, I was in my patient's room getting ready for the day. Now in real life, we are assigned to one patient for both Saturday and Sunday, and we are expected to attend to all of their needs, including bathing, helping them eat, helping them walk around, etc, and we also administer medications one of those days. In this dream the patient that I had in the beginning was a woman I had never seen before, and she was what we in the nursing community call a "walkie-talkie". A "walkie-talkie" is a patient that is alert and oriented (ie not confused), can walk around without worry that they will fall on you, and is independant with all their self care needs (ie bathing, eating, toileting). Basically a nursing student's dream patient.
So, getting back to the dream. I was in this patient's room, and my instructor walks in with a few other students, including one of my friends that was in my group in the dream, but not in the program anymore in real life. My instructor tells me there is a patient on the unit that is dying, and she wants me in there with this patient today because all of my other classmates have already seen someone die. (Which is not the case at all, only one person in my group was actually with someone when they died this semester). I started FREAKING OUT that I did not want to see anyone die, and that I was afraid to touch a dead person. I really am terrified of touching dead people. I am scared I'm going to touch them and they'll pop up and be like, "BLLLAARRRRGGGGHHH" or something. I guess I have watched one too many zombie movies.
In the dream, my friend demonstrates to me how a person screams just before they die, and that made me get even more upset, but my instructor told me it was just something I would have to do.
So I get to the patient's room and the room is HUGE, probably close to 5 regular hospital rooms put together, but its what you would imagine a 1950's hospital room would look like. There are 3 CNA's in there taking care of this woman who is elderly and morbidly, morbidly obese. She was wearing an oxygen mask, breathing very fast. The CNA's keep trying to raise the head of her bed, and end up raising it to the point where the bed is perpendicular to the floor and the woman slides down the bed onto the floor, so they pick her up and put her back in the bed and lower it so she is laying flat on her back. At this point she starts seizing, so they raise the head of the bed to about a 45 degree angle and she takes off her mask, looks at me, and asks me to please pray with her. There is a rosary on her side table and she hands it to me and I start saying the rosary. After a while, it looks like she's not going to die yet, so my instructor has me leave the room. Finally, another of my classmates comes running in the room saying it looks like she's going to die at any minute. I walk back in and instead of this morbidly obese elderly woman in the bed, it is the same woman, but she now she is very thin and fragile looking. There is a priest in the room and everyone is singing, "Amazing Grace." For some reason, only the priest and I know the words because we are the only two Catholics in the room, but I know that's ridiculous because pretty much all Christian denominations sing that song. Anyway, that's how the dream ended. I never actually saw her die.
So now I'm wondering what does this mean? I mean, I know that actually seeing someone die is probably one of my biggest fears. So is having to touch a dead body. Nurses do BOTH of those things on a pretty regular basis, so I'm going to have to get over that. I don't know. Any ideas?
Monday, November 22, 2010
Hello world!
Good evening, my name is Sashimistat, and this is my first foray into blogging. So I am guessing your first question is why I don't put my real name or picture up here. Well, there's a good answer for that. I am a nursing student. And I am going to be writing about what its like to be in nursing school. See, we have these fancy laws nowadays called privacy laws, and while I would NEVER mention anyone by name, its safer if I don't use my own name either, capice?
So, a little about me. I live on the east coast. I'll give ya a hint but just one. We do have winter where I live, but its not like negative three hundred below in winter here either. I like it here on the east coast, but I'm not sure I want to stay in this state forever. I've been here all my life. I'd like to go either south or west one day. I am married, no children (human children, that is). I do have 2 dogs and 2 cats. I love, LOVE sushi/sashimi hence the name. Unfortuantely right now we are too broke to enjoy either, but thems the breaks right?
I am a nursing student. I go to a community college and when I finish I will have an Associates and be able to sit for my NCLEX-RN (the licensing exam for RNs). I already have a Bachelors from another school in an ENTIRELY different discipline. It took me 2 years of classes before I could even apply for the program I am in now, but I did, and I got in. I am almost through with my first year of 2. It has NOT been easy at all, and my self confidence has been sorely tested along the way, but I have managed to maintain a 4.0 this whole time. Go ahead, talk behind my back, I don't care LOL! I worked hard for those grades and I am proud of them! I have done things in the past year that I never thought I would EVER be able to do. Namely give shots. I have a HUGE needle issue and used to not be able to even WATCH someone else get a shot, but now I give 'em like a champ. Clinicals are over for this semester, and I have heard that next semester is the hardest yet, so strap yourselves in and get ready for the ride!
So, a little about me. I live on the east coast. I'll give ya a hint but just one. We do have winter where I live, but its not like negative three hundred below in winter here either. I like it here on the east coast, but I'm not sure I want to stay in this state forever. I've been here all my life. I'd like to go either south or west one day. I am married, no children (human children, that is). I do have 2 dogs and 2 cats. I love, LOVE sushi/sashimi hence the name. Unfortuantely right now we are too broke to enjoy either, but thems the breaks right?
I am a nursing student. I go to a community college and when I finish I will have an Associates and be able to sit for my NCLEX-RN (the licensing exam for RNs). I already have a Bachelors from another school in an ENTIRELY different discipline. It took me 2 years of classes before I could even apply for the program I am in now, but I did, and I got in. I am almost through with my first year of 2. It has NOT been easy at all, and my self confidence has been sorely tested along the way, but I have managed to maintain a 4.0 this whole time. Go ahead, talk behind my back, I don't care LOL! I worked hard for those grades and I am proud of them! I have done things in the past year that I never thought I would EVER be able to do. Namely give shots. I have a HUGE needle issue and used to not be able to even WATCH someone else get a shot, but now I give 'em like a champ. Clinicals are over for this semester, and I have heard that next semester is the hardest yet, so strap yourselves in and get ready for the ride!
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