On Writing

Everyone around me it seems,
 is writing--
or writing about writing.
 I spend my days
driving through a land of cornfields
with words dancing though my head
snippets of poetry,
essays on life's lessons learned.
Thoughts on marriage,
the beauty of the everyday,
how I need less stuff
and an ode to the Carolina wren
nesting in the window box.

I come home and stare
at an empty screen--
the words are in my head,
but somewhere between
brain fog and fatigue
the words refuse to come
coherently through my fingers.
I close the computer and sigh.
These words will have to wait
for another time and day.

Then I spend the evening writing
words destined to be locked 
away forever in a virtual vault--

I write of  icky stuff in lungs
wound drainage, and poo.
Notes about swollen ankles
cardiac meds and diuretics,
with an honorable mention
to  potassium levels.
Phone calls to the physician
and the physical therapist
counting bruises, describing falls.
I write of medications taught 
and how the patient learned 
to change his ostomy bag. 
The stuff of a nurse's day
and the contents of a nursing note. 


Someday the fog will lift 
and the words will come
to my fingertips--
until that time comes
I will continue to dream
of words to write
as I spend my days driving 
through this land of tasseling corn.  


With a shout out to the women in my blogging mastermind group--who are writing--and writing about writing. 


And here is a little taste of what some of them have been writing:

Trina Holden--Do You Have an E-Book in You?
Gretchen Louise--Of Story
Natasha Metzler--Writing Your Story (when it intersects with other peoples)
Jessica White--A Body Worth Loving
Diane Shiffer-- I Miss My Boy
K. J. Tanner--Table and Coffee

As the Night Falls

Today, at the end of a long hectic day, I stopped for a moment on the edge of a winding country road to breathe in quietness and beauty as the night fell and the colors faded from the sky and water.

Linked to Skywatch Friday.

A New Nursing Job

Chickens in the barnyard. Photo taken 12/4/11.

(This week I've been calling my husband morning and evening to remind him to let the chickens out of the coop in the morning and then lock them up for the night. And to tell him I love him, of course. :)

I started a new nursing job on Monday. This wasn't a planned change. At the end of October the home health care company I was working for made the unexpected announcement they were closing most of their Michigan offices, including the one I worked out of. That left all their employees scrambling to look for new employment. Thankfully for most of us, this turned out to be less difficult than we had initially expected.

The company I now work for was looking specifically for a home care nurse to cover the area between my corner of the county I live in and the the medium size town about 25 miles away. When we moved out to the country two and a half years ago, I had resigned myself to the idea that I would be driving a good distance to any workplace and as long as I am in home care, I would be driving hundreds of miles a week. That is the price of living far out in the country and since I love doing home care, I just put a smile on my face and gas in the car. Then I soaked in the beauty of long drives on country roads and enjoyed spending time getting to know patients who often lived far out in the country in crumbling old farm houses. It was not unusual for me to drive over 1,000 miles a week in my previous job.

With this new job, I am hopeful that I can still enjoy the beauty of country roads and visiting with elderly farmers and country folks---but it sounds like I will be able to do it in a smaller driving radius, which means less driving, more time to finish charting on the job, and maybe getting home earlier and spending less time finishing charting in the evening. One can always hope and once again try to be more organized and efficient!

The next several months will tell. In the meantime I am spending this week in a hotel about 85 miles from my home in a classroom setting, learning the ins and outs of the new company. Next week I will be back in my own part of the country seeing patients. While this was not a change that I was looking for or desired, it certainly does appear to be a change for the good. I am looking forward to seeing what the future brings!

(Snow covered teasels--photo taken this morning at the edge of my hotel parking lot.)

Embrace the Storm

A tree that grows alone
is battered and shaken
by the storm
 but it grows stronger
and more graceful
in form
as it bends
and dances with the wind

I pray that
like the tree
I may grow stronger
and more full of grace
as I embrace the storm
and dance
with the winds of life.

Linking up with Five Minute Friday over over at Gypsy Mama. Today's prompt is "grow'.

New Horizons

Wow, almost a whole week went by without me taking a single photo. Monday ended with an unexpected announcement. The home health care company I work for is closing one third of its offices across the United States...and that includes the office I work out of. My head is still reeling from this announcement and most of the week has gone by in something of a daze. I am continuing to care for the patients we have and assisting them with transferring to the home care agencies of their choice, as well as exploring employment options for myself.

I've also spent some time staring blankly at the wall as I try to comprehend what is happening.

I thought I finally had my nursing career all figured out. I love the company I work for. I love the fact that they hold all their employees to high standards of integrity and honesty while giving us the tools we need to take very good care of our patients. I love my patients. I love my coworkers. I was planning to be with this company for the next 15 years at least.

I finally got outside yesterday evening and explored a new nature area that I hadn't been to before. Just needed to get outside and get away from paperwork, job hunting, and clear some of the fog out of my head. I let my mind wander as I explored the woods and wetlands and watched the sun set over the little lake in the nature area. And I took lots of photos.

And I got a little excited thinking about the possibilities ahead of me. This will give me an opportunity to once again step outside of myself, change and grow, explore new horizons, become a better nurse and in the process, hopefully become a more understanding and better person. Challenges and changes aren't bad, they can be very good, it is all what you do with them.

Linked to Skywatch Friday.

October Day

I got up this morning with a long to do list. Laundry to do, the chicken coop to clean, canning apple sauce, picking and freezing the last of the green beans, mulching some of the garden rows, vacuuming, 

 I started the day with a quick walk to watch the sun rise through the mist over a field of Michigan soybeans.

The back to the house to start on my list. Except somehow with the warm sun shining outside, the list completely lost its appeal. Blue skies and butterflies gently beckoned through our glass front door.  The hammock between two pine trees in the side yard was calling my name. It had been woefully neglected since my husband put it up for me this summer.

The hammock and a  couple of books won out over the pile of laundry and gardening chores.

I spent most of the day reading and sleeping and watching the chickadees that flew in and out of the pine branches, often landing on the hammock and looking at me, trying to decide, it appeared,  if I really was a human or not.

I don't take a lot of days off and just decide to do nothing. Most days when I do nothing it because I'm not feeling well, and I always feel guilty about it. Today, I just decided to do nothing and not feel guilty about it. The nature of a woman is to nurture and care of others and in doing so we often forget to nurture ourselves. Nurses are especially notorious for this and it is one of the reasons there is a high burn out rate in nursing. We are always caring and doing and don't take a lot of time just for ourselves to just be.

I read two books today. That is something I don't often do these days, take the time to read a book from cover to cover, without interruption. The Chicken Chronicles by Alice Walker is the gentle story of healing and restoration that came to the author through watching and learning from her small backyard flock of hens. As a chicken lover myself a lot of her story resonated with me.

When You Eat at the Refrigerator, Pull up a Chair by Geneen Roth is a gentle and humorous book that encourages women of all shapes and sizes and brokenness to discover their true beauty and nurture themselves. A good reminder for this often busy and stressed out nurse.

All in all it was a good day. I didn't accomplish anything tangible, but did something much better--fully lived--mostly outside, on a perfect October day.

I ended the day with another walk--this time to watch the almost full moon rise over Michigan farm country.

And I will end with a quote that rings so true with me:

People travel to wonder at the height of mountains, at the huge waves of the sea, at the long courses of rivers, at the vast compass of the ocean, at the circular motion of the stars; and they pass by themselves without wondering. - Saint Augustine (354-430)

Linking to Straight out of the Camera (unedited photos) and Imperfect Prose.

A Picture of Joy

They have been a couple since they were 14 and 16.

They got married at ages 18 and 20.

They have been married for 52 years.

In August he had a stroke. He was in the hospital for 10 days, then in a rehab facility for 20 days.

Listening to them tell the story of the last 30 days, it sounded like this was one of the most painful experiences of their lives. Not because the stroke left him permanently disabled. And not because of they where worried about hospital bills. They didn't seem worried about long term care either.

The reason it was a a painful experience is because, for the first time in their lives, they hadn't been able to be with each other all the time during the last 30 days.

Finally, today, he was home and they were together again. She tenderly held his disabled right hand in hers. A crooked smile lit up his face and her eyes sparkled. JOY. That was what was what was writen on both their faces. Joy, at simply being together again.

Linked to Five Minute Friday. This week's subject is Joy.

On Beauty...

In my work I witness people and moments of beauty

that inspire and fill me with awe

hardship and sickness like a refining fire 

can bring what is most beautiful to the surface

a woman with tired face and kind eyes,

caring for a husband with dementia

and a father with metastasized cancer

gentle, caring, loving, giving, true selflessness

a husband and wife in their 90's

still as much in love as the day they wed

her eyes light up with joy

when he comes in from running errands

the tenderness of a son

 as he lovingly cares for his frail mother

tending to her most basic needs

with gentleness and deep respect

I am honored and privileged to be

a small part of these people's lives

and hope that I bring a small measure

of beauty and hope into their lives as well

This post is part of five minute Friday over at Gypsy Mama and Imperfect Prose.

Every Day....

It is easy to become overwhelmed
with everything life throws at me...
a complex, time consuming nursing job
that requires mountains of take home paperwork,
house work that is never done,
13 acres full of invasive weeds that won't stop growing on their own,
a Spring that is racing toward summer
with so much work to do, and so little time to to it in.
Dealing with chronic fatigue each day doesn't make it any easier, either.



Every day I have the choice of racing through the day
trying to get as much done as I can, then collapsing when the day is over,
or I can go at a slower pace, and savor the little things...
like watching a poppy flower unfurl,
Or stopping at the side of the road to admire a field full of daisies and lupines.
Or taking that extra 20 minutes to just BE with a patient's wife,
 as she cries and makes the hardest decision of her life---to place her husband in hospice care.
Or at the end of the day, to fix my husband a simple hot meal,
though he doesn't expect it of me, when I come home from a long day of work.


(Daisies and Lupines--photo taken yesterday while driving between patient visits.)

In the grand scheme of things, it is the those little things that matter the most.
The big important things will get done, one way or another.
But it is taking the time every day to stop and do those little things
that brings joy to each day and makes life worthwhile.


(Poppy photos taken yesterday--same poppy--five minutes apart. I like poppies, because they grow themselves...just scatter the seeds one year and poppies will continue coming up year after year...)

This post is part of five minute Fridays over at Gypsy Mama.

The (Almost) Adventures of a Little Dog

I'm skipping 5 minute Friday today because--well, I can sum up my view of waking up in five words--"Waking up: It is hard to do."  I'll share a little story from my day instead.  Let's see if I can do this in five minutes.

 Why did the traffic keep slowing down when I was in  a hurry?  I was in between patients and running late. I didn't need one more thing to go wrong and put me even farther behind. Then I saw it, a little fluffy white dog in the middle of the road who seemed intent on getting someone to stop and pick him up.

He would run up to an approaching car, stop in front of it, and when it did not stop, he would chase it for a moment before going on to the next car.

When I got to him, I pulled off to the side of road, more because I didn't want to hit him than any other reason. I certainly had no intention or desire to be the good guy and stop and pick him up. A bunch of other cars decided to stop too. The little dog eagerly made the rounds of all the cars.

We all sat there looking at him, and at each other, waiting for someone else to do the right thing.

No one else was was making a move, so I finally opened my car door to get out and try to get him out of the middle of the road. I didn't have to try very hard though. The little dog took one look at my open door, came running  and on his own accord jumped into my car and hopped on the passenger seat and plopped himself down on my pile of patient charts. 

He looked at me with bright black eyes and wagged his tail enthusiastically as if to say, "Okay, let's get going! It's adventure time!"

"Um, no, Dog, it is not." I told him. "You may be cute and all, but you are not coming home with me. For one thing I am 50 miles from home and I'm in the middle of my work day,  and for another thing, my husband doesn't like dogs. Trust me, unless you want to be sleeping in the chicken coop (or worse) you don't want to come home with me."

Little dog didn't seem to get the message and just jumped onto my lap and kept looking at me and wagging his tail. 

"You are too friendly for your own good." I told him, while wondering what the heck I was going to do with a dog if I couldn't figure out who his owners where in the next five minutes. I mean, seriously, I was on the job and I didn't have time to deal with a lost dog who seemed determined to either get himself killed or kidnapped. But at the same time I couldn't just let him go again in the street because that seemed like sure death.

Fortunately, he had a collar and a tag with a phone number--that 1) actually worked, and #2) someone actually answered. "Yeah," the tired sounding voice on the other end said, "he's always running out into the road and chasing cars. I'll come and get him."

She came and got him and he didn't seem very happy about it. "Darn it!" his eyes seemed to say, "You've ruined my adventure for today."

"Um, no, Dog," I told him. "I saved your life. That is what nurses do. If you want to get yourself caught up in high adventure instead of getting your life saved, choose a different car to jump into next time."

(Sometimes doing the right thing isn't so hard after all.)

Little Stone Bridge

It has been a long three weeks...four weeks...five weeks? I've lost track of the how many weeks it has been since I've had a real day off where I didn't have to go out to see at at least one patient and wasn't scrambling to finish paperwork late at night. It has been several weeks of lots of driving, long days, and coming home dead tired.

But this weekend I have two days in a row completely off and I'm not going to go anywhere. I'm going to turn my cell phone off and stuff in under the couch and not turn it back on until Monday.  

 My goals for this weekend are  to winter sow all my hardy flower seeds, as well as plant some apple seeds for rootstock to graft in a few years. If it is warm I'll clean the chicken coop. Maybe I will even cook some meals to freeze, so if the hectic pace at work keeps up, we will have something to eat besides canned sardines and crackers for dinner every night.

I became a nurse knowing that I wanted to be a home care nurse. After graduating from nursing school, I did the mandatory  year and half on a busy med-surg unit, then switched to home care. I love it, but never dreamed it would be much harder in a lot of ways than hospital nursing. It is the sort of job that you can't just walk away from at the end of the day. There is always paper work to finish, phone calls that you are waiting on to be returned,  patients to follow up with, visits to be scheduled, looking up medications or medical procedures that are new to you. It is one of those jobs where you can't start at a prescheduled time each day and end at at presceduled time. You start the day when you first patient needs you, and end your day when your last patient has been seen. All visiting nurses complain that we we can't fit all that needs to be done into an eight hour day. It all depends on how much driving you had to do, how sick your patients are, or if they have lengthy procedures that need to be done.

But there are things that make it all worth while. You see one patient at a time. You get to focus completely on that one patient. You can make him feel as if he is your most important patient. You don't have call lights going off, your pager beeping constantly, or the person in the next room screaming for pain meds. You can tailor you care and teaching to exactly what each individual patient needs.

 You get to see your patients as individuals complete with their interests and personalities and and quirks. You get to see all kinds of interesting things--like one patients amazing collect of antique ivory that he inherited from his great grandfather, or another patient who raises parrots and hatches out the little parrot babies from eggs, or another one has poured her life and soul into the most amazing 5 acre flower garden ever and now her son has taken over most of the work.

If you are a home care patient, your nurse thinks of you by name, not by a room number and a medical condition.

A big benefit to home care nursing is that we aren't cooped up all day in one place, never seeing the light of day. I do a lot driving, and while I am not exceptionally fond of driving, I do love seeing new place and and exploring the country side in the 60 or so mile radius that I cover. I am someone who tends to stay home and not go out much if I don't have to. My job forces me to get and explore. I wouldn't be doing that working a a hospital. And then, there are some days when you do get your work done early and you do get caught up and you can go home early.

So any way, earlier this week, I drove by this little stone bridge--a thing of beauty, out in the country, nothing else around. It didn't even seem to be connecting a trail. It was the day of the ice storm and I stopped for a second in the middle of the road to snap one picture.  Another car was coming up behind me so I didn't stop long, since I didn't want him to slide into me.  I thought the photo turned out pretty well, given that it was the only one I took, and it wasn't in the best of circumstances.

Today I drove the same road and since it is no longer icy, I was able to park for a few minutes and take a few more photos. The photo at the top of this post was taken as the sun set behind me--you can see the glow from the setting sun on the trees.

The Farm Around the Bend...

You know how every now and then you find a place that touches a cord in your soul? Almost like you have found a place where there is a bit of heaven on earth?

There is a bit of farm land maybe 20 miles from us that does this to me. The farm belongs to one of my patients. I've been seeing him once a week for the past few months. Every time I go to his home, I drive slowly 'round the bend in the road that leads to his house, just savoring the landscape of gently rolling hills, red barns, sheep and cows grazing in the pasture, and the wind swept hay meadows.

I drive through a lot of farmland every day, but of all of it, this 100 acres feels like home.

The barns were built in 1830. The farmer who lives here now is the 4th generation and his sons hopefully will be able to take over from him. Due to poor health and family feuding a lot has been lost and, and the barns are not as well kept up as the farmer wishes they were. None the less, the place is clean and peaceful without the multiple pieces of large broken down and rusty equipment that most farmers around here seem to collect in plain sight. There are no, rusty old cars,  ugly metal sheds or misplaced outbuildings to mar the landscape.  Yes, the barn and old farm house are worn and are showing their age with missing boards and stones, but they have the simple beauty and grace that comes with aging with dignity.

I've wondered about the man who originally bought this piece of land. Most farm land around here is flat and easy to work. Flat land is desired as farm land. While this piece of land is beautiful, most farmers around here probably wouldn't prefer it because it is most definitely hilly.

Today I asked the great grandson of the man who built the barns and farm house why his great grandfather chose this piece of land.

The answer was simple, but made complete sense.

"Because it reminded him of upstate New York, where he grew up."

Ah, yes, I completely understand now.

                                                          The bend before the farm.

(I always hesitate to photograph anything that pertains to my patients, so I have not taken any pictures except this one, but one of these days I am going to ask him if I can come on out on one of my days off to take some photographs of his barns and the farm house.)

Reminder

This was a crazy weekend for work, with lots of patient visits. I'm staying up late tonight finishing up paperwork. It is on days like this that I need a reminder why I love being a visiting nurse. Today I got one of those reminders.

The driveway was a grassy two track through a swamp with willows, cattails, and stagnant water on either side. It wound quarter of a mile through the wet land, then through a thick dark hemlock forest. A tumbled down barn in the woods was the first sign that someone might have once lived here. Finally I came to a little disheveled house covered with spiderwebs. A pond covered with thick green algae stretched out beyond the house. A family of sand hill cranes--the parents and their half grown craneling--stood almost as if they were guarding the house, and made no move to flee when I stopped my SUV and got out.

I stood there for a few minutes just taking in the complete silence and the green darkness of the forest and water. Despite the eeriness, it was incredibly peaceful and beautiful.

When I knocked on the door, I half expected it to be answered by a little old lady with a broomstick and a tall black pointy hat. No such luck, but the 81 year old home bound woman who lived there was quite a character. You would have to be, to live alone in a run down house in the middle of a swamp by yourself at age 81!

Our goal as visiting nurses and therapists is to keep people home as long as it is safe for them to be home. It is a great privilege to help a person like this woman, live independently in the house she and her husband built together, surrounded by the wild animals, birds, and the wet lands she loves.

Wedding Annoucement---Country Style

(you don't see cool things like this hay bale bride and groom when you are stuck working in only in the city...)

Some of you may recall that in April I quit my job as a visiting nurse with one home care company and took a job as a visiting nurse with another company that was much closer to home with the promise of less driving. Well, it did have significantly less driving, but had very little else going for it. The main problem was that patients did not get a primary nurse. I was used to case managing as many patients as I could comfortably see in a weeks time. I got to know my patients, they got to know me and a trusting therapeutic nurse/patient relationship would develop. In the new place, patients did not have one nurse who oversaw their care and we rarely saw the same patient twice. The patients weren't happy about it and I found it incredibly stressful and felt as if I could not provide good patient because I never got to know the patients or follow up if something was wrong. I would always be in fear that I missed something important related to the patients health or care because that trust that is so essential in medical/healing relationships was never developed.

And believe it or not, I missed the driving after all. 95% of thepatients I saw were within two to three miles of the office, which meant they were all in the city. I missed driving through the country side, exploring small towns I'd never been in before, seeing cows and horses and chickens, I missed watching the farmers plow their fields and missed watching the corn and soybeans grow. I missed admiring the views from patients' windows and chatting with patients about their animals, gardens, and property. I missed watching the sand hill cranes and turkey families.

It only took six weeks of stressed filled days with very few rewarding moments before I decided to call my former supervisor and see if I could have my old job back. Yes, it was still open.

So I am back to driving several hundred miles each week and seeing my own patients everyday. No, the job isn't perfect. I suspect no nursing job is. There are a lot of things I would change about it if I could. I still  come home very late some days. A lot of days I come home so tired I fall asleep as soon as I get home and don't wake up until the next morning. Some nights I stay up very late trying the finish the stacks of paperwork that Medicare requires of visiting nurses. But the important thing is that I feel like I am able to  properly care for my patients and I don't feel like I am stuck in a prison-like job.

Silver Laced Wyandottes

One of my patients' bought 4 little chicks in early April, thinking he would build a coop in his back yard and have fresh eggs all summer long. It turned out the project was just a little too ambitious for his current state of health and one day last week the chicks ended up in my SUV and came home to live with my California Whites. They are about 9 weeks old and in theory we are suppose to have four hens, but I'm thinking I see two roosters and two hens. See how the combs and coloring on the heads are different on the two in the center? It will be another couple of months before they start laying large brown eggs. These chickens get quite large. The hens are up to 6 lbs and the roosters up to 8 lbs, so they still  have a lot of growing to do as well.

Nursing Diagnoses

If you are a home care nurse you take lots of verbal orders--we can't put on a band aide or tell a patient to take colace or tylenol without getting an okay from a doctor. (We rarely ever talk to the actual doctor though, it is the doctor's nurse or medical assistant who gives us the orders.) Each home care agency has a very specific policy on how the orders have to be written.

Where I worked before it was pretty straight forward. Patient has a headache, asks me if it is okay to take Tylenol. Tylenol isn't on patient's official med list. After confirming with the patient that he or she doesn't have liver problems, I call patient's doctor and talk to the nurse at the office. "Hey, Mrs. White has a headache, is it okay with Dr. Smith if she takes Tylenol for it?"
Nurse replies, "Oh, yes, that is fine."

So I write my order. "Patient to take tylenol 325 to 650 mg every 4 to 6 hrs by mouth, as needed for headache. Not to exceed 3000 mg in 24 hour period. Order effective 5/14/10." I sign it and put it in the bin to be faxed to Dr. Smith for his signature and tell my patient she can take tylenol as needed for her headache, as long as she doesn't overdose on it.

Or if one of my patients were to fall I would call the doctor's office and get an okay to send out a physical therapist. I would write an order that simply said, "Physical therapist to eval and treat patient for instability and gait disturbances. Order effective week of May 17, 2010".

Where I currently work, writing an order is a major headache, and I find myself poring out a long list of official nursing diagnoses trying to figure out how to write my order. The order has to include a problem, which is supposed to worded as an official nursing diagnoses, an intervention (what you are going to do, like tell the patient to take tylenol), and an achievable goal (Pt will be relieved of headache).

Nursing diagnoses are kind of like a secret code that nurses communicate in. An example of one, if a patient's problems are mostly related to being overweight, we would give him the diagnoses of "Altered nutrition, greater then body requirements" instead of saying that he is obese. For a list of official nursing diagnoses, click here.

An order I have written several times using this format is one where a patient is taking medication to prevent blood clots and needs frequent lab draws to monitor the effectiveness of the therapy:

Problem: Ineffective anticoagulation therapy.
Intervention: Skilled nurse to draw PT/INR in one week. Results to be called to Dr. Smith.
Goal: Labs will be within therapeutic range.

Today I was talking to a sweet elderly patient who is currently living with her grandson and his wife. She reluctantly confided to me, that she feels like they think she is a burden to them, even though she is pretty independent. She feels like they have been cold to her and are ignoring her most of the time and thinks they want her out of the house, even though she says they would never say that out right. I asked if she would be interested in talking to a social worker to explore the options for assisted living or other types of appropriate housing.

She said yes, and looked very relieved that there might be some hope for getting her own place. I called the doctor office and spoke with the nurse. Our conversation was literally:

Me: Hi, this is Kateri, one of the RN's at (insert agency name). I'm calling to see if it is okay with Dr. Jone's if I send out one of our social worker to talk to Anne Brown about options for assisted living."
Nurse: "Oh, that sounds great. Go ahead and do it."
Me: "Thanks so much. I will write up the order and we will fax it to for Dr. Jones to sign. Can you give me your name?"
"It"s Debbie."
"Thanks so much, Debbie."

Great. I have my order. Except now I have to figure out a nursing diagnoses that fits the problem of "my family seems like they are sick of having me around." (Especially since there doesn't seem to be one that fits "I'd like to move into assisted living.")

Hmmm...how about...

Caregiver role strain? That doesn't seem right.
Risk for caregiver role strain? No not that one either.

Compromised family coping?
Readiness for enhanced family coping? Don't think I will go with either of those.

Dysfunctional family processes? That sounds a little harsh. And I'm not sure that the family is really dysfunctional.

How about something not related to to family or caregivers, such as...

Readiness for enhanced decision making? Okay that sounds really pompous.

Risk for compromised human dignity? No...

I like this one: Readiness for enhanced power.
But I'm sure if I use that one, the doctor will take one look at it and think, what the heck is this nurse talking about?

I finally give up on nursing diagnoses and write my order in plain English:

Problem: Patient states she would like to explore options for assisted living.
Intervention: MSW to eval for alternative housing and other community resources.
Goal: Pt will find a living arrangement that meets her needs.

(For some reason you don't have to put the effective date on orders for this agency. The effective date was the huge sticking point for the company I worked for previously.)

If my supervisor wants to scrap my order and rewrite it the proper way with proper nursing diagnoses, that is fine with me. I would just really like to know which one she decides on.

(Names and circumstances changed to protect patient privacy.)

First Daffodil and Other News

First and most importantly, our first daffodil bloomed today! I snapped a photo before I went to work. By the time I got home, three more were blooming. I planted about 500 bulbs last fall and am looking forward to watching them bloom for the first time. I haven't found many bulbs planted by previous owners. There is one clump of daffodils by the upstairs front door, and a few crocuses and hyacinths. I do know there are several lilies as well because they were blooming when we moved in last summer. I deliberately did not touch the established flower garden last fall because I wanted to see what would come up this spring before I started digging around and destroying things.


I've confirmed that the fox kits are red foxes. According to this website red fox babies are distinguished from gray fox babies by the white tip on the tail. These kits have the white tail tip. They seem to be doing okay. At the advice of several people I switched to feeding them canned puppy food. I have not yet heard back from of the wildlife rescue despite another phone call.

I will admit that in the corner of my heart I'm still hoping their mom is alive and will come back to them. Very unlikely I know, though. Terry suggested that the mother might be coming back at night. If that is the case, why would she have let three of her babies die in the rain? I did clean up the dead animals in front of the den today (a rabbit, muskrat, and the three dead babies). If new dead animals appear then we will know the parents are still around.

(Note the white tip on the tail.)

(As a side note, picking up dead animals is about my least favorite thing in the whole wide world. Even though I wore gloves and used a shovel for most of the task I still felt totally soiled after the the task was done. I couldn't help wonder why I'm so repulsed by by animal corpses, but not human corpses. When I worked in the hospital, I didn't mind preparing patients' bodies for the family to say goodbye to, then wrapping them for the morgue, the few times we had patients die. It was a quiet, reverent task, a final way to show kindness and respect to the patient. I never felt repulsion, just sadness and respect for the empty body. Even when I had to bury Blackberry and when I buried my chicken a few days ago, the the feeling toward the corpse was one of repulsion--I couldn't touch them with bare hands. I loved both our little kitty and my chicken, but it was hard to take care of them after they died. I don't understand why I have such different emotions... )

We will not be getting the goats after all. This is a sad thing for us, but a happy thing for the owner. The reason she was looking for a new home for them is because her house with five acres is being foreclosed on and she though she would not be able to keep them when she had to move. Happily for her she has found a way to keep them.

Last of all, I start a new job on Monday. Today was my last day of work at my current job (I work for a home care company). While for the most part I liked the job I just left, I was frustrated by the amount of driving I had to do and by the paper charting system. My new job is also in home care, but it is much closer to home and they have a very user friendly computer charting system that will make my life so much easier. I was able to shadow one of their nurses for a day and was very impressed with her ability to get her paper work done. Paperwork is the bane and the downfall of visiting nurses and with the new health care reforms that are coming, I sure the amount of paperwork we will have to do will get larger.

Prison Walls

The block long, beautiful stone wall with castle like turrents caught my imagination the first time I saw it. The side that I drive by almost daily on my way to see one of patients, looks abandoned, and through one set of open doors you can a weedy, abandoned field that is about the size of football field. On the other side that I have driven by, the massive stone wall is almost all obscured by large modern buildings and shops. I wondered what such an impressive structure in the middle of a city would have been been built for and why it now appears to be completely abandoned. I thought these beautiful walls should enclose something of beauty, some kind of a haven, or refuge.

I asked my patient about it. "That's the old prison," he said.

I admit I was a bit shocked. One of the largest prisons in the United States is only a few short miles away from this beautiful wall. And I drive by it almost daily as well. It is anything but beautiful.

My patient, an older man who has lived in this city most of his life, told me his version of the prison. "It was built during the civil war," he said. "It was used to house the captured confederate soldiers. There are coal mines under the prison and the prisoners where forced to work in the mines."

When I got home I did an internet search. Yes, this beautiful wall once enclosed a prison. I was unable to verify that it housed confederate soldiers or or that there were coal mines underneath it. There are tunnels under the prison, though I was not able to discover what they were used for. I did learn that it had the capacity to house 6,000 men (in very small cramped cells that were 7' x 3') and was the largest prison in the world during its time.

In the last few years, on the far side of the 20 acres that this wall encloses, some of the prison buildings have been converted to low income housing for artists, musicians, and others who are pursuing creative arts. There are communal art studios and workshops, as well as an art gallery that is open to the public. You can also tour what remains of the prison and and the tunnel system.

One of these days I am going to drive around to the other side of these prison walls and learn more about its history and the beauty and hope that is now being created inside a place that I am sure was once filled with ugliness and sorrow.

A Nurse's Prayer

Watch , O Lord with those who wake, or watch, or weep tonight, and give your angels charge over those who sleep.
Tend your sick ones, O Lord Christ.
Rest your weary ones.
Bless your dying ones.
Pity they afflicted ones.
Soothe your suffering ones.
Shield your joyous ones.
And all for your love's sake. Amen.

(This is a prayer by St. Augustine, and is very much my prayer tonight for the patients I spent time with today).

Little Country Graveyard

A wistful soul well at ease

A humble resting beneath the land

An entrance to a kingdom grand

So is the destination after death

The final thought gone with breath

Here they lie beneath this earthen sea

The flesh and bone of memory

(poem by Morgan Carlson)

This is where I pulled over yesterday between visits to patients, to eat my lunch and complete my charting. This is one of the reasons I love being a visiting nurse. I get to see something new and different every day.