Learning Outside the Classroom

A few weeks ago I had my last day as a CNA in a convalescent home. In no way did I anticipate what an emotional experience that would be. My almost two years in that position were, without a doubt, the hardest thing I’ve ever done. I was hit, scratched, spat on, cursed and yelled at, vomited on, had urine splash on my face–and once had projectile, bloody diarrhea hit my face. Fortunately the communicable diseases spared me.

I’ve cared for people who weigh over 300 lbs., have C. diff, and have no ability roll over. let alone stand up. This means that the CNA needs to roll their body over for diaper changes, which are frequent with C. diff. Some patients don’t want their nasty, soiled, diaper changed, and push back on the wall as hard as they can while you try to push back with one hand and position the clean diaper with the other. I worked in a “no lift” facility but everyday lifted several people from the bed to the wheelchair. Yes, I’m massaging my own back right now.

Receiving my CNA certification, May 2014
Receiving my CNA certification, May 2014, with my teacher Abigail.

Most of the patients were really wonderful–being old can make one aware of their own vulnerabilities, and very tender and appreciative. But sometimes it’s the opposite, and some are struggling with serious issues. Imagine being an older woman with Alzheimer’s, in a nursing home, with no family visiting ever. I can’t imagine how vulnerable that would feel (and hope I never do).

Unlike the hospital, in a convalescent home the CNA spends more time with the patients/residents than anyone else on staff. The care in this setting is generally not urgent–for the most part the patients require help with bathing, toileting, dressing, and sometimes feeding. Because of the longer length of residency, CNAs get to know patients pretty well and are also responsible for reporting any changes in behavior–confusion, lethargy–and are usually the person present when things do become urgent, due to a fall, a stroke, or simply due to dire health that on a typial day is not quite bad enough to require hospital care.

RN and LVN positions have government imposed nurse/patient ratios, but that’s not the case for CNAs. It’s determined by the facility, and mine was about average–about eight patients during the day shift. It doesn’t sound like a lot–you might think “oh, eight patients, that gives you an hour with each person”. But we also pass breakfast and lunch trays, help feed some, change linens, take and record vital signs, and chart everything we do in the day for each person–did they eat, how much did they eat, are they self ambulatory in bed, out of bed, in the wheelchair, do they use a walker, do they need help getting dressed, how much help, did they have any snacks, how much, did they have any bowel movements or urinate, how many, at what time, was the stool hard, soft, or watery, do they have a catheter, how many cc’s of urine was collected, did they shower or sponge bath, how much help did you provide, did they leave the facility for any reason, were they turned and repositioned every two hours, etc. It’s A LOT of work.

I made $12 an hour, which was more than most of my co-workers. The health benefits, had I taken them, would have cost $900 a month for me and my family. We waived them and continued with our individually purchased plan, which was cheaper. My heart goes out to several co-workers who have worked that job for 10+ years, are wonderful, and such care for the residents as if they were their own family. They taught me so much, most importantly, what is true of every nursing job: that it simply is not ever, about you.

Tonight I start my first day on my own in my new position as a CNA in the Obstetrics unit, helping Mom’s with their new babies. 🙂


The Nervous System I

A quick note to promote Coursera, an aggregator of online classes–if you’re planning to take Physiology anytime soon, I highly recommend taking it here first as a primer, especially if you have no familiarity with the material. The Duke University curriculum and instructors are excellent–and free! You should also consider it if you’ve already taken physiology but feel like you need to brush-up before taking the NLN PAX.

Now on to the nervous system–our nervous system, like the circulatory system, engages every part of our body. But instead of veins, arteries and capillaries, it’s comprised of axons, dendrites and glia, conducting electricity. Working in conjunction with the muscular system, it allows us to move and breathe. And because the heart is a muscle, it keeps the engine of the circulatory system humming. It helps to keep our vitals systems in homeostasis by communicating dangerous rises or drops in blood pressure, heart rate, pH, O2 and CO2 levels and sometimes releases neurotransmitters into the blood to move these systems back to setpoint. Lastly, it communicates a variety of sensory messages to the brain.

So how does all this communication happen? There are two main components: the electrical signal, and the network on which it travels.

The Electrical Signal
The fluid inside and surrounding our cells (intracellular fluid, ICF, and extracellular fluid, ECF) is filled with chemical elements—mostly sodium (Na), Potassium (K), Calcium (Ca), and Chloride (Cl). If an element has more or fewer electrons than protons, it has an electrical charge and is called an ion. The charge is measured, + or -, in millivolts (mV). Remember that.

A plasma membrane, the protective wrapper of the cell, separates the ICF and ECF. The mix of ions in the ICF and ECF determines its voltage, and the difference in voltage between the ICF and ECF determines the membrane potential for that cell. For example, at rest, most neurons have lots of K+ in the ICF and lots of Na+ in the ECF. The difference in voltage is about -70 mV, and this is the resting membrane potential (RMP) for the cells of our nervous system, aka neurons.

When a stimulus occurs–the smell of pancakes, a sting on your leg, even a slight breeze on the hairs of your forearm–voltage-gated Na+ channels on the plasma membrane open and Na+ rushes into the cell. This changes the difference in voltage between the ECF and the ICF and the membrane potential rises–depolarization of the neuron begins. Remember, it starts at -70 mV, the RMP. If the stimulus is strong enough, and enough Na+ moves into the cell,  the membrane potential rises to +30 mV, and an action potential, or electrical signal is fired. The action potential then travels the length of the axon to your brain, where the stimulus is registered and another signal is sent from the brain to your muscles–you decide to eat pancakes, move your leg, or put on a jacket.

In the center, the signature of an action potential. Around it, the phases of cell depolarization and repolarization.

Once the membrane potential reaches +30 mV and the action potential fires, the Na+ channels shut and the cell repolarizes. If the stimulus continues, another action potential is fired. Of course this all happens in femto seconds and is happening in more than one neuron–your fingertips have as many as 100 touch receptors per cm2.

An example of a medication that tweaks our nervous system, as many of our medications do, is lidocaine, which binds and inhibits voltage-gated Na+ channels. Liocaine is what the dentist injects into your gums before drilling your teeth. By inhibiting the voltage-gated ion channels of the neurons in your gums, there is no Na+ entering the cell, no cell depolarization, no action potential fired–no stimulus of the pain/nociceptors, and no pain felt.

That’s a lot of info–welcome to #nurselife! And that’s probably enough info for now. I’ll cover the network that all these signals travel upon next time–the information highway of our bodies! 😉