A patient is experiencing RUQ pain. She had been in and out of the hospital multiple times in a short period of time, and the doctors have not figured out the issue. I walk in. The patient is Black American, but on the lighter brown side. This skin tone can sometimes accompany yellowish tones. Sometimes women have darker lips without makeup on. Sometimes smoking can cause darker lips. However, because she had yellowish skin and sclera, darker lips, AND was in the hospital, I decide to not ignore these signs. I ask her if she had noticed any changes in her face. She replies by saying she had noticed dry lower face (including the lips), swollen tongue, as well as itchy hands and feet. I’m considering that she is having ‘episodes,’ and potentially autoimmune hepatitis (which has high LFTs temporarily, so if you go to the doctor after the flare is over, they may not see it on labs). I evaluated the latest labs on file: - CMP showed low albumin and protein but no elevation of LFTs, Cr, or BUN - CBC: nothing remarkable - Kidney cyst - Bile duct issue that my preceptor mentioned to me but that I did not get to review myself - No autoimmune panel obtained - CT scan did not show anything Now I’m thinking there is an issue in the liver, kidney, bile ducts, gallbladder, and/or still autoimmune. My nurse preceptor is impressed with my thinking and allows me to speak further with the patient. I explain to the patient what autoimmunity can look like while also reminding her that I am not diagnosing. I ask her if she notices these episodes come from something she ate or when she has been stressed, and she recalls that the last time it was preceded by stress. She also says that a few years ago, a doctor suspected autoimmune disease (but it seems like this was not taken any further for a reason I know not). However, she then goes on to tell me that she and her siblings grew up poor and had to drink highly environmentally toxic water. All of her siblings had become sick prior to her. Her sister had breast cancer and now has CLL (CLL can trigger autoimmune reactions). I then provide her suggestions on dietary adjustments to make in case it is autoimmune-related, starting with elimination of gluten and dairy; later consideration of other common food sensitivities such as soy, corn, nuts, seeds; and food elimination challenges to determine other food sensitivities unique to her. She says based on everything she has been experiencing, the information I was relaying to her 'makes sense.' I take that as she is potentially thinking back and recalling flare-ups from various foods. I think next steps for this patient could be thorough autoimmune, oncology, and environmental toxicology workups, either in the hospital or soon-after in out-patient settings. I request to my precepting nurse at the end of my rotation that day that she relay all of this information to the doctor or have the patient do it. This scenario occurred during my second semester of nursing school. The preceptor was supportive and said she had learned from me that day. I, too, was grateful that my preceptor allowed me to step in with my dietary expertise on autoimmunity to give the patient guidance that she could begin using that day to potentially start to reduce her symptoms if any of them were autoimmune-related.

My dad is on dialysis and is in treatment for cancer. He is one of my greatest motivations as I continue to matriculate through nursing school. I was able to help him stay off dialysis for another 6 years, but now that he has been on it for almost 2 years, I am just happy that he is doing what he needs to do to take care of himself. I realized after my first semester of nursing that I was already learning how to help him further. I was able to convince my prideful baby boomer dad to move a cord out of his walkway (he uses multiple machines at night). As simple as that sounds, I may not have noticed the cord had nursing school not drilled that into our minds during the very first semester. Recently, my friend called me crying. Her dad has been on dialysis for some time but has not been compliant with daily treatments. She got a call earlier from the doctor saying he was suddenly considering hospice for him. This happened to be while I was on a two-week school break, with two semesters done. My friend had to go to work that day, and she had not been able to get in touch with her either of her parents, so I offered to contact them several times until I reached them. I was able to speak first with her dad, who sounded like he had experienced a stroke. I was then able to reach the mom. Though the parents had been divorced for years and living in different states, the mom was still involved in the dad's care. She had received word from the hospital staff that they were only able to partially dialyze him, and that he knew his name and the day but not where he was. Per my training of 'A&O,' I immediately informed her what that meant: his mental status had been declining, likely due to toxin buildup from renal failure because he was not fully dialyzed. I later informed my friend, who had POA for her dad, that because of her dad's current mental status, she likely had more decision-making power at this time. I offered to have my dad talk with my friend's dad once he potentially reached mental stability again, because sometimes a man gets better motivated when another man can relate. My friend told me the doctor was not giving full details on what happened with the attempts with dialysis and was just pushing for hospice. I became concerned about his overly simple communication style, so I suggested to my friend and her mom to ask the doctor if the full dialysis was not achieved per a physical barrier or emotional resistance from the dad. I also offered to be on the phone the next time they spoke with the doctor. The other dynamic was that the mom first thought my friend's crying was just due to exhaustion from all the efforts my friend had made over the years to help her dad, and that she just needed to accept what was transpiring and move on - this stemmed from her own multiple experiences. I reiterated twice that this was my friend's father, and to let her grieve the way she needs to. As you can see from these stories and my profile, I have positively impacted the health of my family, friends, and the community. Pursuing the path of nursing is already equipping me to have a greater impact for years to come.