The SOCK Method of Pharmacology

Yeah.
Alright, let's do this. Your intuition gears a little bit. I know that we just got done with the CVC, which is wonderful. Then I'm going doing those last things, but let's get down to some pharmacology. Never heard of this. Auckland. Yep. Cool. Cool. All right, so let me share my screen with you guys.
Okay.
Uh, let's try it. Good. Oh, maybe, maybe not.
[inaudible]
does that look like them? Blank screen. Do you guys alright? One more time? All right, let's try this one more time. We're doing it from different programs. So let's try this. Let's just go screen two. There it is. Cool. It makes you that right.
[inaudible]
let's do it. SOC method. So,
okay,
what is [inaudible]? So the stock method is, is this a [inaudible]? Um, and it's, it's, uh, basically a, a, a memory tool. So I want you guys to think about something just for a second though. We spend about, uh, in the United States at least, we spend about $40 billion taking care of patients that had a med, uh, um, medication error. And that's what we spend continuing to pay from the, for their care every year. If $40 billion, a lot of money there, like seven to 9,000 people that died every year. Cheryl, if your screening is blink, encourage you to just maybe refresh the page and if you have a, a, a PC hit control, uh, if five, if you have a, a Mac hit command shift in that wall, uh, that'll refresh your page. Um, so what's the, what's interesting about that is the, the other information that's really important.
The other statistics that are really important is if you're in the emergency department and you're taking care of a patient and you give a patient a medication and you are giving them one of the top 10 medications that you're going to give in the emergency emergency department and you give it, then you have a medication error, you have a 50, 50 chance of giving them a deadly medication. So we need to make sure that you guys are well-equipped to know, uh, from college. You know, about 67% of students don't feel comfortable. They have oncology like worked into their content or they have, uh, or into their, their courses or they don't really have like this, this one, uh, this one class, it's just based on pharmacology. So we came up with this method that will help you guys better prepare a school talk method. It does a couple things.
First thing that it does is it's going to improve patient safety and also it's going to improve because you're improving your patients. If you're going to have less medical errors, you're going to be able to get the right doses that's going to improve your patient outcomes. The other thing about it is it helps you to hone that critical thinking process because it's really important as you become a nurse that you hone your clinical, your clinical decision making feels and your critical thinking skills. No, let's look at the first thing. So the first thing is, so soc actually likes, let me back up. SOC actually stands for as is owes for Oregon's C is for class cards and considerations. We'll talk about that in a minute. And then Kate means no, and we'll talk about number. Must know. So let's start with the side effects. When we talk about everything that was thrown, braces, everything was thrown in my nursing school.
We had nursing one through four. Yeah. So it's basically like, hey, here are all of these are here, all these disease processes here at all these in nursing processes. And on top of that, we're gonna throw out pharmacology, which like I said, only two out of three people or 203 people feel like they struggle in this area. So we want to make sure that you're, that you're, um, that you're well equipped. Okay. So s stands for side effects. When we're looking at side effects, it's like, okay, I get a drug after thinking about this drug. What are its side effects? I don't need to know all 150 side effects of Tylenol. I need to know when I'm looking at the side effects, what are the life threat? England's first. So if I'm giving morphine, uh, what? Uh, okay, you're on the floor. You have to get four milligrams of morphine.
What are you going to be thinking about when you give them morphine? When you're thinking about side effects of more. Let's think about the life threatening ones. First, I want you to tell me the champion. Tell me what you think you're going to give your patient four milligrams of morphine. I need to think about the side effects. What do I know about morphine? Tell me the check real quick. Okay, cool. Cheryl says respiratory depression. Perfect. The thing about is if I give morphine, if I give them too fast, if I get too much of it to a patient, if the patient can't handle it, I need to be looking out for the side effects. Even if I do get the right dose at the right time, I fell on that patient. Medication administration rights, if I follow all of those and my patient still has a side effect, I have to think about the life threatening ones first and the first one that's going to happen is probably gonna be respiratory differentiate because it's opiate.
The other thing you want to think about, the side effects are the organs and organ systems. What's affected? When I think about side effects. So if I think if I give any oral medication, I know that the side effects that could affect any oral medication period is going to be potentially knowledge and vomiting. We're giving them an occasion in the GI tract and if the body doesn't like it, it's going to use nausea and vomiting to try to expel it. And so that's what we need to think about when we're giving oral medications. Even if I give Zofran, there's still a likelihood that my patient could be, uh, could experience and knowledge of vomiting because of the Zofran, because I gave it oral. Okay. The other thing you wanna think about is with sound effects is something called a paradoxical effect. The paradoxical effect is the opposite, the intended effect. So, um, can anybody give me an example of a paradoxical effect? Is that too long? I can think of right at the top of my head that you'll, that you'll never forget anything.
Okay.
I'll give you guys like 10 more seconds. Okay.
Okay.
Do you have one throw it in there? If not, say no. And that's totally okay because like I said, I don't expect you guys to come out and only being pharmacists. I expect you guys to be nursing students. Sam says if you get, there are some, yeah, some drugs, some drugs can cause hypoglycemia. So when I say paradoxical, if I give a patient Benadryl, what would I expect that patient to, if I, if I give somebody Benadryl, what would I expect to happen with that patient? What's like the number one side effect of Benadryl? If anybody's ever had been a drill, drowsiness, guess what? In some patients it causes them to become agitated. Um, and to become, uh, more alert. A good example of this is my own grandmother. Um, my mom called me the other day. My grandma's had a couple of strokes and my mom takes care of her and she'd come in, she like, Hey, what do you think about giving a Benadryl?
When I was like, it's the doctor says it's cool, go for it. She's like, all right. So I gave her some Benadryl. What happened? She was up all night and just wound her up. The other, the other, um, so don't be surprised if he ever get given a drill if it doesn't work and actually makes the patient more agitated and another class of medications that, um, we'll do this, our anti-psychotics, they do it all the time. You give it anti-psychotics to actually to decrease agitation in, in your patient that may be, uh, agitated. So I've done this in patients at work becoming more in it as the night progressed when I was working nights and gave it to them and it just woke them up and I was not doing what it was supposed to do. So how all this one, how parallel and that, those are times and that's what you, that's what you're thinking about.
So like we talked about Benadryl. What does it key side effects, what are the main side effects with Benadryl? I would expect them to potentially be drowsy. It's just a side effect of the drug. So some patients though, some patients become agitated, some patients do exactly what you anticipate they're going to do. They're just going to go sleepy and maybe taken out. Okay. And then with your other side of you want to focus on abcs, airway, breathing and circulation. So for instance, let's take about a morphine for a second. When you give, when you give your patient for millions of morphine, you have a patient four milligrams of morphine. [inaudible] no, you've, you've decreased the respiratory rate. Now let's say they're breathing four, uh, four breaths in that, okay, now we're impaired. We have breathing impairment. Now we have circulation impairment. Now we're not getting oxygen profusion. Now expect that heart rate to go up. So if any of these drugs are going to consign it, things I needed over the life threatening ones, I know I need to know what organs and organ systems are going to be affected by it or that could be affected by the side effect. I need to know about any drugs that I can have the opposite effect and also I need to focus on any drugs or it could potentially cause, um, airway breathing and circulation issues. That's why it's always important to know I'm a yogurt.
Your patients, like for instance, if they haven't a shellfish allergy, do we need to give them a Beta gun? No, because that's going to constantly. So those are just things to think about. All right, so let's go to the next one. So, um, we're into Oregon. So Oregon medications can affect more than one organ. So now patients got respiratory depression. So now not only has it impacted the respiratory system, it's also impacted the cardiovascular system. So the other thing about these major urban systems, and when you're, when you're doing these drugs, think about this. I want to know first and we'll look at the same facts because I know if I gave a drug, I'm going to make sure that then I can anticipate what negative things may happen. Okay, that's exactly what I'm going to think about. The next thing you want to think about what organs or organ systems can be affected. So if I get, let me think of one. Um, [inaudible]
let's go back to that morphine. So by giving them morphine and then all of a sudden now I've got those two that are affected because that's what should be being affected. I know that the turbot system and one of the things to work on the pain receptors, so we're theoretically dealing with some maybe some nerve stuff or the nervous system, but we know that we are actually affecting not only the nervous system but also the cardiovascular system and the circulatory system. And also when I'm thinking about the organs, I need to also prep or ties, which organs your game being effected. So I need to know that in the case of morphine or any of these other ones that hey, I need to know that I'm going to affect that. The big three. And the other thing about organ systems, here's the also the, the, I want you to write this down. This is the, the ways that the organisms are prioritized asked you their pulmonary in neuro, then you've got renal, then you get GI and you even got integrated and then you got my skills going. Yeah, I'll start it over. Actually I can't write with this. Can I take a note? See if I can make it now?
Nope. Can't make it. No. Sometimes I can. I can't do pointers either. All right, I'll start over. Okay. So you have to do abcs. So respiratory, cardiovascular,
okay, I'll start it over. You've got respiratory, cardiovascular, and neurologic.
Those are all three kind of go hand in hand. There's no way.
That's the way it would tell you what, you know what I can do? I can take it cardio, respiratory, Mira, start there. Then you Arenal.
That's nice because if my cardiovascular system is impaired by a drug in my, in my, uh, blood pressure drops, and then it start messing with my, uh, my kidneys. Now I messed with the Renin, Renin Angiotensin aldosterone system. So now my, my ability to control blood pressure is all jacked up.
You've got GI and you've got [inaudible] and you've got musculoskeletal. Okay.
When we were talking about drugs, I'm looking at the organs of the organ systems. I need to know that my cardiovascular and respiratory systems are more important than, uh,
then if a drug is gonna impact the skin. Okay?
So that's the way I want you to think about those. That's a good, excellent. So when we talk about Si, we talked about class considerations and cards. So see the [inaudible] stands for in class considerations and cards class. What class of drugs? See any considerations we need to think about and cards. We'll get to the cards in just a second. So let's start with class. When we're talking about class, but we want to talk about pharmacologic. If therapeutic class, when you see pharmacologic fans is what does it do? And when I say what does it do, what does it do to the patient? So let's think about something like a Pinto Persol or phonics, which is a proton pump inhibitor. What is, I know you guys can probably given Protonix in the hospital. What is pretax and do
[inaudible]
[inaudible]
can you tell me? So Proton pump inhibitor.
Yeah, the PPI dies. They actually decreases. Yeah, it decreases acid. Right? So remember, so thinking about Proton, who protons or web protons or hydrogen ions, hydrogen ions are existing in the GI trying to particular with these stomach. If it's a proton pump inhibitor, that means it's inhibiting the Proton pump. Well, if you know anything about what the Proton pump does, is it, the Proton pump basically kicks out hydrogen ions into the stomach and creates stomach acid. So what you do is you turn it off, you basically turn the pump off, and so it's not going to kick out those hydrogen ions. That's what a PPI does. And we use PPIs. Um, that's w this is pharmacologic class now it's therapeutic classes. It's anti-ulcer. We will use these inpatients that have ulcers. Initially, upper GI bleeds is in the Taurus. You're gonna see Protonix drips all the time.
So that's the way you need to think about it. So when I s and that reason, the next point, which we just talked about, which is complimenting it in Indiana, the anatomy and physiology, what does it do? So we know, look with the Proton pump inhibitor, turns it all because we don't want you to pump hydrogen ions into the site. And because we're not doing that, we're decreasing stomach gas in thereby improving our patients' outcome because the stomach acid actually makes ulcers worse. And we're making because of that, it makes it an anti-ulcer. So we're talking about generic names, so generic names. This is so like, um, uh, oh man. I'm going to show you guys some things from numbers all came to prison, all uh, Lo, uh, uh, I got spell it. I'm spelling this wrong. Let me see. I'm gonna make sure I spelled this right. There it is, man. So prosol
[inaudible]
you look at the end. What do you guys, what are you guys seeing in these names? And I'm typing in Zoe, right? Zool e means in Bronx EPA. But you know that if you get one, any one of these drugs, you can come in bird and use that invicta reasoning to say, hey, this is most likely a proton pump inhibitor. So I need to know why my patients getting a proton pump inhibitor. So just think about this when we're talking about class and this is what the class comes into. So let's talk about consideration. All right, cool. So what when I'm considering a drug, anything I need to do is consider what am I doing for this drug. So, um, if I give something clones and Denison, those, one second. Let's do this. I'm going to type this in here real quick.
Okay.
Any of you seen this name before in this drug?
Okay.
Yes. Can you tell me when you would use it then? Say
[inaudible].
Anybody have any idea when you would use a dental center? Charles has a [inaudible] what time you're on the right track.
Yeah.
Sharon says, take a car to your, what kind? What kind of tech accordion.
Okay.
We're so close, Mrs PVCs. Nope.
Okay.
Yeah. Supraventricular Tachycardia you for super control can detect. Now what is important to know about identity? If you have a patient in SVT and your provider comes to and says, Hey, go get the dentist and we're going to get in trouble. What do I need to know about it?
Yeah.
And this is where it's really important that you understand, uh, drug considerations. Anybody? It's cool. Just let me, let me know that you don't know by thing. No, I mean it's kind of like it can slap your heart. Well not necessarily like the side effects, but what do you need to know about it when you're giving it?
So theoretically that would be it's intended side effect, how to give it yet. So various says how to give it. The thing about at Denison is its half life is about half a second and I'm not joking. So the way you have to get it, you have to pull it up in one syringe and then you pull another syringe of Selena and you basically prime a stock car, attach it to a patient. And what you do is you basically open it up and you give, basically you slammed it innocent and then you slam the saline because you have to give it all at once. And the thing, the other thing you need to do is when we're talking about patient education, Hey, I'm about to give you this drug. It's gonna make you feel like somebody's going to drop a bowling ball on your chest. I just want you to try to breathe slowly and try to calm yourself as much as possible, but just be prepared that this is going to, um, this is going to be something that I'm going to give and it's gonna it's gonna suck. There's like no good way to say it, but when their heart rate's 180 and you have to get them down, like that's one way to do up the other vital information. What else do we need to know about and Dennison if we're potentially going to stop the heart? Do you think we should have a crash cart next to it?
Yeah. Hell yeah. Gotta have the crunch card cause it did some works and all the sudden he bottoms out and all of a sudden I've got to give up the work. Then we're like in this, this crazy spiral. But the thing to consider it, this is the thing I needed when I'm talking about considerations is hey, my patient's in SVT. What do I know about SVT? I need to give a Denison, but holy hell, I need to make sure that I have all of these other things lined up. I need to make sure that I get my crash card. I gotta make sure you don't say anything. I gotta make sure I stop talking. I gotta make sure I can get it quickly because there's not messing around. Okay. So excellent job guns. So let's go to the next one cards. This is really, really important to the fuck nothing. This is the part where we say that you need to practice. So I'm going to find, let me get this link for you here. I'm just one second. Um, and what it is, is there is, let's see, um, what I'm going to do is I'm going to drop this link for this, uh, this cheat sheet. And what it is, is it's actually a cheat sheet to the, um, let's see. Card.
Okay.
Doing things in the background guys. So hold one for me.
Okay.
Did, did he do okay?
[inaudible]
well, what those stroke heart is, is this a way for you to practice? And the reason it's important you to practice is,
okay,
cool. I want you to create it. I want you to print that. I want you to open this, uh, open up this drug card template. I want you to print these off. I want you to, um, I want you to fill them out as much as possible. I want you to get a blinder. I want you to organize them, organize them however it's best for you. Do you need them by class? Do you need them alphabetical? Do you, would you want on your blood pressure medications together? Do you want all your cardiovascular medications together? I want you to bind to organize them in a way that helps you fill them out. Fill them out as much as possible. Study them. They don't want, don't want you to do, I want you to throw them away and they don't want you to print out more. And then I want you to start filling them out from memory.
And when you get stuck, go to your references. Finish filling them out. Studying them more. When you're done, throw them away. And I want you to do this until you start doing a, until you start getting them all in by memory of all the time you can fill out, I need to know if I give a dentist sent, I need to make sure I get a stopcock. I going gonna make sure you say that I gotta make sure the right dose, I follow these medications and be given for SVT. I'm going to have a crash cart at the bedside. We haven't provided at the bedside, but all these things in place before I do it. But I know that anytime, hey, patient's got SVT core, we doing a distance. What are we doing? Because I've already stopped thought three steps ahead. I've already played that chess game. I've already made my chest. This is how you use the cards in the socket. So let's go to the next one.
Okay. The last one is no Irma's now. So medications are based on needs and research. So if we realize that there is a drug that is good enough to do its job, um, for instance, um, Benadryl, Benadryl is really, really cheap. Um, and that's why I say low cost and low risk or more common, you're gonna see more of those in the market. And what happens is, is for those drugs, Benadryl really cheap because it does a really good job and we don't need anything, uh, and it's gonna come out and, uh, it's going to basically replace it for things like allergic reactions. We know it works fast, we know what works well, we know that there's very few side effects to it and we know that, uh, that it's extremely inexpensive and, uh, you know, affordable to the majority of the population. There's no need to go out and go buy any junk. So I'll give you an example. So there's a medication called finger locks on the, on the market and we'll pick them. Box is, is a big inbox. It's, um, I think I'm saying it right.
[inaudible]
one second. No, it's uh, um, it's not a big amongst, it's uh, hold on. Uh, uh,
okay.
Okay. It's a drug on the market and you're not thinking of it's name, search e. Oh my goodness. It's an approximation and upper zone.
[inaudible]
hello. There it is. Sorry. I need my mobile, like the mobile mobile mobile is, is, is, it's a neproxin
and uh, is he members? So this, I'm gonna write it out, Roxanne and
all right. Based on what we've talked about earlier, can you tell me what those two drugs are? Yeah,
yeah.
We're going to try to apply this in a rural setting. Perfect. It's an incident of PPI. Neproxin vizio. It's a generic name. Can anybody tell me what the brand navel and it is? Aleve and I think it's a premise I think is as members eyes. So Aleve and prednisone in the open market. If I went to Walmart or Kroger or Walgreens or cvs and I wanted to buy a three months supply, oh, these two drugs together. If I said, hey, I'm going to buy, uh, you know, over the counter, um, Aleve and where the counter, uh, premises and I go and I go home and take them and I take them for three months. It's going to cost me 30 bucks, 40 bucks, the mogul on the market by itself, if you go out and buy it, is it $3,500? And it's ridiculously expensive. And so when we talk about medications are based on these at research, sometimes some drugs do better.
And so it's really hard. I mean they can get FDA approval, but it's really tough to justify for patients, um, these replacements of drugs. So we were talking about drugs in the market and Julie, you need to know the Millville because I likely hit a year patient. Um, it's a cool, fun fact that you know now. Um, but it's, you don't necessarily need to know that for your patient in going forward. So if we look at rare drugs or using rare cases, maybe patients haven't tolerated and approximate and privacy together before, and all of a sudden you give them Vimovo and it works great for that. Um, so what we need to know is something called the Pareto principle. Three o principle is 80, 20 rule. Basically. It means that if you give 20% of all of the drugs on the market, you're going to give 20% of those drugs, 80% of the time
and
80% of the drugs on the market that you give. You're only going get 20% of the time and I'm going to say, I'll say it again because it's really confusing.
Okay.
The drugs in the market, which is like 6,800 medications, you're going to give 20% of them. 80% of the time you're going to get 20% such a small handful of them the majority of the time, which is why John came up with 140 months on that. It's what he found out as he's on the floor and he's getting these trucks, he gives one drug. Can you realize he's, he gets it again and you realize he gives it again. They realize it. He gets it again. He's like, oh, I'll give you this drug a bunch and giving it another drug. We'll use it. When he ended up finding out is there were about 140 drugs that he gave all the time. So if you go into the library, you can actually find the 140 minutes from a mess book and it's going to go through all of those minutes.
So that's what the, so when you're thinking about drugs, you need to also think about, let me see if that's on your team. The other thing that's not on here is you need to know the drugs that are on the unit. If I am working at Altec or if I'm working in sniff, um, l talk long term acute care facility or a sniff with a skilled nursing facility, or even if I'm working hospice, do I need to know, uh, the amount of, of cardio that a patient was getting on a drip? Uh, two days ago? Most likely not because it doesn't affect what I'm doing because it's not something that I'm going to give. So you need to know the drugs that are on your unit. If I'm working in an ICU, I need to know the types of ICU drugs. If I'm like, especially if I'm on a cardiovascular floor, I need to know what drugs I'm going to give for my cardiovascular patients, what drips.
I need to know. Um, [inaudible] a night pride, uh, um, the nitrile I need to know all of those room doses because those are going to affect patients that I get, um, that I don't need to know about the drugs that are giving in an Altec or whatever. Maybe some oral supplements that they're taking it home. I don't need to know those because those are not the drugs that I'm giving. They're not applicable to my unit. So the other thing that's important about the talk method is there is a correct order. It's not going to be soc. So you're going to learn the drugs, but when you apply them, you're actually gonna apply them in this way. I've learned them. This is how I apply it. So Oregon's, I'm gonna start with [inaudible]. What is the, I'm going to get it, give this drug and know this about this drug. How am I going to give it? [inaudible]
um, so we're gonna yeah. Okay. C S Right. Sharon, I'll answer your question in just a second. Organs. Most now I need to know, um, I'm going to give a drug. Uh, I need to know what organs are going to be affected. No. Do I need to know this medication? Why, why is it so important? I need to know this medication because if I don't need to know this medication or is there something that I don't need to know? Um, the other thing is run applicable then see what class does it, what do you need to consider about it? Have I practice it with cards? And then the other thing is side effects. Cool side effects are important, but they're not like the most important thing. If I give a drug that, um, for instance, if I give them a Terkel, k is for no, or must know is what that the case stands for.
So what do I need to know about the drug? What do I absolutely must know about the drug? Yeah. So, so think about it like this. If I give a talk with a little, I know that the total law's intended effect is to decrease blood pressure. And it also decreases heart rate. Um, do I care that can cause nausea, vomiting or do I care that it effects the organ systems? Try to kill that affects the cardiovascular system more. I care about them that it affects, borrow their blood pressure on and COPD medication because it gave him too much, too much metoprolol. Then if they maybe get itchy or if they have or maybe they get nauseated and don't care about their nausea, I care about their blood pressure tanking. So that's how this works. Let's see. So yeah, that's all I got for that. So I'm gonna Answer Sharon's question. Sharon says, what's best to stick with work in click. So, um, let me find this thing real quick. I don't want to give you the wrong information. Oops. Uh, Oh, let me find it.
[inaudible]
one second. I want to, I want to get this stat right before I tell you.
Okay.
Actually I can just pull this up here.
[inaudible]
one second. Here we go. This is the NTSB and study plans. So this is what's on the end clicks. So if we go down here [inaudible] so pharmacologic is going to take up about 15 interesting questions. So pharmacologic therapies. So you're going to see something like, um, wait, let's go to it. Well I've got to find it. Bear with me, but it covers a lot. So I want you guys to, I want to make sure that we're on the same page. I'm a physiologic and meditation.
Wait,
yeah. Oh no, that's like a social it with me. Here we go. Pharmacology and peripheral therapies. This is what you, this is what you essentially need to study. You need to know how to get blood products. All right? So when we're talking about medications, performing calculations for the medication administration, you didn't know how to respond to a, I'm here. I'll tell you what. Let's do this. I'll make it easy for you.
Oh, okay,
Gerald. Click that and you can see and go on to page 30 and just let me know when you're there.
Okay.
So with this, these are the things you need to think about when you're doing. So this is where the sock method applies and the in class is a pharmacological internal therapies. So basically how do I monitor an IB infusion and maintain a site? Do what I need to know how to give drugs for pain management. Um, I need to know how to handle it, to consider controlled substances. I need to recognize. So when this goes to the question is okay, you might be, what I want you to do is I want you to click that link, right click that link, save it, save it somewhere. And then I want you to take a look at it later. This is the NTSB and study frame. And we basically what they have is they've outline all the things that they really are going to have on there.
Um, so with this, what you need to do is, uh, when you're talking about the, this document that is, it's to administer medications using their patient rights and medication. So this goes in her room, know and consideration, right? Learning to consider the patient, what do we need to educate my patient on that? Some of the considerations. And then the other thing is know what do I even know about this drug and do I need to know if like they don't say like, Hey, you're on this unit, you have to give this drug. That's what you want to do. A titrate dosage and medication based on assessment ordered parameters. So hey, your patient's online a, a, a base of annihilator and you titrate it to this amount. What would be the anticipated, uh, the things you want to consider? What are the anticipated side effects? Hey, I'm getting a busy night later. I spent those blood pressure to drop a little. So these are the ways I want you to start applying this. You can take the supplement that and apply it to this and that really help you. So what are the questions that you guys have?
If you guys don't have any other questions, I'm going to wrap up for today, but I wanted to come and visit. I haven't visited with you guys this week. I missed out on a real, real busy. Um, but we, you know, I wanted to come hang cause I like doing these sessions. There's a lot of fun. So, all right guys. Well, I want you guys to go and have a bad ass weekend. Um, so sick and as always, happy nursing.