Friday, March 31, 2006

Care Plan Two...DiVa style

I didn't think I did very well on this care plan because my goals are actually interventions, but my prof liked it so well that she is encouraging me to expand my research and have it submitted for publication in a scholarly journal. Whoa! I was not expecting that, nor was I expecting two extra credit points in addition to a perfect score. Check it out...

Admission information

AP, is a 42 year old African American male, was admitted to the hospital for sepsis/pneumonia, rule out tuberculosis. His stage of growth and development is somewhere between stage 5 (intimacy vs. isolation and) stage 6 (generativity vs. stagnation). The patient was brought to the emergency room by his sister with an episode of respiratory distress. Although the patient has a history of HIV, this diagnosis was not the focus of his treatment. The priority at the time of his hospitalization was the resolution of his respiratory issues, pneumonia and ruling out tuberculosis. Additional notes: This patient was being treated primarily for the pneumonia, but actually was experiencing what is known as full blown AIDS.

Medical history Includes

Genital herpes, hair follicle disease, Hepatitis B, HIV, colon cancer, tuberculosis, colostomy and rectal prolapse.


Advance Directives

The patient is a full code. The house officers explained the prognosis of the patient and the family had a meeting. They came to the conclusion that it would be his wish to live despite the odds.

Psychosocial and Cultural Assessment

The patient’s spiritual preference is Southern Baptist. AP is a single man and the hospital staff was under the impression that AP lived an alternative lifestyle. He is currently disabled and relies on Medicaid/Medicare for insurance coverage. AP had only informed his family that he suffered from colon cancer. That was only part of the diagnosis. AP was also HIV+ and had not disclosed his HIV status to the family. This caused him a bit of anxiety because he was concerned that his family would find out from medical staff. To address the anxiety the patient was sedated and the RIKER scale was used to assess his level of anxiety. He made it clear during his primary assessment that he did not want anyone to know. As a result, it is believed that AP lived out the remaining days of his life in secrecy and withdrawn from the people that he could rely on for support.

Nursing Diagnosis and Evidenced-Based Nursing Interventions

Social Isolation and inadequate support related to stigmatization of HIV/AIDS as evidenced by failure to disclose complete information regarding his health status to the family.

Ineffective coping related to HIV/AIDS status and alternative lifestyle as evidenced by medication non-compliance, substance abuse and high levels of anxiety.

Goals:

1. Meet psychological/emotional needs by expressing feelings and utilizing his family as a means of support.

2. Identify ineffective coping behaviors and consequences

3. Take action to correct isolation and participate in support groups once a week designed for members of the community who are a part of the same peer group, and that suffer the same ailment. (AIDS support group)

4. Learn about the importance of treatment compliance and develop a schedule to manage his medications.

5. Develop a relaxation program or tap into spirituality to help develop healthy coping mechanisms to deal with the stress and anxiety associated with HIV/AIDS

Interventions and Scientific Rationales

- Establish a therapeutic relationship with the patient

Rationale: promotes trust and enables the patient to discuss sensitive matters without fear of judgment. Once this type of relationship has been developed, it will be easier to encourage the patient as he comes to grips with the seriousness of his condition and to support the patient when he decides to disclose his illness to the family.

- Encourage the patient to express his feelings through journaling about his feelings of stigmatization.

Rationale: Many people find journaling to be a non-threatening way to share feelings about various life situations without fear. A group of professional nurses from the University of Texas at Austin performed a study on the benefits of writing and discussing the trauma of having HIV/AIDS, which enabled the subjects to think about and reorganize their feelings about their condition. As a result the patients were able to overcome the stigmatization and improve their quality of life. “Psychological benefits include a decrease in depressive symptoms, anxiety, and negative emotion, and higher self-esteem (Esterling et al. 1999).”

Evidenced- Based Support
“Stigma is a real or perceived fear of discrimination (related to the diagnosis of HIV/AIDS). Individuals with HIV/AIDS fear negative responses from others (Bigner & Bozett 1989, Doll et al. 1994, Moneyham et al. 1996). Social isolation and loss of supportive relationships, imposed by others who fear contagion (Muma et al. 1995) are major stressors for individuals with HIV/AIDS (Lippmann et al. 1993). Stigma associated with having HIV causes clients to be concerned about disclosure to family, friends, and co-workers, especially when they are taking multiple medications (Campbell 1990, Weiner 1991, Moneyham et al. 1996).”

“Given the complexity and burdens of HIV/AIDS, there is a need for an effective, easy, low cost intervention that integrates health care services and improves outcomes for patients with HIV/AIDS. When individuals experience stressful events, such as living with HIV/AIDS, and are unable to share their thoughts and feelings with others, they are at an increased risk for physical and mental health problems (Petrie et al. 1998).

“…emotional disclosure through a writing intervention would result in cognitive reorganization and a reduction in perceptions of stigmatization. In turn this would improve the psychological and physical health and health-related behaviours of persons with HIV/AIDS. This hypothesis stems from previous findings that both cognitive reorganization (e.g. Pennebaker 1997b, Pennebaker et al. 1997) and reduced perception of stigmatization (Pennebaker & Seagal 1999) were linked to improved psychological and health outcomes.”
(Pgs. 511-513, Abel, E., Rew L., Gortner E., and Deville, C. L. (2004).


-Plan a family meeting to support the patient as he makes his disclosure to the family. Be available to help educate the family, answer any questions and provide community resources.

Rationales: It is clear that AP felt that his family would abandon him if they were aware of his HIV+ status. His family is a close knit, spiritual family. During his time in the Medical Intensive Care Unit, his entire family stood at the bedside and prayed for him and talked to him, even though he was unable to respond. At the time of this exacerbation of illness, the patient’s sister was the primary caregiver. If the family has support and are well educated about the course of illness, the patient should be able to experience a good quality of life.

Evidenced- Based Support

“Beliefs about illness Studies of low-income and minority populations indicate that many persons have inadequate and incorrect information about HIV and its transmission (Mays & Cochran 1987, Flaskerud & Thompson 1991, Stewart 1993). Individuals may view ART as harmful and doubt its effectiveness, based on their experiences, or be influenced by what others say (Misener & Sowell 1998, Roberts & Mann 2000, Catz et al. 2001, Ammassari et al. 2002).”
(Pgs. 511-513, Abel, E., Rew L., Gortner E., and Deville, C. L. (2004).

A study of patients with AIDS in Thailand performed by nurses at the University of Manchester England revealed the following evidence:
Anxiety, reluctance and stigmatization have often been seen within some families of PWAs due to lack of knowledge and the people with AIDS (PWA) less acceptable behaviors in the past. PWA’s have been left alone in hospitals or temples, increasing their psychological problems (Polmuk, 1996). The acceptance from the family may encourage PWAs to cope better with their illness. Thus, preparing PWAs, family and community to live together well is a crucial health care policy to be considered that should include community and home care programs, (Molassiotis and Maneesakorn, 2004 ).


- Perform regular screenings for depression and medicate accordingly. In addition to pharmacological treatment, the patient will need to develop a network of support within the community.

Evidenced- Based Support

“Patients at all stages of HIV infection need psychosocial support to deal with depression, anxiety, and other emotional problems that can develop as the patient’s condition changes. At each visit, screen your patient for depression and refer her for further treatment if indicated. The health care provider may prescribe a selective serotonin reuptake inhibitor (SSRI), which is considered a first-line therapy for depression. In general, general, SSRIs are well tolerated and relatively safe to use, especially for patients with hepatitis or other hepatic impairment. Any antidepressant should be prescribed in conjunction with counseling, talk therapy, or support groups.” (Pg. 62, Kenny, 2004)

-Develop a relaxation program or tap into his spirituality to help develop healthy coping mechanisms to deal with the stress and anxiety associated with HIV/AIDS
Rationale: The patient history revealed that the patient had a past problem with alcohol and possibly drugs. The use of controlled substances is an unhealthy coping mechanism or means of dealing with stress associated with illness. Additionally, some of the anti-viral medications are incompatible with the use of controlled substances. The history of African Americans includes a rich spiritual component, which was evidenced in this patient’s treatment by the visit, prayers/blessings and anointments received from religious clergy. Since this proves to be a part of the patient’s life, it could be incorporated into his plan of care to help alleviate stress and anxiety.
Evidenced- Based Support
“exploring the contribution of spirituality to health functioning have reported that spirituality did provide some empirical benefit for health status (Levin & Schiller 1987, Levin & Vanderpool 1989, Idler & Kasi 1992, Dein & Stygall 1997, Mathews et al. 1998). Their findings suggested that individuals who reported overall improved health status identified themselves as being spiritual. Additionally, spirituality was found to provide a buffer against illnesses and allow quicker recovery from general illnesses. Although these populations were not HIV infected, they were living with some form of a chronic illness, which HIV has clearly become.”
(Pg. 462 Coleman, 2003)


- Address medication non-compliance and the consequences

Rationale: One of the reasons why the patient experienced this period of exacerbation was because he wasn’t taking his medications properly. Mainly, because he didn’t want his sister to figure out his HIV status by the plethora of medications that he was prescribed, but it could be secondary to the fact that he was not sufficiently educated about the importance of medication compliance.
The following list of interventions and rationales are from a nurse at Florida International University who developed a program of care to address medication non-compliance, patient education and treatments for emotional problems that regularly occur with patients that suffer with HIV/AIDS.

(Pgs 9-10. Jones, 2004)

•” Establish a trusting relationship with your patient. If you’re nonjudgmental when he says he’s missed a few doses, he’ll be more likely to continue being honest with you about his behavior. By understanding why and when he may be missing doses, you can work with him to improve his adherence to the regimen.”
• “Be an educator. For example, teach the patient how the virus invades the body, why the drugs work, what adverse drug reactions to expect, and why he must adhere to the treatment regimen. Encourage him to ask questions and provide other details that he needs or wants to know.”

• “Provide ongoing support. Ask the patient about adverse reactions and other concerns he has and help him address them. Advise him to discuss concerns with the prescriber, in case his regimen can be modified. Encourage adherence by graphing his viral load and CD4+ cell count before and throughout treatment, so he can see the benefits of adhering to treatment.”

•” Find creative ways to help the patient stick to his therapy. For example, help him devise a dosing schedule that fits his daily habits as closely as possible. Suggest the use of devices, such as beepers on watches and medication boxes, to keep him on track. Enlist relatives and close friends to remind him to stick to his schedule.”

•” Tailor adherence strategies in view of any concurrent mental or behavioral conditions. A patient with a co-diagnosis, such as depression or substance abuse, may need additional help and referrals. For example, depression can be treated with the use of antidepressants and counseling or a patient may request placement in a drug rehabilitation program to help him overcome substance abuse.”


References
Abel,E., Rew L., Gortner E., and Deville, C. L. (2004). Cognitive reorganization and stigmatization among persons with HIV. Journal of Advanced Nursing, 47 (5). Retrieved Mar 20, 2006, from EBSCO Host.

Coleman, C. L. (2003). Spirituality and sexual orientation: relationship to mental well-being and functional health status. Journal of Advanced nursing, 43(5). Retrieved Mar 20, 2006, from EBSCO HOST.

Jones, S. G. (2004). Taking HAART: how to support a patient with HIV/AIDS. TravelNursing2004, Retrieved Mar 20, 2006, from EBSCO Host.

Kenny, P. E. (2004). The changing face of aids. Nursing2004. Retrieved Mar 20, 2006, from EBSCO Host.

Molassiotis, A. and Maneesakorn S.,(2004). Quality of life, coping and psychological status of thai people living with AIDS. Psychology, Health & Medicine, 9(3). Retrieved Mar 20, 2006, from EBSCO Host.

Monday, March 27, 2006

If you don't get involved in school activities,

then you don't deserve to enjoy your academic experience.

(By the way, I think this is totally untrue!) I was once told this by one of the post-adolescent traditional nursing students when I asked their thoughts about our school. So I took this pseudo-advice given me and accepted an invitation to participate a school activity. No big deal. Or so I thought. People were expecting that I would not be involved in the activity because of time conflicts with my kids' school activities and other adult responsibilities, so an alternate was elected to step in. I guess in all honesty, the alternate was for anyone who would not be able to attend, but to say that it was for me just sounds more logical.

The reason why I say this is because the group developed their whole strategy without me. I thought that kind of sucked because it was the alternate that made the statement that is the title of this blog entry. The advisor asked that we meet for pre-event meeting, another group activity that was planned without asking my input. I was cool, because people expected me to be a little huffy or to drop out. But I stayed. The alternate was in attendance. The alternate was so quiet around me, I couldn't believe it was the same out-spoken, arrogant person. I think the alternate was quiet because it became clear in that moment that the way I have been treated at school has been unfair. Either that, or I had been bad-mouthed and it was an uncomfortable situation. Either way, I felt it.

The advisor asked me, and only me, what made me decide to participate in this particular school activity. In other words, "What the hell are you doing here?" I said that I was invited to participate by the program director. I made it clear that my talents were recognized and that I was honored to have this opportunity to represent my school and my demographic. Ooo...that was unexpected. I imagine that it was also surprising to find that I plan on staying at my current school for my graduate studies. And that I plan on taking part in developing my own research. Most people think that the non-traditional student is only here to get a degree, get a job and then get out. I bet it was even more surprising that I stay abreast of the current events at the university and in healthcare. Or that I can interact with anyone from the president of the university to my peers with eloquence. Perhaps they were expecting a shrinking violet.

If I weren't a senior, I would probably never get involved in another undergraduate student activity again. Why? Because it was made clear that my presence was not welcome. But then again maybe I would, just to prove that I have a place and a value in student organizations. I have insightful life experiences that people could learn from. After the activity, the whole group went out together, they did not invite me, or even make me aware of any plans. Which was cool because I had other stuff to do anyway. Maybe the reason why I have always felt like I didn't have a value because I never let my inner strength and leadership abilities shine through. I believe that it was Eleanor Rooselvelt that said "No one can make you feel inferior without your permission." In all honesty, the non-traditional student has a lot to bring to the table. Don't be afraid or let anyone intimidate you from being involved.

-DiVa...who at the end of her academic journey, suddenly feels empowered!

Thursday, March 23, 2006

58 days until graduation!

Can you believe it?

I am just in awe. I picked up my cap and gown yesterday, and now that I have the cap and gown in my possession, graduation seems more real. I took my senior pictures. I have my announcements. Time is going along so quickly. I have taken the test to prepare me for the NCLEX, which I passed with flying colors. So for all practical purposes, I am ready to go. That is of course besides papers that need to be written and miscellaneous tests/finals that need to be taken. I am almost done.

When I started nursing school, my children were just 4 and 8 years old. Now they are eleven and seven years old. Everyone has grown up. Including me. Change is good. I have learned about people and how to respond to sticky situations. I have learned how far I can go once I get motivated. I never thought that I would ever have a bachelor's degree, but I am less than two months away from having one. I can't believe it! So many people said I wasn't college material. I guess they were wrong...

-DiVa, so proud she could just cry...

Sunday, March 19, 2006

The nurses have staged a coup...

Okay, so you know that I have been having a pretty hard time with my preceptor, but I have been gritting my teeth and bearing it because I want to finish my hours in time to graduate blah, blah, blah. I worked four days in a row and on the third day, I was washing my hands after doing patient care when one of the nurses came to me and asked me if I liked working with my preceptor. She wanted to know because she and a few of the other nurses were going to the nurse manager to report what has been going on, and they were going to tell her whether or not I agreed with their action because they felt that the way I was being treated wasn't right and that my preceptor should be stopped. They went on to say further that this is supposed to be a learning opportunity and that there was no way that I could be possibly learning anything with the constant insults and embarrassment that I suffer at the hands of my preceptor. Additionally, they felt that my preceptor's behavior was a poor reflection on their unit and the hospital in general and that I should leave their institution having had a satisfying experience.

I was stunned. I had no words. In that moment of silence, I thought about how miserable I am working with my preceptor. In my mind I was saying HELL NO I don't like working with that lunatic! But I said instead, my preceptor and university representative are aware of my feelings regarding working with my preceptor. I told them, I don't want to be caught up in the middle of your unit politics. I just want to finish my hours and graduate from nursing school. (No more drama for me thanks.) So they asked me if I liked working with my preceptor. I told them that working with her is like working with anyone, there are good days and bad days. They seemed disappointed. I asked her, who would be my preceptor if I were to be assigned a new one. It took my university forever to find the one I have now. She said something like she can't understand why they let this woman precept students because she is brutal to anyone who is learning, be it a student nurse, orienting nurse...Even the residents. She said the residents talk about her during rounds by calling her Dr.(insert name). They really make fun of her, and it is not a joke. Well, how come all these nurses didn't step up when my school was looking for a few good nurses? I told them, I couldn't stop them from going to the nurse manager if that is what they wanted to do. I told them that I would tell the nurse manager the same thing that I told my preceptor and the university representative. Then my preceptor walked up and everyone walked away. It was a very uncomfortable situation.

I told the university representative what happened and she thought that I handled the situation maturely. She will be contacting the nurse manager and talking with her personally about the situation and I will be getting a new preceptor. I thought it was the best thing to do because I don't want to be the unit gossip. I guess it is a bit late for that. The last clinical day, my preceptor was sooo nice. I felt a little bad. I guess I shouldn't because she brought it on herself, but then too I promised myself that I was going to talk to her and then give her a week or so to get it together. Well, that is that.

-DiVa, shocked to learn that not ALL nurses eat their young...

Tuesday, March 14, 2006

Everyone needs to come in...

and the house is a MESS!

I was sleeping, because I have to do a night shift clinical tonight. I heard a knock at the door. I thought I was dreaming. I heard it again, and so I got out of bed to answer the door. It was the cable guy. He said the cable was making noise. He needed to come in so he could find out what was making noise that would interfere with radio signals transmissions by passing airplanes. He said that the cable company could get fined if he didn't come in to fix it. He said he needed to do it today, or else he would have to turn off the cable. Crap, crap, crap. This house looks like a toronado ran through it. He said he would start in the basement and work his way up. Like that's any better.

Then while the cable guy was rummaging around the basement, another knock at the door. It was the mormons. Of all days, two more people who need to come in my house. I generally allow religious solicitors to speak their minds until I feel like they are making judgements. This time, I had to cut our conversation short. They gave me a card. The cable guy came up from the basement, he needed to go into my bedroom afterall. I reluctantly opened the door and of course the noise was coming from my bedroom. I could have died. The living room was okay, so was the bathroom. The kids bedroom as usual, messy. The Kitchen. OMG, the dishes were dirty and overflowing in the sink in the kitchen, the trash needed to be taken out it too was overflowing and the trash bill was late so all of the trash from last week is filling the dumpster. There is laundry everywhere, clean and dirty. papers, toys, shoes...ugh! I am so embarrassed...

-DiVa, thinking maybe she should try to find a way to fit in housework...

Monday, March 13, 2006

Two steps forward, eight steps back...

My preceptor and I just don't work well on a professional level. I have come to accept that. This weekend of clinical was very interesting if I do say so myself. I will be the first to admit that I am not a personality for the ICU. Despite that fact, I am trying to make it through this rotation. On to the patients.

My first patient this weekend was a 42 year old man, diagnosed with sepsis. His history includes HIV, hep B, cancer, genital herpes and an assortment of skin conditions that make you itch to think about. He also had a rectal prolapse, a colostomy, kaposi sarcoma, pseudomonas pneumonia and he was a rule-out Tuberculosis. Long story short, he was very sick. When I arrived he was having a broncoscopy done. It was explained to me that he only told his family that he had cancer so to keep the HIV hush. It reminded me of my crazy cousin, and other people I know who live under a veil of secrecy. One of my aunts had HIV and we only found out on her deathbed. It was very sad because she kept herself away from the family due to the shame of being HIV positive in the late 80's early 90's, and we feel like we lost so much time with her.

Like with all of my patients, I felt like I owed this man my personal gold standard of nursing care, even though he was sedated most of the time. I spent at least an hour bathing him. It seemed like a lot longer because I had to wear a duck-bill mask that protected me from contracting his potential TB. Then I lotioned his body down and gave him a fresh gown and sheets. He couldn't speak due to mechanical ventilation/orogastric tube placement, but he seemed to be more comfortable. Most of the time that evening was allotted to suctioning his endotracheal tube, hanging antibiotic drips and putting a saline soaked dressing on his inside-out rectum. What a way to spend a Friday night. And I must add that I had a good night of nursing practice, I really felt like I knew what I was doing.

Then on Saturday night, I had the priviledge of taking care of a patient who was an inmate at a local penitentiary. Despite whatever crimes committed by this patient, I give her the medal of honor because the resident doctors stuck her 30+ times trying to get an arterial line started, all while hand cuffed to the bed by the ankle. That's right, at least 30 times and none of the attempts were successful. If you are unfamiliar with the arterial stick/draw, this is something that hurts a hell of a lot more that your typical IV stick because the arteries are deep within the body and surrounded by nerve endings that are there to cause severe pain so that if you happen to be self inflicting harm, you will stop.

She had a little bit of lidocaine, but it was quite obvious that she was experiencing the sensation of pain. Once she even said, I have a shooting pain that runs all the way to my feet. Do you think that stopped him? Nope. He said something like, that tells me where not to stick next time. Incredible. The patient never complained once but to say, I hope we are getting somehwere with this. The resident finally gave up after over one hour of pokes. He told the patient, I know it doesn't hurt me like it does you, but my ego is bruised. I wonder if he would let someone do an arterial stick on him 30+ times.

The patient came to the hospital, from the penitentiary, complaining of abdominal pain which turned out to be pyelonephritis that had advanced to urosepsis. She had nephrostomy tubes placed in her back from both the left and right kidneys. She also had a a Foley. She had a central line, but because solution had been running through it, we couldn't take a blood culture. On top of that, she had a levophed drip, so we needed to monitor her blood pressure closely so that we could titrate the meds appropriately. These gung-ho residents come into the room intercepting almost any skill opportunity that presented itself.

I was trying to do a blood draw, this guy steps in front of me and proceeds to take over my stick. I was a little heated, but I let it slide. Then of course I wasn't doing the q15 minute vitals fast enough. I took 48 sets of vitals last night and my preceptor was bugging-out because I was late on maybe three of them. She had me running around all night like a chicken with the head cut off. I barely had a break between the patient needing something done, needing to call pharmacy to order meds, paging respiratory, my preceptor yelling at me and the resident asking me stupid questions.

Then I tried to give report. I never am right enough for my preceptor, she always has to add something more to what I say. Very annoying. For instance, the patient was anxious and I explained that the patient stated that she was having an anxiety attack. My preceptor chimed in that the patient had no medicine prescribed for anxiety. I said that she takes Prozac at the penitentiary, and before I could explain that the PATIENT felt it was a medication that SHE felt helped with her anxiety and that she asked for it, my preceptor cut me off and said whatever she said. Basically, the student doesn't know what she is talking about again. Whenever my preceptor does this I shut down. I don't say anything, I just let her do whatever. Only 2 month of this crap left.


DiVa

Thursday, March 09, 2006

Blogging in lieu of sleeping

I shouldn't be blogging right now. I am working another 12 hour night shift. The blog has been calling me, and so I decided to answer. This week has been a very good week. It looks like I will be graduating with honors after all. Two honors. I am ecstatic. That test that I was so worried about in Critical Care...I got a 97.4% Woo-ha! I am going to be so busy soon. I just applied for my Master's program. It looks like I might be doing a blended major. I can't get enough of school.

My father and I were talking today about the future. He and I are co-owners of the tiny little house I live in. He said that he would let me sell the house and keep the proceeds to buy the brand new house I've always wanted. I will believe it when I see it. This house is so awesome! It will have enough space for me and my kids and our kitten. I am so happy. Happy, happy, happy!

Monday, March 06, 2006

Aye sir, my brother graduated bootcamp

He is a marine now, and he really looks good. Our family went to South Carolina this past week to see him graduate. It was like most typical holidays in our dysfunctional family, good to see everyone together again, glad to see everyone go home. I must say, the marines has changed him into a whole different person. He is very neat. I am used to the kid who wore baggy pants and kept his room a complete mess. He is so slim too. He went from a size 42 to a 32 in pants. That alone makes me think about enlisting. I asked him what one of the most important lessons he learned from his experiences and he said, "I learned to be an individual while also working as a team. I am a real man now, I know how to treat people with respect and I get respect in return." I am proud of my brother. I think my Mom and Dad are too!
He took us on a tour of the facility. We saw their base department store and commissary that had super low prices, (another reason I would think about joining the military) and his barracks. I wonder how he slept on those little beds, and if he was warm enough with one little blanket? He seems to be really happy with his new life. I thought that Parris Island was just beautiful.
This is a picture either coming from or leaving Parris Island. After graduation, we went to a nice restaurant and had dinner together. We paid 308.00 for 17 people to eat dinner. I thought that wasn't too bad, but I could have cooked dinner for the family for way less. After dinner my mother gave this really great speech about how proud she is of us. It was rather touching. After that my brother and family left and we planned to go home the next day
...but not until we went to visit Hilton Head Island to see the ocean. The beach was very cold. It didn't stop the kids from playing in the water. We spent about an hour at the beach and then we started back home. It was a long tiring drive. I am glad that we are back home. My brother was glad that we could all make it, our family was prid to witness his transformation and the kids had a great adventure. Congrats to my brother on his accomplishment!