energy slump!

I have sort of been dragging my feet on everything for the last couple of weeks. I can blame part of it on having had bronchitis, and it's lingering effects. But part of it, I think, is just due to getting a lower grade than I expected to get on my midterm clinical eval and letting it get me down. A B+ is a fine grade, but I had it in my mind that my semester was going so well that I deserved an A. Woe is me. Not.

Asking around to my classmates, I haven't yet come across anyone who got an A on their midterm eval, not even an A-. And a general theme in the feedback is that we need to exhibit more confidence in the clinical setting.

That feedback and grade, unfortunately, I let have the opposite effect on my confidence. I skulked into clinical feeling worse about myself, and self conscious, and wondering what it was I had been doing that made me seem not confident (because up until that point, I had felt confident!).

I think a big part of doing well in nursing school clinical is letting go of the anxiety about being judged, and just diving in. I hope that by next Monday, when I go back, I won't be feeling sick anymore, and I can really bounce back and go full steam ahead.

Oh, but this is all just review for you, isn't it?

I kind of love and kind of hate that some of my teachers have so much confidence in me sometimes, or assume that the content is easy for me. They think, oh, she's got a biology degree already, this content is effortless for her!

But stop and think about that for a minute. How many undergraduate biology courses do you know of where they go over acute interventions for increased intracranial pressure? How about the specifics of traction setups? Or different methods of modifying the bowel after a portion of it has been removed?

Yes, I have probably a better understanding of some of the anatomy and physiology of mammals than some of my classmates. And I'm a good critical thinker. But I'm still working HARD!!!

My training in marine biology is not so much helping me with patient care, I promise. If anything, the greatest benefit of having a couple degrees behind me already is that I know how to be a good student; I know how to study well, and I'm not as shy about asking the questions I need to ask.

"RN = Real Nurse"

Today I felt like a real nurse more than ever.

I was on outrotation to ICU yesterday, and asked permission to stay again today. It was really worth it. My more difficult patient, I already knew the nuances of all his equipment & tubes & wires, and was familiar with his MO and particular breed of family drama. My second patient, I knew a lot about her condition from my own health experiences & so felt comfortable managing the interactions, education, medications. It was only my second day in that unit, so I didn't know where everything was, but I knew enough to get by. I was able to do & chart full shift assessments on each, and do a lot of the maintenance stuff all day long as well as both med passes.  I got some positive feedback from the staff nurse, who happened to be charge nurse, early in the shift, which made me feel more confident. She complimented me on my charting.

I feel like everything is starting to come together. Our next two skills on the horizon...IV push and IV starts, I think will really put things over the top. IV push is going to be a game changer in terms of time management, but the next time I go back to clinical I will be switching to DOU (from mostly med surg) and taking one patient for the first day, which will help me get my footing.

Excited! Exhausted. But mostly excited!

Clinical After-Burn

I seem to do a lot of after-processing after clinical and internship. Thinking about the patients I had that day, what their symptoms were and how they led to a diagnosis. How I interacted with them and other members of the healthcare team, and what went well and what didn't. Picturing procedures that I did or saw in my mind's eye.

I think it's a good thing...like how you keep burning calories for a little while after vigorous exercise, even after you've stopped. Getting more bang for your buck. (So long as it doesn't interfere with sleep, which it usually doesn't).

But sometimes there is something that puzzles me, and I get stuck on it, and really without more information I can't reach a plausible conclusion and it BUGS me. Like yesterday. A middle aged woman came into the ED because another HCP noticed that one pupil was larger than the other. They were both still responsive to light. She hadn't been exposed to any chemicals or medications that she was aware of. She had no neurological symptoms, had not hit her head. Her scans were negative for any sort of abnormality...no brain bleed, no hematoma, no tumors. She didn't really even have any symptoms related to the eye being dilated; wouldn't have noticed herself if the chiropractor hadn't pointed it out to her. Her blood pressure was a little high, for her, but seemed hospital-stress related. Over the time she was there, her pupil slowly returned to close to the size of the other one (it started at about 4mm vs 2mm in the other one).

The doctor didn't know what had caused it, and basically told her she might follow up with an opthamologist, but that he thought she must have accidentally rubbed something in her eye (she couldn't think of anything she might have been exposed to). I ran this by my neuro teacher, and she didn't know. She googled a little bit, and ran it through her own experiences and brain circuitry, and finally just told me I needed to let it go! I hear that a lot from my teachers.

Mid-sleep panic

I spent many hours yesterday making my flashcards and reviewing lecture and reading material. Right up until bed time, in fact.. of course, I did listen to a book on tape of something entirely fictional and fluffy in between studying and really falling asleep, but I think the nursing material was still on my mind.

I remember waking up a couple of times in the middle of the night and feeling panicky with thoughts of, "I'm not going to be able to do this, I'm not good enough, I can't memorize it all, I won't get a job..."

I was able to tell myself that the middle of the night is not the right time to be considering these things, and fall back asleep. And I feel..well..pretty good about my path and future by the light of day.

I'm doing well in my classes, clinical is going very nicely this term, and I feel very supported and liked by my teachers and most of my classmates and the staff nurses I've worked with. I don't know why I'm filled with so much self doubt sometimes.

Exam jitters

I had to miss class one day last week. I had caught a stomach bug (two faculty have had it, one of my classmate's daughters). It happened to be a test day. I was feeling only somewhat prepared for the test, so part of me wasn't unhappy about having to stay home.

Now, though, I have to make up the test, within a week. And There are two tests this coming week already, so now I will have three. Adding to my nervousness, without sharing any details of the exam (which I wouldn't want to hear), my classmates have said that it was, "really hard," and, "make sure to read the chapters, not just learn the powerpoints." 

I have been feeling low energy since the day I was sick, though most of the vomiting etc was done within 24 hours, and I have sort of gotten behind on everything. I don't have clinical this week (but do have my internship one day) so it will provide me a little more time to catch up, which I desperately need to use wisely. Instead I am just sitting here being sort of anxious and jumpy, while at the same time my head feels foggy.

I think if I just make myself get started, I will be on a roll. I can intersperse cleaning chores in between to get me up and moving now and then, and stop me from being in a study stupor. Yeah...now...GO.   I said GO!

Brain not cooperating ;-)

Better get to it.

New job, feeling slightly awkward

So, my new job is a two day per week caregiving position. There is another woman who helps out the client on the other days. It pays well, is inherently very easy work, and allows me to keep tabs on the residents of the facility I used to work at without actually having to participate in the drama of working there.

I really like the client. She's not used to me coming there in that role yet, and is a little confused about it, but likes me too. I basically show up during the evening and see her through her sundowning time, keep her occupied and socializing in the evening, and help her get ready for bed at night. We do puzzles and arts and crafts together. It really is sort of a dreamy job to have while I'm finishing up nursing school.

I do feel a little awkward about it though. There is space and time to be filled, and it seems to be important for me to keep talking and moving and creating things to do and ways to interact, because if I don't, she starts to feel self conscious like she should be coming up with something to say or a way to entertain me. That is what I'm perceiving anyway.

I'm sure it will pass, and we will find a routine. Maybe I can take her out to a concert or dinner sometimes, to help pass the time, or talk her into participating in some of the activities in the building together.

She does seem genuinely grateful for the company, but also a little overwhelmed by having someone new there. She already knew me, of course, as one of the people who brought her pills and was friendly, but it is different now that we are together for 4 or 6 hours at a stretch rather than just a few minutes here and there.

My teacher told us not to do that.... :-/

So, I took 3 patients yesterday, from morning 'til post conference. The assessment and morning med pass time period was pretty hectic, and I got kinda sweaty (from being nervous I think, not from running) but it all worked out. It was complicated some by two antidepressants for different patients not being available on the floor and having to contact the pharmacy multiple times (and ways) to get them there. Also, at one point I needed to give my patient morphine, both oral and IV push forms were prescribed either routine or PRN, and I pulled the wrong one out of the pixus the first time. There was a line of staff nurses waiting to use the pixus and I let myself go more quickly than I should. Also, there are three pixus machines on the floor and I had to go to all three of them to get the various medications one of my patients needed.

But I got through it! Yay! I think I'm the first one in my clinical group to try three patients. The two that I spent the most time with (they were higher needs than the 3rd, who had her family with her and was just waiting for surgery) kept bragging about me to my clinical instructor or my staff nurse, whoever would listen. So apparently I did OK. Even with re-heating one patient's coffee about 15 times while trying to get through morning med pass.

Back to the title of my post though... so we are covering central line care and use in school right now, and one of the things my teacher for that subject emphasized, was that whenever you have a catheter going into someone's blood stream, peripheral or central, if the dressing is loose, or soiled, or the site is leaking, you've got to take care of it to prevent infection. Makes sense, no? But she said she ran into IV sites that just had their loose, sloppy dressings taped down a million times rather than removing and replacing them, and that's one of her pet peeves.

Two of my patients yesterday had sort of alarming looking PIV's; one was on a hand, and the dressing was half off. It was awkward placement and I'm sure with eating meals and just going about her day it was pulling loose constantly. The other one had a fair amount of blood visible leaking from the site, underneath the bandage. I asked my staff nurse about it... we haven't been taught to insert IV's yet, but I could change the dressings, could I do that? And in both cases she declined. "Just tape it back down," she said, and to the blood: "Yeah, it was like that yesterday, too. The thing is, she has really difficult veins, and I'm worried if we take the dressing off, the line might come out, too." I heard the words come out of my mouth, "My teacher told us not to re-tape dressings down, just to replace them..." and immediately felt like a little snot. Luckily, my tone wasn't attacky, and she just smiled and said if I wasn't comfortable, she could do it. She is a fairly recent (in the last 2 or 3 years) grad of the program I am in so I'm sure she gets where I was coming from. I suppose I could have advocated more strongly.

I've never been that comfortable with I & O's... for one thing, their meal tray is brought by the CNA and might disappear before you have a chance to look at it. For another thing, remembering how many mL is in a carton of milk vs a plastic foiled cup of OJ vs a styrofoam cup is just bewildering. And some staff nurses prefer you to chart them while others want you to write down the amounts on a little paper inside the closet doors for them to collect at the end of the day. I've got a little reference sheet, specific to the hospital I'm at for clinical right now's dietary materials, which is helping. Got it from the ward clerk.

My next question that has been bothering me... when you do incentive spirometry with someone, in the computer charting system there is a check box item: "Did they hold their breath?" with yes or no responses, and I don't know if they are *supposed* to hold their breath!! I don't remember being taught that they should. Exhale completely and take a deep breath in to make the spirometer go up, try that 3 times, and record the highest one. Get those alveoli open. I guess maybe there could be some benefit from holding the breath with the lungs completely full so that the alveoli are open longer?...

**quick research break***

Yes, you are supposed to have the patient hold their breath with full lungs for 3-5 seconds before exhaling slowly. Well, that was easier than I thought :-)

I had a kind of frustrating start to my day yesterday. I arrived expecting to take care of one person that I had had the day before and pick up two new ones, but the the hospital I have clinical at just hired a boat load of new grads, and they are all orienting right now; us student nurses can't work with a staff nurse that is also in charge of orienting a new grad. A new hire mentoring nurse was assigned to my one patient left from yesterday, so my instructor put me with a different nurse. I had my notes sheet all filled out with my new patients' info, and then, "Oh, oops...that one has a new hire to train, too." So I had to start from scratch twice.

I'm proud of myself though, I kept my cool, and managed to get through my first day with 3 patients. It's all good.

Patient Quantity Progression

In 1st semester, our goal was to be able to do full patient care on one patient plus everything after morning med pass on a second. In second semester, the goal was to do full patient care, all day, on 2 patients, including double morning med pass. In this, third semester, our goal is full patient care on 3 med surg patients including triple morning med pass.

Last time I was at clinical, two weeks ago, I had two patients, and felt like I could easily handle a third. I was planning to start out the day with three today, and see how it went, but when I got there in the morning, my nurse only was assigned three patients total, and their 0900 med lists looked pretty intense. In retrospect, I probably could have done it, but in the moment I panicked, went for two, and added in a 3rd later on in the day when there was an admit (but lost one to discharge shortly after, so I only had 3 patients for a short time).

I'm going back to clinical tomorrow. My same staff nurse won't be there, but I'm hoping to continue with the one patient I had today that will still be left, and add in two more. I can do more of a focused assessment on the guy I saw today, and fuller assessments on the other two. It's going to be awesome. I'm nervous.

My teacher was testing me more than usual today, pushing me just a little beyond my comfort zone with questions. It's good...I learned stuff...but of course I get a little nervous. She still kept it balanced out with encouragement though.

We've got two more big tests this week. I'm semi-prepared for one and not very prepared at all for the other. Luckily, I've got tonight to study, and I'm not completely wiped out from clinical yet. Today was doable.

Feeling appreciated

Before the school year started, I quit my job at the assisted living community. I was struggling with the decision all summer, as I worked 12 days in a row sometimes, watched my boss be demoted, then fired, the med room torn apart and moved into a resident apartment to work out of tupperwares.

See, a lot of the problems that I was concerned about with the way medications were handled, the overall level of care of the residents, who was allowed to be a resident vs needing a higher level of care, education of the people in charge of "assisting" (administering) medications, mistakes being made, etc .... a lot of these problems, and more, finally made it into the owners' awareness when a hired auditor came to check out or building.  Before that, they were perfectly happy with looking the other direction, sweeping mistakes under the rug, and having people in charge that had no idea what they were doing.

For a while there, all of the med techs and caregivers thought we were going to be fired, collectively. The company that was taking us over had done something similar with another assisted living community in town a couple years ago.

I decided it wasn't worth the levels of stress I was experiencing for $11 an hour, the random shifts, the schedule changes, the constant distraction from school. So I put in my notice, and made a leap of faith in to private caregiving instead for the remainder of the time before I get my RN license.

I haven't been back to the building for about 6 weeks now, but recently took on a new private caregiving client that also happens to live at the community I left. So I was back there last night.

When the other residents and caregivers saw me, there were smiles, and hugs, and more hugs, and one resident cried she was so happy to see me. There's something very personally gratifying and self indulgent about seeing and hearing the evidence that I've been missed.

At least two tests per week...

I both love and hate that there are tests every week in nursing school. I love it, because it means that you can't ever get too, too terribly behind. I hate it because it's exhausting, the hours of preparation.

For one thing, now that I'm in second year, we have clinicals on Monday and Tuesday, and classroom work on Wednesday and Thursday (labs on Friday). So after 2 days of clinical, which can be sort of high-stress, what with being watched and judged and trying to find what you need and keep everything running smoothly, when it would be nice to go home and take a nice nap, instead you have to prep for a test.

It's all got to be about staying ahead of things, I suppose. I can't plan on using Tuesday nights to study, because I know at this point that I will be pretty darn exhausted. So I've got to get that test prep done by Sunday at the latest for  a Wednesday test.

The upside is that my instructors this year all write a decent test, and are reasonable and logical, and willing to discuss questions about the exam in a non-threatened way :)

One thing that's happening this year that didn't happen much last year, is frequent verbal references to the upcoming NCLEX. Like, "You don't have to know the types of traction in detail for my exam, but you may need to know them for the NCLEX, especially these 3." Or, "A good test-taking hint is that if it doesn't sound familiar from something we've just recently talked about in class, it's probably not the right answer, although that approach won't get you anywhere on the NCLEX."

Should I be scared of the NCLEX? I know it's very comprehensive, which is intimidating, but I think I'll be okay.

A study tool to share

This is not everyone's style of course, but I've found it works really well for me. I've been using an electronic flashcard app (I used gflash but there are many out there) to translate every factoid from my nursing school powerpoints into a question and answer.

I make a table up of all these Q&A's in google docs, then import into gflash, use that as my drill tool and before long I've got the lecture memorized. It's easier for me than making up index card flashcards because I'm a fast typist. Usually by the time I've typed up all my flashcards from a lecture (about 60-100 questions per 2 hour lecture) I know at least 50% of the material.

Gflash presents you with all the questions to get your baseline, then reshuffles and focuses on the ones you missed the first time around, mixing in a few that you already knew. It keeps doing that until you get them all right.

For me, the repitition, and the in-my-head recitation of drilling these electronic flashcards does the trick. And in order to write a meaningful question on my flashcard, I have to have understood the material.

In my program they give us weekly "objectives" that basically summarize what we are supposed to get out of the content from that week. Sometimes all of the objectives are addressed in lecture, and others you really have to dive into the books to get the full picture. I sometimes translate the content from these objectives into flashcards too, if it is really information dense.

This all takes time but it seems to be a guaranteed "A" unless the teacher is intentionally writing nasty questions (we had one of those teachers last spring).

The other plus is, when midterms or finals come around, you've got a whole database of flashcards to run through rather than going back and trying to piece together concepts from the start again.

There are other tools of course. Published study guides that go with the textbooks we use, and online references and practice tests made by the publisher. I've found these things only moderately helpful in actually doing well in the class.

In anatomy class, I found that making powerpoint quiz files (structure on first slide, labels on second slide) was a really effective tool.

This all may be obvious and natural to some, but the last time I was an undergrad none of these tools were around! Now I can have thousands of flashcards on my ipod and organization is a breeze.

I've also found that it is very soothing for me, the morning of a test, to have the feedback of an app that's telling me I know 100% of the material, rather than flipping back and forth between notes and thinking, "gosh, I hope I remember this all, I have no idea how much has stuck."

Internship in ED this fall

During our 3rd (of 4) semester, my class was given the opportunity to apply for internships with some of our local hospitals. We get 1 unit of course credit for the experience, and it's a good networking opportunity as well as a way to get more hands on skills and experience.

We put in our application (a cover letter, a resume) to a person in the education department of a group of hospitals, told her which unit was our 1st, 2nd, 3rd preference, etc and then waited to hear back. I said emergency department first, NICU second, ICU third. We've gotten to do "outrotations" from clinical to some other areas in the department. So, so far, I've seen med surg, ICU, ED, Peds, mother-baby, NICU, L&D and OR. The outrotations that I was the most excited about so far have been the emergency dept and NICU. I was torn about which to put first, however the hospital that was offering a NICU internship was quite a bit farther away. Also, I thought I'd get a better broad experience and wider variety of skills in the ED.

I had an interview with the ED department manager over the summer. I believe ED was the only department that actually had us students come in person for an interview; the others were phone interviews. Three of us got placed in the ED at this hospital. During our third semester of the RN program, we have 2 days of regular school clinical every other week, so I'm doing one day per week at the internship only on the weeks I don't have normal clinical. The requirement for the course credit is that we do 54 hours of hands on time, but with the department director's consent, we can do more. It's unpaid.

 I had my first day there this past Monday. What a blast. I was there for about 8 hours, and had about that many patients. I was working directly with an ER nurse that is a graduate of my program. I got to see a dressing type I hadn't done before on a finger wound, do lots of glucoscans, discontinue IV's, do assessments on a wide variety of patients, lots of urinalysis, talk with someone who had just tried to commit suicide, prime IV lines (we are not allowed to actually *give* any medications at the internship), do patient education.

I left really excited about becoming a nurse, and hopeful that maybe at some point I could become an ED nurse. It think the variety is really the excitement for me. And the faster pace. On the med surg floor, it can sometimes feel like babysitting. Morning assessment, morning meds, hygiene care, morning treatments, nursing interventions, noon meds, more hygiene care. Some people really like it because it's a more wholistic experience with the patient. At this point in my student life though it feels really good to just be exposed to *a lot* of different situations, even if I don't get the same depth I would if I were following the same 3 patients all day.

I'm sad I won't be going back for another week and a half; I've got a lot of stuff to do in the mean time. Had a quiz today, an exam is tomorrow in my neuro class, we're covering IV push meds in lab on Friday, and I'm back at normal clinical for two days in a row at the beginning of next week. So I'll stay busy. But I'm really excited about going back to intern again!

Oops, I got busy and didn't post.

Before I started this blog, I noticed a pattern in nursing school blogs where they start out strong and then dwindle over time, eventually completely disappearing. I wasn't gonna be like that. But holy cow nursing school is busy. You've got coursework and lab time and clinical, and a job to pay for school, and study hours. Eventually there's no time left to do anything but collapse in an exhausted heap at the end of the day. I do love it. It's going well, and I'll be done with the RN program in about 9 months. Will do a few catch up posts today.