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.

"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!

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.

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.

One scary thing...

At the end of our all day skills day, our teachers sat the whole group down for a "serious talk" about the policies of the program. Most of it seemed pretty reasonable and manageable, like absence and tardy policies, etc. But many of us jumped when they outlined the policy on clinical practice plans.

They went into this long thing about how they are meant to help, not hurt. They will make us better nurses. Oh, I guess I should explain what it is first. If your clinical instructor notices that you are doing something wrong while out in a care setting, they will sit you down and you have to write up a plan together to work on making it better and eliminating the problem. That all sounds great. Maybe a little threatening just in that it's a criticism, but not a HUGE deal. And they say most of us will get one at some point, and probably more than one. Okay. I can cope with that. But then they say, oh, and by the way, every time you get one your grade drops by half a grade. So, say, if I have an A-, but then they notice that I forgot to wash my hands once in a situation where I should have, then B+. Ouch.

Makes me a little more nervous about going into the clinical arena with the instructor.

I've noticed in myself that in the first few days of school, I've been feeling kind of insecure, kind of shy. A little overwhelmed by everyone seeming to know my name and I haven't quite picked up theirs yet. A little self conscious when I ask a question that feels a little out of my league. Happy but suspicious that there's some negative connotation behind it when one of the other students teases me that I'm their class president (elections have not been held, and yeah, I've thought about it, but...).

Deep breaths. No biggy. This is going to be stretching my definition of who I am, but in good ways.

Finger Stick Blood Collection

Tonight was our first skills portion of the phlebotomy class I'm taking. Okay, well, I guess technically we already had one, but that was just how to wash our hands correctly :)

We partnered up, 8 at a time, and went through the procedure of doing a blood collection from a lancet poke in the finger tip, collecting to a capillary tube. I got to practice twice, on two different people. Both said I did a very good job. I was a little nervous going into it (both on the patient side and on the phlebotomist side) but it went pretty smoothly. I think the part I will need to practice most for is not the actual hands on stuff but the best things to say to the patient and being sure to come across warmly and with confidence rather than nervous and new at this. But tonight went well.

I can see that my worlds are starting to collide a bit. The girl I carpool with to phlebotomy class is neighbors with the woman who is out on maternity leave form my new work. So my job is going to know eventually that I am taking a phlebotomy class. Which means that I am thinking of moving on. But maybe that's not necessarily a bad thing. Maybe they will offer me a full time gig if they are keeping in mind that I have other options open.

Feedback at the new job

Things have been going alright at my new job. It is unnerving feeling like I am being watched so closely. And there were some tasks that I had difficulty with, to be honest. For one, I've never used an adding machine, or balanced a cash drawer. I'm talking an old-fashioned with the paper tape type adding machine. My grandpa had one. It's fine now, but I just didn't get it at first.

Then there's the phone. I've always been a little anxious around phones. And this one has a bunch of lines and impatient people (both callers and callees) and special bells and whistles, not to mention very, very specific language that has to be used per company policy (I switched in a "can" for a "may" a few times one day and heard about it later).

But overall, I'd say I'm ding alright. It's, as my counselor says, "a peon job", and it really shouldn't be a huge source of stress for someone my age with a master's degree. The last year has really shot my confidence to hell though, and the combination of low confidence and feeling so *watched* probably made me come across in not the *best* of lights.

Anyway, at the end of last week, Thursday actually, my immediate supervisor started giving me all sorts of praise. Said that I really seemed to be picking up on things, that I had done so well today, that I seemed to be much more confident on the telephone. Really, really laid it on thick. I was feeling good. Whew, I thought, I can relax a bit. And then she says, "because we were worried for a while there".

Back down to a zero again. Thanks, boss.

She apologized the next morning when I came in. Said that it was a rude thing to say, and that she wishes she could take it back. Really seemed genuine about it. But it's already out there, and it bothered me.

I'm trying to just let it go. It's not a career move type job, it's just a way to try to support myself while I retrain. I may even be switching to a different place that is more likely to give me health benefits in a couple of months. But I want people to like me and think well of me.

My counselor told me to focus on the praise that preceded the remark, and remind myself that she said "we WERE worried", not "we ARE worried". Past tense. Let it be in the past and move on.

So that's what I'm working on.