So, I'm a nurse now...

I got busy and let this blog fall by the wayside during nursing school. I think that might be a fairly common pattern for those trying to blog their ways through school!

I graduated from my associates of nursing program in May of 2014, had my license by July, and started my first nursing job on a mixed med-surg/tele floor in August 2014. I worked there for a year and a half (first half nights, second half days), and then requested a facility transfer to a hospital closer to where I live. I now work night shift on a step down unit---have only been there 3 months. I like my crew. I'm hoping to switch back to days eventually, although the pace of nights is pleasant.

At one point I applied for a labor and delivery position at the same hospital. I was pretty excited about it, thinking it would be a key in for eventual move toward NICU. My interviewers realized that too, because I'd been talking to a bunch of people, and they decided to go with someone whose dream was actually L&D. Fair enough. I'm now glad I didn't go that direction. I still think I'd like to work in the NICU at some point, but maybe as part of the float pool at first (get my NRP and STABLE certifications).

I have been working on an online program for my BSN. Two semesters down, and I have one more class to complete before the degree will be done. I've already switched over to the bridge program for a masters of education in nursing. I think I want to teach nursing at the local community college down the road. It will probably take several years to get there, although I could have my M.S. within the next year and a half if I keep up at my current pace.

There were definitely some struggles in my first year of nursing. I'm not going to dwell on them now. Mostly not in the actual care of patients! I may get into them later.

For now, I'm happy to have a stable job near home with coworkers I like and a three-12's schedule that allows for a fair amount of time off.

"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.

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.

A guy walks into the hospital lobby....

No, I'm not about to tell a joke. He came in, limping, dripping blood, and he and his friend wanted to be pointed toward the ER. I ran for a wheelchair, which he didn't want to use, but I was glad I talked him into it. He was acting like he was going into shock, and with the limp, I knew we could get there faster with him in the chair.

He was biking on the road with no helmet, somehow fell, and skidded across a large swath of asphalt. Basically, ouch. He was all trembly and kept saying he felt "tingly all over", which the ER personnel told me was a result of hyperventilating (Oops, I had told him to take deep, slow breaths to help with the pain and calm down...guess he didn't hear the slow part or wasn't able to calm himself enough).

The nurse thanked me for bringing him --- and I stood there like an idiot -- do I stay? do I go? I want my wheelchair back! (in my head) -- but it turned out it was good I was there because she asked me to stay with him a little longer while she went for a gurney.

He looked young & healthy; I'm sure he'll be fine.

Awesome Volunteer Shift at the Hospital Today!

Today was supposed to be my second volunteer shift training at the hospital, but as it turned out, no one was able to train me, so after calling to see if anyone was coming in, I went ahead and did it on my own!

I spent the whole day running and answering questions and helping people. Two different emergency patients accidentally came into the main lobby instead of the ER, and one of them was a pregnant, Spanish-speaking lady and her husband. I struggled, but I was able to communicate enough with them to verify that she was pregnant, 2 months along, and that they suspected a problem with the baby, and that they weren't sure where to go. I called the necessary folks and then brought them to the ER.

I also got to talk briefly with a monitor tech, who told me that the hospital I volunteer at has just started offering basic cardiac arrhythmia classes -- the one for summer has already started, but there should be another one coming up starting in September. I was thinking about doing that course online for about 100 bucks, but wasn't sure if the hospitals would consider it legitimate. I also signed up for the class at a community college campus about 50 miles from here but I would rather not take the time off work and drive there once a week. If I could do it at the local hospital that would be great!

Lots to think about. Hmm.... I just thought that maybe I should have written those 2 ER patients in a log somewhere, other than just bringing them there.... will have to ask next week.

First Volunteer Shift at the Hospital

I finally got my volunteer uniform jacket, paperwork, immunizations, training, and all the little details checked off and finished, so yesterday was my first "shadowing" shift at the hospital as part of the volunteer auxiliary. The lady who usually works Saturdays is out of town for a couple of weeks, so she has a couple different subs lined up to train me over the next two weeks.

Note to self--- this gig requires a lot of walking, so bring a water bottle. At the volunteer desk I'll be working at, we have coffee available (for ourselves and waiting families), and I ended up drinking more coffee than I should have because I was thirsty and it was there. Didn't get much sleep last night.

2nd note to self --- Keep tissues nearby. Nosebleeds on white scrubs in a healthcare setting don't look great (this actually didn't happen, but it was near miss in the morning on the way out the door).

Some of my duties included:

(1) Various units around the hospital would call the volunteer desk and ask us to transport a urine/blood/whatever sample to the lab, sometimes on a STAT basis. I'd go pick it up, take it to the lab, time-stamp it, put it in their inbox, and let whoever was handy know if it was a stat.

(2) Deliver newspapers to patients and nurse stations. We had a cart full of newspapers and walked around the entire building offering newspapers to patients one at a time and leaving copies on nursing units that I suppose had requested them. The hospital was unusually full yesterday, so we ran out of papers before we ran out of patients, and there weren't any left for the front lobby. My hands were black by the end.

(3) Deliver gifts from the gift shop to patients. This was probably my favorite part, because the patients were so happy to see the balloons and things coming in the door. Plus, I got to deliver things to the labor and delivery section, where brand new infants were being gazed adoringly at by their proud mamas and papas.

(4) Handle questions and comments of all types at the front desk. Most commonly, can you tell me which room my family member or friend is in. Some patients are inmates or have chosen not to make their room number public to maintain privacy. Some people who come in are upset because they have an issue that is urgent to them that the hospital can't deal with on the weekend (I'm thinking of a lady that needed a check stamped before she could cash it and none of the departments that could help her were there on the weekend).

(5) Try to be a helpful, comforting presence to anyone who needs it. When I went to the cardiovascular ICU, there was a woman in the waiting room who was looking out the window and sobbing. I think her dad was in with a heart attack or something. I asked her if I could bring her anything, and she said some water would be great, and wanted to know when she could go inside and find out what was going on. I got her a glass of water, and checked with the nurses station for an update. That's a rough spot to be in and I could really empathize with what she was going through.

I think it's going to be a really good experience, overall. Six hour shifts on a Saturday might be a little brutal, but I probably won't have to do every Saturday...and it will all work out.

More updates in a few days.

Hospital Volunteering Options

So I have some options to choose from when I volunteer:

(1) I could help at the Information Desk, directing or escorting people to certain areas of the hospital and answering questions. This one doesn't appeal to me as much and probably wouldn't get me much credit in the eyes of the admissions people, though who knows.
(2) Gift shop. Again, not much appeal there.
(3) Cuddler program, help out in the neonatal intensive care unit, be a "gentle, loving presence" and hold premature infants. This one appeals to me, and would give me some patient contact, though not a wide variety of patient contact.
(4) Hostess cart. Serve coffee and tea to visitors. Not much appeal there.
(5) Emergency department. Provide support and compassionate care to patients and their families. Probably the best choice for a pre-health student in my mind. Sounds more taxing to me than the cuddler program but maybe I could do some of both.
(6) Special Projects. Helping with blood drives, making baby hats for the NICU, helping with clerical needs, delivering newspapers and flowers, making welcoming cards, etc. I could probably do some of this but it doesn't sound like a whole lot of patient contact.
(7) Evening Shift. Doesn't specify what they do but also might be a good choice.

When I interview I will probably tell them I am interested in both the emergency department and the cuddler program and see what happens from there. Maybe I can try out all of the various types of volunteer services.

Turning to Volunteer Work

About a week and a half ago now, I applied for another job, working front desk at an assisted living home. One of my walking buddies who works there let me know that the part time position was opening up, and I hoped that having that personal connection would get me an in, but apparently it didn't.

So I'm coming up on the end of March already (gasp! it's already the 23rd). If I want to show that I have some medical experience before the nursing school application process begins I need to get on that now, regardless of having an actual paid job in the field or not. It also is starting to seem like volunteer work may be necessary to get a foot in the door to a paid job. There was another opening at United Blood Services in the last couple of weeks but they specified that you could have no other time commitments (strike 1 against me, I'm a part time student) and that you needed a minimum of 6 months previous medical experience. No luck there for me.

One of the local hospitals has a formal volunteer program set up. I figure if I apply now, and I get lucky in terms of the whole orientation process going through in a timely manner (which it might not), it still will be quite a push to get 200 hours done by July 1st. If they do the scheduling like the humane society I used to volunteer with did it (all online, sign up for whatever shifts you want that are available), I could easily do 40ish hours over spring break, but they might not do it that way at all. We'll see.

I am going to go to the hospital and pick up an application tonight.

The nursing school I am applying to gives more credit in the application process for hours *worked* than for hours *volunteered* but there's not much I can do about that at this point other than keep applying, and in the mean time I should start the volunteer as a backup.