"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.

First few days of RN program

Monday: Arrive at 8am, sit through 6 1/2 hours of mostly lecture. Ask lots of questions and feel little timid about asking them because I don't know my teachers and classmates yet, not really. Feel completely awed by the first two professors I meet. Go to work immediately after school until 10:30pm, leave about an hour before shift end with my med tech partner's agreement, and crash HARD.

Tuesday: Arrive at 9am having slept like a brick the night before. Everyone is sitting in the same seats as yesterday. There are about 20 chapters of reading I was supposed to have done just for the first week, out of 16 or so different books, and feeling pretty overwhelmed by the quantity of information coming our way and being behind on the reading, but yet also thankful that I'm able to follow everything the teacher is saying so far, and that my most recent job has given me a lot of valuable experience that will help me in this first semester. Almost start crying during the portion of a lecture on therapeutic communication because I've just had a somewhat traumatic experience (for both me and the resident) two nights ago at work that is still lingering in my mind). Even more awed by the teachers today than the ones from yesterday. Especially one of them. I contemplate the fact that I never really admired my science professors as much as I do these nurses I've just barely met. Knowledgeable, wise, and so very intelligent, both academically and emotionally/socially.

Get to go home early that afternoon, around 1:30. Need to tune my brain out for a bit, so put on some TV and end up watching it longer than intended just because it feels so good to let go of that brain overload feeling for a few hours.

Get myself back on track, do a review of some math that's going to be on a test tomorrow (already!) to make sure I remember how roman numerals work and can do all types of fraction math with speed, briefly consider watching the videos about basic bedside care that I'm supposed to watch for tomorrow's skills day, but decide sleep is more important. Then have a fitful night's sleep.

Wednesday: Arrive on campus at 7:30am to the skills lab for an all day basic care activity nicknamed "CNA in a day". Realize that although I have been working in an RCFE (residential care facility for the elderly) for the last 8 months, I don't have a lot of the skills that are considered basic in a long term care facility, like giving a bed bath, sitting a bed bound patient on a commode, taking blood pressures the old fashioned way, brushing a patient's teeth for them or shaving their face, etc.

Tomorrow, Thursday, I'll be going to my first clinical site for orientation with my clinical instructor. My clinical instructor just got hired two days ago, and I'm a little wary of that fact. She will be shadowing another more experienced instructor while teaching us. She seems nice enough so far though.

Fall 2011: school has begun.

Recap: I'm midway through the first week of Fall Semester, 2011. My nursing school application is in, but I won't know if I'm in until maybe March. I'm working almost full time as a receptionist at a retirement home, volunteering 6 hours per week at the hospital, and taking 4.5 units at the local community college.

New news: I decided to quit my tutoring job. I looked at how everything was shaping up, and I went to the first meeting of my phlebotomy class, and I put everything on the calendar. I wasn't going to have any days at all left when I wasn't working in some fashion. Maybe a Saturday here and there when I trade hospital shifts with another person, but no time for studying really, no time for social life, no time to keep up my garden, or lounge with kitties. So I'm giving myself one day back. Wednesday. I will still have class that night but the rest of the day I'm going to take a mid-week pause, to catch up on errands, studying, hang out around the house, and take a deep breath.

I have a carpool buddy to get to the other campus where my phlebotomy course is held, which is a huge relief. And she's very nice, outgoing, and talkative. She's had some crazy experiences...geez. At one point she was working for a dollar an hour in a nursing home about 20 minutes away, as an illegal Filipino immigrant. I have always thought of that kind of situation as something that happens in big cities, near the Mexico border maybe, but not here, not in my county. She's doing a lot better now and has a real (albeit low paying) job but now she's got a little girl and a semi-deadbeat husband to support. She's one tough cookie. Been working since she was 12.

Phlebotomy is good. The teacher is laying down some very hard and fast rules with serious consequences right off the bat, but I can also tell that she's friendly and has a sense of humor about stuff. We watched a video of all the things that can go wrong if you mess up in a lab drawing peoples' blood (and the consequences), and have been taking care of beginning-of-semester administrative stuff, and starting to go through book chapters. Today we went through that exercise where you rub fake germs all over your hands, then wash your hands like you normally would, and check under the UV lamp to see what you missed. I need to pay a little more attention to my wrists, but I was pleasantly surprised at how well I did, because I really did follow directions and wash my hands like I normally would after going to the bathroom or something (some students were doing an intense scrub down!).

I haven't been working through my TEAS studies like I planned. Things have felt so hectic, all day, every day. The test could be as early as next month so I need to get going again.

For now though, it's time for sleep.