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.