One Day at a Time

I’m a new nurse.

I have to keep reminding myself of this. I’m new. I’m going to make mistakes.

Thankfully, none of my mistakes have resulted in adverse patient reactions. I haven’t overdosed anyone on their narcotic pain medication. If my assessment found an abnormality or something new, I reported it.

But I’ve been late on timed lab draws. I didn’t get a “Keep Vein Open” order with a patient controlled analgesia (PCA). I charted something on a patient, only to realize after signing that it was the wrong patient. And I’ve certainly handled a few interactions with less grace and clinical judgment than I would like.

I hate making mistakes; I hate knowing that I’ve failed or been under par. I worry that I will never get this nursing thing figured out. It’s these days that I cry.

But after a day or two off, I pull myself back together. Double check my care plan, make my list, and set out to improve one patient at a time.

And then I come home. And I’m new to marriage as well. We’re both new spouses. We’re going to make mistakes.

Some days, he’s helpful and a wonderful shoulder to cry on when work goes horribly wrong. Other days, he doesn’t see that I’m tired and asks for my help with tasks that, in my opinion, he should be able to figure out by himself so that I can sleep. There have been times where we are both oblivious to the ways we hurt each other. And then when the courage is mustered up to say, “____ really hurt,” it isn’t met with the response wanted but with more fuel for the fire.

Then the time comes where we say, “I’m sorry. Forgive me,” and keep working on this one day at a time.

Emergency

First, a little terminology. In a hospital, you do not go to the Emergency Room, you go to the ED – Emergency Department. Also, what the public knows as “intensive care” or “ICU” is now referred to as “critical care.”

During my critical care rotation, my classmates and I got to experience several days of emergency simulations with medical students and residents. And we also experienced a day in a Level 1 Trauma ED.

I loved it.

I saw one major trauma patient, one stroke patient, but mostly confused older adults. Confused older adults get an ambulance called on them because they fell and now have altered mental status or they had a UTI that went undiagnosed and now they are septic. Again, big symptom is altered mental status.

The ED didn’t impress me with their amounts of drama and excitement. I liked the pace. I liked that after 4-6 hours, patients were discharged or sent elsewhere. I know nurses are thought of as compassionate, but sometimes, it’s nice to not deal with your patients for very long. The priorities of an ED nurse are to assess the patient, keep them safe, and if they are admitted, call a complete report to the receiving unit. They keep up to date charting (as in, every hour at the minimum) and need to know their stuff in order to tell the new interns and residents what is really going on with patients.

In my last semester of nursing school, I spent my management clinical in a slower paced ED. While there was no blood, the patients were exciting in their own ways. Some were still fall risks that were trying to climb out of bed; others had code browns or code emesis. And some just had pain or uncontrolled diabetes flare ups. Still safety, quality assessment, and critical judgement were needed.

I doubt I’ll start in the ED – those positions go fast and tend to be limited in my geographic area. It’s nothing like the show, so don’t get your hopes up, but for those people whose personalities like lots of action with some downtime – it’s all you, baby.

My New Favorite

Not my original today, folks. This is for my fellow nurses and nursing students.

My new favorite blog: Nurse Eye Roll

If you don’t get the humor, might I just say, nursing school isn’t for you.

Nurse Eye Roll is my therapy. Thank you.

The Questions

I’m in an accelerated nursing program. It is geared specifically for people who already have a bachelor’s degree in another field and want to receive their bachelor’s in nursing rather than an associate’s degree. A common question in the first semester is, “What was your previous degree?”

But then, people decide they want to know you more. They now have two options:

1. “Why did you leave ______?”

2. “What lead you to nursing?”

I know that I’m having a bad month here in Ray of Sunshine Land, but for the love of God, these questions are getting on my nerves.

So, let me answer them for you –

1. I didn’t like teaching; I liked interacting with the students, and I liked singing. Teaching those concepts was draining the life out of me. Oh, might I mention a few colleagues made my life a living hell? Yes, teachers can eat their young as well. I found that I was selfish with music – I need it to be my relaxation. I don’t see music and arts as the first thing that people need for their lives. Public education bad days

2. I had a quarter-life crisis. Got tired of doors slamming in my face. Wiped the slate clean of my options, looked at my skill set. Thought about nursing, pursued it and doors opened. Loved the opportunities. Most every clinical I end thinking, “Maybe this career track is for me?” It fits my preferred M.O. as I like to be at a place and just go. I’m not an 8-5 for 5 days person.

And last thing while wrapping this up, I’m tired of hearing, “you’ll always have a job” from people who think they know healthcare because they had their immunizations. Kind of like the people who think they know education because they were students. Nurses are generally the biggest part of an organization’s budget. We are generally the first to feel budget cuts. Yes, there are always healthcare jobs. There are always teaching jobs. They just might not be what the person prefers to be doing in their career.

End rant. Back to studying.

How to Be a Good Patient

While I understand this picture of Grumpy Cat is more the patient’s view, I would like to point out the power/authority that a nurse has and that maybe, just maybe, we have some ideas that you know, deep down, are good for you.

I don’t want to be Nurse Kratchet/Ratched. The summer was long and hard to schedule work around class and being cancelled due to low hospital census. I had some delightful patients and good learning experiences. This is a compilation of not-so-great experiences. A rant, if you will. It DOES NOT mean that I do not value a patient’s opinion or experience. It only means that some patients annoyed me with their similarities of crappy attitudes towards those of us lower on the hospital totem pole (the CNA/Student Nurse).

1. Don’t talk or move excessively during vital signs. Health care workers and providers need to listen and watch for various things, such as your breathing. Movements in the arm while taking a blood pressure can make the final pressure appear too high. Your talking and yammering about how this doctor or that nurse from previous experiences is of no concern to me, especially at 3 AM when all I need to do is count how many breath cycles you have in a 30 second time span.

2. Hospitals hate falls. Hate them. We don’t want your stay extended because someone was unable to standby and ensure your safety. That being said, just because you know who you are, where you are and where the bathroom is in your room, does not mean that you are not a fall risk. We don’t put people as a fall risk because we want to imprison them to a bed, it’s because we don’t want you to get injured from your own stupidity or because you tripped over your own IV.

3. Having been a CNA does not mean you know my job or the entirety of the medical field. Taking Psych 101 and Abnormal Psych doesn’t make you a therapist. Giving a meal or a few dollars to a homeless person doesn’t make you a social worker. Answer our questions truthfully, ask questions (write them down when no one is in the room). The person there to take your temperature is not the person who orders your discharge.

4. Don’t complain that your beeping IV hasn’t been taken care of for 3 hours when I can prove by the time stamp on a monitor and through the electronic tracking system that I was in your room 45 minutes ago and nothing was abnormal. Also, these situations are when you use the call light.

5. Most units I have observed or worked on are post-operative, and most people are focused on one thing: leaving. As one of my nurse preceptors told me, “All patients need to poop, pee, walk, and eat before they can go home.” The faster you do these things, the faster you go home. Cooperate.

6. Don’t assume we are out to get you or that we intend to forget you. Unless you are an ICU patient or labor and delivery, your nurse has other patients. We might have been answering their questions.

Yes, everyone has their personal horror story or has heard of someone who experienced a series of complications only rivaled by a House episode. We know you don’t like the hospital, and our goal is to get you out of here as fast as possible.

Let the barrage of comments begin…

To The Babies I Held on My Birthday

Obstetrics clinical rotations began this past week. Day 2 was Wednesday, July 17 – my 31st birthday. Here’s what I was thinking that day.

Dear Little Ones,

Welcome to the outside world. The past week was filled with a lot of change for you. You are still dependent on your mother for nutrition and warmth, but you are now breathing on your own. And this time it’s air, not amniotic fluid. Your heart and lungs have gone through intense change and you are still causing your mom hormone and physical changes in this post-partum period. Your dad, while not new to this, is still in awe and thankful that the both of you are safe.

You didn’t know it and probably never will, but I took care of you on my birthday. 31 years ago, I was the new bundle of joy. I’ve seen pictures but time fades colors in the pre-digital photography era. I have to wonder if my face looked like a model for a porcelain doll and if my lips were perfect cherry red as yours are. As I held you, I didn’t mourn that I have yet to push a new human out of my abdomen. I was overwhelmed with a distinct sense of hope for you and wonder.

What delights will you bring your parents? How will you and that big brother I saw earlier get along? Will you color on the walls or play in the mud? Will you break hearts or have your heart broken? What will you be so passionate about that could help your corner of the world?

I hope sincerely that you will not disappoint others, but you are human, therefore you will. Thus, I hope more that you learn to ask for forgiveness and extend it. I hope you are able to see Truth and want it for you and others.

As I hear the news of what the world is throwing us – the suffering isn’t new but you are. May your eyes be opened gently so you don’t see too much at once, yet just enough that you are able to have compassion and help as you can.

It is wonderful to look upon you just being you. Content that your needs are met.

Thank you for that gift of seeing life simply when it is complex. My only regret is that I can’t tell you this for when you’ll remember nor can I leave your parents a note – that would just be creepy.

May the Lord have mercy on you daily.

Your Student Nurse

And in case you, the reader, are wondering, here’s from 31 years ago:

Infiltrating

I began my pediatrics clinical rotation last week along with Pediatrics and Obstetrics lecture. Thankfully, I was able to get the type of rotation where each student is assigned one preceptor and follows that nurse for an entire 12-hour shift one day per week rather than two shorter days per week. I would rather have one day that is super busy and tiring and one day off than two days that are busy and tiring. I always collapse after clinical, whether it has been 4 hours or 12 hours.

My unit has medical-surgical patients with various GI, neuro, and some renal patients. Basically, a smattering of low-acuity kids who either need to be diagnosed or are coming back for a few maintenance visits/procedures.

Lesson of this week: pediatric IVs.

I had been warned in both clinical orientation and in lecture, pediatric IVs infiltrate fast. FAST. Also, little people do not or are unable to tell you that something is wrong. A nurse must look at an IV site for redness and swelling every hour and before attaching new fluids or medicines, flush a small amount of normal (isotonic) saline so we can see and feel that the catheter is  still in the vein and not poking through into the tissue. Infiltration is a BAD thing with your isotonic fluids, let alone medications.

In my clinical, I was beginning my assessment of an IV in preparing to administer an IV antibiotic that is a known vesicant.* It didn’t have a blood return (not bad) and flushed rather easily. I let my nurse know that there was no blood return, but continued to set things up. My nurse also assessed the site and compared his IV hand with the non-IV hand; some edema was present. She flushed a little more saline through and asked the patient if it hurt.

“Ow, yes!” (Patient is a younger adolescent).

Nurse, “Yeah, we should probably start another IV then.”

Patient: “That’s okay, I’ll just live through it.”

Nope! It doesn’t work like that kid. On pediatric patients, especially those younger than 16, we just call IV team because veins are not as visible the younger the patient. The IV woman came within an hour, used her awesome ultrasound and placed a new IV in the patient so the antibiotic could be given safely.

The experience didn’t scare me, rather helped me see what else goes into an assessment and better techniques for assessing the pediatric IV. Some catheters are tiny; some only need 3 cells to occlude and clot. It was a reminder that early adolescents need to know the risks of their medications and why nurses check things that seem insignificant.

My next clinical is tomorrow. Hopefully I can remember all the assessment techniques for pediatrics and focus on other important things. Like playing Candyland with a patient.

When The End is Near

The past two weeks The Brain has been in rapid decline. I am thankful I was able to see him over Memorial Day when an hour-long conversation did not take all his energy for the day. Besides, since last Thanksgiving, I try to do most of the talking. He has recently consented to swapping out his usual king-sized mattress for a hospital bed and does not balk at any medication interventions to control secretions or pain. From what I read in updates, he is not uncomfortable but there is a huge battle with peripheral edema that refuses to go down. Edema, or swelling, is a sign that the kidneys are not motivated to keep filtering the extra water and usual waste products out of the body.

We talked about ALS our last day of lecture in Med-Surg 2 along with other “chronic neurological disorders.” I had to work hard to not dominate the discussion. The question was posed to the class, “What do you tell a patient who asks you if there is a cure for ALS?”

Under my breath I muttered, “You tell them to plan their last vacation.”

When going over some of the collaborative care for ALS, a group recommended Physical Therapy along with some other options. I spoke up and said that physical therapy is good, but the patient is not going to improve over time. Rather, massage therapy might be better as it had been beneficial for The Brain. Unused muscles cramp up and become rigid; if the patient will allow a massage therapist to work with the muscles early on, the later neuropathy due to muscle atrophy is greatly reduced. Having helped multiple people move or even roll in bed, those with loose muscles are MUCH easier than those with rigid and spastic muscles.

As I said earlier, hospice nursing is different. You know that your patient will not beat their disease or win the battle with their body. I knew when I first started working for The Brain and Stewie that there would be an end; I just didn’t know if I would be working for them when it came.

My prayer has not changed nor has my view of reality to the situation. Reality is merely coming into focus more clearly, along with the true reality that we are all given the gift of our lives, and we get to share those with others. I am continually thankful for Stewie and The Brain sharing theirs with me, even as ALS is sneaking around the back for its last hurrah.

Thus, as always, Lord have mercy.

Patient Simulations: Medical Student Edition

From: http://www.zazzle.com/funny+nurse+postcards

Thanks to technology, student in medicine, nursing, and other patient care roles can be put thought simulations with patient mannequins. “Mission control” is behind a two-way mirror and can “talk” for the patient, monitors are “connected” to give real-time data, and a lot of sterile saline is used as various medications.

Last Friday, rather than work the floor in my clinical rotation, I volunteered to be a nurse during medical student simulations. These students just entered their 4th year of med school and were beginning their month of ER rotations. The role of the nursing student was to act as the nurse for the simulation: assess, advocate for the patient, collaborate with the physicians, and administer medications while the doctors continued to formulate a care plan. We were not being graded or evaluated, the med students were.

It. Was. Awesome!

My fellow nurses and I got one other benefit over the doctors: we were able to go through the simulations twice. Group 1 rotated from 8-10 and Group 2 rotated 10-12. The first simulation was a practice for all of us – what was I to ask the doctor? The patient? Focus on in regards to care? What information did I need to assist the doctors and the patient? Because of the nature of simulations and how much students should not know before participation, I will refrain from specifics of the scenarios. All three were common emergencies, and one involved pediatrics. I was thankful for two semesters of Med-Surg, so I was way more comfortable with these scenarios than I would have been in January.

I felt as though I hit a stride as a nurse that second time around – the other nurse and I knew the outcomes and what to watch for while the med students were new to the situation. Also, the group the second time around had a GREAT sense of humor. I was asking for more clarity in orders: how much oxygen do you want? What drug and what dosage? Is that an order or an idea? Do you really want to give that heparin sub-Q when the patient already has IV access? By the way, your patient has below 85% Oxygen saturation for the last minute.

At the end of the day, one area stood out: patient advocacy. During one simulation, the benefits of morphine were being debated. Yes, the patient could have been given it, but it doesn’t improve mortality. Thus to a doctor’s mind, there was not convincing enough evidence to warrant a morphine administration. With Group 1, I didn’t push back on the students to order a pain killer. With the second group, I questioned.

“He’s in a lot of pain. Could we give him something for that?”

“Nah. Morphine doesn’t help long term.”

“What about Fentanyl or something else.”

(Voice from speaker) “The simulation is over.”

In post-conference, we talked about the simulation, when drugs were given, and the plan of care. We were about ready to leave when I stated my point. “Just one thing from the nurses. When it came to whether or not to give morphine, I know it does not solve the root cause of this patient’s problem, but to that patient, his pain is why he’s here. Giving half to 1 mil of morphine will ease anxiety, knock the pain down, and to that patient, you are doing something. As nurses, we’re trained to assess and we’ll hear a lot about a patient’s pain. Again, it’s not solving the root issue, but you are doing something. And that will get you far with them.”

My point was not ignored. Instead, the medical school instructor VALIDATED my point.

“That is a good point. As medical students, you need to know that by the time the nurse has time to call you to change or up the pain meds, she’s heard about it at least 12 times.”

I could have kissed that man.

Hospice Nursing

We knew the discussion was coming based on our pre-class preparation videos.

My group was having a discussion on end-of-life care and how hospice nursing is different than other kinds of nursing. We delved into the ethics of giving morphine or other comfort measures that may or may not drop our patient’s O2 saturation lower. I was of the few students who had experience with hospice care and nursing. Caring for The Brain had been most of my formative hospice experience, however, I have had other family members in hospice care and a good friend described her experience with hospice in relation to her mother’s illness.

Hospice nursing is different.

Your patient will not get better. He/She will not walk out of the facility or their home cured and on the path to wellness. “Wellness”, for a hospice patient, is more based on their comfort and whether or not there is peace at the end of life. You meet amazing people with interesting lives, yet you are usually meeting them at the end of their life’s journey.

In describing the above, and using almost the exact words, I teared and choked up in front of my colleagues. I thought of The Brain and my aunt and my grandma.

It’s easy to feel defeated on the floors as a nurse – I didn’t get patient medications on time, I failed to call the nurse or someone about the patient, the patient did not get to walk exactly when s/he called for me, the patient bathed 2 hours after s/he asked for a set up because I was held up in other patient rooms or needing to get vital signs on everyone before the next rounds.

But how does a hospice nurse not feel defeated? Every patient is choosing to stop life-prolonging measures and has, to some degree, accepted death as the resolution to their disease. It is a different form of nursing to know that you have helped your patient live well and provided them with comfort and anxiety relief. You have given the patient utmost consideration, care, dignity and security. You assure them that their body will be treated respectfully when they pass away.

And until those final moments, you share memories. You swap recipes for favorite meals. You hear about the patient’s life, passion, and wishes for care. You look at their choice for a casket or urn. You ask what they need and what the family and caregivers need. You are a nurse that stares death in the face and tells it that just because it is lingering does not mean there is fear.