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.

What I learned in nursing school

In the aftermath of graduating from nursing school, I had a little bit of time to think about all that I’d learned. I would like to emphasize “little bit.”

In my prerequisites, I learned a few more parts of the body (or at least the scientific names for them), the intricacies of how our bodies work, and the microorganisms that both help and wreak havoc on our world.

In nursing school itself, I was presented with the basic tasks of nursing care, the most common diseases and the nursing role in treatment and management of that disease or condition.

In finishing nursing school, after everything I’d learned medically, I really could say one thing:

Nursing school taught me how hard it is to see and love people the way Christ sees and loves them.

I can’t look on the multitudes of patients and have compassion on them the way Jesus did. In fact, most of my patients, their social and family situations, and the diseases they have anger me. They are lost in a world that most have created for themselves and think that modern medicine will wave its magic cure-all wand. Most of my patients see a problem and drink their livers to oblivion before middle age or claim horrible pain in order to get heavy-duty pain meds.

The videos healthcare organizations produce that show CLEAN and HAPPY patients in a well-lit, freshly constructed hospital room are lies. I’m sure there are some fantastically happy patients. Mine tend to have odor and hygiene problems, emotional disturbances coupled with medical issues, and placed in rooms that are showing their age.

So, if you’re going into nursing, know from this new nurse and the vast amounts of seasoned veterans – it is a worthy profession. You see “the stuff of life” as Call the Midwife says. And it’s not all brow sponging and baby kissing. It’s hard emotionally and physically. And you learn more about yourself and your limitations than you ever thought possible.

Floating

Lately, several people have heard my lame joke, “I’m floating so much, I should be a duck!”

I started my student nursing adventures on a urology floor. I really wasn’t that picky when it came to this first job – I had heard from multiple advisers that getting on “a good med-surg floor” was the best introduction you could have to the world of nursing. Medical-Surgical floors (i.e. med-surg) is the basic care a patient needs in a hospital – they have some condition which needs attention through drugs (medical) or surgery. If anything else goes wrong, they can be transferred to a Progressive Care or Critical/Intensive Care unit.

So, I my first steps as a student nurse were spent tracking down a patient’s vital signs, making sure they get out of bed post-surgery, measuring urine and other fluid output (if you only knew how many forms this took other than pee and blood…), and my favorite – trying to keep track of how much they put in.

After 3 months on my home unit, I was eligible to float to others when my unit’s tech staff was overpopulated and/or the patient census was down. Thank goodness, I have been able to keep some of my working hours! At first, I heard from most techs and nurses “Ugh, I have to float!” Honestly, I don’t mind it.

Rather than being in the world of kidneys and bladders, I’m getting to see other medical-surgical and progressive care floors. I’ve been on liver, orthopedic, or digestive disorder units. One of my favorites to work at is the Organ Transplant unit. I’ve also been to an Oncology unit – that’s a post all on it’s own.

And it can not be said enough, ALL nursing is psych nursing. Some of my more interesting floats this summer were patients with alcohol withdraw or other substance withdraw issues. Definitely kept me awake on those 3 AM sitting/supervising shifts!!

My most memorable experience in floating happened in late June. I had settled in to a sitting shift with a patient, when my charge nurse appeared. She explained that one tech coming on could only float to sit and another unit needed a tech to work the floor. So, I pack my things and head to the new unit. I step off the elevator, introduce myself to the charge nurse, and am greeted with these words: “Do you speak Spanish?” Oh, dear.

Apparently, it was a sitting shift; my charge nurse was misinformed. The patient did not like the current sitter whom I was replacing, however, some quick thinking on my part got the patient to trust me. My two years of high school Spanish, one year of Latin, random study of words from my singing past, plus Google Translate helped me communicate to this freaked out patient. He/she went from unwilling to sleep, have vital signs taken, and allow blood glucose checks to resting comfortably in an non-paranoid state. All because I looked up, “Go to sleep. Everything is good. The nurses are taking good care of you.”

Floating has allowed me to see what sort of nurse I might want to be and the sort I do not want to be. I have met patients, families, support staff, chaplains, and a host of others in the system. I have found units that I would consider working on as a nurse and those from which I will run far, far away. It can be frustrating, but as I’ve found out, also rewarding. Both in circumstances and the fact that I am getting paid.

Quack.

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.

When The End Comes

Sorry that I’ve been absent for so long. There has been so much to juggle the past few months, and since I have a few people with whom I can verbally process my life, I guess blogging hasn’t been a top priority. I have plans to fill in some of my thoughts and experiences from the summer, but they will have to wait.

The reason for this entry, however, is that last night I received word from Stewie that The Brain finished his battle/war with ALS.

While I hate that a terrible disease has taken yet another person in such a cruel way, my emotion is not so much based on anger or depression or bitterness. I am actually relieved to know that he fought his battle in the only way he could and was able to let go. I am relieved to know that Stewie will have the opportunity to sleep through the night for the first time in over 2 years. I am relieved to know that The Brain was able to let go of this life and not give up hope.

I’m sure there will be more writings and musings of my grieving. But they will be dampened as I do not feel my life will make as much of an adjustment compared with others.

I have been struck the past few months in how complete the prayers of Orthodoxy are for the human experience. When we let go of our pride that says only extemporaneous or spontaneous prayers are best, we find a vast wealth of wisdom. So, I leave you with several of the prayers available in the Orthodox Prayer Book published by Holy Protection Monastery in Colorado (aka “The Blue Romanian Prayer Book”)

Oh good Lord, remember Your servant(s) _______ and forgive them all in which they have transgressed in their lives, for only You are without sin and can grant rest to the departed. In Your divine wisdom and love for mankind, You bestow all things and provide for all the needs of man. O Creator, rest the souls of Your servants _____ who have placed their hope in You, O Lord, the Fashioner, the Creator and our God. Amont the saints, O Christ, rest the souls of Your servants where there is neither pain nor grief nor sighing, but life everlasting.

In one of my conversations with The Brain before I left for nursing school, he expressed to me his fear of being forgotten after his death. So, I now can pray the words I reassured to him that day: Memory eternal.

 

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:

laurababy

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

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.

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