Training Wheels & Tales of a Registered Nurse

Nine months of labor....

2011-01-03T09:41:00.001-08:00

It's been about 9 months since I've written anything partly due to the sheer exhaustion of job hunting and partly due to the nuances of working full time as a night nurse...it took about a month and half after passing boards, but I landed a job, thank God (which by today's labor market for new grads, was lightening fast!)

Acute medical surgical telemetry...which means you get it all. Sick, sicker and sickest. Sepsis, pneumonia, post ops, chest pain, GI bleeds, MRSA wounds, vacs, UTIs, psych, dementia, DTs, knees, hips, pelvis, abdominal this and that, and an occasional prolapsed anything. Atrial fibrillation, PVCs, bigeminy and an occasional third degree block. This is the menu on my unit and there is always something new. In nine months, I have only seen one patient who had a family member present at the time of death. Every other patient died alone, except for their nurse who is always present.

Working nights, I have lost contact with a lot of my daytime friends and family. This is the only drawback, otherwise I have adapted to the changes in sleep, because my family has made the adjustment with me. We have a do not disturb button on our house phone and since all of us have cell phones now, we don't miss the ringer on the house phone. When I started working noc shift, I marveled at my co-workers ability to eat anything in the middle of the night, but within 3 weeks, my body clock shifted and I found myself famished at 0200. I usually wake up at 1600-1700 without any breakfast pangs and then force myself to eat something before 1900. By 0200, I am hungry. I eat one more time..usually at 0800-0900 and that is it for my work day. I eat twice per day. As a result, I lost about 20 pounds since starting work. It is so strange what your body does to compensate for the shift change. I wake up in the middle of the afternoon after working all night and the first feeling of disorientation is so strange (i.e. where am I, what time of day - should be morning but my brain realizes it is late afternoon, early evening) Some days, after working three 12 hour shifts in a row or an occasional 16 hr shift, I will wake up at 2100 (9 PM) and stay up all night. It's the most surreal feeling to live and work like this when your family lives on an opposite pole. I noticed during the holidays, everybody shifted to my schedule and stayed up later and slept later...so we could spend more time together.

I can say with certainty that I have no regrets about becoming a nurse. It is the hardest, most rewarding career. Everyday is different. After 9 months of labor, I still feel like a baby. I have wonderful colleagues who teach me something new all the time...it's a wild ride worth taking..and I hope I still feel this way 5 years from now.

Now what?

2010-03-02T13:39:00.001-08:00

"So, Mom, did you get a job today?" greets me daily when the kids or hub arrive home from work and school. Looming on the horizon are several things that have me excited and terrified at the same time. One of the kids is graduating high school in May, heading off to Europe for month a half and is hoping to go to college out of state in the Fall. The middle child wants my car, literally. The baby isn't a baby anymore and I am weighing whether to send her to private school. So, in lieu of the hopes of dreams of three older children wanting to spread their wings, is a new nurse mother desperately trying to land a position as a nurse, somewhere...anywhere...hello nurse shortage, I answered the call ~ are you there?

I have applied for 150 positions. Five are in limbo someplace between recruitment and management and no interviews yet. I have tried calling, emailing, facebooking, and physically driving to see nurse managers. The words "new grad" taste like poi at the Luau. You know you have to eat it, but it doesn't taste good. How much can one emphasize one's maturity. Just look at me.

I have modified my resume 20 different ways, and yet the phone doesn't ring. In the meantime, I am selling my nursing books and homeschooling books. It is keeping my mind off the fact that my phone isn't ringing, and will hopefully buy my oldest a round trip ticket to Europe for graduation. I have a lot of books.

In the meantime, my suit is pressed, all my paperwork is in order, my license fresh off the press, and certifications updated for basic and advanced care life support. What more can I do? I have thought about catering lunches for units looking for nurses; seriously gone are the days of signing and referral bonuses. Whining.

Patience, I know. I think pray, hope and don't worry. Ok. Loans come due June 30...something has to happen before then. I'm better than poi.

4 AM....Train pulls in...

2010-02-09T06:11:00.001-08:00

2 AM: I checked the BRN page and the system was starting it's update. I went back to bed. My stomach has been hurting all weekend.

4 AM: My husband gets up and goes out to the family room. He comes back into the bedroom and says you might want to come see this. I stumble out of bed and look at the computer. Beautiful sight after 30+ years of imagining..and 3 years of hard work. My nursing license. A train never looked so good.

NCLEX..waiting for my train to come in...

2010-02-07T16:35:00.000-08:00

Nothing can prepare a nurse graduate for Boards and how you feel after you take them. In my mind, I envisioned hours of testing,thinking about the nurses who took paper pencil tests on every aspect of nursing from neonatal to geriatrics.

My boards were over before they began. I had taken a Kaplan prep course to practice questions and brush up on content I might have missed in school. I did everything Kaplan required and then got utterly tired of doing questions. I simply couldn't do another Q-Bank. I stopped the day before to rest and ended up getting a pedicure and massage. I went to bed early, thanks to Melatonin...and woke with the roosters.

Packing a bag of snacks, eating breakfast, two cups of coffee, listening to happy tunes, saying my prayers. Checking in. All these things I imagined. Then I took a couple deep breaths, put in my ear plugs and began.

Question 1...nothing looked familiar. Question 2....I don't know and so on..This went on for 80 questions and then the CAT screen went to black. What the hell? What just happened? Did I answer those correctly or did I just throw three years of schooling down the toilet?

I don't know...it felt awful. It was surreal. Two other classmates where there taking at the same time and they experienced the same reaction. How can this test that I just took in 2.5 hours determine if I am competent to be a nurse?

This is day 4 of my wait. I don't know what is next. I have 45 days to retest. If I didn't pass, I wouldn't even know where to go to resume studying. Is this the last bit of torture, or is just the nature of nursing..to always be exhausted, psychologically tested and wondering where you stand.

In the meantime, I am standing on the platform, waiting for my train to come in.

Pinning ceremony December 10, 2009

2009-12-15T10:32:00.000-08:00

Dr. Berman…faculty, family & friends.. my fellow colleagues.…The journey that began 11 and a half months ago is now coming to an end.

We told you last January we would see you on the other side of this…and you bore it all so patiently.

How fitting that Dr. MacIntyre welcomed you all to our pinning ceremony, because in many respects, he took this extraordinary journey with the ABSN class from start to finish, Our work with him, from January through December was an examination of conscience & intellect for the rest of our practical nursing curriculum, providing the framework by which we learned about nursing standards, scope of practice, ethics, application of applied research and evidence-based practice.

The most important contribution he made to our cohort, however, was the assignment of a book in November that for all intent and purpose is a book written about us, a book about him…and about some of the very special patients we had this year….The title of the book is “Outliers, The Story of Success” by Washington Post business & science reporter and author Malcolm Gladwell. If you have not read this book, you should.

Outliers are a misunderstood, unique subset of people who fail to fall within in the normal bell curve in standard statistics. They are so far outside the bell curve that when taken into consideration, it is difficult to understand them. They fail to behave the way one would expect, their results are often unanticipated, it is difficult to make predictions about them. Outliers cannot be put “into a box” because their outcomes fall outside the veil of normal experience and expectation.

Our cohort cuts across four different decades, from backgrounds as diverse as photography & psychology to biochemistry and the neuro-biosciences. Our class has civil and electrical engineers, physical therapists, social workers and exercise physiologists. We have a professional homeopathic doctor, an Eastern medicine practitioner, and a theologian. We are a class of educators, writers, and business administrators. In addition, we have a professional musician and a seasoned television news reporter who climbs mountains in her spare time. Several of our classmates plan to be nurse anesthetists and family nurse practitioners and one is planning to go to medical school.

These individuals at this particular point in time decided to become baccalaureate prepared professional nurses. They answered a vocational call to the nursing profession and committed to the intensity of an accelerated bachelor’s program. Who does that? … And arrives on this stage… December 10, 2009 after 11 and one half months?

That would be the Outliers.

Gladwell theorizes that outliers are surrounded by people that allow them to thrive and be successful. People, who happen to be very special family and friends. Wedged into their background is a broad life experience, and additional outliers who are their mentors and teachers and in many respects, nothing but Providence is responsible for this.

Therefore, let our charge be, in our future practice to watch carefully and diligently, for our patients who are also outliers, in order that we might apply our best practice, because no matter what we read in nursing textbooks, in nursing research…No matter what we hear in report, on rounds….or read in a patient’s chart, as nurses who are outliers, we must rely on our other tools and skills, our intuition, our five senses, our own assessments, listening tentatively when we’d rather not, looking for the outlier who defies the odds, rebounds when we least expect it or needs us to advocate for them when no one else will answer the call.

Outliers apply knowledge from a variety of resources to treat patients across the life span because of broad based experience and will go that extra mile…. because somewhere in their past, outliers have had their own obstacles, special challenges, problems to solve and yes, their own suffering to endure.

We banded together as I believe Dr. MacIntyre wanted us to, in order to effect change in the nursing profession …this class not only adopted each other as family; we adopted patients with the highest acuity, the homeless, the dispossessed, the young, the ones left alone to die, and the undesired who desperately needed to be bathed. This class tended after the wounded, the abused, and the burned. We cared for the ones with cancer and the wee ones just born.

This is the story of the success of this cohort who successfully navigated the ABSN program somewhere on the outskirts of the bell curve.

Congratulations to the Samuel Merritt University ABSN Class of 2009.

Catching the ball....run Forrest run.

2009-11-23T21:13:00.000-08:00

The last few weeks were difficult for our unit. We lost three patients close together. Two of the three patients were patients my preceptor and I had the weeks before. Nursing puts us all in that delicate position of helping people at their most vulnerable hours of sickness and death. One of the unique aspects of what we all do, is that when we go to work, we never know what the day will bring.

This week, however, my preceptor allowed me to take the ball and run with the patients I wanted. I always try to challenge myself to pick patients who are the "sickest"...however, in oncology, everyone is usually pretty sick, so the two I picked this week were a great opportunity to exercise old skills learned in med-surg. Taking and giving report, assuming total care, planning, assessments, interventions and evaluations. How would I plan and approach the day? Since I had good role modeling from my preceptor, I decided to use "her" method and hit the ground running the way she does. We round on our patients in the AM, pull labs and meds and bring everything at once to do assessments. This allows for the unexpected admission in the morning, the surprise fall backs and any other delays that frustrate any nurses' best laid plans. It also allows us plenty of time in the room, avoiding the back and forth. So, while one med is running over 10 mins, I can assess other things, do a little teaching and reassess before the next one is given.

The oppty to reconstitute and administer meds, try things with patients with my PRNs to see if they would help. These are all the things I love about nursing and of course, patient teaching. I know I probably won't always be this optimistic, but I like to see nurses who still love what they do 20 years later. It is the kind of nurse I hope to be.

While my patients weren't as critical this week as they were in the previous two weeks, I loved the independence of trying to do everything on my own, classifying, and getting all my charting done and being able to measure over the course of several days how decisions I made, impacted my patients. Running never felt so good!

Seeing the big picture.....at the end of life.

2009-11-23T17:21:00.000-08:00

As a student, learning in the Hem/Onc/BMT unit has been a positive experience primarily because we care for the same patients over a longer term. In many case, patients are in for new diagnosis, post operative, and/or being stabilized towards going home, the outpatient setting, or they are inpatient due to relapse and now our goal is to help them transition toward death.

I've had several opportunities to work with patients who are new to their cancer treatments and those who are at the end of life. Perhaps the most difficult case I've had over the last two weeks is a female patient with Ovarian cancer/mets throughout, whose spouse is in the worst case of denial I've ever witnessed. The patient has intractable pain, unable to tolerate any intervention including sips of water or touching her, and the poor spouse is thinking the next ABX or blood transfusion is going to be the magic bullet. I know how hope and faith serve in rescuing our loved ones in crisis, but this patient had already crossed those turning points. Her body was fighting every intervention and was shutting down in violent opposition.

This has been going on for months...with the last month being the most painful: 3+ pitting edema, an abdomen 10X it's normal size, full of cancer. While I was changing and packing her open abdominal wound yesterday, I told her that she needed to get him ready and tell him what she wanted (she wants hospice..he wants her to eat and gets mad at her for not eating. He wants PT to work with her and she is no longer able to bear weight on her joints and cannot tolerate being elevated or turned in bed.) She cries that he doesn't listen and refuses to talk about it. I told her that it is difficult for him to let go, and she needs to help him.

The situation is like a big elephant in the room everyone refuses to acknowledge. She doesn't want anyone touching her due to her intractable pain, but yet, she is a full code, meaning that when her BP, heart rate and respirations slow down or cease, our response is to intervene with full force, including but not limited to CPR, chest cracking/opening/manual massage, mechanical ventilation, vasopressors, fluid resusciation etc.)

Nursing is struggling with this particular patient because medicine has been slow to address it with the spouse. Social work is waiting for nursing and nursing is waiting for medicine and this patient potentially could code any hour and the husband is still thinking his wife is going to beat the end stage diagnosis/prognosis.

Yesterday, the chaplain came by and wanted to know how she was doing. After reviewing the case with him, he took the husband aside and asked him to consider making his wife a no code, explaining what a full code would look like. A body FULL of cancer that has intractable pain should not be cracked open, compressed and pushed full of more fluids. The amount of intervention in a full code would be agonizing for the dying patient. I also talked to the patient about the importance of getting her husband ready...telling him, even though it would be hard for him to hear it, that she wanted to die, that she was ready to die. The body goes through the shutting down process and she has already started that process.

Death is the big elephant in the room that nursing in concert with medicine and psych-social, needs to acknowledge in unison, in order that we might more effectively guide our patients toward the end of their life in a manner that promotes for their optimal comfort, preserves their dignity and assists their loved ones in their grief toward acceptance.

PS: I got a call from my preceptor today that this patient passed away last night, just a few hours after her code status was changed from full to DNR. I was grateful to hear that she passed away peacefully in her sleep, which was the last thing she said to me, "please...let me sleep".

Comprehensive RN Exam - ATI graduation assessment

2009-11-12T21:24:00.000-08:00

Most nursing schools require that you demonstrate a certain competency in all nursing subjects prior to graduation. It is the precursor to the NCLEX exam administered by the Board of Nursing. In fact, when you finish the assessment, it scores your assessment against all students taking the exam and predicts the statistical probability of whether you will pass the National Boards on the first attempt.

I started studying for this in October and was cramming up and until late last night, with a quick review this morning. The exam was three hours and I took it this afternoon.

With great relief, I passed the exam, 4 percentage points above the national mean and a 95% statistical that I'll pass boards. Kaplan will be my extra insurance policy and brushing up on topics I missed on ATI will help prepare me for Boards. Thanks to St. Joseph of Cupertino for the help. I guess I can graduate now. Whew. (The film of his life is called 'The Reluctant Saint") It's a great story.

Let the Precepting Begin!

2009-11-07T17:46:00.000-08:00

First day of clinical, we hit the ground running with(3) patients right off the top and actually, it turned out to be a great shift. Two cancer patients and one post op Crohn's patient. One of the cancer patient patients was post op bilateral mastectomy/lumpectomy; the second patient was a new acute leukemia diagnosis (2nd day)..which for me was a great opportunity to provide time to the patient and spouse to do some psych/social counseling and research on support groups. The patient happens to live in my neighborhood, so it was great to be able to tell her about Marshall Hospital's leukemia group which she and her husband can attend when she gets out of the hospital. It was also a great opportunity to share with her a copy of Bev Hall's book ~Surviving & Thriving (*thanks to the class for donating these!) The raw grief of the new diagnosis was something I hadn't experienced yet as a nursing student even though I spent alot of my med-surg time on the oncology floor @ Sutter Roseville and a lot of my peds time with the onc patients @ Sutter Memorial. One of my objectives was to work with a patient with a new cancer diagnosis & already this happened the first weekend of precepting.

It wasn't that long ago that I recall getting bad news about someone I cared about & how devastating that can be when you first hear the news. I could see it on the face of my patient and her husband. One minute you are walking the dog at the dog park and the next minute, you are unable to walk, your husband is taking you to the ER and the physicians are telling you that you have LEUKEMIA. *this is what happened to my patient. For a very active 67 y/o female whose been married for 45 years and living a very fit lifestyle prior to two days ago...this was very devastating. To be the nurse that cares for this person up front, is a privilege...there is a lot that can make the transition easier or even more devastating. The 1:1 time I had with her today was very rewarding. I was grateful for the opportunity to have that very intimate contact as a nurse.

It was fun to do procedures today. It was fun passing meds, assessing all three patients and learning all about blood products from the order verification/laboratory verifications and how the PRBCs are primed with NS and administered.

The best part of the experience for me was working with a preceptor who is also a SMU alumna from the ELMSN Case Mgr. program. She has been am RN for the last 18 months and loves working with students (lucky me).

To say that I love the teamwork on this unit is an understatement. I know I am going to learn a lot.

Community Health ...TNT Health Clinic

2009-10-23T22:24:00.000-07:00

It was a bittersweet day ending out little clinic in the transitional homeless community, where we open for business and do assessments, administer OTCs and triage. We stocked up the medicine cabinet, cleaned up and put out a new sign that read, "while TNT clinic hours are done, we will be back as nurse volunteers throughout the winter to assist you with your health needs. Look for our doors to be back open in November.

We spent the last week doing a lot of patient teaching, handing out OTCs for colds, muscle aches and even assessed a client who had been in a motorcycle accident. Our clinic room houses educational materials, an examination table, medicine cabinet, scale and two desks where we park it during our clinic hours. We did smoking cessation, Hepatitis C education, followed a skin cancer patient and handed out goodie bags. We decided we'd partner up with the Recreation Social Worker intern and do a couple movie/education nights in the Rec Room in Nov. just to get people together and talking about their health. We were able see our regular HTN/diabetic patients and get a lot of homework done. There is something about an open door that says c'mon in, because people came by to talk and we listened...because that what nurses do.

57 Days to Pinning....

2009-10-14T20:54:00.000-07:00

We are planning our class pinning ceremony with all the zest of people who are about to be released from captivity...not necessarily the serious POW kind, but in a sense, the walls of our classroom have no windows and some days feel like hostage crisis, Day 283, especially today. So with a little creativity and somewhere sandwiched between mental and community health, a couple classmates put their photography skills to work shooting headshots and candids of all our classmates for our pinning ceremony, to be held on Dec. 10, 2009, approximately 57 days from now (not that I have a countdown on my lap top or anything like that!)

As we approach this milestone, thoughts about the people I've shared my life with over the last 283 days are fond. We navigated some serious landmines in theory and clinical, shared a lot of laughs and tears. I made friends in nursing school that will be life long friends, professional colleagues I know I could turn to in a crisis. ABSN programs are unique nursing programs, pouring out insane amounts of learning wherein 38 adults from all walks of life, dedicate a year of their lives in pursuit of a common goal, supporting each other, knowing what we have emotionally, physically and financially invested in this journey. I can't begin to count the sacrifices we and our loved ones have had to make in order for us to get to this point. These are the best people...super human student nurses, supported by super human family and friends. The nursing profession is going to benefit from the heart this ABSN centennial class will bring to it. That's not to say there haven't been moments of sheer irritation. It's a lot like family.

Breathe. The roller coaster is starting to slow down. Hallelujah.

Psychiatric Nursing ~ Can we talk?

2009-10-11T16:22:00.000-07:00

Psych nursing is different. You have the med room, the nurses' station and the hallway. Interspersed are bare bones rooms without any exterior trimming to allow for someone to harm themselves. The inpatient facility where we are rotating resembles a really old prison ward. There is a day room and a TV room. The facility is locked down and the LPTs wander the halls looking after the clients. The clients have access to meds (which they obtain at the nurses' station) from the med room nurse, and they have access to television. Other than that, there is groups during the day to attend, and meetings with psychiatrists/conservators and family members. If you are not insured, this is where you go and to be honest, if it were not for the generally optimistic people that work there; hell would be a picnic. Comrade X talked once about how painting a psych intake room the color pink would, in effect, calm a patient who was in crisis. After being in the concrete walled rooms of this facility, especially the intake/isolation rooms, I got the picture and thought it was research worth looking into. I've seen better dog beds at Costco. It's a sad indictment. Luckily, the best thing going at this agency, are the employees and it seems the long termers...the nurses and social workers, truly care about the patients.

My last day of clinical involved interviewing a paranoid schizophrenic patient with a long involved psych history and drug abuse history. This patient also had a history of violence and conduct disorder as well as developmental delays. It was not a situation where you would sit down and talk, much like the patients I met with who had major depressive disorders, bipolar and personality disorders. This patient was suspicious and tentative, was careful to keep his distance and took a very long time to get comfortable with me. I sat across the room so that he could get his bearings and then waited. It was a long wait. When he was ready, he talked. I didn't ask a lot of questions, because I noticed one thing about this patient that I had not experienced with any of the others...this patient made no sense at all. Disjointed sentences, with little connection between first and second thoughts, subject verb agreement, word salad...people inserted into thoughts that had no congruence or meaning. "I worked at a top secret place, my land lord dipped me upside down into a vat. She does not hear me. It didn't burn it did. He will kill me. They kicked me out. My parents are dead. I was adopted. I saw my dad today. I have 4 brothers. 2 brothers. Four years....and...."

This went on for an hour. Any attempt to redirect failed. Any thought became negated by another or an illusion. He could not maintain eye contact as he was always checking around us to see if I had moved was planning to move, or if someone else was coming. The affect was guarded and tense. As long as I wasn't talking, he was calm. It became apparent that interactions on the simplest terms could affect these patients dramatically, as if their sensory perceptions were all on another plane or out of whack or heightened or lessened.

I waited a long time to write about this because I realized that there was absolutely nothing I could do first as a student, or as nurse, other than listen, redirect, listen, accommodate and accommodate. Nothing I said mattered. I haven't been around someone whose defensiveness was so palpable. It was an interesting learning experience that I won't soon forget. Mental illness can not be dismissed or trivialized. How we deal with the mentally ill in society is certainly an ongoing subject that needs to be addressed, because obviously not much is left for the mentally ill other than hopelessness, despair, long roads and new challenges.

Longest baseball game & Precepting assignment

2009-09-30T00:45:00.000-07:00

The best laid plans have side roads...and due to timing and circumstance, I will not be precepting at the VA after all. There is simply not enough time to secure a contract with my school.

In any event, I found out that I will be precepting as an oncology nurse for 7 weeks (120) hours at a local hospital with a reputable cancer program. So much ahead @ and only 71 days to pinning! I had no idea it would go this way. I hope I learn a lot in this last clinical rotation.

We have one month left in psych and community health. After that we slide into home plate with leadership, senior synthesis (policy) and preceptorship, in what will have been the longest baseball game of my life....nursing school.

Community Health - Homeless Transitional Housing

2009-09-28T17:07:00.001-07:00

Having this rotation during the health care reform debate has been interesting to say the least. In order to better understand what homeless people have available to them at the county level, Trude & I went to the county to check out the services and waiting areas of the local primary care center. More on that eye opener in a bit.

Our community health site is located on a closed air force base. Volunteers of America and the county share responsibility over various work/educational programs affiliated with this transitional housing venue that utilizes what's left over from the abandoned military barracks. Most of the residents are recovering alcoholics, drug addicts, parolees, or simply those down on their luck. There are two sides to the resident program (a singles side and a family side). Trude and I have the single resident students. We go to their community meetings each week and staff clinical office hours.

Our office was an old apartment that had a lot of broken down furniture, bags of old stuff, expired medical supplies and dirt. After we cleaned the place up, Trude managed to get an old exam table and now it looks like a little medical clinic office. We have a locked medicine cabinet with OTC medications, first aid supplies and health education materials.

TNT Tuesdays (Trude & Tam) opened with people getting their BP and blood glucose checked. We have smoking cessation materials, movie nights (coming up) and have set up free teeth cleaning appointments and mammograms. We're always looking for health related materials for our residents.

It's been one of those experiences that started out with a lot of cynicism on my part (lack of available resources, budget cuts) and we're having to reinvent the wheel. Trude's got her creative juices flowing and a sense of optimism to outweigh my cynicism, so we're pulling rabbits out of our hats when we can. When the staff has us speak at the meetings, they refer to us as the 'nurses'. We talk to the residents, counsel them, teach them. Taking a little bit of knowledge and applying it in a dignified manner, respecting each person where they are at. Once again, the patient is the best teacher.

The biggest challenge currently being faced at this site, is the potential closure of the entire program due to a long term, ongoing county budget crisis. We attend the community meetings and have witnessed the despair the VOA staff members are experiencing in trying to convey the latest news to the residents. There is a Board of Supervisors meeting this week. We're going to try and get to the meeting to support the residents.

Now, back to the county health primary care center. The building is relatively new and is easily accessed. What blew me away was how apathetic, rude and mean the staff at the bullet-proof glass windows were. The waiting rooms were empty and the staff looked like they would rather have a root canal rather then be at the window assisting patients. No wonder no one wants to access the county system for health care. What a sad indictment on government run health care. At least the veterans get better care at the VA, currently, the highest rated health care system in the country.

Fall Semester~ Get to work!

2009-09-22T19:28:00.000-07:00

Fall semester is the back end of our nursing program. It essentially takes the entire nursing program and puts what we learned into action. We are put back into the community in public health settings, psychiatric inpatient and outpatient settings, management and preceptorship nursing practicum, essentially where the whole thing ends (the icing on the cake of nursing school).

I picked a community health site that appealed to my sense of stepping outside my comfort zone. It is a transitional homeless shelter program.

My psych clinical site is a locked 16 bed facility. Patients are voluntarily admitted, or admitted on legal holds. Some are on conservatorships. It is a whole different level of theory and clinical that is bent more on service and safety.

Five weeks of Pediatrics - Putting it all together

2009-09-14T23:09:00.000-07:00

I deliberately stopped writing Tales during my pediatric rotation for many reasons. My stress levels increased significantly over the summer and came to a peak and I was simply too exhausted to write anymore. We had a bunch of busy work and it seemed I was treading water trying to stay ahead of all the projects, papers, research and clinical expectations. So I shut down on the one thing I always used to de-stress...writing. Instead, I stayed above ground and when I wasn't doing anything related to school, I slept. Seems like we took a running leap into this program, kinda like leaping off an endless abyss, and the fall at the end of it was hard. It took several weeks, plus a summer break to come out of it. Sheer exhaustion.

When I started pediatrics, I was going into a facility where my kids have been patients. Specifically, one of my kids was critically ill in this facility and walking the halls was all too familiar. I also had memories of helping a family who had roomed with us say goodbye their child and part of our helping them was being there when their daughter passed away and helping them with the funeral. I know the room that MJ died in. I had patients in the same room she shared with my daughter and where my daughter's PICC line was inserted. It was surreal, but being there as a nursing student was different. Significantly different.

As I mentioned in the previous post, I asked to be put with the sickest kids for a reason. I wanted the cancer kids, the CF kids, the heart kids and the dying kids. I definitely wanted a NICU and PICU experience. I got everything I asked for and then some.

As a nurse on the other side of the nurse's station, I saw the other side of the story. The family dynamics, the innocence of sick children along with the functionality of strong families, coupled with the weaknesses of the broken families.

My patients had leukemia, hypertrophic heart problems, cystic fibrosis, sickle cell crisis, post op complications, brain injuries, respiratory and renal failure. The babies I took care of were preemies and had a host of complications, namely they were too fragile and small to be cared for outside the clinical setting; one patient I cared for on a Saturday NICU rotation had been a patient her entire life, 13 months to be exact. She still has a long road until they she can grow up outside the hospital.

There were heartbreaking stories in the PICU of viral meningitis, heart/kidney/respiratory failure, Valley Fever...and bad prognoses. With one admission, I looked into the faces of the parents and I instantly saw people I knew. My daughter recovered. I knew that theirs wouldn't.

After my clinical final evaluation, my clinical instructor asked why I wanted a generalized preceptorship. She thought I should specialize. "You're good with the patients and their families, you connect with the kids and have the critical thinking skills"

The answer is simply this...if you could guarantee that I could work two years with critically ill kids...without falling apart after every shift, I would consider it. The challenge is to find the area of nursing that is most comfortable, where I can give without losing myself and or ability to function outside the clincial setting. Dying kids is a tough job for anyone. Pediatric nurses are special. I'm not so sure I could do this for too long.

Still trying to put it all together.

Preceptorship???

2009-07-10T17:11:00.001-07:00

Before we started our last summer rotation in pediatrics, our managing director handed out preceptorship applications. This was one of those things in July that stressed me out, because in a certain sense, I had no direction on what course to take with regard to specialty. I talked to my Labor and Delivery OB clinical instructor (she's been a nurse for over 30 years) and asked her advice. I thought she'd push me to request a rotation in maternity or public health since she wears her hats so proudly, but instead she asked me what I thought about my nursing school experience.

Contemplating the journey, I was at a loss for what to think because I came into nursing with so many preconceived notions about what I wanted. Initially, I thought, I'd be one of those ICU experts who would enjoy the 2:1 patient ratios, and 1:1 with higher acuity...I also harkened back to my experiences with my father as a patient, my daughter as a pediatric patient and those I loved who succumbed to cancer. Did I want onocology? Did I want pediatrics?

Pediatrics was about to begin and I had not idea what to expect. I asked to be put with the sickest kids to see how well I'd function, but this wasn't a part of the consideration for precepting, because the applications were due before the rotation began, so I stewed for about a week.

My clinical instructor asked me the following week and I explained my dilemma. She then said without missing a heartbeat. "You need a solid foundation, one that will get you employed at the end of this" Go back to basics...go to med-surg. Hmm...really? Yes, give a bunch of meds, do a lot of IVs, procedures, reports and care and refine your style of nursing...do that for yourself.

She told me about a nursing student at another school's campus who had idealized everything about her nursing school experience and was thrust into the Veterans Hospital for her preceptorship. She reluctantly went and found out that everything she ever needed to know she learned at the local VA hospital. That sounded very appealing to me. I contacted this nurse and she said she tried two different settings in my area, one a private, not for profit hospital and the VA. She preferred the VA.

This got me thinking about Comrade X (who is also a VA nurse) and it occurred to me that all the things I love about nursing; the advocacy, protections, education that nurses offer to vulnerable clients could be well served at the level of serving our nation's veterans. It was an epiphany.

I think the nursing director at my school was surprised by my request, but when I turned in my application, I was convinced that I needed to serve in this capacity to launch my nursing career. Giving back doesn't always necessarily mean making tons of money. Sometimes, it just means doing something that we feel called to do.

Post Partum last day - Week 5 - Newborn Nursery

2009-07-10T17:10:00.002-07:00

I had the chance to hang out again the nursery at the end of my rotation. The baby assessments were interesting and fun. I enjoyed checking in on the new ones, showing the primips (first time moms) 'the tricks of the trade' when it came to taking care of, holding and feeding their babies. It was a great opportunity to share motherhood as well as nursing.

The nurses in PP were all long timers, meaning they had their teams in place, the colleagues they liked and trusted and physicians they preferred to work with. They were willing to work with the students who wanted to work hard and learn. Overall, it felt like med-surg without the meds. We did vital signs every shift unless orders specified more frequently, we took out a lot of c-section staples, talked to the moms about their babies and what to expect in the first weeks. Mostly, we had long philosophical discussions with our clinical instructor about the present state of nursing and health care. The agency I was at was a teaching hospital, so I enjoyed working with the medical students and nursing staff. Mostly, I loved welcoming new little people into the world.

Triage - IV practice, no laughing matter

2009-07-10T17:10:00.001-07:00

I missed my triage day because it was scheduled on a day off...but that didn't stop me from eventually getting in there one way or another.

I had a very slow last shift of labor/delivery. I was following a grouchy nurse who wasn't a big fan of students, so we spent the first half of the shift playing hide and go seek. I stocked her patient's room, helped the OB put in an internal fetal monitor and then she did the disappearing act. Rather than play the game with her (I've seen this with my classmates), I headed over to triage to see what Trude was up to. She was super busy. She promised me an IV stick at the first opportunity. so when she called me in on a difficult patient second triage in as many days due to dehydration. I gathered everything I needed to get it started, prepped the patient, found the scant trace of a vein and went in quickly. She screamed. I could hear my sister from another mother snickering in the hall. Ooops. Three RNs and 4 sticks later, the IV finally was started. The care nurse signed my stick sheet with the words "a very difficult stick." All I remember is Trude laughing.

Patients who need moms...Score 2

2009-06-30T22:44:00.000-07:00

Post partum day 2 found me with 4 completely different patients. The first was 19 and a first time mom. The second was 30 something and a first time mom. The third was almost 30 and gave birth to a set of twins (this her third time giving birth). The last was a post hysterectomy patient who came to PP as an overflow. She was in her 70s. After doing initial assessments on all four patients and giving my notes to the care nurse (probably one of the nicest encounters I've had with another colleague)...she asked me which one I wanted to assume care on...I thought about it in a split second. "I want the 19 year old." Before I explain why, my reason was simply this. She needed a mom who could also be her nurse.

When I first came into the room, it was dark. The shades were closed, the room was hot and the patient was down in the bed...curled in a ball. Her newborn in the bassinet looked small and jaundiced. The mother's affect was flat and emotionless. She refused to make eye contact with me. I had taken report and heard this first timer was "difficult." My care nurse was awesome. I loved her style. Pulling my patient up in bed, I explained to my 'baby' that we were going on a journey today. She was going with me, and we were going to learn all we could about her baby. This required me to take care of her, so that she in turn could take care of her baby. She looked at me totally surprised and asked "why?" Laughing, I told her to smile, she had a baby, it wasn't the end of the world. I went out and reviewed my plan with my nurse who belly laughed and said "good luck". Ok..it was a little too cheerleader. After I packed her hemorrhoids, gave her breakfast and a motrin, I pulled out supplies, and told her to put her baby in the window near the light because he was looking yellow. While she did that, I asked her to take a shower. A shower to wash all the labor and delivery away. A shower to wake her up. She had no idea how much her life had changed in 12 hours.

I reviewed her chart. She had a history of a neurological disorder and learning disability. The flat affect could be slightly explained with the neuro disorder, the psych problems were situational. So, after getting a handle on her situation, I went back into her room to talk to her some more about her support system. She had no parents. Mom was dead. Dad was absent. Boyfriend was dysfunctional and abusive. They were living with his mother in what could only be equated to a double wide in a bad neighborhood. This case screamed for long term support. I could think of a handful of couples I know who would take her baby and raise it for her. She chose to do this, but I wonder for how long and at what price.

After talking to the nurses, they called social services, who in turn, came in for a second eval. The first didn't go so well. It was decided this time, the patient would get a public health nurse home health referral. Score 1.

Throughout the day, as I gained the patient's trust, we talked about how the days ahead would be for her as a new mother. What resources were available to her and her baby and where respite care and services could be attained. We talked about depression and abuse. She looked at me like my teenagers look at me when I am giving them a lecture, but while talking to her I did so more as a nurse who was also a mother. Her boyfriend and I talked about shaken baby syndrome. It all sounds so simple, when I say I told him "don't do that under any circumstances" but if ever there was a candidate for something like that, it was him.

Perhaps the connection for me was in the questions she asked, the suggestions I made that she obeyed. She got outside while her baby when to the nursery for phototherapy. She came back and watched all the instructional videos and she asked me questions. At the end of the day, she smiled and said 'thank you'. Score 2. I did nothing but get her out of bed and into her new life as a mother with a future paved with uncertainty. The rest is up to her.

L & D Day 2 - Standing O for the G2, P1.

2009-06-22T19:38:00.000-07:00

Day 2 of L & D started out with hitting the ground running with an active labor admission who came in dilated to 5 cm. I knew I'd be around when the baby was born, so I got report, met my care nurse (who is pregnant) and followed her into our patient's room to meet our patient, G2, P1 20-something. The patient was side lying and comfortable - ready to get to work. Her membranes ruptured, so we did a quick assessment, got a bedside report from the night nurse and talked about was going to happen next. My nurse was a pro. Mostly I admired how calm and soothing she was the patient who was breathing through some pretty good contractions. Her quiet reassuring manner was what made her such a great labor nurse. After she checked her, she looked up and said nonchalantly, "we're going to get going, she's at 10 cm." Cool. This mom had an epidural but only got a bolus of anesthetic so she was feeling everything, nothing was running. We got her into good position and as she pushed through her contractions, I could see the baby's head crowning. The patient, while in a great deal of discomfort, was totally in control of how she wanted this birth to go. Within 15 minutes of pushing, the residents showed up and caught the 9+ pounder who was mad as hell at having his wonderful uterine world taken away from him. Head full of hair, plumpy thighs and big belly, he was only happy when he was swaddled next to, and latched onto his momma.

While I watched this young woman give birth, great admiration towards her kept coming out of of my mouth as I recalled my own birth experiences. Holy cow, this birth was one where the panel of judges would have stood up and applauded how the whole thing went from Triage to Delivery.

I was more of a wimp when it came to childbirth, giving up before the marathon even started. My kids came by NSVG, but not without Pitocin and it's friend epidural. Pain is one of the greatest subjugators. I witnessed something in this birth that reminded me of how nursing teaches the teacher more about herself than anything nursing sometimes is able to impart on the patient. I was humbled and privileged to be part of this experience of welcoming this new life into the world. Wimpy loved it. Whether we like it or not, our patients give us gifts everytime we care for them.

L & D Day 1 - Disparity is alive and well.

2009-06-22T14:18:00.000-07:00

Labor and Delivery...where everyone comes into the world one way or another, whether you are at home or in a hospital birthing center. Without regard to race, religion, status...we all get here the same way. How nursing and medicine facilitates it though is a story worth telling. NSVD, C-section, or VBAC. Day 1 in L & D, I was told by my expert nurse to observe and watch what she/he does/did. "You'll pick it up as we go." Here is what I picked up Day 1.

Single early 20-something, hispanic woman G3, P1 versus married physicians, mid-30s, G1, P0. It's the difference between a having pillows tucked everywhere around your cute little petite pregnant form, being served a carefully mixed juice cocktail, snack box, peace/quiet, an early epidural and collection of classical music and discussing your goals for the day, versus "oh yeah, can you get her some water...I forgot about that...c'mon breath through it...you're up next for an epidural...make him (the offending boyfriend) wait in the waiting room. What's with all the noise from those kids? Sigh. Tisk Tisk. Irritation. Stomping around and then the pass off to another nurse. Once that was done, feeling better. More time to schmooze and discuss goals for the evening with MPs. Whatever you decide...if you wish...we can arrange for a (C-section). "You look so tired...so concerned. Can I get you anything?"

Yeah I learned so much by the afternoon. Disparity is alive and well in nursing L & D. The thing is, we are all guilty of it in one way or another, no matter who we are or what capacity we are serving within. It's the difference between taking care of someone you respect, and someone you refuse to understand.

Small miracles...big machines

2009-06-17T17:25:00.000-07:00

List of things to do: orient at a new agency, watch moms before, during and after birth, take care of newborns, wipe the smile off your face. Maternity rotation started last week. Love this part of nursing school...play with babies, coach their moms, teach stuff.

So stinkin' cute I can hardly stand it. My first rotation was in the newborn nursery and I had a boarder baby. A boarder hangs out in the nursery when mom is not on post partum. My little male was the 2nd heavyweight champion of the nursery for the day weighing in at a hefty 4200+ grams. Since he arrived by c-section, his head was perfectly round, his cheeks perfectly plump and his thighs in the sumo wrestler genre. Heel sticks, supplemental feedings and assessments kept the day busy. Was able to learn about hearing tests and how they are done. Listened to the peds interns give their group report and bought a really cool adaptor for my stethescope from one of the docs who had an extra one. My little guy had a murmur best heard on his left sternal border, which is exactly where you can here mine from time to time. Hopefully his will go away as he settles into life. I did my initial assessment of him when he was 8 hours old and he was pink everywhere (even his hands and feet.)

Basically, babies love to be locked in and loaded up. My buddy was perfectly content as long as he was swaddled in tight and loaded up with food. Later that afternoon, while showing Dad all the neat things he had to look forward to, like diaper changing, holding and feeding, I took Baby D's rectal temp and he passed the last of his meconium, giving his Dad a big smile. Small miracle yes...but also a major machine!

Last Three Weeks of Critical Care

2009-06-09T17:35:00.000-07:00

This is hard to write about it because the last three weeks were times of real discouragement for me in school. The whole time I was in school I felt uplifted in support by clinical faculty, care teams and friends. The last three weeks felt like a desert. I had a terrible midterm evaluation, a clinical instructor who made it obvious that she didn't care for me, and had a lot of sleepless nights worrying about everything; school, family, missed friendships, and second guessing whether I made the right decision to go into nursing school in the first place. There is this "myth" out there that nurses eat their young. For 3 weeks, the emotional toll this took on me made me rethink a lot of the optimism I had about becoming a nurse, how I could help people, working in a constantly changing environment and adapt to multiple personalities and temperaments.

Week three I went back to Tele (cardiac care) for two days and prepped on two patients. The first was a deaf patient with pneumonia and the other was a late Friday afternoon admit, whose records were still being assembled while I prepped on him. I made as many notes as I could gather assuming I would finish all my history gathering the following day as I assessed and care for him. Since things change so fast in tele...we always risked full preps on people who might be discharged the next day. This always happens with me, regardless of the acuity level of the patient, and as I arrived on the unit the next day, the care nurse told me that she was orienting a new nurse and to essentially stay out of the way. Nice.

My 2nd and 3rd patients were interesting. One needed an adenoscan. Went with him to see what that was all about and decided that if I ever needed one of those, I would not consent to one. Essentially, adenosine chemically induces the effects of running a marathon while you lie still. My patient freaked out. As I tried to reassure him, he looked at me like I pulled fast one on him. The first patient I was supposed to care for, but ended up deferring to the new orientee was just a little too active for the care nurse so she asked me to restrain him. As I zipped up his vest, he looked at me and said "no, SN not you!" Feeling like 'one of them', I cried in the shower that night. Seeking refuge with a little sweet old lady who need ortho HTN vitals done, I rounded out the day talking to her about books we both loved. After renal diet teaching and discussing the importance of medication compliance with my young dialysis patient, I went home to update all the care plans..four pounds of paper later...zzzzzz.

Week 4 was in ICU: My patient was in respiratory failure. My nurse was a tazmanian devil and really sharp. We had a loaded unit with two suicide attempts. My patient's family reminded me a lot of my own. They were there all the time. Dad was really struggling with breathing and as we tried SAT and SBT trials to wean him off his vent, I witnessed the most rapid respiratory failure I had only read about in books. Being Sunday, all I could do was pray hard that we could keep him calm while the RT fetched the BiPAP machine. Holding this guy's hand, it felt oddly familar. That weekend wiped me out.

Weekend 5 was full prep with two patients. One had a decub that wiped out his heel at a SNF. Seeing someone with DP pulses and missing his heel tissue was another one I thought I'd only see in the books, but SNF neglect still happens. Boatloads of meds. I enjoyed getting this guy up in a cardiac chair with PT and giving him my farewell speech. We both knew he was going to lose his lower leg two days later in surgery - I tried to equate this with the problems my own father had following his hospitalization and I demanded this patient keep his gym membership and never give up. Everything about recovery is in attitude. He had several rough months in a SNF - he could make it. Shaving away the last remnants of his beard, he laughed at the amount of cream I put on his face...we had to laugh. There was so much to cry about.

As I left that night. I was sad and tired. Spent and frustrated. Second guessing everything. This was the hardest part of school for me. The biggest learning curve and the most difficult to navigate. My CI gave me my final review and I passed. For some reason, I was numb. My clinical group all made it. But we all had that same worn torn look of fatigue.

Are you still here???? Yep! Wouldn't miss it!

2009-05-21T13:08:00.000-07:00

My partner & I arm wrestled for a CRRT trauma crush patient last Friday. I had first choice the weekend before so she took him. The next highest acuity patient was in the room down the hall according to the shift charge, so I grabbed the chart and started to prep. While prepping on my patient, I noticed the neuro doc stopping by to meet with the family. The code status was downgraded from full code to DNR. My patient 'Pebbles' had a brain aneurysm that ruptured and she was not doing well after surgery. I finished my prep at midnight and went to bed. The next morning I arrived to find that she had died two hours after I left the hospital. Picking a new patient, I got report, started reprep and began to take care of a patient with a brain mass, status post surgery, ventricularostomy and ICP monitor. I learned about calibrating his arterial line and ICP line, how to monitor intercranial pressure and doing frequent neurological assessments. My patient was affable, talked a lot and was very alert and oriented to his situation. I hung several IVPB medications and took care of his needs for the day. I was able to take out his arterial line, foley catheter and get him out of bed several times to assess how intercranial pressure would be affected with increasing levels of activity. Learning about brain compromised patients is fascinating and exhausting at the same time. I finished his care plan and helped with other patients on the unit. My partner's patient had a Swann Ganz line and an expert on the line taught us about it as we looked at his monitors.

In the midst of caring for this patient, my care nurse had a patient who also had a stoke, whose family withheld treatment. In that regard, we were providing comfort measures to him. His lungs were filling with fluid, so I was able to help suction and clear his airway to ease his breathing and offer reassurance. By the next day he was gone. Two patients in one weekend. ICU is fast and furious in one respect and slow and intense in the next. The contrast in the ICU was black and white. Such differences with each patient.

On Sunday my happy patient was downgraded and I re-prepped (again) on a new admission from a motorcycle accident who had broken his femur and ribs. He had a chest tube and his leg was pointing in several different directions in a Bucks traction device (something invented in the Civil War - much like a weight and pulley system) that stabilizes the bones and joint while the patient waits for his surgeon to fix his leg. I was able to do some patient teaching on pain management using a PCA device which is a button system the patient uses to deliver his own analgesics. Assessing his breathing was interesting. When someone has a pnemothorax (collapsed lung) due to trauma, their breathing sounds like hiccups..short inspirations which are cutoff midway. I made a bath blanket splint which he could use when he felt the urge to cough and help ease the pain from his broken ribs. We talked about his surgery and a few of his friends came to check on him.

That afternoon I went to the OR with my patient and watched his surgeon prep him and open his leg at the thigh. What resembled a car (up on a jack), ended up being huge rods, nails, pins, and drilling sounds with hydraulics set against the sound of Enya playing on the surgeon's IPOD. I saw more blood with this procedure than I saw with my previous OR rotation ( thorocotomy, total neck and ventriculostomy)...the blood was all over. Everything was done with X-ray for placement so we all had to wear to protective aprons in addition to our OR gear.

In the middle of my patient's surgery, one of the OR nurses came in to grab me to help with a trauma coming in (a self inflicted gunshot victim who had severed his popliteal artery which was being held closed with an EMT's finger ETA 8 minutes)...while the room was being prepped, I sterile gloved and waited with my heart racing as to what was going to show up. (Apparently, not realizing while cleaning his gun, a bullet was lodged in the chamber, it fired into his leg...owwwie)

As they wheeled in the man, his clothing was being cut off, I grabbed all the gurney materials, clothing and bags and sorted through the bloody mess to get the patient belongings into a separate bag. Throwing the gurney back into the hallway I re-gloved and went in to assist the prep. The patients legs needed to prepped and elevated for sterile wash and possible vein grafting. I had one leg and another nurse had the other. It felt like each leg weighed about 100 pounds each. 10 minutes later, the surgeon was there, draped and cutting into the leg to secure the leg to repair the artery. The anesthesiologist was the same one I had observed with my OR rotation and I was amazed at how fast he was able to get this trauma patient under and intubated.

With the muscles in my arms still shaking from holding the gunshot victim's leg up for so long, I walked back to the other OR to check on my patient who was coming out of OR and going back to ICU. I escorted him back to the unit and with my care nurse, completed the PACU assessments in the ICU, which involves assessing all his vitals every 15 minutes, getting blood samples and cleaning him up after surgery. My patient had been intoxicated when he was injured. Earlier in the day we talked about drinking and driving. My patient verbalized how fortunate he was to be alive and that his friend (riding on the rear) had not been seriously hurt. You wonder if it is a wake up call or a pattern of risk taking that will eventually catch up to the patient. We are there to treat and teach.

As my patient woke up, he looked at me and said, "Are you still here?" "Yep!" Wouldn't miss it!

Welcome to Neuro Trauma Intensive Care... Roll with it baby

2009-05-10T20:30:00.001-07:00

Web photo courtesy: (Hartford Hospital Images)

Excited about the prospect of critical care for the weeks leading up to it, the 4 days prior to prep were nerve wracking to say the least. We finished last semester after being in a comfort zone with theory instructors and clinical faculty that I came to depend on. You go into this learning curve which I liken to a roller coaster; already defensive, the next loop might be the one you totally barf on- because so much time, resources, blood, sweat and tears is invested into the venture of this type of learning. It can be disappointing to be treated like you haven't worked hard enough, long enough or know enough to be successful.

I went to prep as early as permitted on Friday (just knowing how slow prep can be for me). I tried to pick the most complicated patient based on the recommendations of the ICU RN in the unit at the time. Little did I realize how fast some of these patients turn over either to a step down unit, transfer to med-surg, home or sadly, to the morgue. So, I wanted someone with airway problems, perhaps some brain issues and maybe some renal stuff..so that it would be complicated enough. Sure enough, my patient had a brain bleed, he had a craniotomy and a ventriculostomy (both of these surgeries were procedures I had seen on OR rotation, so I was excited about taking care of a patient post op in the ICU. This patient had airway issues too, with failed mechanical ventilation, a relatively new tracheostomy (something I already had experience with)...and renal compromise because I saw they were doing a 24H urine collect on him and I knew he'd be around for the weekend....it was that or I was looking at taking care of a patient with a hip fracture. Been there. Done that. So, I thought I had a good one.

Knowing how much of his care was multi system, I went to my old friend (Lewis textbook) and started looking up care plans for inter cranial bleeds/increased intercranial pressure..management of trach patient and (oh, my patient was also in DTs for ETOH withdrawal, so I had resources there). What amounted to be a NANDA compliant, medication compliant (I had 7 pages of medications I had to reconcile) and also look up this patient's labs and diagnostic studies, ended up amounting to an 11 hour prep including time in the neuro ICU making sure I had all the information from his chart that weighed about 15 pounds...head home...and 8 hours at home all night. With my own brain function ceasing at midnight, I collapsed into bed, a complete insomniac, because I was trying to remember the sequence on the crash carts. Imagining I would surely be working a code (the imagination runneth). In addition I was looking at neuro trauma information on the web from allnurses.com and trying to be sure I brushed up on things in case the docs caught us off guard. We hadn't worked 12 shifts yet and this was going to be a new first this weekend. So after drifting off at 1:30, I remember I hadn't done a patho-map (the one thing I've NEVER been good at doing well)...so I went to concept mapping (saw "uncontrolled HTN")..wrote on it that it was draft and I would do a real one the next night after I met and assessed my patient. (Note: We can't show up to clinical unless we have something...I had to get up at 5 AM to be at clinical by 6:30 AM). I dropped off to sleep at 2:45 AM and the alarm nudged me at 4:45. I shot out of bed like a cannon ball, showered, gathered up my stuff and headed out the door to find an open coffee shop. With 3 shots in my cup, I got to the hospital early, met our new group in the lobby and met the first of our two new CIs (clinical instructors). We went to our assigned units. My buddy and I headed up to Neuro Trauma, to get report from the night shift and meet our care team.

My care murse (male nurse) was a staff III nurse. We had a great day. He was very experienced, had a wealth of knowledge and allowed me to ask a lot of questions. I was able to work with my patient a lot and he gave me the space to also work with the patient's family. One thing I immediately noticed was how much my patient had improved in the 24 hours since I prepped on him. His ICP monitor was out, his NG tube was out and his trach was being weaned. I was able to take out his foley catheter, get his head shaved completely..because believe me, it looks kinda ridiculous to have half your head shaved and the other lookin like Bozo the Clown. He now had a nice Daughtry-esque appearance that made him more comfortable in bed. I did my neuro assessments and head to toe assessment and watched how my care nurse charted on the new flow sheets. I gave a lot of meds, changed EKG pads (because how else could my patient be smiling and in asystole at the time) and then watched how everyone else around me adjusted to life in the ICU. It was impressive. My buddy pulled an ICP, inserted a NG and did all kinds of cool stuff on her patient who was coming off a dirt bike trauma. The hours passed and I think I got home around 8:30 PM. I had been up since 4:45 AM.

I left the shift utterly exhausted and went home to hand sketch my pathomap with colored pencils and a sketch book pad...I updated notes on my care plans pertaining to my patient, logged med reactions, made sure the lab results were updated and did my self-evalution..After all that, I went to bed at 1:30, only to get 4 hours sleep and then rush back for day 2.

Rushing to the hospital, I made it in time for report. Different care nurse. Different clinical faculty. My patient looked great. We were able to repeat a lot of day 1, activities, plus shave his face and get him bathed. My second CI dropped by to look at my paperwork and asked me a couple questions about brain hemotomas and ACE inhibitors. Not knowing too much off the top of my head (at hour 5 of 12), I went to conference with the answers and decided I liked this style of teaching and interaction. She wanted to get to know us better and allowed us to say a little bit ourselves to her. She also passed around a bag of chocolate. We went to skills lab and reviewed a few things about different types of med pumps, and looked over the crash cart again for a quick brush up. I actually left this shift totally spent ,but relieved that I survived. I liked the high acuity level, respected the nature of people's perspectives and differences of opinion and learned a lot. Most importantly, I gained my patient's trust.

On the way out the door, I stopped by the floor where my patient was moved (as he had been downgraded - meaning he was improved enough to be off ICU) to say goodbye. It was sweet to wish him well and say goodbye, plus it was rewarding to hear a little gratitude from the patient and his wife for the 24 hours we spent together. Nursing is an intimate relationship that starts and ends quickly between a nurse and patient, but leaves an indelible mark on both.

Expect anything and roll with it. I guess I just want to be a nurse.

Week 10 - MCA II Finale - real cute boy

2009-04-27T22:35:00.000-07:00

Picture: Courtesy of the Web: National Association Down Syndrome - Adult Center)

We rounded out our medical surgical rotation with a nice little final exam on ICP and other complications from neuro trauma and the like (truly you don't want this) and we had a wrap up in the other classes with presentations and potlucks. I'd collapse in bed at night ...wishing for the end of term.

Clinical found me in the Med Tower with a leukocytosis patient with very loose stools. Nursing students somehow always manage to end up with these patients. I haven't had one until my last rotation day. I guess I was saving the best for last.

As I completed his assessment he asked for a hug and told me that he was a 'real cute boy.' How could I disagree? My patient was a middle aged adult with Down Syndrome. I practically pulled the rug out from under Trudy to get this patient. I have a real fondness for my friends with DS. Giving him a hug and holding his hand, I let him listen to his own lung/heart and bowel sounds. He had ticklish feet and the assessment felt like a fun little game, rather than a chore. Even when feeling like garbage, my patient was happy, albeit in a sore, dehydrated and slightly elevated temp sort of way. He didn't have a care in the world.

My last hours in MCA II were spent watching Bonanza with him and cleaning up some of his 'loose ends' ~ For some reason, I managed to go an entire 10 weeks without a single splash down until the final day. As Trude fetched me some linens and pads (probably relieved that it was me dealing with this for a change) I was intrigued with the notion that I didn't mind how unglamourous it can be (sometimes, it is dirty work)..but there we were -chatting up a storm about Hoss, Little Joe and Pa.

He giggled and laughed about everything and nothing at all. The 7-up tasted good. The rash hurt, the wash cloth felt good. The incentive spirometer was an exercise in futility. I think I needed it more than he did. I charted and tried to figure out what I could do about the perianal rash that was developing due to the two day advent of acid laden loose stools. After a nice paint job with barrier cream, we talked about friends and how everyone had nice eyes, pretty hair (especially care nurse Jaime). We talked about eating slow (I should really take my own advice) and not eating so much. He wiggled his toes, sat up in bed and wanted more 7-up. I remember thinking that the idea of 7-up sounded so good....

I think it was rather cathartic to end the term on this happy note...a pretty rank and dirty splash down...strip bed, paint job, one med, a couple hugs, ticklish feet and a real cute boy.

Bless your heart buttons...

2009-04-21T00:28:00.000-07:00

Back to oncology this weekend. I had picked two patients on Friday- that one of the AM RNs said would be around for the weekend. One had INR issues and the other was supposed to have a chest tube inserted so she assured me they wouldn't be discharged. I prepped on both and discovered they both shared virtually the same diagnosis...malignant cancer of the lung. One had a stage IV pleural effusion that needed to be drained. The other was coming off chemo with a persistent fever of unknown etiology and needed to be stabilized before his next round of chemo.

After prepping on my patients, I knew I was going to learn a lot this weekend because one was a retired health care professional in a specialty that involved his own diagnosis, and the other was an independent retiree who reminded me of my dad. Nothing was keeping "my guys" down. They had loving, well educated spouses who had been married to them for over 40 years. One of the spouses was a retired ICU nurse and the other was a fireman's wife.

These men both enjoyed long fulfilling careers in their fields. They were fighters through and through. The medical guy knew exactly how things were going to go for him and he taught me a couple things I'll never forget about respiratory assessments particularly. For example, he suggested that the best way to ausculate the lung fields is from the back side and if you ask the patient to say the letter E with each field through all the points of ausculation..and it gets to a point where the E sounds like an A...that's the point of effusion in the lungs and you can mark it with a pen. Since he had a chest tube inserted, I got him out of bed and tried this technique. My care nurse and I were both amazed that the E does sound like A..and we didn't need an X-ray to know where the effusion was in his lungs.

It is difficult to explain what it means at the end of the weekend when you are either discharging your patient home to an uncertain future of months or days or whether you leave them not knowing if they will be back next week because of an infection or recurrence of their symptoms. I always try to say goodbye to my patients because the time spent changing their dressings, assisting with personal care, medicating them, injecting them or teaching them something important about their care, is a time when a bond of trust is established. I feel the same way about the families who stay with them. When I left Sunday night, I knew my 'teacher' wouldn't be there the next day. He made eye contact with me, wished me well with nursing school and we bade our farewells...he might be back soon because his diagnosis is terminal, but knowing him, he will prefer to be at home when that time comes. It's the kind of person he revealed himself to be and I was certainly humbled by the inherent dignity our patients possess when they are the most vulnerable to us as nurses. I was able to medicate him, obtain cultures, humidify his oxygen and change his chest tube dressings. The best thing I did for him however, was switch out the remote control on his television set. He went a whole week waiting for one. Mostly, nursing is about listening. I haven't always been a great listener...because I like to talk. I am learning to be a better listener.

One LOL (little old lady) was on my unit this weekend with an acute bout of pancreatitis. I could read the body language of her son, who was irritated to be summoned to the hospital and it made me mad because he wanted nothing to do with her. As I took out her IV, she rubbed my arm and said "Bless your heart buttons." She was a dear. As a total stranger pulled up in the Lexus SUV to pick her up to take her back to the board and care home; they wanted us to scratch off the prescriptions we transcribed and phoned to the pharmacy, because they didn't want to pay for them. I knew the sweet LOL wouldn't be getting half the medications the doctor ordered for her because they owner of the board and care wouldn't pick them up at the pharmacy. As she waved good bye to me...I wished in my heart that her son would care enough and that she would never realize that he didn't. Bless her heart...sweet little button.

Easy does it

2009-04-14T01:37:00.000-07:00

Couple things happened this weekend. I went back to surgery and had a nice run of abdominal cases with penrose drains and minor complications (peritonitis and bile leakage.) I have done a lot of dressing changes, so this weekend I perfected my skills at changing abdominal dressings and charting the character of bodily fluids draining out of incisions and drains. I also admitted my first post op trauma patient who had a dirt bike accident. Between these three, I had a three day run of staying busy and honing some skills. I dc'd my first foley and Trude inserted her first, so it was all good.

I didn't expect to wake up with a call from the school that my son had a accident at school. With DH following the ambulance team into the ED at the local hospital, Trude and I weren't far behind, all decked out for clinical . We saw the team in the ED (slow day) picking him up for radiology (Trude's first reaction upon hearing that he sustained a pelvic fracture, said, "We have a care plan for that"...yep. Irony reigns eternal.

Finishing up clinical early we trudged out with two weeks to go before start clinical for critical care. I would prefer not to have a parallel experience in the family while this is going on...so be careful people...easy does it.

Nursing outside the box

2009-04-06T11:25:00.000-07:00

I am a changed person. I've seen the light. Call it an epiphany of sorts.

We've had a lot of lectures in health assessment about this topic and the focus this week in Medical-Surgical Care of the Adult II was OBEEEEEESITY (say that in the movie trailer guy deep slow voice), and all the resultant complications , I've pretty much lost my appetite. Trude will tell you I haven't eaten in a week. To top that off, after my theory instructor had a big story about a Pickwickian patient she had once that she found hard to forget and she shared quite a story with the class. Guess what kind of patient I had this week after my ARF patient when up to the ICU 15 minutes into shift? Yep, a very sweet P.W. patient with long lasting COPD and a health history that beats "Roots".

In any event, I had to pull a rabbit out of my hat this weekend when it came to nursing interventions for this woman. I absolutely fell in love with her. She had one of those big girl beds and I knew that for any kind of real nursing care, I was going in and under like 20,000 leagues under the sea..remember the arm story that Talitha told. We can do bowel management and that makes us good plumbers but really...the most important assessments are the spiritual and sexual assessments we do as nurses (I digress). Those of you who were present for April Fools Day lecture will understnad that line.

So, I decided to really take my time with her and just talk. She has a lot of neglect issues. I asked her the question (don't ask me why) "if she had one wish what would it be" and she said "I'd really like a hot guy with 6 pack abs and a tight ass to come in my room and talk to me"...

Missing my husband, I told her without missing a beat, that I could arrange this for her and asked DH if he would stop by Sunday night and see my patient. (not quite a 6 pack, but he is quite charming, very handsome and has his Zoolander moments.)

With flowers and a chocolate egg, he spent about 90 minutes with my patient, visiting with her, massaging her hands and talking to her about nutrition and friendship and her family.

I loaded her up all weekends with meds and assessments, but this by far was the best care I gave all semester. Trude doesn't think he's hot. But my patient fell asleep with a smile on her face.

This story is true. The opinions expressed do not necessarily reflect the opinions of my school or it's affiliates

Difficult day or Chicken Little?

2009-03-29T23:10:00.000-07:00

I headed back to Medical this weekend. I prepped on Friday on a patient recommended to me, who had a lot of care issues. After prepping for many hours, I decided I better watch procedure videos and pull out the E.P.P. chapters on management of a tracheostomy and PEG tube feedings because we've some theory on tracheostomy care, however, no real practice.

The PEG management seemed relatively easy once I had my routine settled on pulling back residuals, flushing the line and making sure that the valve was open for each administered medication and closed between. That wasn't an issue at all and I felt comfortable for the most part, doing my full head to toe assessments and dressing changes on the stoma in the GI and evaluating the trach site in the neck. I valued this experience because it was about as close as I was going to get to the ICU, without actually being there just yet. Since Critical Care is coming up, I jumped at the chance of learning some new skills. The first day went fairly well. My patient seemed comfortable. I was able to render full care, manage pain, complete all the charting, manage the nutritional aspects of the PEG line and spend valuable bedside time with my patient. After reporting off, the care nurse thanked me for all my help and I went home feeling like it was a decent shift.

Today was a different story though. I was ready for report and took some notes on hand-off about what a great job the care nurse did during the day shift. However, when I went in to assess her, her room looked like a disaster struck. She was down in the bed, the room was in disarray and nothing looked like the day before. I went over to arouse my patient and she immediately whispered to me that she had to go to the bathroom, and she was very uncomfortable. I repositioned her in bed so that she could sit on the bedpan and while she was voiding, I did my neuro assessment. She was A & O X3 and clearly stated something was wrong. After I did the toileting and assessed pedal pulses, femoral pulses and her back & abdominal assessment, I listened to her lungs and heart and noted the diminished lung sounds and long rhonchi and crackles...Her lungs were very congested and she had visible mucous in her mouth. I suctioned her several times and tried to get her comfortable, but she kept complaining that something wasn't right. When I went to give her meds, I told the care team that I did my assessment and thought respiratory therapy needed to be contacted and asked if we could call the pulmonary specialist too. I got that "But, it's Sunday..look." Ok, and what does that mean if we have an on-call physician or a back up hospitalist? Another blank stare that basically asked me if I was daft, without saying it outright.

They didn't seem too alarmed because she was still SPO2ing above 90, but I thought her breathing was labored. The other care nurse disagreed and didn't think she was in distress. I decided to stay in her room for the duration of the shift and it appeared she was getting worse. Nursing has a term called "snowing" a patient. This is to relax a patient who is experiencing anxiety. In some cases, it helps. I think in this case, while it was perfectly appropriate to help manage a patient's pain and anxiety with a tracheostomy, I was worried that something else was going wrong because she appeared to be breathing through her mouth and not her trach. All the secretions were coming into the mouth and should have been coming through the trach. I periodically mentioned that I thought she needed the trach assessed or removed and could we please call the on-call physician. The care nurse still didn't believe it was a problem and one told me to stop talking to her because she was transcribing orders and wanted to finish. She also happens to be an instructor at another school and I could tell she did not want to discuss the issue because it wasn't her patient. She also thought the patient wasn't in distress. I even asked her if I was overreacting. She thought I was and that I should accept that the drugs were doing their job and her saturations were acceptable.

Three or four times I asked two care nurses why we couldn't call the on-call pulmonary physician. I asked them to call RPT again and this time a therapist came up and agreed with what I was seeing, her sat were gradually going down even though we were titrating her O2 higher and higher. In this case, the R. Therapist could not even administer medications through the airway because it wasn't a patent airway. Bagging her failed as well. It appeared the trach was loose and blocking the airway. After being told several times to "stop being so intense" and this is not a problem, I was finally getting some answers. The RPT got her supervisor and we were able to open the stoma and see all this old gauze and secretions blocking the airway which we were able to clear, place the trach and cuff back in place and slightly inflate it to seal it a little better and she was back up to 99-100% SPO2 status after sitting at 88-90 on 65% oxygen. She had a blocked airway.

As I completed my charting, I saw that the last two shifts charted dressing changes on the trach site that clearly hadn't been done. I also saw that the PICC line was noted to be in the right arm when it was actually in the left. My charting always looks different in some way and I wonder if apathy at some point will kick in because I clearly am coming behind apathetic attention to detail and this isn't the first time. One oncology nurse took me aside last month and rechecked all my assessments because they were 'different' from the previous chart notes. She agreed with mine and signed below my name.

The care nurses tonight went behind closed doors to bag on me and one went to my instructor to say I was "too instense". The care nurse responsible for my patient told one of my classmates the same thing. The RPT went to my instructor and supported me in my assessment and said the patient had a risk for ARDS and coding without having a patent airway, and it was correct for me to want to get an order for the physician to reassess or remove the trach altogether. Since she is going to have a procedure in the AM everyone thought it could wait. I wasn't comfortable with it..neither was my patient. Difficult day or Chicken Little? Who cares? Another one of my classmates brought up a good point which actually made me feel a lot better about being such a pill tonight: If that was my mother, I'd be in the hallway naked screaming for someone to do SOMETHING! This is probably the first time since I started school, that I wondered if I wanted to work in an environment where your own colleagues refused to back you up.

I got in the car and felt close to tears but I knew I couldn't sleep tonight if I left the hospital with this patient snowed in with a closed/partially trapped airway. If that makes me Chicken Little, well then, the sky is falling...pick it up.

Going to the O.R.

2009-03-25T17:45:00.001-07:00

Fabulous day last Monday, donning the blue scrubs, hat, booties and donning gloves for my trip into OR 6 and OR 2 for several procedures, including a thorocotomy, total neck dissection and finally, a ventricularostomy. The circulating nurse manages the team and the charting while the patient is in the O.R. We would go and make sure that all the consents and forms were executed in the file, fetch the patient, reassure their family, take the patient to the operating room, transfer them to the OR table, insert their catheters, hook up their monitors, round up any last minute supplies, coordinate any final preferences from the surgeon, the anesthesiologist, tie up the gowns of the sterile crew (tech/doc/etc) and call for the final time out before the operation begins. As the procedure opens and closes, every little thing gets counted, down to the sponges, laps and needles...because the last thing you want to do when you staple someone shut, is leave something inside.

The patients were all women...ages 78 to 34. The last patient had Hep C and a ruptured brain aneurysm. As I peered into her skull, the surgeon said "OK Sam Adams (my nickname) how come I didn't use the bipolar on her?"....thinking of my best Trivial Pursuit answer (which would be France..by the way)...I tried to equate it's equivalent answer in medical terminology and answered, "ugh...doc, that would be due to increased risk of infection?" Ding Ding Ding...what did she win Bob? Nothing.

I was amazed and humbled at how fast, clean, and closed everyone looked after they had been sauteed, fileted and drilled.

Going to the O.R. was a blast. It would be fun to work as a circulating nurse or nurse anesthetist.

Clinical Week V - MCA II - Props to Trudy!

2009-03-22T01:45:00.000-07:00

Wow, how quickly 5 weeks comes and goes. We are officially second semester nursing students! Tonight, Trudy had a pancreatic patient that she did an awesome job with. She was able to insert her first NG tube & I was able to function in the capacity as her first assistant, which essentially means, I hold stuff, prop the patient's head forward and get him to sip water while she runs the line down to his stomach. The placement was so quick, the patient hardly gagged. It went smooth as silk. I was very impressed with Trudy. Gold star moment, red letter day. Yeah, I had to explain red letter to her. LOL!

Tonight was my night for sub-cutaneous (SQ) injections. Heparin and Insulin. I also learned the nuances of using a Lantus pen. The clown who invented the Lantus pen, is obviously not a nurse. It's one of the most difficult things to maneuver when you have to administer a SQ injection. The pen itself is too long and the distance between your fingers and thumb makes it difficult to manuever with one hand. You need someone to hold the patient's skin/tissue, while you work with this dial up pen/needle system. Hate it. Very glad to have the practice with the different syringes on real people, instead of lemons and oranges. No one hollered and one patient thanked me.

My patient this weekend is status post total abdominal hysterectomy. She is doing well and will probably go home tomorrow. I was able to work with my 84 year old patient that I had last weekend. He was talking up a storm and telling me about his big plans for going to the gym after discharge. He was the one that said thanks for the injection. After one week, I am fully convinced that Halidol should be outlawed for the elderly. What a cop out to give something so strong to someone so weak.

Another patient I worked with tonight was having a bad night and was calling out for his wife. It touches my heart to see the aging process, the ups and downs. One of the older gents on oncology was up on a chair, drinking a special cocktail I made for him with 7-up and apple juice and reading vogue magazine like it was the NY Times. He was another patient I could have adopted. Maybe, I am being called to geriatric nursing. It just feels so natural to me. On the other hand, I haven't had my ICU or peds/maternity rotations yet. I really like the older folks. Always have.

Trudy took our practice NG tube to post conference. After one of our classmates gathered all her stuff up for her and brought it to the front lobby, he remarked, "hey, here's your coffee...and your straw!" What a great shift.

Weekend III - Clinical MCA I Final

2009-03-22T00:11:00.000-07:00

Brief little ditty about last weekend: Busy day on MT for two days ~ but we had some personality difficulties that resulted in our self exile out of MT for the rest of the semester. Actually, I think our instructor had enough of some of the mean girl antics and once we transferred to Oncology, we heard that they had a reputation for that and that most people refused to float to that specific unit.

Big deal...who has time for that? I had some decent patient interventions for my post appendectomy patient. He was ready to be discharged anyway and was happy with the care he had for the two days I took care of him. The last day of clinical found me on Oncology working with 84 year old man who had acute renal failure and an altered level of consciousness. When I prepped on him, I decided that my goal for the single day I would be caring for him would include a discontinuation of his soft restraints, close observation and weaning him from the anti-psychotic medications he was getting since he was admitted to the ER, so that we could properly assess his LOC. What a difference a day makes. Taking the time as a student to really be with your patient makes all the difference in the world.

We were able to see vast improvements in his communication with his family, he was able to eat after we completed a swallow evaluation and I was actually sorry to lose the follow-up time with him. After a long weekend on two different units, I studied for the MCA I final exam, finished research on a group project and completed my write ups for my care plans for midterm evaluations.

We had two long days of lecture/theory and new assignments that need some tweaking for Healthy Aging. I've pretty much decided that anyone who decides to prescribe Ativan and Haloperidol to the elderly doesn't care too much, because all the drug research I did in the last week stated that they don't metabolize these drugs like their younger counterparts. My patient was also in renal failure, so it was even worse for him to receive these because his kidneys weren't working.

I saw the massive effects the combination of these drugs had on my Dad a couple years ago, and I saw it in one of my patients this weekend. Frankly, it makes me angry to think some physicians think this is perfectly ok (chemical restraints/physical restraints/tying people up) sometime, I'd like to stick these docs in poseys and give them a taste of their own medicine, ah but I digress.)

To be able to discontinue the restraints and these anti-psychotic drugs only reinforced my belief in this regard about the efficacy of protecting your patient, at all costs. I had a completely different patient once these awful things were D/C'd. He was slow to respond up front at first, but perfectly aware at a measurable point in time, and I was able to get him calm and comfortable. He slept for the first time in 30 hours. Believe it or not, I was able to reassess the 84 year old the following weekend (tonight) and will include the update on him in my next post tomorrow night. There is way more to report in this current week IV. Trudy & I get to work together this weekend. It should be fun!

Weekend II - Clinical - Surgery Floor - Difficult People

2009-03-12T15:26:00.000-07:00

Going from the medical side of nursing to the surgery side of nursing was interesting for me because I never differentiated much between the two, but they differ. Keep in mind that I am basing my opinions on two separate weekends of 14 hour days. AM staff is way more grouchy than PMs. Faulty conclusion. Maybe.

In order to give you a five week picture of what we are doing at the hospital I guess I should explain the weekend cycles.

The agency where I am rotating has several units that we are rotating through this cycle. 1) Medical Tower which is basically a step-down telemetry unit from the ICU. There are complex cases and some hospice. Next, 2) is Medical which is the melting pot for a plethora of health problems 3) Surgery, the floor they take you to after you've had it 4) Oncology, the floor where our friends with cancer are admitted, and finally 5) the O.R. where people actually have surgery. Our clinical group is rotating through all these areas. Week one, I started in the medical area, and last weekend I was on the surgery floor.

Surgery is different from medical because the patient populations there are diverse. I had no idea what to expect.

AM Day one, I went over to the nurses station to introduce myself. Huge mistake. The float nurse taking a new admission looked at me like I was piece of rotting meat underneath her shoe. I asked one of the regular, less threatening looking nurses if she could recommend a patient for me to prep on and she recommended the patient the floater was admitting. Of course and great! When people are being admitted, there is little, if any information about them available because the chart is literally being assembled during the admission process. The only thing I could gather from looking upside down at the Kardex the float was writing on, was that the new patient was a 74 year old female and she was being admitted for ORIF Tibia fracture (basically it is an open reduction internal fixation procedure with a scope and meniscus repair.) The float looked up at me and said, "I wouldn't prep on this patient. She's not going to like you because you are a student!" Well...well...well... thus begins my first challenge on the shift and it didn't come from the patient. 'Thanks for the advice, but I'm going to prep on her anyway." The float scowled at me walked away with the chart so I couldn't copy down any more information. Fun. At this point, I made a mental note (Note to self: "Don't bring the box of Truffles for the nursing station until AFTER report).

I walked down the hall, poked my head in the door, foamed in and saw a delightful 74 y/o woman sitting in bed with her knees up like Gidget and her husband sitting on the couch next to her. Humor always works for me so I just dove right in- "Hi, I'm student nurse...I'm going to be taking care of you tonight after your surgery...I can see you had a little trouble on the slopes recently!" Now keep in mind, no one could have prepared me for the response I got.

"Yeah, we were coming off the lift at Mammoth and the wind just kicked my legs out from underneath me...just a stroke of bad luck I guess." Gidget was skiing. Holy cow. I fell in love with her immediately. She was in better shape at her age than I was at 27. To say I was convicted to go back to the gym is an understatement. Her labs told the rest of her story. She was as healthy and fit as anyone 50 years younger than her. She just broke her leg skiing. After getting a good history, I went back to look up her three prophylactic drugs and I prepped.

Well, I knew I was in for a triple care plan weekend because when she got back from the O.R., she didn't even return with a foley. Now that's huzpah. She was discharged before I got in the next day for my AM coffee. I was able to do a few things for her before she went to sleep for the night, like change her and her bed and frequent vitals. She asked me all kinds of questions about my family and refused all her pain meds. "They make me sick" she said... In my mind I thought to myself, 'yeah, kinda like mean old float nurses.'

My second patient I met on AM Day two. Since Gidget went home before the cock crowed, I got dirt bike guy with the ruptured appendix and peritonitis. The charge nurse told me he wasn't going anywhere for the rest of the weekend so I decided to prep on him. He was just back from an early surgery to clean out his gut and he actually looked pretty good. I was able to meet his wife and kids and talk with him a bit before I prepped, so we established some rapport.

Day one with dirt bike man was relatively uneventful. The anesthetic was wearing off and he was walking around the hospital. Day two, the pain set in and I could barely get him out of bed. He went from no drugs to IV morphine. I did a head - toe on him and talked to his wife about limiting his activities. Peritonitis can be very serious. I didn't get to spike his bag because I can't do IVs yet, but I watched/monitored him & kept him comfortable, did his assessments and monitored his drains for signs of infection. I let him listen to his bowel sounds.

As I took primary care of Gidget and Dirt Bike Guy, I also took of the other patients my staff Rn was responsible for. I did the fingersticks and charting, ran a host of errands and completed patient teaching on several clients with family present. I had a little run-in with the staff CNA who didn't particularly care for student nurses. She wrestled the Dynamaps from us and took issue with me taking vitals on one of her patients who was decompensating. The CNA also had a penchant for recording respirations without actually assessing them, (which I took issue with). The only reason I know that she did this was because she did it while I was assessing dirt bike guy. My respiration count was 12. She wrote 20 on her clipboard. She also got mad at me for taking an axillary temp on a patient who was in acute distress with pneumonia. I noticed the patient had oral vitals all morning (she was stroke patient who had no control of her tongue). When I took her axillary temp it was 3 degrees higher than the oral probe. They weren't valid vitals.

The lesson from clinical this weekend on the surgery floor was learning how to deal with difficult people. Luckily my partner and I had two incredible staff RNs mentor us and show us procedural things and organizational techniques that were great learning tools. The nuances of nursing school are learning how to navigate the difficulties because the difficult people are always going to be difficult. They aren't necessarily always going to be the patient though.

Holding steady...a great place to be

2009-03-12T14:31:00.000-07:00

March 10 was two days ago and it occurred to that I am 9 months from pinning (which will be December 10 at the Crest Theater in Sacramento). Nursing school is kinda like being in a high risk pregnancy, except the labor lasts about 9 months. Some days/nights, I miss seeing the kids for entire days because they are already in bed by the time I get home. Some days I feel like an early Alheizmer's patient suffering from dehydration. Other days I feel like a meth addict spiked up on caffeine. But enough about clinical.

What do I do when I am not in clinical?

Now that things have ramped up quite a bit, I can't post to "training wheels" nearly as frequently as before. The clinical weekends are quite long- due to the prep and polish time for care-planning plus the pre & post conferencing we do with our group prior to and after we get off our assigned floors. Care planning keeps me up late but it is getting a little better (thanks for the tools Comrades X & Y)

We basically have (4) courses now.

MCA-I theory is like the prime rib of nursing theory. It's the foundation for everything we do, but we only get 3.5 hours per week of lecture on the material and that includes an NCLEX style exam. This is heavy only because the theory chapters are extensive. Week one included the nursing process, complete health assessment & physical, stress & pain management + comprehensive management of the respiratory system. Week 2 included a cargo ship on management of comprehensive cardiac disorders, reading EKGs and peripheral vascular/immunology problems. Week 3's menu featured an exam on fluid/electrolyte imbalances, arterial blood gases, hemotological disorders, wound care & the inflammatory process. This last week we are all about perioperative stuff (pre-op-post) including a comprehensive final exam on all of the above. We had a very nice guest lecturer from the med center (an OR nurse) come in and show us all her toys. I loved it.

Your main question probably is, how do you squeeze all that into 3.5 hours of lecture each week? Well you don't. You cram all the chapter key points into your head, memorize lab values and abnormals and all the classes of drugs that you used within those systems. You practice hundreds of NCLEX style questions within those body systems to get a feel for what to look for on the exam, and then you wing it, baby, wing it. Week 1 (77.5%), Week 2 (95.5%), Week 3 (80%)...so you can basically tell that I am a perfect bell curve for MCA I. I am learning to settle for C's and B's (especially with all the effort I am expending to stay above the water) and am grateful when the periodic 'A' shows up. (old faithful friend)

My second course is Health Assessment II: I am a little irritated with the amount of time we are investing in this course when we really need the MCA I time. I guess what I am looking for at this juncture is skills. The roadies already outlined the whole textbook and we are doing head-toe and focused assesssment on our hospital patients, so when I get lectures on learning theories and nutrition, I want to shriek because we already mastered these subjects prior to entering our accelerated program. I suppose that if I hear the word Piaget one more time, or if some instructor asks me how many kilocalories there are in ETOH, I am going to the nuthouse. We really need a certain level of skills training.

Clinical is my 3 days of darkness because the days start in the dark and end in the dark. I love it because it feels like nursing. The prep time makes the days run together though. This last weekend I prepped on (3) patients. I am doing accuchecks now and full assessments. More on that in the next post. The good news is that I can pass meds this weekend. The reasons are a conglomeration of love from family, friends and help from on high: 1) Comrade X plugged me into a web tutor, Trudy did some dimensional analysis with me 2) My parents prayed for me and I gave a shout out to St. Joe 3) and I figured out that mg and mcg are the difference between 1 and 1000 (rocket science I know). I am learning to weigh my patients in kilos and I know how to read medication labels. I went from abject failure to 100% on my medication exam - so thanks Mom & Dad & Comrade X -I book marked your website and gave props to God & St. Joseph since they helped out too. Thanks to all for the leg up.

We are one week out from finishing MCA I - our final exam is next Wed. We have case study projects too. I have to do nursing research on the subject of rhabdomyolysis and since I have had some experience with that, that's my piece of the presentation. In the midst of all the this, there are quizzes mashed in there somewhere, like pieces of garlic that bite you in the ass.

Did I mention that in addition to weekend clinicals, Health Assessment II and MCA I, I have a very interesting gerontology class called Healthy Aging? Trudy and I are doing face to face meetings with a couple in my neighborhood as part of our gerontology project. Considering I am 19 years from my own gerontology status upgrade, I don't feel too far from home. I actually love this course; kinda like dessert.

With 272 days, 9 hours and 38 minutes left, it is important to think positive, be positive and stay positive. So, as of March 12, 2009, we are holding steady and it is a great place to be.

First Clinical MCA I - it felt good

2009-03-04T19:48:00.000-08:00

I want to take this opportunity to say thanks to the roadie who posted this weekend about her clinical experience. AKA IMDOINGIT...I refer to her as (Bee) though because she's busy busy! It's nice to read someone else for a change.

This weekend was an exercise in the virtual unknown. As I reflect tonight on what some of my classmates experienced in other facilities, I am even more grateful for the opportunities I had this weekend at my hospital. One of my classmates was prepping on a patient who did not fare so well and coded. This would not be a good first clinical experience and I felt sorry for my classmate. Another friend of mine who is in another BSN program in town told us about being on a floor where a hospital employee coded and how upsetting that experience was for her. To say I had some fear going into this, is an understatement, but at the same time I was excited too.

Going into the first three-day clinical rotation was filled with anxiety, only because we had no idea what to expect, how we would be received, who our staff and charge RNs would be, and how our patients would receive "us".

The great relief for me going into this practical side of nursing school, was knowing somehow that my clinical instructor was going to be someone whom I respect and admire because of her willingness to be a good guide, a collaborator, and a nursing student advocate. That took away 50% of the stress up front.

Day one was a rather extensive orientation to the hospital. As we went to our assigned stations, three things occurred to me 1) Holy Cow, I get to take care of people & 2) Holy Cow, this is why I am sitting on my butt all day at school!! 3) Holy Cow, the things I do today are important and it feels kinda like nursing.

Three of us rounded the corner at Medical 4-5 and at the first stop, the RN at the station said she had a patient who was an 84 y.o who had an altered level of consciousness (dementia) and host of other problems and I offered to take her. After reviewing her chart, I stopped in to introduce myself and basically stared into the face of what could have been my Florida grandmother. We held hands for a bit and talked about the next few days and then I went home to prep. This involved looking up all the medical problems, all the drugs the person is taking (and the importance of the pharmacology behind the drugs - pharmokinetics) and then we evaluated all the labs in light of our patient's medical problems. After putting the puzzle pieces together, I put together a plan over the course of the weekend as to what I would do for this person as their nurse.

Without making too many assumptions a couple things occurred to me. This person was dehydrated, nutritionally deprived and lacking sufficient oxygenation. Since she was a no code, (basically if she were to decline for any reason, no extraordinary measures would be taken to save her life- like CPR, ventilation etc), there would be limits as to what interventions nursing and medicine would do, if she were to get critically ill. I decided that I would work up a plan that involved basics. Basic care like feeding, hydration, bathing, toileting, fluid/electrolyte homeostasis and ADL interactions. I thought back to my own parents and what I would want a nurse to do for them and I wrote out some goals. First and foremost, I wanted to get my patient out of bed. Second, I wanted to get her cleaned up - peri care, hair and (especially her mouth and dentures) and bathing. I also wanted to assess her skin and respiratory status since she was on 2L of O2 NC. All day long, I was planning on working fluids into our interactions (she required thickeners because she had swallow precautions) and getting her to think about eating (she was very anorexic). Since her diet was mechanical soft, I knew we had to work on getting her food flavored up a bit, because like it or not, ground-up-anything looks like dog crap and tastes like nothing at all.

When I arrived the following day, the family was there and we all talked. I wanted to include the patient in our conversations and involve her in some of the decisions about how the day would go. As we did this, I was able to start assessing her orientation and it didn't appear to me that she really had dementia. I think she actually had dysphagia , which definitely caused her to speak slowly, but she didn't appear as confused as her chart said she was. The night before she was in wrist restraints and these were removed when the family arrived. With the IV out and some of the more powerful drugs DC'd (discontinued), she seemed much more alert from the previous night.

We spent the day, focusing on sitting up in a chair, drinking and eating all her soft foods. I talked to her daughter and grand daughter about thinking about creative ways to get calories into her (like Jamba Juice) since this was a thick enough smoothie that she could eat with a spoon. She didn't have the sugar or fat restrictions that would preclude this, it would help her get her tastes buds stimulated a bit, because it was very apparent from looking at her intakes that she didn't like the texture or lack of flavor in her hospital "food." I also told them that they could also bring her soups she liked, provided they were thicker cream based (which would also up her calories a bit). The patient hadn't had a BM in a long time, so we got a stool softener into her and by the end of the shift the following day, she had two.

The "dementia" patient I had was AOX4 and talking up a storm with her nephew, discussing politics and asking me about that 7-up smoothie I made for her, wanting more. With 2000 mL of fluids - her urine turned clear and yellow and she perked up, making jokes about me being an old lady myself. She let me overhaul over dentures and I was able to to do a head to toe assessment on her.

After talking to the daughters some more about how simple little things can make a huge difference for their mother...I charted some noticeable changes on her chart (as her fluid balance was restored, her labs were improved from two days previous.)

I am not saying that this person doesn't have a long road ahead of them at the SNF (because she has some serious health probs) but I felt like her level of awareness was markedly improved by food, fluids, time, attention and TLC.

It felt like nursing and it felt good.

I Did It!

2009-03-02T21:56:00.000-08:00

Last week was wild. We had our first exam in Managing the Care of Adults I, had out Medical Math Exam and started clinicals! My partner and I were assigned to a orthopedic post operative/medical-surgical floor. I was a bit unsure of what to expect - okay, very sure of what to expect. We made nice with the charge nurse and unit assistant, our nurses, and the CNAs right away. That, and God's blessings, really helped us to have an awesome three shifts! WE WERE RUNNING! We both selected patients who were fairly stable. There was a lot going on with them, but they had devoted spouses by their sides, so needed us less than many of the other patients who did not have family with them. My partner and I helped care for about 12 patients each over the course of our three evenings. I love working PMs.
I was able to help cheer a near-centurian who was very lonely and very depressed. The charge nurse commented on how surprised she was at the patient's response to me...apparently the poor dear had earned the title of "crotchety" and perhaps rightly so. One of the beauties of being a student nurse is that you get to provide the extra attention the nurses don't always have time to give...the smile, the pillow fluff, the ever-filled cup of water, the fresh gown and sheets, the tucking in and wishes of sweet dreams at night. So many of us are simply lonely and need a little TLC. It really goes a long way. I was truely honored to care for these dear ones. I loved it. I helped toilet, turn, adjust, dress, scoot, etc. a lot of people. I was not surprised at bottoms or other private areas, but was discretely checking them for edema and redness. I was not appalled at swollen and gnarled legs, ankles, feet and toes, but was providing comfort and freedom from tangled tubes - ensuring that indentations went away. I did not pass out when my nurse changed a dear one's abdominal dressing, but watched with interest and awe and prayed the dear one could endure the pain...the dear one did. I faced my fear of hurting someone by assisting a nurse in lifting the leg of a dear one who just had radical surgery as the leg was placed in a CPM (a device which moves the leg in a painful bicycle motion to prevent freezing up of the joint)...the dear one groaned in pain and I lifted higher (eliciting further groaning) to enable healing. I was concerned and praying, but lifting all the while. I practiced patient teaching to yet another dear one who was embaressed by this "young girl" explaining the procedure and use of a handheld urinal. I earned the respect and affection of my nurses, the charge nurse, and the assistant manager on my floor.
So, so, so much more happened, but that is enough for tonight. Coronary revascularization awaits me and I must tend to much more reading if I am to get a good grade on this exam.

Student Nurse on the loose...

2009-02-27T20:26:00.000-08:00

T-Minus 18 hours and we are meeting in the lobby at our first 10 week rotation for medical surgical nursing I & II. Yes, I expect to look this ridiculous. Toodles and I drove over with Comrade X today and looked around. How fortunate are we that the Comrades have adopted us like papa birds pushing us out of the nest. My wings are barely flapping. I felt like an elephant at the ballet. We went to check out the lobby, cafeteria and med-surg floors. We checked out an empty room, located some of the safety equipment, called a code (just kidding...but the button is blue) and we touched something Comrade didn't want us to, so we got a wrist slap. We foamed in and out of the room and I cleaned up my first spill.

The campus is lovely. The best part about today was realizing that the Comrades have paved this road for us and we are traversing it with less bumps.

We have a four hour orientation at noon and our clinical faculty is going to ease us into our new roles as we begin to prep on our first patient for the weekend. Did I mentioned that I feel like a kid going to kindergarten?

I've been up late studying, trying to familiarize myself on reading and analyzing EKGs. Our second big exam is next week and I'd like to do a little better this time around. I have so many books, I have a rolling library at my fingertips.

In preparation for tomorrow, I went and visited my hairdresser, who butchered me up real nice for the hospital. She took one look at me and knew the stress we've been under. I could see how frown when she said, "Woman...people much dumber than you have done what you are doing, and you're smart, so stop it!" I looked over at Truddles and said, "Did you hear that?" She mumbled, "yeah." Well, in that case, I guess we'll just hum along then.

I didn't get the math score I need to pass meds, so I have to bone up over the weekend to retake that test. I know it had to with some conversion I missed on the dimensional analysis of converted volumes and weights...so back to the drawing board one more time. It's pretty embarrasing, considering that I thought I did OK on that test.

I am ironing my scrubs (LOL) and loading up my clinical prep sheets, stethescope and all my badges (there are so many) and hoping to get some sleep while my mind races tonight. I will look over my cardiac stuff for the exam and hope that tomorrow is everything I hope it will be...easy. May the spirit of Cherry Ames reside with us...what a dork.

I am a Phoenix...a 90.1% would be sweet

2009-02-25T21:36:00.000-08:00

We had our first MCA I exam which essentially slammed down any good feelings I had going into this week. I shouldn't complain because I passed the exam. However, I didn't score nearly as high as I wanted to. It seems like very little payback for the work that went into it (we are talking about 9 chapters of medical-surgical nursing with focus on respiratory structure & function/pathophysiology/treatment.) We had a day & half of lecture, the rest was self taught. I think I can speak for my class when I say that the most frustrating part of the process was the inability to decipher how the test would be administered to cover such a broad scope. To prepare for the NCLEX style of testing, I looked at about a 100+ potential NCLEX style test questions for the respiratory system + read the outlining we did in study group and the pathophysiology review we spent hours on. I spent every hour outside class on this. It was an exercise in futility when it came to the exam. I shouldn't complain ~ they keep telling us that if you are passing the exams, you are doing well. Wished I could have slayed it.

Projects...presentations..two more courses...advil...motrin...coffee...fluoroscent lights. Did you know that chronic levels of fluorescent lighting can cause hypovolemia & eventually hypoexmia (this is the environment we live in...) I'd be willing to blame anything at this point.

We had a 4 hour lecture today with a 4 minute bathroom break. I remember eating a small pasta salad outside in the cold because I had to get out of the building to escape the lung damage.

The strategy going into this was putting on a nursing "thinking" cap, eliminating choices that were obviously wrong and then weighing what were potentially two fair correct answers. If you over thought it or psychoanalyzed it too much, you probably guessed wrong. In my case I switched three answers that were correct (which is really a personal trademark of mine) and probably accounts for most of my GRE guffaws.

This is a whole new beast. I am getting clammy...and the synapses are misfiring. We are reading EKGs and all I am remembering today is "snow over tree", "smoke over fire" and how much I love chocolate being close to my heart. (this is a mneumonic for where to place your leads.) I know serum potassium level norms...but angiotensin II seems so far away. I could use a pedicure. I really could use a tune up on my hair. I wonder if the kids have done the laundry that is piling into next year.

Saturday is first rotation for my group. Classmates who started last weekend talked about their patients today without violating any HIPPA rules. I was impressed with how respectful they are when referencing their patients.

The biggest laugh I had this week was seeing Mr. Johnson on a powerpoint presentation. Old Faithful friend. Can't wait to bring your Jamba juice and benedryl. I miss you.

Speaking of beasts, my calculator and I took a medical math test today on which I had to obtain a 90%. I am waiting to click onto blackboard to see the score. I am sure that on this first day of Lent, Ash Wednesday, I could use a Phoenix. A 90.1% would be sweet. My luck tells me it'll be something closer to an 89%

MCA I, Dose calculations & Clinical clarity....yahoo!

2009-02-21T21:49:00.000-08:00

I love my MCA I instructor. She is a graduate of my school, is working as a CRNA (is a nurse anesthetist) and is very organized! I think I am getting clarity. We had an intensive skills day last week and surprisingly everything clicked. With the a little practice, I think I have my dose calculation formulas down pat and it's hopeful that the exam for that on Tuesday will go swimmingly. We have to have a 90% pass rate, so I have to be very careful not to make any careless mistakes.

Speaking of med-surg, we met our clinical faculty for SR Hospital last Thursday and I am so happy! We have a great group of classmates, plus an experienced teacher and nurse. I remember trying to take her dose calculation last summer, but having to drop it because of an accelerated statistics course I was taking. Now, instead of having her as an online instructor, I get to work with her three days per week at the hospital.

We have managed to divvy up the work for the next couple of weeks on the theory side, so hopefully when it comes time to do careplans and patho maps, we won't feel so stressed out.

I have no idea what to expect with this first MCA I exam on Wednesday, as I understand the questions are written NCLEX style, which means at least 2-3 of the answers will sound good, but they aren't the right answer...So I will have to bone up on my test taking skills by reviewing the NCLEX book in addition to the numerous chapters we've outlined since last week. We've had MCA I for one week, and have already covered 1/3 of the textbook! It's amazing...the lightning fast paced we are operating at and the amount of retention that is taking place.

I am thinking about switching from caffeine to "Go Girl" drinks. Yahoo!

Do the math

2009-02-17T22:20:00.000-08:00

Medical Care of the Adult I started today. We have an instructor who graduated twice from our school who is also a registered nurse anesthetist. Five weeks and another final exam. Another 5 weeks and another final exam. I lost a cartridge of ink printing the summaries we outlined over the weekend. Okay. We are on day 1. There were about 40 chapters somewhere in there. I can't read what I printed. Where are my bifocals?

Today our ND gave us our clinical prep sheets, patient and self assessments and told us to bone up on our math (dose calculations/conversions). I broke out into a sweat and thought for one second that it might be menopause (then I popped back into reality)...the panic has begun. Hot flashes are for home. Diaphoresis is for school. So is sacral tenderness, and borborygmi.

So essentially it breaks out a little something like this: try and follow me now:

Wake up at dawn
Do I wear white or do I wear street?
My bags are packed and ready to go (la la la - sing it might help)
Meet the roadies at carpool/caffeine junction. Swallow caffeine fast. Carpool lane.
Go to lecture/theory...sit for 4 hours..take notes (oops, course not loaded on blackboard yet?...take really good notes) Listen with rapt attention to a lot of important stuff that might save someone's life someday.
Go to the bathroom fast - eat something quick - burp. My stomach hurts. Sacrum is tender, but no sign of a pressure ulcer. Do you have a motrin?
Sit in Lecture for another 4 hours (take really good notes again - when will that be posted?) Tinel's sign positive. Is that carpal tunnel..is that nagging pain my thigh a DVT?

Boss comes in to give us a pep talk. We listen like little puppies to how we will be evaluated for every rotation. I feel no pain. Synapses are firing now.

We must get a S (satisfactory) to survive (70% or higher on exams)and we must complete all these forms in pencil. We must prepare for exams and care plans. We must sleep, (sucker). Read in reverse. Do the math. It amounts to a nap at 4 AM.

Clinical tips:
We must prep every patient night before. If patient gets better, we must prep again for a patient not getting better. If that patient gets better, we must prep again until we have a packet of paper with all kinds of information, drawings and sketches (AKA patho/concept maps) to turn in to our teacher who will either give us
a) a S (this would be good)
b) a MS (this is not good, but acceptable if you have a plan to improve or change)
c) a U (this would be a disaster)and would cost a lot of $$$$$$, mental instability and probably crying. Perhaps it would cause one to take medication. Maybe not, but at least we have Mosby's.

When going to clinical, we should take everything with us, but not take it really. We should leave it in our car, which will be parked at least two football fields away so that if we need it, it will require us to exert a copious amount of Carbon dioxide to retrieve it.

We should report to our charge RN on prep night and ask that important person (who thinks we are ridiculous in our large white uniforms, to help us pick a good patient for our rotations. If that person likes us, I think we would get a patient who might stay longer than 12 hours. If not, go back to Clinical tips above and do not pass go or collect $200, because you have to start all over again. This might require staying up until 4 AM after the PM shift because "under no circumstances are you to report to the next shift without a care plan for a patient - you will be sent home" This is where most us start to feel the effects of diaphoresis. I am fanning myself as I write it. I am faint. I should go to bed now.

Okay. This little thing goes on for three (8 hour shifts) in a row. If you count the prep, it's (4) 8 hour shifts in row, this does not count as theory..this is clinical only because there are 40 chapters somewhere to read too - because you want to get that S...remember? I think somewhere in there, I've signed up for about 450 care plans and maybe a couple dozen papers. I heard that somewhere in this are games, powerpoints and meaningful group interactions; perhaps a project on a big piece of cardboard. Group projects:concentration camps, what do you think? Do the math. Food factors in here somewhere. Trudy fed me a stick of gum - because no one wants halitosis.

In the event, that the staff RN hates you, see your clinical instructor who will most likely give you a MS on your interpersonal skills, which if you look at b) above is really your only option. I think if you do the math, you'll see where this is leading.

You are a smart girl and I know how to deal with smart girls...

2009-02-13T21:22:00.000-08:00

You're a smart girl and I know how to deal with smart girls.

James Cagney..in Mister Roberts..was referring to a boy..but in nursing school, for some reason, the trouble makers are all women. Women, who don't like women. Women who want to appear to take down other women, spank down women or just don't plain like women. Modus Operandi tactics primarily being humiliation, ridicule and gossiping.

This can be the case with over zealous TAs, teachers and students. It's ugly on you and a waste of time. That's all I'm gonna say about it.

Full of surprises....N-125

2009-02-12T10:09:00.000-08:00

We had final examinations this week, plus a visit to the skilled nursing facility, where were assigned a real patient for a full health assessment. Two surprises occurred in the process of cramming final papers, quizzes and examinations into this week.

We completed a entire textbook, study guide and chapter reviews/NCLEX style questions for this course. We completed a comprehensive skills labs. We prepared a 90 page study guide for Health Assessment and shared it with the class. We practiced our full body assessments on ourselves and our SNF patient. The papers we wrote for ethics and health assessment were extensive and mentally challenging. I was expecting the worst going into the final exam because of two factors:

1) we had a 90 page study guide
2) I had a rather embarrassing lab day the day...being first to go with Sim Bob was frustrating..as I failed to verbalize what I did prior to coming into the exam room...i.e. review his chart etc.

So, with all the anxiety looking over everything we did to prepare for the final exam, we all crammed again all morning...we paired our study guide down to 21 pages. We crammed in the car all the way to school. I prayed to every single one of my patron saints and thanked God for my parents who pray for me everyday to do well in school...and then I grabbed my pencil and placed my binder under the table. Taking three deep breaths, I let go of the stress.

As our professor passed out the exam, she instructed us to put our last name first and our first name last. Our instructor looked at us and said, I looked at the study guide you all prepared and figured out that you already knew everything. Here is your final exam. I turned over the exam and there were 6 simple questions.

The last question on the exam was "What is the most important thing you learned about health assessment in this class? My answer: Health Assessment is the foundation for the entire nursing process and dictates the success of each phase of it. In addition, the teacher of this course is full of surprises.

Comrades X & Y RN, BSN

2009-02-05T18:50:00.000-08:00

The Comrades-at-arms of SMC '08 ABSN were distinguishable at their pinning ceremony, not because of their physical height and distinguished good looks, but by the sheer tenacity of their perseverance and accomplishments. Both are entering final careers later in life as male nurses. Both had extraordinary journeys in the 12 month program overcoming obstacles that took them away from their support systems (primarily their wives and families) and they were completely humble and unassuming about what they had accomplished. Within three days of each other, they both passed their licensing boards and are now officially registered nurses with the Board of Registered Nursing. I have learned a lot about what it means to mentor others by watching how X has mentored me into this process. He is the jewel swimming in a sea of sharks. I wouldn't have taken the step to do something this intense, had he not tread the path before me. We were always told the truth about what the program entailed, the demands of it and how it would effect us. We are more patient about the setbacks of being in an accelerated program because we were prepared by those who had suffered through it.

To say they have nursed us through this process is an understatement. Both have willingly given of their time, talents and treasure to help us transition from part-time students to full-time accelerated nursing students. It is easy for me to write about these two guys because they are patently real with people, truly genuine and humble, and will be such an asset to the profession of nursing.

I was thinking about how much my own husband impresses me with his abilities to nurture his students for the last 23 years and what it means to be a male elementary school teacher in a profession primarily dominated by females; and it occurred to me that there are so many men impacting the nursing profession in much the same way. What a refreshing new dynamic. My son, who is fascinated by science and how the human body functions may live in a world of medicine in 20 years where half of the profession is occupied by men. It wouldn't surprise me if this would be a fulfillment of Florence Nightingale's vision for healthcare when she wrote of the men who supported her by sitting side by side on her sofa rendering her support in writing regulations and shaping the social policy of her day. " You say women are more sympathetic than men...I would say they have none!" Obviously she had strong disagreements with the females in her life who saw her work as inconsequential. No doctrine she embraced was embraced by women; they were embraced by men of power who saw her work on the dying fields during the Crimean War as changing the way society viewed efficiency within the military, not to mention her impact on health within the family unit. She shaped society from the smallest unit to the largest. Her views simple, but carved within her soul was the conviction that empathy and excellence is born out unselfishness, humility and hard work

In our class, we have (6) men from various backgrounds. Two of those men have wives who are already nurses. Everything is about balance...and it delights me to think that men are re-shaping the face of the nursing profession for the better.

When the boards were looming over their heads, the Comrades hunkered down, took the Kaplan prep course for the NCLEX and went into attack mode. This journey into the nursing profession is one of the most difficult things any of us have ever done. It requires an enormous amount of sacrifice from our families and takes an emotional toll on the student who wants to enter nursing.

Having good mentors along the way makes all the difference.

The Roadies have successsfully completed month 1, Term 1 and we will be taking final exams next Thursday and Friday. We are all working toward collaborating to help everyone else in the class who is taking this journey with us because as John Donne once penned "no man is an island..." But if I needed a nurse on a desert island, I would hope that Comrades X & Y are on shift ~ I think Flo would be proud of you both.

Congratulations to Robert W. Nutter, RN BSN & Ryan Kapty, RN BSN
You are official.

It's Pat!!

2009-01-28T18:25:00.000-08:00

I've known a few Pat(s) in my life. My father in law & brother in law, my next door neighbor's mom (when I was growing up), and my favorite professor who was my medical terminology instructor at CRC are all "Pats". The television series, Saturday Night Live poked fun at the unisex nature of Pat & the confusion over whether Patricia is really a Patrick and vis versa. Today in lab, we had sim-Pat. Our procedure was to intubate him with a nasogastric tube for suctions, feedings/medication administrations etc.

The roadies had watched the video over the weekend and were anxious to see how we'd do in the simulation of it. Essentially you have a patient in bed (sitting up) in what is called a high Fowler's position. Pat was conscious (as much as a dummy can be) and part of it was working through the approach to prepping for the procedure, explaining it to the patient and gaining their trust and cooperation, "Ok, Pat, I'm student nurse. I'm going to stick this long piece of hose up your nose & down your throat...which will pass along your oropharynx and into your esophagus where it will enter into either your stomach or your lungs. I am going to shoot for the stomach - but I want you to hold up your index finger, if something doesn't seem too right, you just let me know..but...first thing's first, I am going to make this tube nice and slippery, ask you to tilt your head back and when it hits the back of your throat and you feel the gag reflex, I'm going to have you tilt your head forward chin down, while sipping this water, which will help the tube slide down the back of your throat and into your stomach."

Piece of cake. Right.

Once the tube is in the stomach, the nurse then verifies that the tube is in the right place. The process involves pushing an air bolus through a syringe into the tubing while auscultating (using the stethoscope) the stomach to see if you hear a swoosh. After that, the nurse aspirates gastric juice to assess it visually and either re-injects it and/or tests the gastric fluid's pH. If that doesn't satisfy the nurse's assurance of the tubing arriving at ground zero, then radiology will bring up a port and confirm placement with an x-ray. Whew. I'm feeling a little sweaty.

After securing the line, everything is charted. Rechecking placement occurs often & according to suction, feeding and/or medication schedules.

The class was so focused on Sim Pat's throat, we didn't know he was a she until we went to ausculate 'his stomach...that's when the big reveal occurred. Whoops. Hello Patricia.

Just when you think you've seen everything

2009-01-24T16:59:00.000-08:00

The way the roadies are coping with the workload is dividing and conquering the reading through outlining and presenting. This is helpful when approaching quizzes because its easier for me to remember that Pebbles talked about Integumentary, and Bam-Bam's chapter was on the heart.

My chapter this week was about the breasts. When I think about breasts, I tend to focus on BSEs (breast self-examinations) and the methods we use to evaluate them. The common methods noted in the text are the Circular, Vertical and pie methods; the medical standards for assessing breasts. However, in outlining the chapter today I came upon a phenomenon I had no idea existed and one that nursing protocols insist we assess - that of multiple nipples...or supernumerary nipples. Not only can you have them on your chest in different places, but they can even grow on the bottom of your foot! Whoa. Just when you think you've seen everything...

Palpating the peeps

2009-01-21T19:47:00.001-08:00

Having TAs for labs from the ELMSNs program has been great. They have one year on us, having been in the clinical setting for several months now. They are prepping for the last of their pre-licensure work, so their tips for doing things are fresh and insightful. It gives them opportunities to teach and mentor and gives us the perspectives we are craving, facing the uncertain days ahead in clinical. The Roadies were discussing how confident the ELMSNs students are now that they have been student nurses for one year. They reassure us by saying we will be the same way too, and sooner than we think.

For instance, a good example of this was during our health assessment lab today. We all had to practice and demonstrate head-waist assessments, verbalizing our thought processes, using the appropriate medical terminology and techniques, while modeling how one comes to certain conclusions on what they are feeling or seeing. I liked this exercise because it allowed us to not only make objective observations (mostly we were observing a lot of "normal" things), but we were also learning about how assessment is so important to the nursing process. We keep talking about how early intervention saves lives, and assessment is a big piece of this. Thinking critically about how someone looks as their status is changing, avoiding a full crash by recognizing signs and symptoms of "going south" and how things look, feel and sound abnormal.

Perhaps the most compelling thing I discovered this week in the reading was how one important assessment tool could have been utilized on my Dad pre-op in 2005, which might have prevented his surgical complications. There is a technique of assessing the ankle-brachial indexes for a high risk patient that helps spot signs of peripheral vascular disease..by taking specific blood pressures and using dopplers at the posterior tibialis and dorsalis pedis pulse points. The test is also helpful in diabetics who present with vascular calcifications. These assessments show whether someone might have problems perfusing O2 or if they exhibit signs of PAD. I can't help but wonder if some of these specific assessment tests had been done on my Dad pre-op, would it have been a good indicator for the use of Lovanox during his AAA repair...but hindsight is 20/20. The only reason I make this comparison about the use of mild amounts of anticoagulants during surgery, was due to the fact that it worked so well a couple months ago and he had such an excellent post op course.

Personally as a patient, I've never had the kind of physical assessment that we are doing on each other in nursing school. This leads me to believe that at some point, people cut corners, recognize obvious things only, and fail to see what may be hidden most of the time. Another student made the comment that she has caught things on rounds that staff RNs have not, only because of the prep she has done at school. Let's face it, students are more eager to do well, spend more time with their patients and are open to learning. At what point does the apathy set in and what should the nurse do who is burned out? I guess each person has to answer that for themselves. I know we are going to run into the super nurses, the ones who like students and want to teach them the right way to do things. I also know that there are going to be difficult people, like anywhere else, who would rather see anyone-except a student on their units. I guess the best approach is the diplomatic approach and when someone wants you out of the way, "step aside". In the meantime, Ms. Pebbles..appears alert, oriented X3 and resting.

We found some nice polyps, enlarged taste buds and a deviated septum today. It was interesting to discover that crepitus can be felt in/around the thyroid gland. The work we are doing on each other is giving us a good idea of what abnormal will look like once we get into the Skilled nursing facility and on our clinical rotations at the different agencies (that's ANA-speak for hospitals).

The feedback from our TA was very helpful today...and palpating the peeps never felt so good. (in a purely professional sense...you know what I mean)

The final analysis...anyway

2009-01-18T22:11:00.000-08:00

People are often unreasonable, irrational, and self-centered. Forgive them anyway.

If you are kind, people may accuse you of selfish, ulterior motives. Be kind anyway.

If you are successful, you will win some unfaithful friends and some genuine enemies. Succeed anyway.

If you are honest and sincere people may deceive you. Be honest and sincere anyway.

What you spend years creating, others could destroy overnight. Create anyway.

If you find serenity and happiness, some may be jealous. Be happy anyway.

The good you do today, will often be forgotten. Do good anyway.

Give the best you have, and it will never be enough. Give your best anyway.

In the final analysis, it is between you and God. It was never between you and them anyway.

-this version is credited to Mother Teresa

____________________________

2. The Original Version:

The Paradoxical Commandments

by Dr. Kent M. Keith

People are illogical, unreasonable, and self-centered.
Love them anyway.
If you do good, people will accuse you of selfish ulterior motives.
Do good anyway.
If you are successful, you win false friends and true enemies.
Succeed anyway.
The good you do today will be forgotten tomorrow.
Do good anyway.
Honesty and frankness make you vulnerable.
Be honest and frank anyway.
The biggest men and women with the biggest ideas can be shot down by the smallest men and women with the smallest minds.
Think big anyway.
People favor underdogs but follow only top dogs.
Fight for a few underdogs anyway.
What you spend years building may be destroyed overnight.
Build anyway.
People really need help but may attack you if you do help them.
Help people anyway.
Give the world the best you have and you'll get kicked in the teeth.
Give the world the best you have anyway.

Cry baby

2009-01-17T14:31:00.001-08:00

I hit a wall this afternoon and wondered what the heck I'm doing. I feel like I'm totally in this washing machine that I can't get out of. I stayed up late studying..watching skills video that made me laugh. (Demonstrations on how to brush and comb someone's hair and clean their dentures) It felt insane to watch a step by step procedure that any monkey can do (i.e. "use careful brush strokes first horizontally and then vertically, spritzing and arranging....) Like an episode of Twilight Zone where I landed on a planet where no one knew how to brush their teeth or comb their hair and the only person who could was Nurse Betty who was holding classes at the Y for $59.99 on how to brush your dentures. In the video, Nurse Betty was providing oral care to her comatose patient. It was all so Marcus Welby. I thought to myself, I don't remember once...not once, that a nurse did this for my Dad during his 3 month stay in the hospital, not even while he was in the ICU. In fact, the first thing he did when he "came out of it" was sit up in bed and brush his own teeth. I remember writing a column about what a freaking miracle it was to see my Dad escape from the the throes of death and brush his chops; Monday - he gets last rites...by Friday, he is brushing his teeth. As we sat around crying with relief at the sight of him brushing his teeth, his nurses stood around looking at us like we were crazy. Were we the only ones who knew a miracle when we saw it?

My aunt (who is more like a sister to me) called last night and wanted my advice about Grandpa, who is dying in the hospital ....I shut down. I was outlining chapter 15 in Health Assessment about the peripheral vascular system and all these memories flooded back about Dad and those long days in the hospital...like PTSD and overwhelmed me. Can I do this again? Will I be a good nurse? Or is this a big act and someone will walk up to me and say, "you can't do this...you won't do this...or we don't do things like that anymore - we just CYA on the medical charts"

Sometimes, I wonder if I have just gone down a rabbit hole that I don't belong in. The really hard part of being a nursing student in an accelerated program, is that so much is last minute - repetitive or too much and the difficult days of school haven't even started yet. I want to be nurse. I don't want to write a paper APA style. APA? I thought I left all that behind in 1985. We had a three hour lecture on APA. I want to do what most nurses don't have the time or patience to do...take care of sick people. Wash their hair, brush their damn dentures and teeth (even when they are in coma), give them good ADL care, even help them manage their toileting (something no one wanted to do for my Dad). Tell me now, if I won't have time to do that. Tell me my patient will be my patient and not the chart. I don't want to work with people who don't want to be there, who resent sick people and their families, who hate their colleagues who do care about the little things like pain mangement, and comfort care. I already did the medical - legal thing. I don't want to be a claims person again. I took a quiz on the law and almost feel asleep. I know this stuff is important. I know you aren't supposed to slap your patient, restrain him against his will or talk about him to other people. I only got an 80% on that stupid computer quiz that took over one hour. How does this validate what kind of nurse I will be? I want to take care of sick people. What a cry baby.

Seven habits of highly effective nurses

2009-01-15T21:52:00.000-08:00

.......who do we want to be when all is said and done?

1. Proactive
2. Thinking ahead about the last thing - Seeing the big picture - the finish line
3. Thinking about the first thing - Understanding why you are doing something
4. ~ Collaborating ~ Seeking out the Success of Others ~ Team Building
5. Exhorting/Encouraging ~ our clients and our colleagues
6. Mentoring and Educating ~ those behind us and those in front of us
7. Reforming ourselves and our profession

Good luck to all the Kaiser scholar candidates as you interview tomorrow. All shall be well!

Shut your boca...and when to speak up

2009-01-14T18:57:00.000-08:00

Something struck a chord with me today probably because I am an older person. I guess nothing you do in school can prepare for the circumstantial things that will stay with you in clinical. For instance we were in lab doing assessments (this is the practical applications of nursing without real patients~but scenarios and role playing ...I think that's probably why I was such an intuitive claims person and fraud investigator, I loved putting the puzzles together and I played with a lot of barbies when I was young, so there was hours of role playing. Today, we did vitals again and also pain and skin assessments. Hospital Barbie (I thank you) and all those little old people at PVCH who put up with me when I was a CNA kid.

When you are in pretend situations, story telling comes out of real life experience and so we get to hear a lot of war stories from more experienced student nurses and instructors. I like the war stories because they bring the theory down to tangible learning...I call that my 'note to self' moments...for instance, so-so told me she did this...don't do that! Or so-so told me about a great thing she or he did, I am going to file that away for future reference - remember to do that! That's the primary reason mentors and preceptors are so important when it comes to the healthcare professions.

The war story I heard today reminded me of the days I spent in the hospital with my Dad and daughter. I learned more from seeing how good nursing affects outcomes and how bad nursing makes the situation worse. One of the stories we heard today was a nursing student who was doing a dressing change on a patient that was a terminal patient who had all kinds of multi-system complications, including lesions, organ failure and intractable, excruciating pain. The student didn't want to change dressings without providing pain relief prior to starting procedure (essentially wanting the patient medicated 30 mins before) and the supervising RN working with the patient said no. No reason, no explanation..just no with a cursory intonation "don't ask me why, it's none of your business...get to work"

How to handle the difficult people...the politics of students/nurses/faculty and then the ethical issues that come along with what one perceives to be their primary responsibility (the patient)..why these should be in conflict is a mystery to me when you consider that the new wave of healthcare is supposed to be collaboration and team building. Are we that much of a threat to someone's ego, that patient care gets compromised? Is it politically incorrect for me to even think that this is some sort of travesty. Am I an idealist student nurse who will soon be a burn-out? Doesn't it seem reasonable to think that with a little prioritizing and planning that we will have time to provide pain relief prior to dressing changes or will we stop caring about these minor little details. It seems to me that the nurse who had this patient, had little time to either pay attention to the student nurse, the patient or what is the best practice. Does this happen to everyone at some point? These are all hypothetical questions that our whole group talked about today.

We talked about whether it would be a good idea to speak up, because after all, we are supposed to be advocates. Who knows when to shut your boca and when to speak up. I've always spoken my mind (not in a harsh manner, but asking questions in a probing way that seeks to clarify a purpose - we are supposed to do this as students and patient advocates). When to speak up...? I guess I'll find out for myself as time goes on, whether I will have to shut my boca or speak up. In effect, we need to challenge ourselves to ask questions in a manner that is non-threatening or in a way that seeks to clarify a procedure or the best way to do it. Right now, I think diplomacy goes a long way, whether you are a patient's family member, a friend, a colleague or a merely a student nurse. I pray I have the patience to listen when it's my turn, be patient in the process and grateful that someone else has provided input. It could mean so much to a client, having the courage to speak up in a diplomatic way without calling someone's expertise into question.

Breadth, Depth and Diversity

2009-01-12T17:42:00.000-08:00

Incorporating some planning and paranoia can sometimes be a good plan of action in an accelerated program, as was evidenced today in theory. We read and outlined all the reading for this week ahead of time and in doing so, it seemed that theory wasn't as abstract as it could have been. The roadies have pro-actively sought to eliminate as much stress as is foreseeable by dividing and conquering most of the reading. I know that the pace is slower now than it will be in about 2 months, I can't even anticipate what this diary will look like and in a nutshell, I hope I can come up with some creative acronyms for expletives.

I felt better today due to several factors. A former ABSN new grad, who has yet to take the NCLEX, showed up on campus today with a smile on her face and spring in her step, due to having several interviews lined up and one job offer. She was picking up study materials for the exam and ended up coming in to our N125 lecture to say hello. That 10 minutes of questions/answers was worth the brief interruption, as she was now out of the program and shared honestly her experience of being outside the SMC experience (much like what Comrade X has provided to us in the latter days of the program and continuing to the present day~ THANK YOU). Making the decision to do this program entailed overcoming the hurdle that the financial investment represented. How can I justify spending this amount of money and what return can I expect on this investment? Week 2 has begun and we've already covered approximately a little less than one-third of the material in Term 1. Wow.

We did something a little different today. We took our breaks. Getting outside the building and walking around outside in the sunshine helped break up the day a little, as the days are long and arduous sitting for lectures.

Everyone is getting to know one another better. I feel like I'm sitting amongst the best and brightest minds and encouraged by the breadth and depth of the people in our class. Our instructors are as a diverse as our classmates. Prior to nursing school, (in pre-reqs), there was a good percentage of people in class who either never showed up, did any work, or studied. They ended up dropping when it came time to take exams, or they failed. I can't see anywhere in our class where slacking or being a slacker is an option. This class also feels like a safe place to be yourself. One of the most comforting comments a teacher made today was that we were not competing against one another, the class is not graded on a curve and that working together would be to our advantage. It's the way I've always operated. Seeking out how to help others; moreover, helping them seek out their own success is what good nurses do for their clients.

My adviser happens to be my ethics teacher. We had a discussion today after class about end of life issues. It's funny to contemplate that so much of what we do in nursing involves evaluating professional values, economics and our own personally held beliefs; and that not everything acts in concert 100% of the time. It's a matter of being a nurse who has the courage to have breadth, depth and diversity in thinking as well as compassion.

The "F" Word - Flexible

2009-01-09T00:23:00.000-08:00

"BE FLEXIBLE!"...the mantra to attend nursing school with and skidding into the last day of the first week, I am astounded at the tenacity of the roadies to persevere in optimism. I am afraid of the potential we all have to succumb to fatigue, pressure and the ever looming prospect of getting by, however, we are all learning the fine art of flexibility. This is the first fruit of patience and understanding and maybe even fortitude. It looks like it hurts a little (don't you think?)

We were able to talk about this briefly yesterday with our managing director, who is refreshingly real as an Academic. She assured us that while it would be really nice to achieve the A's we were accustomed to receiving in our prior coursework, don't expect the same results in nursing (as it is it's own special beast). She also said we'd burn out fast and furious (this should be noted for future reference- note to self: "Avoid the pitfalls of burn-out, do you really want to be angry & bitter?" No it makes strange bedfellows with resentment and depression. Best coping mechanism...organization and communication (even when you've made a mistake). Also, trying your best is sometimes good enough, even when you've studied all night and missed points anyway. Learning is an imperfect, dynamic and constant process. Go with it.

Professionally speaking, the word collaboration has come up more than once this week. As a student nurse, I am grateful to see that while my instructors encourage flexibility for us as we cope with the challenges of an accelerated program, I also have seen concrete examples this week of how they mirrored by example when we've asked it from them. That's an F word, I can live with.

First Day...Community Orientation...let the games begin!

2009-01-05T21:59:00.000-08:00

First day of school was relatively relaxing and not stressful. We (the ABSN class) found out that we had a mountain of reading to do for Wednesday and that our lab for tomorrow was canceled, which gives us an extra time to tackle the reading; so that was actually not a bad deal in the end. Being sick the first day of school was a drag. I bought this really nice thermos for hot tea and it was so effective I couldn't sip on the tea for several hours because it was too HOT! LOL.

The other assignments included along with the reading, are to review DVD demonstrations of the psychomotor skills we need to get checked off on...for clincial health assessment. Essentially, they want us to be able to take a radial pulse, BP, temperature, demonstrate medical asepsis (handwashing technique) PPE equipment applications, and assess respiration. This is our prep for the Wednesday lab. The skills will get progressively more technical and there are about 7 pages of skills to be signed off on throughout the year. We have a student binders for these and apparently these also are to be used as our calling cards to our facility and clinical instructors, as they also have biographical pages included that basically give a profile of us to our teachers, along with our skill levels. So anyone who works with you can ask for your binder and read "Hello, my name is student nurse...and I know how to wash my hands!" Actually, with so many students, this is a pretty good thing to have on hand.

We have a brief lab rotation through a SNF (skilled nursing facility) next week to practice our assessment and people skills before med-surg rotations start in a few weeks. We have Comrade and his classmates to thank for that! It's obvious their suggestions on program improvement were taken and implemented! So all thanks and gratitude to the persevering Comrades!

We had a community orientation today. This is a mandatory requirement for all nursing students in the Central Valley area. All the hospitals in the area cooperated with all the schools in orienting new nursing students to their facilities (once & at the same time). Since we start clinicals earlier than any other school, we had to do this via video (not as interactive as a live presentation but it did the job. There was a book that went along with the orientation which essentially states in a nutshell...don't do anything...don't talk to anyone...be a nice person, play well and document document document. We all signed a bunch of paperwork for each facility we're expected to rotate into.

There were about 82 of us in class all day. They had the Masters and Accelerated BSN students together. We'll split into our classes later on this week and we go our separate ways from there. The ELMSNs go to psych rotations immediately. We prep for med-surg for 4 weeks and then go to clinicals. The class seems like a really diverse, well rounded bunch of adults who have a lot to contribute to the field of nursing. I am particularly impressed with the number of men we have in our class.

I went through three purse packs of kleenex and a bag of Ricola lozenges. If I wake tomorrow any worse, I'm going to the doctor while I have the time. The kids did fine on their own today. Everyone got to work and school on time. They seem very motivated to take over more responsibility. This is going to a real challenge this year (being separated so much)however I am impressed with the fact that they are so prepared for this, probably moreso than their mother. Dear husband is taking up the slack and assuring me that all is well.

Pop called and said my stethoscope came and he was sending it today. Just in time, we have lab this week and we hit the ground running, next week with the old folks (my favorite). The practical parts of nursing are what the last three years have been all about. Mom and Dad have been supportive. I can't wait to learn how to use this new little piece of equipment. It will be difficult not to chase people around in order to hear their heart, lung and bowel sounds. It will be neat to listen to a baby's heart beat in his mother's womb....my sister will have to sit very still. It's all about practicing.

Trude and I plowed through a lot of the reading tonight. This is much more interesting than any other classes we've had in the past, because we are reading nursing books now. The challenges to come are exciting. I am looking forward to learning a lot this year! Let the games begin!

In need of nursing...

2009-01-04T20:15:00.000-08:00

School starts at 9 AM tomorrow morning. After celebrating Bird's 12th birthday yesterday, I arrived home with a nice fever underfoot and a supreme cold. We were supposed to meet Comrade X and his wife tonight for pre-school wine and cheese...that doesn't sound right I know...(preschool wine?)

I couldn't even make it out of bed for Sunday Mass. After loading up on Zicam, Vitamin C and B, plus Lysine, I overdosed on pomegranate/blueberry juice with a Grand Marnier chaser. I packed my bag for tomorrow and called the roadies to let them know that I wouldn't cross contaminate them tomorrow by carpooling. Showing true attention to airborne pathogens and avoiding the roadies, I will drive myself to school tomorrow sans carpool lane. Nice way to start the school year!

I am printing out stuff I need for school tomorrow. I logged onto blackboard and let my classmates know that it would be great to swap labs since I don't have the same lab times as my carpool mates. It's wonderfully isolating to see how the year is springing out the door for me. The kids are probably relieved that I am finally getting back out the door again.

I fetched my transcripts for pathophysiology from Santa Barbara via the snail mail route and decided that I didn't learn much, well maybe a few things. The online format for pharmacology and pathophysiology is quick and painless, but I am starting to wonder how much of it I actually retained.

I did some reading in preparation for school and outlining for med surg, but some of these chapters are so incredibly long, it's hard to decipher what is overkill and and necessary for the group to know.

Orientation is all day tomorrow. I packed plenty of kleenex, antibacterial gel and throat lozenges. There are other people in the class who've been sick too, so perhaps we need to set up our first quarantine area on the first day of program.

Good show...to go to nursing school in need of nursing.

That's how I roll

2008-12-29T21:21:00.000-08:00

I've been on facebook alot lately...I confess it's a total distraction to all the reading I know I should be doing. One of the big surprises about networking and finding old friends from elementary, high school and college is the people my age who have gone back to school for nursing! What a surprise. Here I thought I had a singular idea in 2006 when I enrolled in Maria Alviar Agnew's summer school chemistry class. Little did I know that so many of my old friends had been doing the same thing!

I'm not any more organized than I expected to be at this stage in the game, with 6 more days to go before I head out the door for the first day of program. This is going to be a year of surprises and new experiences. I had a chance to see a old family friend hospitalized over Christmas after a nasty fall off his roof December 12. He has triple pins in his pelvis...and almost all his ribs broken. He's lucky to have survived it all. When I walked into his room at Santa Rosa Memorial, it was the same room Pop was in three years ago. Feeling a sense of deja vu, and seeing Pop walk down the same hallways he could only traverse by gurney three years ago, was really strange. Ray looked at me and said, "Are you sure you want to do this?" I've never been so sure about anything in my life, except marrying my husband.

At t-minus 6 days...I'm ready. That's how I roll.

Cleaning the boca and true teachers

2008-12-22T15:12:00.000-08:00

I had my teeth cleaned today and realized I won't see these wonderful people who take care of my big fat boca again until I am half way done with the program..half way...unbelievable! While I was sitting in the chair having my chops digitally x-ray'd and sonically cleaned (yep..no picks), I thought about a few friends of mine who are suffering in the hospital right now with various trials...cancer, fall from a roof, a knee replacement and embraced the thought that every day of my life over the next 12 months will be learning the skills I need to care for patients suffering from cancer, broken bones, failed lungs, degenerative diseases and everything that comes with getting through a temporary or permanent crisis. My roadies are applying for loan forgiveness programs before school starts and Wells Fargo sent me a letter congratulating me on the exorbitant amount of debt I've just incurred. Thank you. I'm speechless.

We are well on our way to the insanity we've signed on to embrace over the next 12 months. Sitting here at the 14 day mark, I have several wishes for Christmas. Facing a life ending illness as a family is a time of tremendous stress, and can be a time of enormous grace. My buddy who is the hospital with broken bones after falling off his roof...is letting others take care of him now. We are all temporarily here in whatever state we find ourselves in, (healthy, sick, chronically ill, terminally ill), for a long life, or a very brief glance of life... what manner we arrive or leave, it's a gift; this journey. We better be equipped to make it better for those coming behind us, and leave something worthy behind. Merry Christmas and God's blessings to all, especially the sick and the suffering...you are the true teachers.

Collaboration...from fellow roadies

2008-12-20T14:47:00.000-08:00

I've decided, at the suggestion of Comrade X to open access to the blog as a journal for us all, in that we are sharing experience, studying and hopefully supporting those coming up behind us. Training Wheels and Tales of Student Nurse applies to all of us taking this adventure together. You are welcome to post your own experiences. I think we need to avoid peer bashing and maintain confidentiality of patients and instructors, but the posts don't need to be lengthy. Hopefully we will learn from each other, while chronicling the roller coaster ride.

Surfing a perpetual learning curve

2008-12-18T10:36:00.000-08:00

The roadies decided it was time to get a head start on reading and outlining, since we are in an accelerated program that essentially demands that we have eyes in the back of our heads. I am thinking I need one head to stay home, while the other goes to school, while the other studies and preps for clinicals. Then maybe the 5th wheel can come pick me up and start assembly somewhere near the laundry pile. I thought about giving up caffeine for good and the thought left as soon as it entered. Thank God. I know Christmas is days away. There is an attack plan for both. In the meantime I walk the dog down to the gravel road PRN for elimination purposes.

Medical-Surgical nursing is the basis for all the specialties that come out of it; oncology, pediatric, intensive care, maternity, geriatric, cardio-thoracic, neurology, and telemetry (nursing by monitoring).

The textbook is roughly 2000 pages with 12 sections, appendices, glossaries and a lot of stuff I won't have time to read, ergo the reason we need to divide and conquer it up front. We are supposed to master this stuff within a few months. I think med-surg is in constant influx and therefore we will be surfing a perpetual learning curve.

So overwhelming...

2008-12-15T16:57:00.000-08:00

The roadies drove to school today for our library tutorial and it was nice to know that we have access to so much research. One of the roadies has already named her ulcer and I'm wondering if dementia will set in for me either before or after Christmas with all the stuff I have to remember for school. There is one side of me that is totally confident that I can knock this out and get it done in 11 1/2 months...and there is the other side that might as well be Thelma and Louise driving off the cliff of the Grand Canyon in a convertible.

Someone I admire greatly emailed today and reminded me how hard my program is. I think I am going to see if Costco has cases of bicarbonate...it's all so overwhelming.

Dansko is the way to go...

2008-12-14T14:51:00.000-08:00

I forked over the money to purchase and break in a pair of black cabrio Dansko's because everyone tells me they'll last forever and save my feet, legs and back on the long clinical shifts. I also picked up a pair of white ones on ebay...for school. I am wondering why it took me so long to invest in a really comfortable pair of shoes.

I know after wearing them for the last 3 days, that I'll be buying these again...they are amazingly comfortable...hand made shoes.

Pinning Ceremony

2008-12-12T10:31:00.001-08:00

Last night's pinning ceremony at S.M. didn't look quite like this (which is a traditional Capping and Pinning Ceremony), times have changed a little. Unique to the nursing profession is the symbolism behind the pinning which has it's roots that date back to the Knights Hospitalers and the white cross they bore in serving the ill and injured. Florence Nightengale distinguished herself during the Crimean War nursing sick and wounded British soldiers. Because of her selfless duty during the Crimean War, Florence Nightingale became known as the "lady with the lamp." As a tribute to Florence's dedication, the lamp icon became symbolic of nursing. Some ceremonies use the lamp/candle as part of their ceremonies.

Each graduate selects their pin...with the symbols that represent their school and RN designation. The person who pins them must be a fellow RN. What was perhaps the most touching thing for me to witness were the family members pinning their daughters/sons who shared the tradition of nursing in the family. Trude & I were pretty touched to witness our Comrades X & Y pinning ceremony. They had been through a lot. To hear the stories of what they endured over the last year, how they have changed, who they have become in the process. I also believe in the process of becoming nurses, their spouses should be commended as well, for taking this journey with them. The stories of separation while in school, the sacrifices they made so that they could succeed...the patients they cared for...the impact they made and will continue to make in nursing...we were humbled to witness it.

It would be cool to bring back some of the traditions since we are the centennial class of the newly designated S.M. University...

Below is the pledge thousands of nurses have taken in the past: I liken it to the Hippocratic Oath:

The Florence Nightingale Pledge

"I solemnly pledge myself before God and in the presence of this assembly to faithfully practice my profession of nursing. I will do all in my power to make and maintain the highest standards and practices of my profession.

I will hold in confidence all personal matters committed to my keeping in the practice of my calling. I will assist the physician in his work and will devote myself to the welfare of my patients, my family, and my community.

I will endeavor to fulfill my rights and privileges as a good citizen and take my share of responsibility in promoting the health and welfare of the community.

I will constantly endeavor to increase my knowledge and skills in nursing and to use them wisely. I will zealously seek to nurse those who are ill wherever they may be and whenever they are in need.

I will be active in assisting others in safeguarding and promoting the health and happiness of mankind."

Early bird gets the worm

2008-12-10T16:40:00.000-08:00

Trude and I went to CSUS and turned in our letter of declination. I was the last person they accepted. The point cut-off was the highest it's ever been in that program's history. I don't have the time to worry about whether or not I made the right decision. We are set to get started at SM, we've got more than 1K invested already in books, tests, deposits, fees, classes...it's just time to say enough and go with the early bird special.

We heard Comrade at arms were going to go through ceremonies after all and decided it was important we be there. After all, it'll be us next year...it's so hard to imagine at this point.

We picked up rolling book bags today at 50% off. After stopping by and seeing the admissions director for CSUS, who has been gracious through this entire process, we headed over to LaBou and contemplated the last 25 days of freedom we have. Oy vey.

Pathophysiology made incredibly easy

2008-12-09T12:25:00.000-08:00

I knocked out my pathophysiology final today and whew! This represents my last nursing pre-requisite and I finished it 26 days before program starts. I know this subject will stay near and dear to my heart once my regular nursing classes get underway, so the fact that I waited to take this class doesn't bother me since most of it was a review anyway. My textbook for the class was "Pathophysiology for the Health Professions", which was a fairly decent book, judging by the way I ear marked, highlighted and basically destroyed it.

At the suggestion of Comrades X & Y, I purchased a copy of "Pathophysiology made Incredibly Easy!" I swear Lippincott is making a fortune on this series...because you can also get NCLEX, Charting, Med-Surg and practically any other nursing subject made incredibly easy...at your local bookstore or at Amazon.

Another book arrived yesterday, "Surviving and Thriving ~ After a Life Threatening Diagnosis." This gives me a great idea after graduation...Maybe I could sell Training Wheels and Tales of a Student Nurse to some poor saps who don't realize what they are getting into!

Stethescopes...back ground checks...cake

2008-12-08T09:27:00.000-08:00

Trude & I went by Bischoffs and tried the Littman Master Cardiology stethescope. It was comfortable...I still don't know what the hell I am doing. Since Mom & Dad wanted to buy this for me for Christmas, I am accepting it graciously...with the hope that I will be able to hang onto it and not lose it. Comrade X said I wouldn't need anything too expensive and they would teach us how to use it properly.

The only think left to get for my kit is a blood pressure cuff. I will only need this for the labs at school..because no one at the hospitals carry these around any more.

Financial Aid is settled...I'm set for disbursement Jan. 2, which means I will be letting the other school know that I am not attending. Two months ago I was dying to get into that school and now I get to finally tell a nursing school "no thanks" after being told that a few times over the last year and half. It actually feels good to have these options after so many attempts on my side.

The other thing we did which I said I would never do....is buy a pair of used professional shoes. Okay, that sounds gross...I know...but I Trudy and I both saw two separate pairs of white Dansko's on ebay that had hardly any wear at all. These medical shoes are well over $100 and we barely paid a fraction for them for a couple scuff marks on the bottoms. Anything to save a buck.

I am assuming I passed my drug and background checks, otherwise someone would have called saying I had some 'splaining to do. In the meantime, I take my pathophysiology final today. Comrade X steered me in the right direction to get that class at a community college in Southern California. I am relieved I decided to take that class on-line at the last minute, because I needed it for my program.

Speaking of Mr. X....He is graduating this week and is interviewing for his first nursing job. It will be so great to see people I had classes with actually placed in their professional. This same class takes their boards in one month. Light at the end of the tunnel, gold at the end of the rainbow...Given that the old Comrade has been such a help in the past...I hope I can be just as helpful to people coming up behind me...by the way, this pathophysiology final exam will be a piece 'o cake!

Dreams of my father & mother

2008-12-07T21:24:00.000-08:00

This is funny... because as far back as I can remember, my Dad (I am sure this started when I was fairly little) would ask me the question, "What do you wanna be when you grow up?" I would answer like a robot drone..."a doctor" and he would respond aptly in the affirmative and this was the little game we would play until I actually got a job as a high junior at the local ice cream parlour. The dream completely dashed forever, Dad stopped playing the game and I jumped into the teenage mode of doing whatever I (%^&*well) pleased. That was the story of my teenage years except...one particular month, after scooping perfectly weighed (yeah right) 4 oz. scoops of Mr. Mikus' special blend of Swensen's ice cream, a new girl started at the ice cream parlour (she had this crazy big 70's/80's hair) and she told me about a job she had as a certified nurses' aide working part-time at the local convalescent hospital. I had worked at the same place as a candy striper (not to be confused with stripper) when I was 12 years old. I asked about the work she did as a CNA and talked about certification and it peaked my interest. I decided that when my best friend left Swensens, I would too. The following summer I applied for the job at the hospital and they hired me. Based on some of the dirt bags they hired, I probably looked like Mary Poppins, sans umbrella. I was hired on the spot. I couldn't believe that I was going to be a professional CNA at 17. Little did I know back then...we did ALL the work, and I mean everything. The nurses passed meds and did report. In addition, they clouded up the break room with TV soaps and smoke and called doctors a few times. We did as much charting as they did and all the patient care.

Dad started to ask again what I wanted to be when I grew up...and my answer started to be "I wanna be a nurse"...at that point, Mom started to suggest a nursing school in Ohio (St. Lukes) and the dream began to fade up from black again. The irony of being me, is that within several months of working at the hospital, I ended up working as a high school senior volunteer at the local radio station. Take sound effect of deflating balloon.

When my patients started to die, plus sexually & verbally harrass me, I stopped thinking I was saving humanity by working as the only compassionate CNA at PVC Hospital. I remember baptizing a dying patient who asked for it and wondering if it really worked. I started to get burnt out on the heavy work that no one else wanted to do or avoided; such as impacted bowels, giving enemas, baths, and cleaning up accidents and soiled bed linens. I remember the night shift avoiding their call lights and just leaving the last minute stuff for the day shift. Getting deceased patients ready for the morticians or coroners was also a job that was a little depressing in that many of the patients we worked with had little family contact. A few times, after hard shifts, I'd come home frustrated and depressed. My uniforms stank and the little extra miles I did on the job seemed to leave little impact on the patients or my co-workers. The supervisors resented CNAs who made them look bad, so there was an unspoken rule to be just average. Whiners weren't tolerated and whistle blowers were put out.

As a senior, my grades were decent so I received scholarships for nursing (little ones but I was excited nonetheless). I registered for classes at the Junior College and started with Chemistry. As an 18 year old, I was not prepared for the level of study and tutoring I'd need to master chem, so I dropped it. It was a pre-req for every class I needed for nursing. I saw it as a sign to quit, so I transferred mid-year to SFSU and declared a new major, total unrelated to nursing. I liken that turn in the road as providential because it lead me to my husband and a couple careers I enjoyed.

As a nine year old, I would help my grandpa while he lived with us, with his meds or getting him blankets...and he would call me his little nurse. Was it a seed planted by my parents, my grandparents, or was care giving and advocating part of my genetic makeup. I'd like to think that there were specific calls from within my soul at 9, 12, 17 and 43 that called my soul to nursing. When I went back to school in 2006...chemistry was the beast I had to conquer and after taking 10 units of general and organic chemistry, I knew I was ready and it was time to finally fulfill, not only dreams I preceived my parents had for me, but the dreams I've always had for myself.

Sign on the dotted line...and never look back

2008-12-06T11:15:00.000-08:00

To attend a private school, one has to look at the cost higher education with a sense of total abandonment and leave it at that. Whether you are attending Harvard Law or SM College, there are schools, anywhere and everywhere, that are willing to have you sign on the dotted line and sign your life way in three easy installment payments of $17,000.00 for one year's worth of tuition. Yep, that's how much it costs to go to 12 month nursing boot camp. I can't think about how I will eventually manage all this, given that I have just purchased what is equivalent to a souped up Lexus...but if I was a retiree who had just lost his shirt in his 401K, investing in your education doesn't seem so bad after all (this being the analogy that Comrade X's spouse gave me...and it makes perfect sense.)

When I look at the end of this ride which stops one year from now, I hope some nurse manager somewhere on this path will look me in the eye and tell me to come see him/her about a job when I graduate. Jobs in the market where I live are a little saturated right now for new nurse grads, but I know all things are cyclic and there will be openings eventually. Economic projections for health care are still the hottest commodity for future employment as the boomers retire.

My Mosby's diagnostic manual arrived this afternoon; it weighs as much as short bus, so I know we're going to need book bags with wheels on them. I am too old to do the backpack thing again. Can't wait to see the Med/Surg book... I'm going to put on my bifocals and get back to reading. Comrade X said this would be a good thing to do before school starts...plus the roadies agreed to help start outlining. Regarding my student loans though, my ultimate strategy at this point is to sign on the dotted line and never look back.

Meeting my roadies today...signing up for the same pain.

2008-12-05T20:17:00.000-08:00

Trude and I met up with our roadies (we're all driving in when we can) and if study group is possible, we'll be helping each other out.

My buddy friend nursing student Comrade X is graduating and pinning next week so we are planning on taking both X and buddy Comrade Y (their spouses too) out to dinner to celebrate. They made the decision to go to SM more palatable. We basically saw what they endured (much like a long trip through purgatory on a really hot day) and since they are no longer on fire, we feel we will survive the walk. Toasty trip...maybe some tears, but survivable.

Incidentally, after talking today to Comrade X's spouse, it looks like there is a light at the end of the rainbow. They are both very happy...and I am so blessed to have friends such as these to help navigate the treacherous waters of nursing school.

Last night Trudy and I got the news we were accepted into another program (one we had tried twice before to get into - much to our utter despair)....getting the congratulatory email was rather anti-climatic because we had requested news on our admission status, actually begging and bribing for it...to no avail. As a result we had to pay for SM, attend orientation and order books. Getting asked to attend a program by two prestigious schools (one school offering two seats in both an accelerated BSN and Masters program); is nice, but after what we did to get there, I was actually too tired to actually be happy about it. "Congratulations on your admission...thanks...I guess." Bah humbug.

So, we met our roadies today and decided we had some things in common...the next 11.5 months are going to be spent with these people and it was easy to welcome each other, knowing we had all signed up for the same pain. Now if we could all just get the same lab schedules. I have a lot to look forward to.

I have my limits

2008-12-04T08:54:00.000-08:00

The last couple of people I talked to about the issue of uniforms and student attire have all said the same thing. It's humiliating. The white scrubs never fit right and you can see through them. My guy friends who are nursing students recommended wearing cotton boxer shorts underneath. They said eventually the women all get a clue and figure this out, except for the ones who want you to see what's underneath door #2. Last night I tried on the uniform again and realized I ordered the wrong size school scrub tops. My buddy Fred gave me one of his old uniforms and it fits perfectly (but of course, in a fit of wishful thinking I ordered one size smaller at orientation). School hasn't even started yet, and I am already admitting my first mistake to my nursing director. Good job Snurdly!

The bottoms can never be overestimated and are fine because I washed them several times and they shrunk. I put on the whole ensemble last night, including the shoes...and drum roll please....my son laughed at my shoes. If he laughed, then I know I looked like a complete dork. (I don't even like that word..) There is simply no glamour in my life anymore.

Thinking I had smartly put this whole thing together...I am totally self conscious. So, it's off to Walmart to find men's boxer shorts to wear to school/clinic under my uniform. I think the deal breaker would have been white panty hose. I have my limits.

I think I can...

2008-12-03T18:06:00.001-08:00

The first batch of books arrived today...plus my NCLEX review (that is over 1000 pages long!) I was talking to Trudy about the fact that every stethescope I've tried thus far requires an air tight, completely insulated sound proof environment for me to hear the faintest hint of a heart or breath sound. The only exception would be the abdominal sounds on my son...who is quite a volcano any given moment of the day. So, other than having an amplifed stethescope, I am thinking Littman has a cardiology model I can invest in, or maybe I just have ear wax that needs to be removed.

My physician called the other day to tell me I need to give more blood for my titers because the lab messed up the order for my physical. He also politely reminded me that I should watch my serum cholesterol (I do...just not the way I should); I expect that number will go down soon as there will be no time to eat once school starts.

Financial Aid called to say hello today. I developed acidosis and promptly medicated myself with Cosmic Cafe to intensify the stress. Who says we're so darn smart?

Today I opened, "Surviving Clinical" and promptly felt my BP rise. They are going to hate me. I know it and I am training myself to suck it up by making my kids irritable and not reacting to them. A couple people flipped me off on the highway today and I smiled back as if they kissed me. I can take a good beating...insults and criticisms. Clinical instructors are angels of mercy...I keep telling myself that...knowing they are going to kick my ass. Just keep on believing...I think I can...I think I can...

T-Minus 32 Days

2008-12-02T21:38:00.000-08:00

January 5, 2009 marks a day that will ultimately lead me toward a lifelong goal I've had to become a registered nurse. I've known that I wanted to enter the nursing profession since I was nine years old. Given that I am now 45, it has taken a few decades for the synapses to start firing in the right direction. Like many middle aged nurses who entered the profession late in life, it took a few tragedies in 2005-2006 to wake me up to the idea that I've always been called to this profession, I just never quite got around to answering the phone until now. What has ultimately began with a summer school chemistry class, has now turned into an accelerated second bachelor's program that will last until the middle-end of next December.

I think I wanted to chronicle this journey for myself and my family, because they have sacrificed so much to support me in it. I also wanted to have a diary of sorts that revealed what struggles may come, as well as triumphs, knowing that each day will be different, every patient ~ a blessing and a challenge. How will I change in the process? What will I learn? Will this be the what I expected? How will I deal with the obstacles? Will Trudy still my friend and lab partner at the end of this roller coaster ride? (More about her later).... What physical and psychological challenges will I face? These are all unknowns right now, at T-minus 32 days.