First Clinical MCA I - it felt good

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.