finally a format...

i can't believe that i have not formatted this computer since early 2005. what a shame, really. i never usually wait that long. ever. but boy oh boy is my computer running smmmmooooooth!! it just feels good to have it feel like new again. too much stuff accumulates after so much time, you just have to format to get it good and clean again. now, the microsoft updates must be for dummies because it took me forever and a million years to update everything. and had to validate windows 100 times over to make sure it was genuine.... isn't once enough???

well not much else to report other than xmas coming soon, we all know this! that's all!

Long Night, Indeed

Got called in to work last night around 11:15. Just told that they really needed my help in the unit, which is okay but that was all I was told. Little did I know that I would be walking into a full code situation, several times over. Seems we spent a good amount of the first 4 hours strictly in that room, only getting about 30 minutes before we had to code the woman again. She was 40 years old and brought in unresponsive. Pupils fixed and dilated. Epi would bring her up, but once it wore off, she would brady down and no perfusion. Finally, the family said, just one more time and then we don't want you to do the chest compressions anymore, but leave her on the ventilator. They got to spend some time with her for about 45 minutes before she brady'd down and went asystole.

At least when dealing with a patient, we are able to compartmentalize our emotions and do what is necessary. It is when dealing with the families that we aren't as able to do that, and emotions can just erupt. Not one of us in there had a dry eye. For me, it was their singing of Amazing Grace that really got to me, and then her 15 y/o son having to experience the death of his mother just a few days before Christmas. We do what we can to be strong for the families, but the truth is, this affects us, as nurses, just the same as it may them because we invest emotionally into our patients.

I wish this night had a different turn out than it did, but we did all that we could do. The only thing really keeping her alive was the epi, and once we stopped that, it didn't take long for her to follow on nature's course. Once we got her cleaned and the family taken care of, we got another new patient. A 24 y/o man with sats in the 80's and LOC of obtunded. Reasoning was unknown other than a possible od on perhaps methadone or benzos. Another sad situation really, and quite a complex situation. Not sure how he will turn out, I suppose that is all in what happens over the next 24 hours. Luckily for me, I am going to Christmas party this evening and am NOT going to work at all. Even told them, don't bother calling because I am not coming in. I hope the night goes well for them, even though I wasn't upset to have to go in last night. Being able to help your colleagues once in awhile makes a person feel good, even if you work your ass off all night for it :)

Christmas Shopping

I didn't realize how difficult it could be to buy items for a 13 y/o boy. Suddenly the shirts he wants are $50 and pants are $70 a pop. I understand though because I wanted name brand items when I was a teenager, but that certainly didn't start until I was well into high school, more like my sophomore year and beyond mostly. Now everything just seems to start much sooner. I told him that he has to understand if he wants the more expensive stuff that he will have to settle for less presents because even though he might have less to open, the money spent will be the same. Of course he doesn't understand that! (all kids think that money grows on trees, right??)

Actually, the biggest problem that I have found while shopping for christmas stuff is that most kids seems to wear the same size clothes that mine do because those are the sizes of all the cute stuff that is completely sold out! Go figure? Lots of all the other sizes but the ones I need. Anyhow, I need to go out and finish some of this shopping.

Asystole?

Typically, when you think of asystole, you would think of a flat line on the cardiac monitor right? Well, our monitors out on the tele floor are just very sensitive to movement and such, and sometimes, the asystole alarm will ring with a rhythm full of artifact. Unfortunately, the nurses on the floor have become a little complacent because these alarms ring off all of the time for nonserious things. But the other night, it so happened that it rang off for asystole, and this time the rhythm was not full of artifact, but instead looked like there was a slight ventricular beat but that was about it. Being the astute student nurse that I am, I said to the charge nurse.. "hey, this one is for real." I took off immediately for the pt's room to check the pt.

He was arousable, and I immediately checked all of his leads. Got him to sit up on the side of the bed, and finally the charge nurse decides to come down to the room. She asks the other nurse at the monitor was it said now, and they told her that his hr was in the 70's, so she left. (not exactly the best thing to do, but it was her last night at the hospital as she was moving away, so i dunno if she cared?) i got a BP on the man, and it was about where he had been running. I told him that his rhythm had changed and we had to make sure he was ok. I told him to lie on his back or on the other side for a bit and we would be back soon to check on him.

I went up to the desk and got the print out of this rhythm and took it over to the unit for the nurses there to look at. They said that his pacemaker wasn't firing, and that is why his rhythm looked like it did. They asked if he was okay, and I said he seemed fine. I went back in to check on the patient, and he was still sitting at the side of the bed. I checked his leads once again, and when he had moved, his red lead had come off, so I fixed that and let him go back to sleep. There were no further incidents the rest of the night.

Now the man was admitted with vertigo and dizziness. When his pacemaker failed for those 3 minutes, the reasoning behind his symptomology became clear the next day for the doctor who evaluated this occurrence and all of the symptoms he had been having. Luckily, we were able to capture it on the monitor for evaluation. His pacemaker was failing and would need to be replaced. He may not have been a true asystole, but it was a serious incident that will hopefully get these nurses at the tele station to realize that they need to pay much more attention to those monitors. (in my opinion, anyhow).

Yeah!

Finally, this semester is really, really over! Passed my final exam with flying colors and am now ready to finish the last 15 weeks of the program. I cannot begin to tell you just exactly how excited I am to be that much closer to my degree :)) Graduation day is May 15 and coming up soon! *pats self on back for a job well done!*

last class!!

Finally! Our last class of the semester was today. Too bad I was too tired to enjoy it. Our final tests are on Monday with finals on Thursday :) I am soooo happy to finally be done. Now just one more semester before graduation and I cannot even begin to relate the load that is slowly coming off of my back. Woot! :))

Hoping to have more time to post some stories and stuff and get this blog completely updated over break. See you very soon. Gonna be a busy weekend with work and studying :)

goodness, time just flies by

well we finished our fall break without incident, for sure. just have one more test this semester, ati, and then our final exam. i am so excited to be just almost finished with just one more long semester to go. unfortunately it is going to be filled with nothing but med-surg, and i have already been forewarned of just how difficult it is. i just want to be done, but moving ahead slowly but surely. this semester has seemed to just simply fly by. i can remember our first clinical in the psych hospital, and now of course, we are finished with clinicals for this semester. having gone through all of the OB stuff has been really exciting. it will be difficult to go back to the other stuff and have to relearn and review it all over again in even more detail than before.

work has still been crazy with the census fluctuating from shift to shift it seems. we have been blessed with warmer than normal weather lately and people just aren't really sick yet. i have a feeling that when they finally do succumb, we will be getting slammed. i am ready for all the learning experience i can get in the icu over this winter and spring so that when i graduate, i am ready to work. i will probably have to work on the floor to begin with, but i still hold out the possibility of working in the unit when i graduate. that is why they are spending the time with me to work in there, because that is where they are planning for me to work if there is a spot open.

A break!

well finally we have reached our fall break (or thanksgiving break really). i am so excited not to have to look at anything for a whole week... well if that were exactly true it would be nice. we will have our second peds test when we come back, so i plan on reviewing so i don't have to cram it all in at the last minute. i hate cramming for a test. 3 more weeks before our final exam an then a glorious 15 weeks left of school before i graduate. i am getting so burned out on studying that the day cannot come soon enough for me. unfortunately, i am scheduled to work for most of my break, so no real vacation for me. it would be nice, but my kids want to play youth basketball, so have to earn the money for that! :)

Random Ramblings

I am so happy to be almost finished with OB. We have our last lecture on it today with our testing on Monday. Not that it wasn't a fun and interesting rotation. I actually loved it. But it is another milestone conquered in the happenings of nursing school. We are left with Peds for the rest of the semester, and I am so very thankful to have completed that clinical rotation. We all know that caring for sick children can be very demanding. In fact, it is probably the parents that can make the experience even more difficult. I just know that I am not cut out to be a Peds nurse at all, ever.

Census is still down at the hospital, so it seems on the weekends anyhow. Or at least there haven't been too darn many critical patients. In a good, perfect world, that is really is a GOOD thing, right? But man does it ever make my paycheck stink. I need people to be sick enough to be in the ICU so that I can work and learn, don't they know this? It is times like this when I wish that I would have just stayed out on the floor instead of being a little hot shot and transferring over to the unit. I know I made the right decision for myself, just perhaps not my paycheck. I love working in the unit though, and I wouldn't trade the experience for the world.

What do you say to a fellow student who thinks that she is the know all to everthing, talks over you in clinicals, interrupts when the instructor is asking questions to answer the question that was asked of you? Do you just let her go on and make a fool of herself because she doesn't know when to shut up? What do you tell her when you are going to do some patient education, and it is her wish to follow you, knowing when she gets in there, she will take over and mark it down as her accomplishment? Well I let her talk over me in front of the instructor so that the instructor could see what she was doing, but when it came to my patient, I politely told her, "I think I am going to do this one by myself, thanks." Yeah, it pissed her off pretty good. She won't talk to me, heck she won't even barely look at me. I don't see how this is my problem anymore :) I know she is sensitive to matters like that, and I am sure that she took it personally when I said I wanted to deal with my patient by myself, but that is what we are supposed to do! I certainly didn't follow her into her room and interrupt her whole educational session with her patient. I know she just wanted everyone around to know that she knows everything. Well, now she can go bother someone else because I am sure she won't bother me anymore.

have to run to class in a few to get our last OB lecture. ciao.

a mini vacation...

census is down and i did not have to work ALL weekend long. i cannot even begin to tell you just exactly how much i needed these days off to recover from lost sleep and whatnot. it was beautiful. really. so did i get to work on the project due at the end of the month? nope. did i review my study notes from the lectures? nope. haven't cracked a book or looked at anything to do with nursing in 3 whole days. i feel like a new person though! i feel like i might actually be able to concentrate in class tomorrow. i am refreshed. renewed. ready to finish out the rest of the semester. i try not to think of next semester when we have med-surg II. i have heard the horror stories. i have heard just exactly how hard it is. i don't want to go back to hard, but i don't have a choice, do i? although i am more comfortable with the knowledge that we get with med-surg. it is more focused upon the stuff we will really see in the hospital. i love ob and i love the newborns, but in my area, there is no hope for a job there. those people just never leave. they stay in that unit for years and years and years. i will have to move if i have ob aspirations. even in the icu, the same goes for in there as well. another unit where people aren't inclined to leave or even transfer out. i will have to move if i plan on having a job in that area. although there is one possibility of a person leaving, i just have to hope that they hold out til may or close to it. but i will probably have to chose the med-surg/tele mixed floor where the unit director wants me to start until they have an icu position open up. i want options! i want to make the decision for myself. i don't want to feel pushed into accepting a position that i might not want. sure i still have several months before this arrives, but they are already discussing it, without me, of course. and still, people ask my opinion, where do i want to work when i graduate? i always answer the same and tell them that i don't know. i don't know what will be open when i do. somewhere in there, they aren't getting the options message. i suppose i just need to lay it out for them and tell them that i don't want to commit yet. that this is a decision i need to make on my own. will they listen? nah. i doubt it. all they see is a potential person to fill that open slot on nights. sigh. i know new grads often have to work nights because days gets the more experienced nurses. i even don't mind working nights. but that is still them making the decision for me. i will figure it out. soon.

been awhile...

well it has been awhile since I have had the time to update. I didn't imagine that it would take quite this long for me to get back into the swing of things, but it has. This semester in school has really taken a toll, and it is supposed to be the easiest semester out of them all. I might disagree. Although the subject matter might be a little easier, we have had projects out of the wazoo to do which takes up a good amount of time.

Our Psych rotation came and went without an ordeal. I wish that we would have been able to have our clinicals at an acute Psych facility, but on the other hand, I am glad for the bit of experience that we did get. It was enough for me to know that is so not the field that I want to go into at all! Now we have started OB and Pediatrics. I have finished my Peds rotation, thank goodness. Another field that I know I do not want to go into. :) Not that there is anything wrong with kids, but it is just not my thing. I have had the opportunity to work a few more shifts up in the OB unit at work along with my clinical experience, and I do still really enjoy that. I don't know if that is what I want to do or if I want to stick with the hopes of being in the ICU. It will all depend upon what is open when I graduate. But I love, love newborn babies! In addition to the hospital clinicals this semester, we also have to do clinicals in the health department and in two schools. I dunno what I think of that yet as mine do not come up until November.

That's all I have right now for a little update. Nothing really significant or exciting has happened lately. Census has been down a bit at the hospital, as is expected, but I know things will pick up soon with the colder weather moving in.

DNI

We had a lady in the unit who was loved by her family. They were not quite ready to let her go. In fact, they requested that everything be done for her, except intubation. Unfortunately, she was in respiratory failure. So overnight, her sats began to go from the 90's on a bipap machine to the 80's, then to the 60's and so on. Her fingers were purple, but she had a strong pulse generated by her pacemaker. The daughter was called in because it was obvious that we would have to code this lady. The charge nurse pulled the crash cart into the room and RT was called. Once they had the ambu-bag set up, CPR was started. Drugs were pushed. Her BP came up from the epi push. She had agonal breathing, and unfortunately the efforts to keep her alive without intubation failed. The family came in the room to say their final goodbyes, and she passed on quietly.

I had a hard time understanding why the family wanted CPR but not intubation when the patient was in obvious respiratory failure. I don't know if it was a lack of understanding of the procedures, but generally in this situation, intubation is probably the only thing that would have kept her alive, but she would never have come off of it. Perhaps that is what they were told, and thus the decision not to have intubation. But CPR on a respiratory failure? Did the doctor not fully explain? How come there aren't booklets or pamphlets that will explain this to families and patients, in terms that they can understand? Maybe there are, but I have not seen them. People have spent so much time watching patients miraculously saved on tv shows, and this just isn't reflective of what really happens. When the body is in multi-organ failure, time is minimal and probably not even CPR or intubation will be able to save the person, only prolong the inevitable.

If I were a politically active person, I would be all for pushing for the patient's right to be comfortable in the end. I also believe that if doctors were there on the floors having to care for these patients like nurses do, so many more things would be done to provide comfort measures at the end of life. Especially for DNR patients. I guess I will end my rant here... I understand that ethics is a major player in the above situations for everyone involved. Just sometimes it can be frustrating to watch a person suffer.

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On a different note, I get to fully transfer to the ICU as an extern in September. I am so excited!! I have spent the last 6 months out on the med-surg floor, and I am ready for some new areas to explore. I plan on spending the rest of the summer trying to learn the rhythms and ekg's. I have already learned a little bit, but not nearly enough! Though I can pick out a PVC, not that is too difficult really. I just need more experience, plus learning how to recognize the different lead views etc that is shown on the monitor. I am even thinking of purchasing a book to study up on it. It's not that I don't have a ton of things to already finish the rest of the summer. I have to finish my project for the fall. Have a great idea for that. I also need to go down to the school and finish some computer modules that are due this fall as well. Am doing great in my pharm class... our final is coming up soon. Otherwise, have a wonderful rest of July. I am taking a break from blogging unless something fantastic happens in the meantime before school begins.

it's a girl!

I finally got to go to OB for the first time last night. What a refreshing experience!! And to go there and find a lady about to give birth. Since we are starting on our OB/Maternal-Neonatal rotation in the fall, I jumped on the experience as soon as I found out. It took 2 hours of grueling pushing to finally get the baby out.. a whopping 9 lbs! And her first baby... but it was so beautiful. Beautiful in the sense that a new life has joined the world and beautiful in that it was so nice to see healthy young people instead of our normal elderly patients on the regular floor. I really love to work in the unit, but I really enjoyed working with the moms and babies as well. I do hope I get to do it again sometime in the future. I am up way past my bedtime, but will add more to the story later when I can get my thoughts completely together. :)

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On another note.. my youngest son's baseball team won their first All-Star game yesterday. Congrats to all of the boys on the team and hoping for another win tonight in the tournament!
Unfortunately, they lost the next two games and were defeated :( I am so proud of my son for his outstanding performance though. It is really something when the coach of the other team comes up to tell him what a good ballplayer he is :))

A Final Goodbye

Tonight one of our long term patients passed away. He had been there right around a month, so we all knew him and his family quite well. At the 4 am rounds, nothing seemed to be out of sorts. Vitals were good. A half an hour later, the son comes out of the room and says that there was some blood around his IV site. I went in to have a look as my preceptor was taping her report. I didn't see anything that was unusual. Sometimes blood comes back with a flush, which had just been done a bit earlier. The son was worried he might be in some pain, so I gently asked the patient, who was not very verbal, to try to squeeze my hand. This was to see if he could follow commands. He squeezed my hand several times. So I asked him to give a good tight squeeze if he was in pain, but he did not differ in how he squeezed. I told the son that sometimes about 3 or 4 in the morning he would wake up for about 30 min to an hour and have a spell where get got a little out of sorts, but it usually passed. The son left the room for a few minutes, and I decided to wet a cool wash cloth and hold it on his forehead for a minute. I wiped his face off and the edge of his hair. Lifted up his non-rebreather mask and wiped his face under it. I could tell that this had a great calming effect on him. I held his hand and told him that he was a special man who had family that loved him very much, that they had been here with him every day. I began to notice a change in his breathing, so I watched closely for a minute. I knew that it was time. I zipped out to the hall to get my preceptor, whom I could hear at the nurse's station and told her to move it in there. She came in and a had a quick look and took off to get the son. I told the patient that his son was just outside and he would like to say goodbye before he left us for good. I told him everything was okay; he was not alone. He looked at me for a moment and shut his eyes. The son came in a bit confused, and I told him that his father was about to pass on. He immediately began to tell his father what a pleasure it was to be his son, that he was proud of him and to go be with his mother. His father took 3 more breaths before he left this world. I told the son to keep talking because hearing was the last thing to go, that it meant a lot to be able to tell someone you love them and to say goodbye. The son was amazing. I hoped that my children would do the same for me when it is my time to pass on. A few minutes later, my preceptor comes back in, checks for heart sounds. I told her there had been no respirations for about 5 minutes now. She told the son then that his father had for sure passed on. And he finally cried. And so did we. I always wondered how I would handle such a death, now I know. I am proud of myself for being there with the patient so he did not have to be alone. I am just thankful that he is suffering no longer. May he rest in peace at last.

she's a sneaky one

i got to work in the unit the other night at work. because we had an extra person, i got to actually shadow one of the rn's around for the night and participate in care. i got to focus care on one of the patients who was stable, but still on full support vent with trach collar.

she had been in there for 2 weeks and is now a bit more alert and oriented. unfortunately for her, the icp from the trach secretions has caused her to blow out all of the vessels in her eyes. it looked horrible. and painful, to me anyhow. so they were trying to d/c her soft wrist restraints (which are needed for most people on a vent who can be alert at times to prevent them from pulling out the tubes). her ativan drip kept going off as occluded.. i was told that with a drip only running at 5 cc/hr or if even at kvo, it can sometimes just not be enough to keep the line patent. we flushed the line... and she taught me that when flushing the cvc, to use positive pressure rather than just straight pushing. after that was finished, we decided to check her residual on her tube feeding and do the flush while we were in there. she had explained to the patient about trying to keep the restraints off while i was doing the flush. got her all straight in the bed and walked out. it wasn't 2 minutes later that she was trying to get up in the bed and had her feet half off of the bed. the nurse cut the light on, we got over there to get her back up when we noticed that her feeding tube had come out. i hurry up and shut it off so we don't have a huge mess, then go and get a new tube to put in while the nurse gets her straight back in the bed. lucky for me.. i get to put in the new ng feeding tube, which went so very well. no resistance, no coiling up in the back of the mouth.. straight on in. it was beautiful. and she was pissed. she was not a happy patient. i can understand... i wouldn't want all those tubes in me either. we just had to keep reminding her that it takes time to come off of all of this stuff and right now it was helping her. she finally took a good nap once her ativan started kicking back in. and we were able to leave the restraints off.. until she woke up.

she starts moving around in the bed again. i go in there, and she is very restless. i calmly but firmly tell her she cannot get up. help get her moved back in the bed. she keeps making a face at me and i can tell something isn't right. so i ask her if she is in pain. she shakes her head no. she burps and makes that face. the one that looks like move it.. vomit coming soon. i ask her if she feels like she is going to vomit. she shakes her head yes. in the meantime i am steadily keeping her hands down from pulling on her trach. i really didn't want her to pull it out. so i hook her hands up and go tell the nurse, who is in with another patient, that mine is nauseated. see they teach you in school (which i am sure this is common knowledge to all nurses, or it should be) that vomiting + intubation/trach/etc = aspiration. which is bad. so she is nauseated.. and i cut off the feeding. residual is 0. we assess and think it is probably just gas causing the nausea as her bowel sounds are hyperactive. since she cannot talk, we unhook her hands again so she can point to where the discomfort is. she points to her belly. responds yes to the pain question this time. she is actually cooperating quite well. then she wants to pull her hands up to her head again. the nurse says, "let's just see what she is going to do." she asks the patient, "do you want to scratch your nose?" she shakes her head yes. so we let her. she moves her hand ever so slowly up to her nose and then with the speed of lightning grabs that ng tube and starts pulling. what she didn't realize was that the nurse was ready for that and grabbed it at the tip of her nose and kept it in place. i giggled a bit and told her she couldn't take out the tube and pried her hand from around it. and so we hooked her back up, gave her some demerol for her pain, & let her sleep for a few more hours.

karma & supply shortages

last week i brought in an article on c. diff to my preceptor. for her reading pleasure, of course. but you see, it brought on the bad karma. the next night i come in to work and suddenly we have 7 patients on contact(and 2 of these on droplet as well) isolation... for c. diff (as well as a few choice other bugs added to a couple of them). i can imagine it was my payback for being a good little student. now here is the problem.

the c. diff article (published in AJN recently) stated how c. diff has been appearing in patients who are not on antibiotics. of course we all know that c. diff is highly contagious and can certainly be spread from patient to patient by not washing with soap and water before and after any contact with the infected patients. but it also brings up the point that it is possibly equipment that is doing a lot of the spreading, such as dinemapp's and portable thermometer's. ok. i can understand that too. not a problem to actually do things manually. however, whenever you have a good number of your patients on isolation, supplies can be an issue. heck they are an issue for a floor full of regular patients. hospitals (well the one where i work) can be stingy on sending supplies to the floors. i cannot tell you how often we are constantly "stealing" from another floor or dept because we have run out of something. and it isn't like the supply people work from 11p-7a either. hospital administrators need to address this issue and make it into some sort of policy. enough supplies should be kept on the floors to accommodate as if the floor was full at all times. perhaps if they had supply people who didn't bring up the stuff and just drop it where they see fit, we could find things. perhaps if they developed a system with bar coding, like in a grocery store, where we could check things out as we use them, they would know what to bring us the next day or later that evening before they leave. something else has to be more efficient than what we have now.

i watched a show on discovery or tlc the other night about a surgeon who developed a bar code system for checking surgical supplies to cut down the incidence of surgical supplies being left in patients after surgery. i think it is a novel idea that has uses in other areas of the hospital as well. after all, the pharmacy is able to keep track of all the medications and resupply as needed, why can't material management keep track of the supplies? are they not as important as the meds? it could even possibly be more cost effective in the long run as well.. perhaps.

truth takes time

you see, during my entire first year of school we focused upon support of each other. and then the support turned into expectations and lots of taking but no giving. i am all for supporting other students who are having problems... but not when it is taken for granted. these type of things can be deceiving for a long time, and many people do not see it in their desire to please everyone. however, there comes a time when you should see it for what it really is... and thus is why, truth takes time.


picture is from an episode of alias... where indeed, though unclear at the moment, the truth behind a situation is revealed eventually. my problem is that i cut off those people who were taking advantage of my helpfulness... i couldn't understand why i should work my tail off and they shouldn't have to.. only to be able to use the work i did.. such as all the work i did for our final in health assessment.. these people expected me to send them my notes.. didn't even bother working on it beforehand, just expected it. after that, i was finished. i was not going to do the work for several people.. i have my own self to worry about. i don't think i am being selfish, but how can people expect to pass nursing school riding on the coattails of others. well, truth be told.... several didn't pass into the second year, but there are a couple left in our program. but if you cannot bother to learn (not memorize!) the information, how can you expect to become a respected nurse and make responsible decisions and use any type of critical thinking? i just don't get it. anyhow, so this group that is left has banded together.. and made me the bad guy in the whole ordeal. because i refuse to let people walk all over me. because i had the courage to tell them that they really needed to do the work on their own and stop asking everyone else to do it for them. i am not trying to get the best grade in the class. i am trying to learn everything i can, including from my mistakes, so that i can pass the nclex and be a competent nurse. i don't have the time to play the silly mind games of classmates that are meant to drag a person down. i just don't have the time.

i know this is a downer post. nursing school is difficult enough without the interferences of teenage acting middle age women. i can only hope that there are others out there who may be going through the same dilemma. i just learned to say no. and it is telling when people stop talking to you or whatever because you decide not to carry them through anymore. i thought i had lost some good friends, but i guess they really aren't friends. the truth just took some time is all. ok.. i really must get to studying since we have another test next week. ciao!

What kind of nurse are you?

The place where I work seems to breed 2 types of nurses. Perhaps all places are like this? I don't know; I have only the experience of my place. In our place, we have the nurses that do, and those that don't. Do anything. By nurses, I am talking about our RNs. The one I work with most of the time, is one that does. She gets out on the floor, takes care of patients and all the while is still charge over the whole unit. On the other floor, those charge nurses sit at the desk all night and don't do. I overheard a conversation last night that postulated the type of school these nurses went to.. supposedly (hearsay is such a BAD thing) it was stated that they went to school to learn how to be a charge nurse. I butted in and said, "well it sure isn't where I go to school." They continued to make the comment that a nurse, no matter their degree or license, has to be able to do nursing stuff.. which includes vitals and wiping butts as well as assessments and orders and all the charting and paperwork. I sure told them that we get that full experience where I go to school.. we are taught to do. Get 'er done... is what my instructor taught us. I mean.. everyone can have time to take a break and sit for a few minutes... if everyone works together. I understand that different shifts have different responsibilities. I also understand that working nights on the floor spoils a person just a bit because of the lack of person-person interaction that we have... such as with families and doctors and such. But it doesn't mean that we don't work hard. Other shifts assume we don't work hard, but it's just different responsibilities.

There is one floor in particular that breeds these nurses that don't. The new ones come in and sees how those that have been there awhile do things... like sit at the desk and make the lpn's run their tails off while they sit there and say they are busy. They aren't busy, they can't be. We handle the same amount of patients on our floor and our 1 charge nurse (this other floor generally has at least 1 charge per 6 patients, while ours is 1 charge per 12 patients). Anyhow, the new nurses see how they do things, and thus it makes them become that way. Follow by example, right?

In that sense, I am lucky. If I follow by example, I will certainly not be one of those nurses. I will become a nurse that does. I even asked my mom.. after all, no matter what you can say about mothers, mine is brutally honest. So I asked her, "Mom, do you think I will be one of those nurses who will just sit at the desk and watch everyone work?" In her loving way, she replied," Nope... you don't mind getting out there and cleaning up poo." I hated to tell her I do mind, but it doesn't matter.. it has to be done, so it gets done. Get 'er done.

I see and hear how the nurses complain and have no respect for those nurses that don't... I don't want to be that nurse. I want to be one that has respect from my peers, one that they know will be there to help if it is needed. See I am learning something as an extern. So what kind of nurse are you?

code blue

I got to go to my first real code last night. As an observant. I was excited.. heart pumping.. thinking of all the things I would see when I got in there.. people rushing, meds going in, decisions made in seconds to save the person's life, the experience of seeing someone shocked for the first time..... so we get there, and it wasn't quite what I expected. It was a respiratory arrest that only required an airway. I have seen an intubation, so I made myself useful and helped pull things out to make room for the vent and answered the phone. I did get to see the RT bag someone, hadn't seen that yet.. but I still await the first real full code to watch. I need the experience of seeing it with observation so I can assess what is going on and take it all in. See what people do. It is amazing really.. in these type of situations. Everyone pulls together as a team and each person has their own role in the code/emergency situation. There is no arguing about who is doing what.. they just do. I respect that about those involved in a code, and all I could think was that when I graduate, and it is my turn to participate, I hope to hell one of these nurses is there with me! They know what the hell they are doing! :)

But I have to admit, when the er doc was intubating last night, all i could think about was that episode of er (yes I know.. it's not real and all of that, just things stick in your head) where pratt is intubating a kid and when he is lifting the neck for access, he breaks his neck. I could literally hear that crack inside of my head... of course that didn't happen last night, but I couldn't help thinking about it. Must stop watching er.

scheduling mishaps & conversations while dreaming

tonight i go back into work... had to change my schedule to only work 8 h tonight... i tried to schedule just working three 12 h shifts to maximize my home, study and family time. luckily for me i am able to adjust my schedule as i need to, as tomorrow night i have to change my 12 h shift to only an 8 (again) because of baseball games and practices. When both kids are in different areas of town, it can be difficult to manage everything involved with the games and practices. so back to the 8 h shift I go.

tonight i get to work in the unit.. i love working in there. i especially love the monitors that already have the vitals all ready for you :) makes my job so much easier, plus i have time then to learn from the nurses that are working. i guess i will take in my school work to see if i might have sometime to work on that a bit in the slow periods. that's one bad thing about nightshifts... it can be verrrrrrry slow quite often.
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the other day while sleeping, my youngest son woke me up (love how they do that!) to ask me if he could walk up to the convenience store to get some candy. (normally I wouldn't care if he did, as long as he asked). i am not sure what i had been dreaming about, but i told him plain as could be that " no, you can't walk up that far. you have high blood pressure, and i would be very worried that something would happen to you." he looked at me and said so innocently, "does grandma know i have high blood pressure?" as soon as he asked me that, it dawned on me that i had been half talking in my sleep and i couldn't help but laugh at myself and told him "honey, no, nevermind, try not to talk to me while i am sleeping huh? you don't have high blood pressure, you are only 9!!" LOL i still get a giggle out of it... and it's things like that why i tell the boys do not wake me up for any phone calls while sleeping... i never know what i might say to people!

summer pharmacology

this is the second installment of the course. we had taken the first part in the fall last year. one thing is for sure, pharm isn't for those who don't take the time to study and review the material. my biggest issue with this class this summer is that we have no class time/no lecture time at all. we are self-directed, teach this to ourselves, then go in and take a total of 3 tests for the "semester."

my biggest issue with myself is that i am so lacking in the self direction part. i just do not want to study anything at all right now.. just want a break so i can be fresh in the fall for psych. i am lucky that we have at least already worked with the cardiac and respiratory meds so i do have a foundation.. it is just remembering all of it for the tricky test questions.

tomorrow is our first test.
with so few tests, i really pray that i pass the test...
not that i am afraid of failing,
i just know how difficult it is to make up the scores to get above an 80.


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* Update: Passed my test *smile* phewwwwwwww :)

Poo Poo and yes, More Poo

One of the things they don't tell you before signing up for nursing school is just exactly how much poo you get to observe and evaluate for its color, consistency, amount, and unfortunately, the odor is an added bonus, and I cannot forget being prepared to scoop for specimens. One thing is for sure, nurses must have a keen sense of smell and a strong stomach. They can identify the differences between tube feeding poo, c diff poo, gi bleed poo, iron poo, and so on. And it is always good to have something special that helps sidetrack the odor once a whiff is in... we use shaving cream, a cheap odor buster that doesn't irritate the bottom.

These past few days, I got christened with starting my first tap water enema. I worked the floor with my first year instructor -- she was excited for the experience it would give me. I wasn't necessarily thrilled, the pt drank the whole gallon of golytely and didn't go one time the entire shift---- so I knew it was not going to be pretty. And it wasn't. The pt was being prepped for a colon, however it was a no go. After the 3rd one, it was clear the pt would not be having that colon that morning. It would have to wait for the next day. I felt so bad for the pt. Over 90, state dnr, but yet the dr insisted on the colon d/t the possibility of a lower gi bleed. After the colon was finally done, nothing was found. There was probably a bleed somewhere, but they do not know where. That night after the colon, they had to be transfused with 3 units prbc. And this was nothing new for the pt as they have had multiple transfusions over the past few months. My preceptor didn't think the pt would make it through the night, that all of this was too much for them to handle. They were still alive when we left this morning, and hopefully they are still alive by the time I go back on Saturday.

Sometimes, I just wonder when enough is enough as far as taking into account the person's age and etc. I have seen them do a colon upstairs, it's not pretty. If I am over 90, just LET ME BE. I think I will create a do not do these procedures on me list for when I am that old. If I make it that long, I expect to be able to eat what I want, or what I can. Drink what I want, and golytely isn't going to be on that list. Sign me right up for comfort measures only, and let me enjoy my last days in peace. Just turn me over every 2h so I don't break down.

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And I just wanted to do a small update on the intubated pt from the previous post. They had been extubated, but the sats fell down to 19% and they were coded and reintubated. It's unclear whether or not they will be able to come off of the vent. The tracheal deviation was d/t a mass pressing on the trachea. However, they were flown out to a bigger hospital yesterday, but I don't know why. It's obvious the condition was much more critical than we could handle.

5 minutes.

It was a relatively quiet night in the Unit. One had a possible PE and was alert and oriented. One was on a trach-vent and very well-behaved. One was in with sepsis s/p not going to dialysis with consistent low bp's, and had mrsa in the blood as well. So after a a fairly quiet evening thus far AND being able to to do actual nursing stuff rather than just simply cna stuff, I was quite enjoying myself. It was my first night in the Unit as well.

The nurse that I was assigned to and I worked on her assessments. We had to draw a blood culture from our trach pt d/t an elevated temp. So we were getting ready to put in the order and were discussing about how to draw blood from a cvc line - flush, draw and discard, then you draw the blood for keeps. This was just around 9pm. Then we hear a splash and the other nurse yells out to my charge nurse. We get up and look in the room of the sepsis pt to see blood everywhere. From the pt all the way to the edge of the door. So I run to get my "haz-mat" suit on (will explain in a minute)... my charge nurse immediately starts calling the doctor and getting meds and fluids for the room and calling the family. The pt only had a saline lock. I grab some pads to spread out over the floor to be able to walk into the room and immediately am told to suction while the other nurse gets the fluids ready to bolus wide open. As I am suctioning, the pt continues to vomit up copius amounts of blood. Clots the size of grapefruits come out. But the more I suction, the more the blood keeps on coming. The pt rolled the eyes, lurched forward, and then collapsed. And all we could do was continue to suction and stand there and watch that last final moment. The pt was a DNR. And it took exactly 5 minutes for them to bleed out and die.

However, there was no time to reflect. No time to call a code. There was no code; there was only 5 minutes. And in another 5 minutes, the family would be there. The experience was adrenalizing, and it would not end yet. We had to clean up that room and the patient so that the family did not see their beloved in such a shocking state. There wasn't time to think about it, we just started soaking up the blood from the floor, from the door, from the wall, from under the bed, from under the patient, from all over the front of the patient. Blood was absolutely everywhere. Yet as a team, we got it done. And the patient suffered no more. And the family did not have to suffer from the sight of all of the blood.

You always hear that a person can bleed out in 5 minutes, but it is just one of those facts that you store away in the back of the mind. You believe it, because they tell you it is so. Even though a small part of you wants to not really believe it, as it is such a short time. But that 5 minutes seemed like eternity. And until I saw it for myself, I was part skeptic. Now I believe completely.

As for the cause, it was a ruptured esophageal varices. Had there been time, we would have gotten the GI doc in there asap. Had there not have been a DNR, we might have had been able to try to do more to keep the pt alive. But we only had the 5 minutes of acute hemorrhage and it was over.

Now for some of the other side of the story... right before the "splash" the other nurse said that the pt said to "call 911" then it all began. Amazing how people just know, isn't it? But as we were scrambling around in our isolation gear to get this or that, especially for the clean up.. our alert and oriented patient was able to view the goings on. That door was shut, but there was no time to worry about blocking the line of sight. We had a medical emergency. So after it was all done... that other pt told me that they knew something bad must have happened as we were all running around in our haz-mat suits. It was actually posed more as a question, and I politely had to tell them that I was sorry, but I am unable to talk about that. 5 minutes later, they were calling for the chaplain to visit. Of course that pt was okay, no impending doom. Just fear. Fear that they too now knew just how quickly death can take a person.

Intubation...

Worked in the unit the past couple of nights, and for the most part, everything was very quiet. However, Wednesday night, the er admitted a pt under 40 y/o to PCU who had sats in the 60s down in the er, but by the time they got to the floor, they were sat-ing in the 90s. Then for some reason the sats dropped down to the 50s, even into the 40s, and they became completely unresponsive. So off to the unit they went, at almost shift change even. In the er, they pulled off 3000 cc of fluid with lasix. Anyhow, as soon as they came into the unit, anesthesia was called in to intubate. [For some reason, I believe I heard the er doc state that the pt had tracheal deviation to the left, but I didn't see the xray reports this evening past to know what had happened.] They were given a Diprovan drip to keep them sedated so they wouldn't fight the tubing. The BNP was only 309, which is elevated and thus the diagnosis of CHF. But at such a young age? The nurses speculated that they must have had HTN for quite some time for the heart to go into failure, or something else must be going on. I don't know how long they will be on the vent, but I felt so sad for them. The PCO2 levels were 118 and PO2 was 39 at the time of intubation. No doubt they were in critical condition. It was an interesting experience nonetheless, even if it happened too close to shift change. Emergencies are never planned for sure. I know some complained about them staying down in the er for so long, but when they came in, the main complaint was that the eyes were burning and that the feet were swollen. Not exactly a rush with those complaints. I truly believe that if they knew just exactly how bad they were, they would have gotten them straight to the unit without having to go through all of the waiting. I wish it were easier to educate people on the signs and symptoms that are serious and need attn right away. Ah well, now I am rambling.... after a long night of fairly quiet patients, I am just ready to go on to sleep.

Days off... RIP Jack

Finally finished 3 shifts in a row... not a whole lot of excitement within those days, and thank goodness mr. fists was gone. about the only thing that really happened was we had a confused little lady pull her foley out. ouch is all i can say about that. i know it must have hurt terribly, but on the other hand, thankful for the experience of getting to put it back in.

Today i start my second section of pharmacology. I am a little unsure about taking this class over the summer, mostly because it will be an intense 10 weeks with so much information to learn in not quite as much time. Will keep posted about how the class goes. I just know that I am tired and a little burned out on studying. I really need to stay focused toward my goal, no matter how difficult it is.

On a personal note.. my youngest son is "graduating" elementary school today. Fills me with a bit of sadness because he is my baby, and growing up so fast. Another sadness in my heart is the death of Jack Bristow. I loved Alias, and I loved his character.. and I hated it that they killed him in the end. Why couldn't he have just waited for help? Why? It was however a great end to a great show.. one that I truly hated to have to watch, because I knew that it was the end. Loved Syd and Vaughn finally on their beach in the middle of nowhere just living life... but with so many things coming to an end, yet the idea that some openings were left to be able to pursue if this show is ever revisited in the future. I will definitely have to rewatch all the dvds this summer, just to keep the whole series fresh. Anyhow.. I have to run to get ready for the ceremony... RIP Jack, you will be missed.

No Psych Meds?

This post stems from my experience at work the other night. I just wonder why it is when the psych patients get moved into the hospital that their psych meds do not tend to come with them or get ordered accordingly. There is a reason that they are on these meds! And when they do not have them, they can be restless and agitated and combative. Case in point, Mr. Fists. A rather non-eventful fellow, as long as you weren't touching him. He did not like to be touched, so getting his vitals and fbs was a bit of a problem. I did get him to lift up his arm for his bp, but as soon as I slid the cuff up and under, he changed his mind and flexed his arm catching my left arm at his elbow/bicep. Now he is a strong fella, but as I tried to get him to relax his arm, he decided he wanted to dig his fingers into my left wrist. Ugh. It broke the skin and caused a little bit of bleeding, nothing serious by any means. Unless of course you think about where his fingers had been before that and omg.. who knows what kind of crazy diseases this person might be carrying. I even had gloves on, but he dug through the end of it and still managed to get my skin. So, I quickly move to the sink and begin scrubbing my wrist with the warm water and soap. Heck we all know that the skin is our first line of defense, and so many infections are introduced by a break in that integrity. So I scrub. And try not to be upset, because he really doesn't know what he is doing.. or does he? And why didn't he have enough of his psych meds to calm him down so that we aren't having to be put in these types of situations. Anyhow, I ended up having to take a urine test - because the patient scratched me. I think that is ridiculous... I would much rather them test him to see what was growing under his nails rather than to test my urine. I have no worries; I am clean.. but is he? I have kept some antibiotic ointment on the site for a couple of days now, but one spot is still a little red. I have no doubt that I will be okay, but it is just the thought of bringing something home from the hospital that I just really do not want. I just hope that when I go back tomorrow night that he has been discharged. (please?) Although I am sure that our lovely Ms. Situation will still be there.

Ms. Situation was just admitted to the floor Tuesday night. Her responses were mostly limited to "yeah" and "uh-huh". To every question. Although she would answer "that would cause another situation" to some questions, such as when asked if there was any pain upon palpation of her abdomen. Not quite sure what her situations were, not sure I really wanted to know, but I did find it mildly humorous at the time. It can be difficult to ascertain specific responses from these type of patients, when they aren't exactly in their right mind, nor their left as it seems sometimes. This is when the training into non-verbal cues can become very handy. Even though the palpation may have caused a "situation", her grimace on her face told a larger tale. It was painful for her, perhaps she just didn't know how to express that in the right words. Well we shall see what happens when I go back tomorrow night :)

if you ever remember anything...

this wise words came from my preceptor at work... about blood transfusions. You have to understand first and foremost, she is quite an anal person. But anal is good in nursing, after all, we do have some responsibility and accountability for our actions and misactions. So anyhow, she is telling me, "if you ever remember anything about blood transfusions and blood warmers, always remember that the tube coming from the warmer goes directly into the iv site." Now I am not sure if the previous nurse that had set it up did it wrong, but by the look on her face and the disgust in her tone as she said this to me, but I assumed that it was indeed, set up wrong. I can already tell from my other experiences with blood, that it is not a fun task, not at all. I mean so many things can go wrong, and you have to continously monitor the pt's condition along with all of the other patients on the floor as well. Anyhow, keep those words in mind, tuck them away into a memory to be used later. I really would like to talk about the person who was receiving that blood, but first, I have to give another word of warning about blood transfusions. When running them as secondary piggyback, always make sure that the secondary is running and not the primary. This could cause big problems (like air in the filter!), especially since blood can only hang for a predetermined amount of time (4 hours). Tuck that information away for future use as well, I promise it will most likely come in handy.

Now about Mr. Transfusion... such a lovely fellow with a GI bleed who was absolutely zonked on pain meds the first part of the shift and all through the transfusions. Never even knew what was going on I believe. Working the floor like this, I don't usually get to go through the entire charts and learn everything about everything, but mostly just observe and assist when needed. So anyhow, halfway into the shift he springs to life. As I am entering the room for the second set of vitals, this man has his jeans on, and he is bound and determined that he is going to make a phone call, at 4:30 in the morning. No idea who he wanted to call, he just had to make a call. In fact, he demanded that someone wheel him downtown to make his call. As I tried to calm him down and assure him that he would be able to call from his room, he got a bit more agitated and things weren't looking so hot from my angle. So I went to the charge nurse and let her know about this patient and his demands and his agitation. From further assessment, it was pain driving his agitation (as well as an extensive etoh abuse history), so he received his pain meds which sent him back into the lovely pt he had been at the beginning of the shift. Sometimes I do find it intriguing when a pt throws you for a loop, this time however, I was just happy to have him sent to his own personal la-la land where I know he was much happier.

on my day off..

and i cannot sleep, of course. this is absolutely a side effect from working nights. You work nights therefore, you cannot sleep at night. Anyhow, I am just now getting started on my blog as you can read. I am about to enter into my last 2 semesters of nursing school and am so looking forward to this time next year when I will be done with this part of it forever (unless I decide to pursue my master's). I am currently working nights as a student nurse extern, in which I have seen and done so much more than I have ever thought of doing during my clinical experience. For that I must thank my POE (place of employment) for giving me the opportunity to stick tubes into people.. I love it! *grin* Unfortunately the rest of the reality is that those of us who have accepted this position are really not much more than glorified CNA's who are allowed to "do" things from time to time should the opportunity arise.

I have listed a few of my stories that I will share over the summer as well as adding in some new ones that I experience along the way. It is so difficult to find a way to share some of the stuff that we experience and see, as most people just really do not understand it. I am lucky in that my mother is an RN, so I can talk about things with her, but she has done it for so long, the little things that intrigue me tend to bore her, so this is how I decided to let it all out in a blog.
Enjoy.. and off to write my first little story...