Clinicals

Clinicals were very stressful. It was like living in your own little world for about 2-3 days a week because you have all of this information to write down and put in your head for quick retrieval. It gave me horrible hand cramps from all the writing. In fact, our first year, we had to literally write out each drug card. Not typed, not pre-printed, but hand-written. It sucked, especially when I had a patient like patient 1 below. We prayed for the patients with only like 5 medications. But I also learned those medications very well because of it. In our second year, which is exampled below, we were allowed to type up the drug cards or use the pre-printed ones if we had them. Most of us didn’t, we just typed and printed them ourselves. One day, in our first year, I had a patient with anemia. Instructor wants me to write up ALL the anemias. I could have died. Do you know how many there are??? My hand cramped for like 3 days after that because we had to hand write those too. She was a tough one, but I respect her for it, even today. Ok, so you want to know what it was like in my clinical experience? Read below.
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Here is an example excerpt from my clinical experience:
Day 1: Attend lecture. Get patient assignment for the next day, which will be 2 patients.
Patient 1:
Diagnosis: Pneumonia. Patient history includes: HTN, DM, COPD, CHF, Hypothyroidism, AFib, GERD, CAD, CABG (2005), Bilateral Fem-Pop (2003, 2006), Smoker.
Med List: Protonix 40 mg, Atenolol 25 mg, Lisinopril 40 mg, Diovan 80 mg, Reglan 10 mg, Digoxin 0.125 mg, ASA 81 mg, Glucophage 1000 mg, Glucotrol 5 mg, Levothyroxine 100 mcg, Pravachol 20 mg, Lasix 20 mg, Aldactone 25 mg, Coumadin 2 mg, Novolog Sliding Scale, Lantus 40 units, Multivitamin, Zosyn 3.35 grams, Solumedrol 60 mg, Levaquin 500 mg, Xopenex/Atrovent nebs, Advair, Spiriva, Nitropaste ½ inch, Nicotine patch 21 mg, Ativan 0.25 mg, Gabapentin 600 mg, Hydrocodone 5/500 mg prn moderate to severe pain, Tylenol 650 mg prn mild pain, temp > 101.
Treatments: Blood sugar glucometers AC/HS, O2@3L per NC, Nebs q6 hours, Daily PT/INR, daily weight
Patient 2:
Diagnosis: Acute Pancreatitis. Patient history includes: GERD, ETOH abuse, Smoker, Cholecystectomy (2000), Appendectomy
Med List: Protonix drip 8 mg/hr, Demerol 50 mg, NS with MVI, Thiamine and Folic Acid to each liter @ 80 cc/hr, TPN @ 60 cc/hr, Lipids @ 10 cc/hr [total 150 cc/hr IVF], Nicotine patch 21 mg, Novolog Sliding Scale, Ativan 1 mg prn, Librium 50 mg prn.
Treatments: Blood sugar glucometers q 6 hours, Central line, Neuro checks q shift and prn, NGT to LIS with 30 cc irrigation q shift, bilateral soft wrist restraints

With assignments in hand, off to the facility (45 min away) for chart information to include: H&P, lab data, and any other information pertinent to the preparation tool and treatments scheduled. This takes 2 hours of writing stuff down and then 1 hour to drive home.
Get home. Make sure uniform is clean and ironed, if not , throw it in washer stat. Order pizza. Kids love you for ordering pizza. Send kids in other room to watch whatever they want. Kids love you more because they can watch Spongebob, Sportscenter, videos all evening as long as they get their homework done. Hole yourself up at computer or desk or kitchen table with all your Med-Surg, Drug, Lab, and Care Plan books. Write up the main medical diagnosis and one additional diagnosis for each patient – complete disease pathology plus anything else the book has in it so nothing is missed. Make a list of nursing diagnoses and care plan interventions expected for each patient. List all abnormal and pertinent normal laboratory data with explanations of each and why abnormal. Write or type up each medication listed on index cards to include: name, action, dose and route, contraindications, administration information, side effects, and nursing implications. Make sure kids are bathed and tucked in by 10 pm. You finally get to bed at 1 am.

Day 2: Alarm goes off at 4 am. Shower. Iron uniform if not already done. Pack bag with all needed nursing supplies, paperwork, and whatnots. Leave house by 5:15 am. Get to facility at 6:20 am and on the floor by 6:30 am for pre-conference. Discuss expectations of patients and their diagnoses. Get report from floor nurses. And off to the floor to begin your patient care. You are selected to give medications today on both patients. You have to do all patient care to include toileting, baths, linen changes, meals, etc. Also reviewing drug cards so that when quizzed by the instructor, you know these medications and why they are being given. You also have to find time to write your notes and assessments for review by the instructor. She would like to have these by 10 am. Continue throughout day until 3:30 pm when you break for post-conference. Leave facility by 4:30 pm. Get home by 5:45 pm. Plop on couch. Nap for 30 minutes until kids wake you up. Take youngest child to basketball practice. Bring sandwiches to eat on the way for dinner. Get home at 9 pm. Put uniform in washer again. Review paperwork for tomorrow and make any needed changes. Iron uniform tonight. All in bed by 11 pm.
Day 3: Alarm goes off at 4 am again. Get up at 4:30 and shower. Bag still packed from yesterday. Enjoy extra 15 minutes of coffee. Get to facility by 6:15 am and repeat yesterday all over again. Leave facility by 3:30 pm today as instructor will do post-conference in class tomorrow after the test. Get home and finish up clinical paperwork due tomorrow. Fix a real dinner tonight and get kids to help with clean up. Gather books and notes to study for test tomorrow. Get to bed by midnight.
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How the day went in the hospital depended largely on the patient. If you had a lot of extensive things going on, like above, it would be so hard to get everything done, but you did it. You knew your drugs. You knew their medical diagnoses in and out and could spew off tidbits of information at the drop of a hat. When the instructor asked you about the most obscure medication on the list and you didn’t know it, she would let you look it up and then tell her about it. One thing about clinical is that your fellow students were usually there to help if needed. And your instructor was always available. It was a team work environment. But I am so glad it is over :)

er trip

oldest son 'partially subluxated' his right shoulder joint this evening playing basketball. supposedly, he 'packed' a shot, felt the shoulder "slip out" and couldn't move his arm. so being the tough dude that he is [he is almost 15 now], he decided he would try to put it back in himself. then he calls me at work because he is in a lot of pain. oh yeah, he was in pain. but he got the joint pretty much back in place, so the er doc had very little manipulation to do. for me, the mom and not the nurse, this made me pretty happy because i would hate for him to have to endure anymore pain than he has to. although i have to say, that my son is pretty stoic when it comes to pain.

now he has to wear a sling for the rest of the week and got a note to get out of PE. he was ok with that, but he really wanted a slip to get out of homework for the week because he is right handed and said he won't be able to write. KIDS. :)

i wish i could say that this was one of the few er trips that we have had to do. well for my oldest, this is one of the few. he doesn't get hurt often. he has broken a toe before, and that is about it, really. oh yes, once he broke out in hives but never did figure out why.

my youngest has been to the er as a baby for influenza, hydrocele blocking urine output (several times) until that resolved, rolling down the stairs (hangs head -- who knew he would roll over to the stairs?? lol), falling down the stairs in the walker (yes, those warnings were heeded, and yes we had a gate, but oldest son left gate open!). One of the sounds you will never forget is the 'thump, thump, thump' of your child going down the stairs. Oh and he has had broken a finger too.

now, those are about the only reasons that they have been to the er. tonight a whole family with 5 kids running around the er waiting room, jumping, laughing, having fun, acting like normal wild toddlers all came in for an 'overdose'. Must have been benadryl with paroxysmal effects or something. they were seen before my child with the dislocated shoulder. good thing it wasn't serious on either accounts.

ok off for the night. gotta work in the morning. sigh.

where have i been?

I would love to say where I have been today, but it's a little to close to home. Just let me say that it involves something famous. :) once in a lifetime.

It was fantastic, really. But that is all I can say.

orientation

monday began my official orientation to the icu. started with the standard critical care classes, and orientation on the unit. not that i needed to be shown around much, after all, i did work in there as an extern for almost a year.



i just wanted to say how happy i am to get up in the mornings and show up for work. what a difference a change makes, especially a change to an area of your career that really pushes your buttons in the right way.

Continuing Education

Is it just me.. or shouldn't all states require nurses to keep current with the nursing practice? After short research, I have found that approximately only 30/50 states require the nurses to have a certain number of CEU's per required time period. In fact, I live in a state that does not require nurses to fulfill any of these requirements. Is that a good thing.. or a bad thing?

Sure, I think that we should all attempt to remain current after our graduation. But on the other hand, some of these continuing education units are damn expensive. Who wants to pay 30 bucks for each test that is sent in? I don't! I don't understand why it is so expensive, and just where does that money go? For instance, if your state requires 30 units/hours over a course of 3 years, and let's say for the sake of it, each article in your favorite journal that has these continuing education articles/tests for $29.95 each and worth 1.2 contact hours each.. that means that you will spend approximately: $750 to continue your education if you only go that route. That's a good little chunk of money for some people.

But, does this also mean that nurses who live in a state that requires these units are considered to be more 'up to date' than those who live in states that do not require these units? Does the responsibility then fall upon the facilities to keep nursing practice updated on new standards? Who is responsible for teaching these 'old' graduated nurses the new tricks of the trade? Graduate students? Staff education? I don't know! I guess if your state doesn't require these ceu's, then the responsible thing to do as a professional would be to subscribe to a journal or two or so to keep yourself updated. I know I do.

change of shift

Change of Shift is up at Dr. Anonymous. I am pleased to be included in this week's edition.

Go on.. have a read :)

10 things I can't live without

No particular order here...
1. DVR/Tivo
2. My car/My job/My paycheck (ok that is 3 things but they are all related)
3. Diet Mountain Dew
4. Coffee with Hazelnut or French Vanilla creamer
5. Ben & Jerry's Chocolate Fudge Brownie
6. XM
7. Netflix
8. Laptop/Internet
9. Cell phone
10. My kids... of course.

TV

What am I going to do this January when I have no new shows to watch? Other than American Idol. I loooove American Idol, but no 24???? No Lost????? and so on??? Do they not know that the only tv show my step-father watches religiously is 24? Do they not know how miserable that is making my mother, having to listen to him gripe about nothing to watch this winter since 24 is suspended indefinitely? All of this over royalties for web content, if I understand what I am reading.

I urge the studios to give these people what they want. Without them, you have nothing, as you will soon see. People love to watch tv. Love it. Especially in the winter. There is nothing else to do! But on a high point, I am taking 2 classes for the spring semester, and this will allow me to concentrate on my classes instead of being disrupted by tv. Shoot, maybe even families will start spending more time together. Maybe even people will get up off of the couch and start exercising???? (I doubt it.. luckily, cable provides mucho entertainment, even if they are reruns).

Anyhow.. I will probably have a boring winter with nothing to look forward to on the tv. Boring. I guess I can up my netflix and watch a load of movies. What other option will I have? Other than American Idol and all of its cheesiness.

Fatal

It was a simple case of clostridium difficile. Or so it was thought. But in reality, it was much, much worse. Thanksgiving day, the patient was in good spirits, mad as hell that there was no turkey to be ate or the day spent with the family. Mad as hell because the doctor said that the patient was full of stool and what was escaping was also positive for c. diff. The patient is on isolation. Lots of handwashing going on in the room by the staff, and family had been told to be sure to wash well too. But did they? They were reminded time and again, but can we monitor their every move? Anyhow, the patient was ordered a laxative to get the stool out overnight, which did not work until the next day. Samples sent to the lab continued to come back positive. Patient is in fairly good spirits, no distress, just upset because the laxative seems to have been working overtime now.

I did not have this patient the next few days. But fast forward 2 days, come into work and the patient is being transferred to ICU. WBC count suddenly up to 48. Is it an acute abdomen? I will never know. Once that patient was out of my care, then I had to worry about my new patients and their problems. But this patient just looked bad.

Fast forward 2 more days. WBC count suddenly up to 120. Pt dies. From C. diff resistant to antibiotics. Gone. Coincidentally, patient had a family member that had passed very recently from complications associated with the same disease. Hmph.

This is scary to me for several reasons. Did I wash my hands enough? I think so, god, I hope so! What about the family that had visited him on the holiday? Did they wash good enough when I wasn't there? Did the other nurses remind them to be diligent on handwashing? Did the other nurses wash good enough and often enough as well? Did the housekeepers clean the room good enough so that the next person doesn't get this disease?

I have had a lot of patients who have had C. diff. A lot. It can become so common at times (they seem to all be in the hospital at the same time) that it just becomes a nuisance. The constant stools. The smell. But never had anyone died from it here recently in the last few years anyhow. Now, I know I will learn from this. I am sorry this patient had to suffer that fate. Truly sorry. But now I will be super diligent in handwashing and all the precautions that come with this disease. Not that I wasn't following the guidelines before. Not that I didn't wash when entering and leaving the room. I always had on gloves, always. But the idea that somehow I may contact this highly trasmissible disease is just simply scary.

And for all the nurses out there, hopefully this will serve as a reminder of the true seriousness that C. diff can present. Be diligent.

Pt satisfaction rules, hospitals drool

Perhaps I am a bit jaded. I don’t know. I cannot for the life of me remembering being taught that the patient is always right. Now, I know that the “customer is always right” is an old adage passed down in customer service to keep those customers coming back. But when did patients suddenly begin to apply to these same standards? More often than not, the patient isn’t always right, otherwise why else are they in the hospital? Most don’t choose to be admitted, although granted there are those people out there who enjoy nothing more than being in the hospital.

I also understand making that stay in the hospital as pleasant as possible. Sick people are miserable and have the capability of making everyone else around them miserable as well. This misery feeds on the environment and trickles down to all levels of employees. But with the implement of all the muriad of information about patient satisfaction, I think it is high time that health care professionals take it back.

Being in the hospital is not about what you want, it is about what you need. Staying in the Hilton on vacation, for example, is what you want. But you don’t necessarily need it. The hospital is definitely not the Hilton. I mean, I would much rather be in the Hilton, but they probably are not going to be able to give me IVF. You will pay lots of money to stay in either, but only in the hospital do the employees also potentially pay for your stay, especially if you are on Medicare or Medicaid. Medicare or Medicaid certainly will not pay for your stay in the Hilton. Since many hospital earnings come primarily from these two sources, why can’t the health care professionals have a say in the care of the patients? Why do we have to bend over backward because the administration says so? Between all of the taxes paid from our paychecks, we probably send the government enough money to pay for that hospital visit. Why do we have to heed to the complaints of the people who didn’t get what they wanted out of their hospital stay?

Not all patients are like this. Many are very gracious about the care and information that we give them. But it is the few worm infested apples of the bunch who take the time to send in those surveys who ruin it for everyone. I don’t know if some people think that there is no need to send it in if you had exceptional care. It seems it is only the ones who had a “problem.” Is that really reflective of the care we provide as professionals? We are admonished like school children if we are not doing everything possible to ensure the stay in the hospital is not like the stay in the Hilton.

Some examples of things that will never be like the Hilton in the hospital:

* Your food will never taste like it does at the hotel. In fact, it won’t even taste like the food at home, let alone McDonald’s. But because of the food you eat in those places, you are in here with a blood sugar of 600. Please don’t be upset with us when your food tastes like cardboard. We are trying to make you better, and that food will most likely have very little sugar and salt. Sorry. And we will probably see you again in a few weeks because you didn’t follow the instructions that we left with you at discharge on your diet or medications.

* You will get woken up at all hours of the day and night. We do not have a wake up service. We need to monitor your vitals and all sorts of things, even at night. Unlike in the hotel, you are not here for rest and relaxation. You are here to get healthy, and if that means waking you up in the middle of the night because your heart rate suddenly dropped to 30, then we will do so. Sorry.

* You can call for room service in the hotel. They are happy to bring you whatever you want whenever they can. Shoot, you even tip them for their services. At the hospital, we cannot accept tips, even though we may bring you many things you want throughout your stay. But just because you want something, doesn’t mean you can have it. For instance, the person above with the cardboard tasting food, please don’t have your family bring you a bucket of chicken in. It will only make your stay that much longer because we will not be able to get your blood sugar under control.

* In the hospital, all rooms are pretty much created equal. [Unless you are in the OB ward, but that is different.] Please don’t complain about the furniture or comfort of the bed. In the hotel, you can have a nice, soft, pillowed mattress. But in the hospital, those types of things are difficult to clean and breed germs that we may even be unaware of. Yes, we understand that it is not like sleeping in your bed at home or at the hotel. There is nothing that we can do about that. Really.

Well, those are just a few things that I can think of anyhow. All I want is to take care of my patients in a safe environment. I cannot help it if the MD orders something not to the patient’s liking. Like actually getting out of the bed and sitting in the chair for a few minutes a day. Or being on a fluid restriction because your kidneys cannot handle it, and the extra fluid will send you into pulmonary edema, but every drop of fluid you can get your hands on you suck down in a blink. Gone are the days of patient responsibility. It has become an all hospital responsibility to ensure that everything is done to the patient’s satisfaction, regardless of outcome.