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.