well the nurse manager where i work has decided to fill the open positions in the ICU, so it seems as though I will most likely be starting out on the tele/med-surg unit. Actually, it is quite ok with me. I love working in the ICU, but I am not stupid to think that I shouldn't get good floor experience before moving into a specialized area. It is a bit of a relief because now I don't have to rush to take ACLS or anything like that before moving into there. :)
We got the papers to fill out our official application to sit for the nclex exam after graduation. Just having the papers and the book makes me nervous lol. Just thinking about filling it out makes me nervous. What if I make a mistake? I guess I will really have to review it before filling it out to make sure it is all right when I hand it in. Nervous.
Ahh well, am sure things will work out in the end as they are supposed to be. I won't spend a lot of time worrying about the little stuff because I have too many other things to do and other things to worry about, such as my test coming up on Monday and my other classes as well.
Ok off I go to review a bit before getting ready for work.
23 February 2007
01 February 2007
weight a minute
Last week, I had a really great learning experience. This week, my assigned patient (Yes, we were supposed to have 2 this week. Unfortunately, census was down so we only had 1.) Anyhow, my assigned patient was admitted over the weekend with a change in mental status. Try writing that up for clinical prep – shoot there are so dang many things that contribute to a change in mental status. It is difficult to know which direction to effectively write up without knowing any further history. But I got it done. Arrive at the clinical hospital 0630, ready to go. Get report on my patient, learn some things important, like there was a right subclavian portacath. (immediately knew that she was most likely a cancer patient, since they tend to have these for chemo medications). She was s/p breast ca and a left radical mastectomy. She became seriously confused, was admitted, and had a raging UTI.
It’s no secret that a UTI will cause a confused presentation in the elderly. Much documentation has been done on that subject alone. Heck, Pope John Paul the III died from a UTI that progressed to sepsis. But this woman was only 50. Hmm.. ok, I thought. Also learn that she has a positive history for diabetes and hypertension. Pretty common these days, especially together. But I was not prepared for her. Not by any means. You see, I walk in to greet her, and find out she was the size of the hospital bed itself. Literally. They had ordered the special bed for her, but it had yet to come in. So in the meantime, she is packed into the regular bed on an air mattress. She couldn’t turn or move because there was no room. None. She is 530 lbs. And full of fluid.
She has widespread anasarca, which is now weeping and causing skin breakdown. Everywhere. Straie were puffy and full of fluid, looking like they would bust at any moment. Left lower leg is dusky and her toes are almost black. Her skin is literally sloughing off from the fluid overload. But that wasn’t even her main problem. Nope.
Although that in itself is pretty horrible to see, it must be even more horrible to experience.
Her main problem, however, was pancytopenia from the chemo. Her WBC count… normally 5-10, were 0.9. Hgb was 7.9 after a unit of prbc’s and procrit. Most seriously though… her platelets were 6, when normally 150-450. There was petechiae everywhere and purpura over her left leg as well. DIC was a formidable risk, and ever present in the mind. Sure she had open sores where her skin was tearing to let the excess fluid out. DIC, on the other hand, could be a potentially fatal complication. Yes, she had received some irradiated platelets, but still her numbers only went up to 12. She was on vitamin k. Her bleeding times were well out of whack.. as to be expected.
She was really a nice woman struck by cancer and now all of these complications. She was concerned that she was dying, and chose to ask me instead of her primary physician about her prognosis. (of course, I told her what I knew, that her blood counts were really low and her circulation was disrupted from her edema, but it was not my place for talking about a prognosis). Luckily, the second day, she had received her special bed and we were able to move her around in the bed to the best of our ability. Most of all, I felt sad for her situation. There was nothing as a nurse that I could do to really help her other than continue to try to keep her as comfortable as possible and monitor for any acute bleeding and pain. Couldn’t even dress the wounds properly as her skin was just too moist to have anything adhere to it. She was a completely different patient than I had last week, but still, extremely sick nonetheless. I guess that next week I will get my walkie-talkie :)
It’s no secret that a UTI will cause a confused presentation in the elderly. Much documentation has been done on that subject alone. Heck, Pope John Paul the III died from a UTI that progressed to sepsis. But this woman was only 50. Hmm.. ok, I thought. Also learn that she has a positive history for diabetes and hypertension. Pretty common these days, especially together. But I was not prepared for her. Not by any means. You see, I walk in to greet her, and find out she was the size of the hospital bed itself. Literally. They had ordered the special bed for her, but it had yet to come in. So in the meantime, she is packed into the regular bed on an air mattress. She couldn’t turn or move because there was no room. None. She is 530 lbs. And full of fluid.
She has widespread anasarca, which is now weeping and causing skin breakdown. Everywhere. Straie were puffy and full of fluid, looking like they would bust at any moment. Left lower leg is dusky and her toes are almost black. Her skin is literally sloughing off from the fluid overload. But that wasn’t even her main problem. Nope.
Although that in itself is pretty horrible to see, it must be even more horrible to experience.
Her main problem, however, was pancytopenia from the chemo. Her WBC count… normally 5-10, were 0.9. Hgb was 7.9 after a unit of prbc’s and procrit. Most seriously though… her platelets were 6, when normally 150-450. There was petechiae everywhere and purpura over her left leg as well. DIC was a formidable risk, and ever present in the mind. Sure she had open sores where her skin was tearing to let the excess fluid out. DIC, on the other hand, could be a potentially fatal complication. Yes, she had received some irradiated platelets, but still her numbers only went up to 12. She was on vitamin k. Her bleeding times were well out of whack.. as to be expected.
She was really a nice woman struck by cancer and now all of these complications. She was concerned that she was dying, and chose to ask me instead of her primary physician about her prognosis. (of course, I told her what I knew, that her blood counts were really low and her circulation was disrupted from her edema, but it was not my place for talking about a prognosis). Luckily, the second day, she had received her special bed and we were able to move her around in the bed to the best of our ability. Most of all, I felt sad for her situation. There was nothing as a nurse that I could do to really help her other than continue to try to keep her as comfortable as possible and monitor for any acute bleeding and pain. Couldn’t even dress the wounds properly as her skin was just too moist to have anything adhere to it. She was a completely different patient than I had last week, but still, extremely sick nonetheless. I guess that next week I will get my walkie-talkie :)
Toot Toot from the trainwreck
Each week, we are required to fill out a self-evaluation of our progress in lecture and in the clinical setting. We all stress out, hoping that our performance was satisfactory in our instructor's eyes. Since I had a difficult patient last week that I had felt I did pretty good with.. I gave myself all S (satisfactory) in all of the categories. I didn't make any mistakes, and did the best that I could with a dying patient (who passed over last weekend). We give this "tool" as well as a myriad of other paperwork for our clinical prep to our instructor to review and comment upon.
Now to toot my own horn :) I got my self-evaluation back with not 1, not 2, but 3 E's (for excellent). Yeah, I think I just grew about 3 inches lol. No one has ever mentioned getting an excellent in clinicals before, so maybe they were just afraid to say anything, like me. Some students can be so touchy when others do better, sometimes it is just easier to play things off. But to know that I did excellent in critical thinking, prioritizing care, and discussing scientfic rationales for treatment and planned medical care made my damn week.
Oh and I was sure to thank my ICU cohorts for all of their assistance and teaching so that I was able to competently care for that patient. They deserve huge kudos for contributing to my educational efforts :)
Now to toot my own horn :) I got my self-evaluation back with not 1, not 2, but 3 E's (for excellent). Yeah, I think I just grew about 3 inches lol. No one has ever mentioned getting an excellent in clinicals before, so maybe they were just afraid to say anything, like me. Some students can be so touchy when others do better, sometimes it is just easier to play things off. But to know that I did excellent in critical thinking, prioritizing care, and discussing scientfic rationales for treatment and planned medical care made my damn week.
Oh and I was sure to thank my ICU cohorts for all of their assistance and teaching so that I was able to competently care for that patient. They deserve huge kudos for contributing to my educational efforts :)
29 January 2007
Oh that quivering heart
Unfortunately we only had 1, yes 1, critically ill patient this weekend. Words cannot describe the letdown of complete boredom when this said patient slept the entire shift, except for a few moments of waking and talking to her family. It was the longest 8 hours ever. Well, almost ever. At least I didn't have to squirt any saline into my eyes to keep them from shriveling up from dryness :)
90 y/o comes into the ER from the nursing home with bradycardia. Turns out the potassium is 8.2 and is also in acute renal failure. Rhythm is oh so regular after atropine... 3 nsr beats and then a nice long sinus arrest pause. And it stayed this way for awhile until turning to sinus brady, rate of 40-50. Wonderfully spiked T waves. Emergency dialysis was scheduled, and a catherter inserted into the femoral vein. 15 minutes into dialysis... those T waves came right on down and NSR emerged with a rate of 70s-80s. Amazing, really.
This was the night before. Now, as my night moved along at the speed of a snail... I continuted to watch the rhythm, if not for a lack of better things to do. Potassium was now 2.3 and some ST depression was evident on the ECG monitoring. Some PACs were thrown in now and again, coming at faster intervals as time moved along. About 6 am...the rhythm went to 2:1 flutter for about 30 seconds and right into AFib. Have to say, that was about as interesting as the night got. Can't say that I have ever seen someone convert to AFib, so got to see something new. I wonder though.. did it stay in AFib or was it just transient?
I don't know where this patient progressed from there... I left at 7 am and didn't have to return until next Friday night. Chances are that this patient will no longer be a resident in the ICU, but moved out to the floor or even back to the nursing home by that time. Perhaps next weekend will be more interesting. Although I have to say that after this last week of clinicals.. it was nice to have an easy night of work.
One last bit of information told to me by the charge nurse: If you have to ask if you should call the doctor, then you probably should.
have a terrific monday! :)
90 y/o comes into the ER from the nursing home with bradycardia. Turns out the potassium is 8.2 and is also in acute renal failure. Rhythm is oh so regular after atropine... 3 nsr beats and then a nice long sinus arrest pause. And it stayed this way for awhile until turning to sinus brady, rate of 40-50. Wonderfully spiked T waves. Emergency dialysis was scheduled, and a catherter inserted into the femoral vein. 15 minutes into dialysis... those T waves came right on down and NSR emerged with a rate of 70s-80s. Amazing, really.
This was the night before. Now, as my night moved along at the speed of a snail... I continuted to watch the rhythm, if not for a lack of better things to do. Potassium was now 2.3 and some ST depression was evident on the ECG monitoring. Some PACs were thrown in now and again, coming at faster intervals as time moved along. About 6 am...the rhythm went to 2:1 flutter for about 30 seconds and right into AFib. Have to say, that was about as interesting as the night got. Can't say that I have ever seen someone convert to AFib, so got to see something new. I wonder though.. did it stay in AFib or was it just transient?
I don't know where this patient progressed from there... I left at 7 am and didn't have to return until next Friday night. Chances are that this patient will no longer be a resident in the ICU, but moved out to the floor or even back to the nursing home by that time. Perhaps next weekend will be more interesting. Although I have to say that after this last week of clinicals.. it was nice to have an easy night of work.
One last bit of information told to me by the charge nurse: If you have to ask if you should call the doctor, then you probably should.
have a terrific monday! :)
27 January 2007
Does it change you forever?
I heard a line from a tv show preview... stating that once you see someone die, it changes you forever. The first person that I ever saw really die was my grandmother. I am not sure to this day that I ever really got over that, to tell the truth. I still miss her terribly. Now, I have seen people die in the hospital many times, but it has never really affected me as much as my grandmother's death. Of course, I knew and loved my grandmother, so I am sure that would be the difference there.
But, I think that being with someone when they pass, especially if they do not have any family there with them, is important. I wouldn't want to die alone, and I don't think that anyone should have to. I'd like to think that there is an unmeasurable amount of comfort for that person, knowing that they aren't alone; that is okay to let go.
Just had to ponder that for a moment... now I have to go study.
But, I think that being with someone when they pass, especially if they do not have any family there with them, is important. I wouldn't want to die alone, and I don't think that anyone should have to. I'd like to think that there is an unmeasurable amount of comfort for that person, knowing that they aren't alone; that is okay to let go.
Just had to ponder that for a moment... now I have to go study.
26 January 2007
trainwreck approaching.... choo choo
We attend clinicals twice a week, and luckily, I survived our first 2 back in quite some time. So did my patient. Yes, that would be one patient. It was supposed to ease us back into real clinicals again. (Not that OB/Peds/Psych aren't real clinicals, but totally NOT the same as med-surg patients). However, when I got to the floor Tuesday morning, my previously assigned patient had checked out (probably transferred to a higher level cardiac facility d/t an acute MI). So low and behold, the charge nurse was more than happy to assign me my new patient. Beware when they say.. oh she is a good patient (HA). I should have seen the warning signs... heard the upcoming choo choo.. chug a chug a chug a chug. I didn't but it wasn't long before I was hit by it like a mack truck.
Let me first preface this by saying that under no circumstances should this patient have been on the floor... but should have been in the ICU. She was a full code and in acute heart failure. Her BP sucked and was falling. She was in atrial fib paced rhythm (dual lead pacemaker) with episodes of RVR. She continued to get all of her cardiac meds because the physician said that the benefit outweighed the risks. It didn't matter she was vasodilated in every inch of her cachetic body. Her heart required it. She was on a 100% nrb. She couldn't take but one bite of food before becoming breathless. Her veins sucked. She continued to infiltrate IV site after IV site. So much so that her arms were edematous from the infiltrations. She could not tolerate fluids. Her wbc count was 30.5 but not septic yet (blood cultures were negative, however, it would probably not be long). Thus, she had to have an IV to run her antibiotics. Central line attempts were unsuccessful and would send her into runs of vtach. Her blood sugars were consistently below 60; she refused to eat more than one or two bites. She had pneumonia and pulmonary congestion from the heart failure. Her hgb was 9.5; but had already received 4 units of prbc's earlier in her admission. Now she didn't even have an IV site appropriate to run blood. That is the picture of my two days in clinical. yeah, fun... all I can say for myself is that I am very lucky to work as an extern in the ICU at my hospital or I may have freaked completely out. (my instructor told me more than once that she was impressed with how I handled this patient).
On the upside, I did have the rare opportunity to see the cardiologist start a peripheral IV. I am assured by many nurses that this usually does not happen, ever. He is also the one who was talking to the family when we left about her code status. (I can tell you that I prayed and prayed that she did not code on me while I was there). It was a clinical of balancing on the tightrope, hoping that one small reposition didn't vagal her into oblivion. I also learned a lot. I learned that acute hf patients get their cardiac meds even with bp's as low as they can tolerate. Meds can be changed every hour. Orders written and rewritten every 30 minutes. Vegitation means to look for potential clots (not growing potatoes in the heart as I jested to my classmates hehe). Seriously, I knew it had to be something, I just didn't know what it was.
Next week, I take on two patients. Let them be stable. Hell, self-care would be wonderful even. I know that I am ready to jump back on the bandwagon and take on more than 1 patient, but not more than 1 like I had this week.. our supposed "ease back into the swing of things" week. I think that my clinical instructor would also like the same. Nah, no thinking.. I am sure she is hoping for the same!
Let me first preface this by saying that under no circumstances should this patient have been on the floor... but should have been in the ICU. She was a full code and in acute heart failure. Her BP sucked and was falling. She was in atrial fib paced rhythm (dual lead pacemaker) with episodes of RVR. She continued to get all of her cardiac meds because the physician said that the benefit outweighed the risks. It didn't matter she was vasodilated in every inch of her cachetic body. Her heart required it. She was on a 100% nrb. She couldn't take but one bite of food before becoming breathless. Her veins sucked. She continued to infiltrate IV site after IV site. So much so that her arms were edematous from the infiltrations. She could not tolerate fluids. Her wbc count was 30.5 but not septic yet (blood cultures were negative, however, it would probably not be long). Thus, she had to have an IV to run her antibiotics. Central line attempts were unsuccessful and would send her into runs of vtach. Her blood sugars were consistently below 60; she refused to eat more than one or two bites. She had pneumonia and pulmonary congestion from the heart failure. Her hgb was 9.5; but had already received 4 units of prbc's earlier in her admission. Now she didn't even have an IV site appropriate to run blood. That is the picture of my two days in clinical. yeah, fun... all I can say for myself is that I am very lucky to work as an extern in the ICU at my hospital or I may have freaked completely out. (my instructor told me more than once that she was impressed with how I handled this patient).
On the upside, I did have the rare opportunity to see the cardiologist start a peripheral IV. I am assured by many nurses that this usually does not happen, ever. He is also the one who was talking to the family when we left about her code status. (I can tell you that I prayed and prayed that she did not code on me while I was there). It was a clinical of balancing on the tightrope, hoping that one small reposition didn't vagal her into oblivion. I also learned a lot. I learned that acute hf patients get their cardiac meds even with bp's as low as they can tolerate. Meds can be changed every hour. Orders written and rewritten every 30 minutes. Vegitation means to look for potential clots (not growing potatoes in the heart as I jested to my classmates hehe). Seriously, I knew it had to be something, I just didn't know what it was.
Next week, I take on two patients. Let them be stable. Hell, self-care would be wonderful even. I know that I am ready to jump back on the bandwagon and take on more than 1 patient, but not more than 1 like I had this week.. our supposed "ease back into the swing of things" week. I think that my clinical instructor would also like the same. Nah, no thinking.. I am sure she is hoping for the same!
15 January 2007
delegation made into an official paper
curiously, i have worked on this delegation assignment for about 2 weeks, really. our list of very sick sample patients is comparable to what you might actually see in the hospital. i have searched the nursing journals forwards and back looking for good reference articles, which is actually quite a chore because i haven't been able to find that one really good article that sums it up perfectly. of course, there are thousands of articles on diseases, and i really think that may be my next step in searching. my biggest problem is deciding who gets which patients. surely, it is based upon complexity of care. the rn gets the more complex patients, but not all of them at one time, either. the lpn, according to our book, can take care of the stable patients but not the complex ones?? something must be wrong with where i work then... either the charge nurses aren't dividing up the patients correctly, or the lpns have a broader scope of practice than is presented in my leadership book.
now i have to put most of this together into an apa style paper. we have to use references on why we chose each patient for a particular nurse. to me, that is the most difficult part, because i have stated above, the literature just isn't actually available with specific references. not that i have found, and i have searched long and hard for it. somehow i know i will get it finished. i don't mind having to think critically but it sure does put a lot of things into perspective. it makes me consider how they divy assignments at the hospital where i work. there are plenty of lpns who have been there a really long time who are more than capable of working with a complex patient. yet, i don't think i should base my delegation assignment on what my experience tells me, but more along the lines of just how my book states it.
off to ovid i go.... hunting and searching for the next perfect article. wish me luck!
now i have to put most of this together into an apa style paper. we have to use references on why we chose each patient for a particular nurse. to me, that is the most difficult part, because i have stated above, the literature just isn't actually available with specific references. not that i have found, and i have searched long and hard for it. somehow i know i will get it finished. i don't mind having to think critically but it sure does put a lot of things into perspective. it makes me consider how they divy assignments at the hospital where i work. there are plenty of lpns who have been there a really long time who are more than capable of working with a complex patient. yet, i don't think i should base my delegation assignment on what my experience tells me, but more along the lines of just how my book states it.
off to ovid i go.... hunting and searching for the next perfect article. wish me luck!
11 January 2007
Odd Duck
I have come to the realization that I just don't really fit in with my co-students. I am not sure why it is.. I get along with most everyone ok.. other than a few things that have happened here and there. But I don't think the same as they do, and I just feel like an odd duck when I am around them. Perhaps it is because I didn't grow up in this area? I dunno really. Maybe I am just a little more laid back than they are? I can't quite put my finger on it.
I know many people form good friendships with their co-students while in nursing school. I just can't imagine really ever talking to these people ever again once we are finished. As of now, I don't really talk to any of them outside of class unless I see them out somewhere. Maybe I am just dysfunctional, after all? Most of the time I don't have a problem forming friendships, but these people are all wound up so tight, one pinprick and I think they would float away to the Atlantic ocean or something.
We gained a student this semester from another campus. I wonder what she thinks of our class? I know we have a completely different aura than the class that she had previously been with. I know it must be hard for her to have to assimilate into our own little strange co-existence that we all have with each other.
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On another note, today we began our discussion of ekg rhythms/rhythm strips and such. and on the subject of conduction... our teacher reinforced it with how they say "clear" with defibrillation. I posed the question... "I wonder how long it took them to figure out that they had to clear before proceeding with the shock?" Seriously though. Who was the unlucky soul(s) who suffered a great shock while attempting to save the life of another? What did that first code team think when one of them dropped to the floor because they didn't clear and thus were shocked as well? Interesting to consider and sure am glad that it wasn't me. So, the instructor said that she wondered who discovered that certain rhythms were indeed shockable.
After doing a bit of reading, I have determined that this discovery was made by two scientists from Switzerland in 1899. However, perfection of the testing was done by Carl Wiggers, from Ohio, done on animal models. (Remember this was in the 1930's and 40's and so no unlucky person I suppose, only the unlucky animal). The first life to be saved by shocking VFib was done by Claude Beck in 1947 in Cleveland. Now you just learned something new today :)
Have a great night.. I have some statistics to work on and I continuously find myself deviating from that subject. Heh.
I know many people form good friendships with their co-students while in nursing school. I just can't imagine really ever talking to these people ever again once we are finished. As of now, I don't really talk to any of them outside of class unless I see them out somewhere. Maybe I am just dysfunctional, after all? Most of the time I don't have a problem forming friendships, but these people are all wound up so tight, one pinprick and I think they would float away to the Atlantic ocean or something.
We gained a student this semester from another campus. I wonder what she thinks of our class? I know we have a completely different aura than the class that she had previously been with. I know it must be hard for her to have to assimilate into our own little strange co-existence that we all have with each other.
----------------------------------------------------------------------
On another note, today we began our discussion of ekg rhythms/rhythm strips and such. and on the subject of conduction... our teacher reinforced it with how they say "clear" with defibrillation. I posed the question... "I wonder how long it took them to figure out that they had to clear before proceeding with the shock?" Seriously though. Who was the unlucky soul(s) who suffered a great shock while attempting to save the life of another? What did that first code team think when one of them dropped to the floor because they didn't clear and thus were shocked as well? Interesting to consider and sure am glad that it wasn't me. So, the instructor said that she wondered who discovered that certain rhythms were indeed shockable.
After doing a bit of reading, I have determined that this discovery was made by two scientists from Switzerland in 1899. However, perfection of the testing was done by Carl Wiggers, from Ohio, done on animal models. (Remember this was in the 1930's and 40's and so no unlucky person I suppose, only the unlucky animal). The first life to be saved by shocking VFib was done by Claude Beck in 1947 in Cleveland. Now you just learned something new today :)
Have a great night.. I have some statistics to work on and I continuously find myself deviating from that subject. Heh.
10 January 2007
The roads we take
There were so many things that I wanted to learn during my time working as an extern. I suppose our hospital doesn't do the extern program like so many other hospitals do; this being said because we don't get to follow the RN around most of the time.. instead we are utilized as UC/CNAs (as they call them here). Yet, I think that this experience has given me the most useful lessons of all. No, I may not be passing meds or doing procedures that I have done in school or in clinicals. But I have realized what it takes to be successful at time management, patient care management within my scope of practice on the floors and in the unit, how NOT to treat other people, and definitely HOW to treat your supportive staff.
Perhaps some nurses forget that they too were once in our positions... low (wo)man on the totem pole. Who said that dirty work was only for those who did not have a degree? The best nurses I have had the opportunity to work with have been the ones who get out there and get dirty with the rest of us. Teamwork goes a long way; farther than just simply getting your work done faster. Sure, I know when I graduate, I will have new roads to conquer... new battles to fight. But I vow not to forget the road I have taken to make it there.
Perhaps some nurses forget that they too were once in our positions... low (wo)man on the totem pole. Who said that dirty work was only for those who did not have a degree? The best nurses I have had the opportunity to work with have been the ones who get out there and get dirty with the rest of us. Teamwork goes a long way; farther than just simply getting your work done faster. Sure, I know when I graduate, I will have new roads to conquer... new battles to fight. But I vow not to forget the road I have taken to make it there.
22 December 2006
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!
well not much else to report other than xmas coming soon, we all know this! that's all!
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