50% RN

It’s over, folks! We made it through the second of four pre-licensure semesters.  I’m absolutely flabbergasted at how much we have learned in the past 10 months!  Last night S was asking me about the different types of shock and I actually knew how to give him an intelligent response (except when it came to cardiogenic shock…apparently we ALL flubbed those questions on the exam).

We walked out of our Public Health final yesterday and went straight to a rockin’ end-of-semester party thrown by one of our classmates.  It was really nice to just hang out, goof around, and NOT have to stress about the next paper or test.  You could see it on all of our faces…the tension melted away and we were all smiles and hugs and funny faces.  And I have hundreds of pictures to prove it.

So now we have two weeks off, and we have been informed by our Public Health professor that if we even crack a nursing textbook in that time, she will personally find us and “kick our butts.” I’m spending the next week doing everything I don’t normally have time to do: sleep in, clean out the DVR, work out on a daily basis (hoping that I can keep it up better if I reestablish a routine), and give the apartment a much-needed deep cleaning.  I’m going home to visit my mom for the second week, and S will meet us there for the Relay for Life that we’ve done the past three years in honor of dear Dad.  Then we fly back here the night before classes resume.

So I may be off the grid for a bit.  My life without nursing stories just isn’t quite as blogworthy.

Beyond Technique

Ladies and gentleman, I have survived advanced Med-Surg!  My final exam was this morning, followed an hour later by my simulation exam.  Quite a brain-busting day! And I have absolutely no desire to study for my Public Health final, which is the only thing standing between me and the end of the spring semester.

The simulation itself was the source of much anticipatory anxiety over the past few weeks.  Nightmares, insomnia, the whole nine.  My wound sim last semester didn’t go so well – I had a bear of a time hearing the blood pressure on the mannequin.  It doesn’t sound like real Korotkoff sounds, dammit!  So you can imagine my trepidation about assessing a “patient” in hypovolemic shock, a crisis situation that requires taking blood pressure not once, but twice (once to establish baseline, then again when the patient’s condition changes).

So I took a deep breath, walked into the room, and went to work. I will admit that when I did hear those blood pressure clicks, my brain sang the “Hallelujah” chorus.   Once I got over that hump, the weight lifted and I tried to forget that this was an exam.  There were a few minor assessment details I left out.  Pretty easy to forget measuring capillary refill on a piece of plastic.  I know I should have gone through the motions anyway, but hey, if that was the biggest issue, I’ll take it.  Give me human flesh and I’ll pinch that finger (and toe) !

The best part, the part that pretty much made my semester, came at the end of the simulation, when the director of the sim lab and one of the nursing instructors walked in with big ol’ smiles on their faces.  “You can be my nurse any day,” said one. “Ditto,” said the other. “You’re hired!”

Technical skills will grow with time, and I need to cut myself some slack in that department.  I am still a student, after all.  But something that is more difficult to teach is rapport and confidence.  And it was very affirming to hear that even in a high-pressure situation, I could handle myself in a way that kept my patient calm.  It’s the art of nursing that goes hand-in-hand with the science.  And at the end of a very challenging semester, I feel validated in my artistic skills.

I’ve never been so sure of anything in my life.  Nursing is what I am called to do. Even when it’s hard.

Especially when it’s hard.

Med-Surgically Speaking

My advanced adult health nursing rotation is officially donezo! It was a SUPER busy final day, but I made it!

My patients this week were as different as night and day, and I thoroughly enjoyed working with them both. One was a younger woman who had a long and complicated medical history and had been hospitalized with chest pain related to fluid buildup in her lungs.  She had ascites in her belly like you wouldn’t believe (although no liver problems), and the fluid had apparently found its way into the lungs due to holes in her diaphragm.  Not to mention the intense pain she was in around the clock. Can you say “Whoa!”!?!  The pulmonologist was recommending surgery to repair the holes, and inject talcum powder into her chest cavity in order to prevent it from accumulating fluid in the future (a procedure known as a pleurodesis).  It was either that or repeated taps of her belly and lungs for who knows how long.  Either way, it’s a risk, given her multiple co-morbidities.

Then there was my “crotchety old guy” whom I absolutely adored, in the hospital for a week following a repair of a dissecting aortic aneurysm.  Despite a foreboding report from the night nurse on my first day (see here for my skeptical take on change-of-shift reports), we hit it off and he turned out to be a sweetheart who was a) very distressed about the toll his surgery had taken on his body, b) very distressed about being unable to control his self-perceived “hostility” and grumpiness, and c) very, very lonely.  Working with him for a couple of days had a profound effect on me … it not only reinforced the importance of patient-centered care, but it also hit me like a ton of bricks that I really like adult nursing!  Especially nursing of crotchety old guys. 

So yes, I still see myself working in peds, but I wouldn’t be broken-hearted if I did some adult health nursing at some point in my career.  And I have a long career ahead of me, with opportunities to try many different kinds of nursing.

All-in-all, a very successful and validating experience.  I have SO MUCH to learn still, but I feel more and more like a nurse with each new day.

Reporting for Duty

I am realizing the importance of taking some of shift change reports with a grain of salt.  While the background information and clinical updates are extremely helpful, it is hard not to inject some of your own biases about the client into report.  This just sets up the next nurse to walk into that room with preconceived notions and often negative expectations.

Twice during this rotation have I received report about how “difficult” a client is, and then ended up having extremely positive experiences.  Yesterday morning, the night nurse told me how sorry she was that I had to deal with a particular client all day.  I was expecting a nightmare of a shift but instead the client and I really bonded.  Sure, he was a little grumpy at times, but I would be too if I’d just had an aortic aneurysm repair and had been in the hospital for a week.  The key was nonverbal communication that conveyed acceptance and understanding.  He actually ended up apologizing for being a “hostile old man” (his words, not mine).

I truly believe that a lot of negative encounters with clients could be prevented if we didn’t expect them to be negative.  An important lesson to keep in mind when I grow up to be a real nurse…

Last day of Med-Surg clinical! Then I have over a month off before my peds 12-hour shifts begin.  My feet are oh-so-thankful!

Nurse Feel Good

It was a good week for Nurse Teeny. All three of my patients provided positive feedback that made me feel like I might actually know what I’m doing. It was very validating. They knew I was a student and they knew I wasn’t an “expert,” but they still trusted me and believed I would provide good care. Warm fuzzies all around, folks!

I also had a really special bond with one of my patients who had lung cancer and had just had a lobectomy. Take away a couple decades, and it would have been my own dear father! Same sweet nature, same sense of humor, and same pure sense of trust in his health care providers. It was especially weird since both men had lung cancer, and he had the same soft downy head of post-chemo hair that Dad sported for six months. I had been super nervous when I heard his diagnosis, but it turned out to be validating as well, that I could care for someone who reminded me so much of a loved one. I realized that I could do it without breaking down. I also realized that I could use the familiarity of the situation to my patient’s advantage by demonstrating empathy. I didn’t tell him my own story because I didn’t feel it was appropriate (“Oh yeah, my dad had lung cancer too, but he passed away”…not a real confidence-builder for someone still fighting the disease). But what I did do was redirect my emotions toward providing warm and comforting care. And my patient noticed, and thanked me.

It was hard to say good-bye at the end of the second day. I wish him the best.

Stress Management

Bravo to the students at Baylor Louis Herrington School of Nursing! Way to let off steam AND give me a much-needed laugh! Enjoy…

Silly Nurse Teeny

So I’m happily filling out my brand spanking new brain this morning at clinical when I realize there is a critical piece of information missing…

The patient’s freaking diagnosis.

Kind of important, wouldn’t you say?

So I’ve reposted the brain here: Nurse Teeny’s Clinical Brain (Revised), this time in “.doc” format, rather than “.docx”, to allow folks who don’t have the most recent version of Microsoft Office use of the file. I’ve also posted a PDF version: Nurse Teeny’s Clinical Brain (PDF).

Again, feel free to make your own changes as you see fit. It ain’t copyrighted.

3 more shifts and a simulation exam to go, and I am DONE with Med-Surg. Never would have thought of myself in adult nursing, but I’ve really liked both of my rotations. So the possibilities remain endless.

All I can think about now though is now much my feet hurt. Nurse Teeny has decided to buy herself a pair of Danskos when she passes the NCLEX (knock on wood). A fitting self-congratulatory gesture, if I do say so myself.

Needle & Thread

I was 2 feet away from a beating heart today.

This morning I awoke at the crack of dawn to complete my final extra clinical hours, this time in the Cardiovascular OR. Three words: A.MAZ.ING.

I observed an aortic valve replacement and the surgical team really stepped up and made me feel welcome.  I went through the whole process, from meeting the patient in pre-op to watching them prep and drape him and put him under.  Once everything was ready and the safety checks had been completed, the anesthesiologist set up a platform by his station and I got to stand at the patient’s head and peer over the drape into the sterile field.  As they cut through the pericardium, the heart emerged!  I literally had to catch my breath…I could have reached out and touched it!

The surgeon explained what he was doing step-by-step, and the anesthesiologist filled me in on how the entire team operated.  The craziest part was when they injected “cardioplegia” – a cooling agent with pure potassium to make the heart stop beating.  I watched on the EKG as the T-waves peaked, the QRS complexes widened, and the patient went into asystole before my very eyes.  They turned on the heart-lung bypass machine, clamped the aorta, and were off.  When the surgeon took out the stenosed valve, he held it up for me and pointed out the calcifications and fused leaflets.

After 2 hours, my feet ached, and I was cold as hell (those ORs are flippin’ freezing!), but I was absolutely pumped.  The human heart has always intrigued me, and to be that close….I am really beyond words.

In other news, our summer clinical placements were sent out today – I GOT PEDIATRICS!  Yay!!  I’ll be working Friday 12-hour shifts for 6 weeks, plus one extra Saturday shift, at a hospital that is known for its pediatric care.

It’s been a good day.

My Clinical “Brain”

Every nurse and nursing student has his or her own method of tracking important patient information throughout the day. These are generally one- or two-page tools known as “brains” – they include spaces for recording vital signs, medication administration, details from report, current labs, etc.

I’ve found a few over this year that gave me a good place to start, but there was always something about the layout or some missing tidbit of information that made it “not quite right” for me. So inspired by a classmate who created a layout that worked for her, I decided to create my own. After a few months of cutting and pasting and rearranging, I have succeeded!

So without further ado, here is Nurse Teeny’s Clinical Brain! There is space for two patients per sheet and and it is double-sided: side 1 has a place for patient info., vitals/CBGs/I&Os, and general notes; side 2 features medications by hour and labs.

Feel free to download and adopt/adapt for your own clinical use.

Code

I started Clinical Week 4 by finding out that one of my assigned patients was on comfort care, which is when your interventions with a dying patient focus on just that…comfort.  Do not resuscitate (DNR) status, no invasive procedures, no blood draws, not even blood pressure.  Just turn for comfort and to avoid skin breakdown, monitor for pain and anxiety and make the patient as comfortable as possible.  I spent a lot of time just chatting with the family and making sure their needs were met; the good news is that they had accepted their mother’s situation and were at peace with keeping vigil by her side until she passed anyway. But as I know well, that doesn’t make it hurt any less.  As of this afternoon when I left, however, she was still hanging on.  The doctor is trying to convince the family to transfer her to a hospice facility but they are hesitant because her death is so imminent and they’d rather she’d just stay where she’s comfortable. Tough call.

My other patient was a young man in his 30s with a history of chronic kidney disease who for some reason started experiencing congestive heart failure AND renal failure about two weeks ago.  The docs are stumped as to the reason at this point, but it’s a distinct possibility that he’s going to need dialysis, some pretty heavy heart medications, and possibly a transplant in the future. He has handled these rather significant life changes very gracefully, but I can tell he and his new wife (yup, he’s a newlywed too) are pretty shaken up.  Nicest couple ever, and so in love.

Then there was the general atmosphere on the floor today.  One patient coded in the morning, and although he also had a DNR, the family asked for the code team anyway.  When the team arrived, they explained the interventions they would need to try and bring him back, and the family ultimately decided to let him go.

A few hours later, another patient’s life support was withdrawn.

There are some days that just feel heavy…