Category Archives: Nursing

First paid vacation!

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I scheduled my first vacation as a new nurse.

Granted, it’s a week trip back to my hometown in Michigan (nothing too glamorous, just time with the family), but I’m getting paid for it. Sweet!

Timeline from starting at the hospital:
Mid January 2013: Date of Hire
Beginning of July: Accrued 2 weeks of vacation time (6 days). By end of this year, it’ll be a total of 4 weeks (12 days).
End of July: Requested for 2 days off
3 Days later: Approved request (only 2 people can take vacation on a shift at a time)

It’s like what my critical care professor said. After you start work, you’ll put in 6 months where you’re a little nervous about going to work. Then around 8 months in, you go on vacation. 1 year later, you’ll look back and see how far you’ve come since the beginning. So far, she’s pretty accurate. :)

One of the great things about working here is a work-life balance and the 4 weeks of vacation time that I get after coming off probation. :)

I’ll never look at antibiotics the same way again

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I heard it again. Another code. This time, it was for a patient getting this specific IV antibiotics for the first time. She went into a full on allergic reaction, or anaphylactic shock. I ran over, “Jessica, get the ambu bag!” This will force air into her lungs. Already compressions were started.

“Get a 1000cc bag of normal saline!” She had low blood pressure because her heart rhythm went into v-tach and her pulse is through the roof.

Her airway was swollen so respiratory therapists were there to make sure the airway remained open. She was eventually stabilized and sent up to ICU.

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Lesson Learned
For first dose antibiotics and blood and any medication…
Always inform your patients of possible allergic reactions and to alert you if they develop these symptoms: difficulty breathing, itchy, redness, chest tightness, swelling.

If they do, always STOP giving the medication (or blood, especially if IV) immediately and give Benadryl, an antihistamine that stops the allergic reaction.

Then DOCUMENT it in the allergy section so that it won’t ever happen again.

Remember, the first time exposure to a medication typically has a mild reaction. But after the first time, your body has built antibodies to react to the allergen. The subsequent exposure will tend to have a more severe reaction.

Nurse Gail – Travel Nursing

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I love the Internet because it allows you to connect with people that you may not have otherwise. Nurse Gail is a prime example! She went to University of Texas for nursing school and now is a travel nurse in NYC for 6 years. It has given her the opportunity to experience New York in a wide variety of settings and has challenged her everyday. We will both be attending NYU College of Nursing for our Master’s this fall so I’m very excited to meet her in person. :)

Her blog discusses the challenges of NYC nurse working conditions, pros and cons of travel nursing, and nursing related issues. One I particularly liked discussed a journal article on the effects of aggression towards the nurse. Medical errors increase so the bottom line is to be nice to the nurse! I encourage you to check out her blog.

Until next time,
Jessica

First Code – CPR or hospice care for terminal illness?

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This 90 something year old man was repeating, “I want to die” a couple days before. With stage 4 cancer (meaning, it spread from the source location), he should’ve been DNR (Do Not Resuscitate). But since he started to lose his mind (he couldn’t answer the 3 questions: name, location, and time), his family members began to make decisions for him (as a Heath Care Proxy). His family was in such denial that it was time for him to pass away. They believed he didn’t need morphine to ease his pain and should remain in full code in case his heart rhythm converted to v fib or v tach (at this point, you do CPR).

Throughout the night, he kept moaning. But his family would only allow him to take Tylenol. Which honestly isn’t enough if you have overgrown cells invading essential organs. And these organs allow you to breathe and circulate blood throughout your body.

After I had given out my morning meds and taken out a foley, I saw a nurse run. The next thing I heard was “999 on 1 West”. I saw 2 nurses with the crash cart wheel past me heading to a room in the next district over. When I saw them wheel the cart into that room, I knew it was him. The nurse there was already doing CPR compressions and someone else got the ambu bag ready. Though it felt like 5 minutes, about 30 seconds later, 2 critical care PAs, 3 critical care nurses, 2 MDs, respiratory therapist, nurse educator, patient care assistants, and all the nurses on the unit were there. The PAs took over the compressions. The pads were slapped on.

The EKG monitor was still on, so I watched it go in and out of v fib and v tach. Nurses made the call out to the attending and the family to tell them to come in immediately. My nurse manager told me to go the next unit over to get the Line Cart. I learned fast that’s the cart with the equipment to do a central line. Inserting a central line would allow them to bolus (or “quickly give”) fluid directly to his heart to increase blood pressure. Without a properly beating heart, the body won’t have circulating blood.

When I came back, I saw that he was also bleeding out from his rectum and abdomen. Cracked ribs and his tap sites from before may be the cause. Regardless, I primed the normal saline line to attach it to blood that we would give to him.

More epinephrine was needed. More flushes. The nurse educator asked if I knew any of the nurses in the room so she can document everything that’s happening in the room. I gave some names and then let the nurse who was taking care of him take over.

After the defibrillator delivered the shock, I heard that sound. That sound was an asystole sound. A solid beeeeeeeeeep. I looked at the EKG monitor and saw a solid line. He was gone. He got his wish.

This happened in 17 minutes.

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If only he had been DNR and was comforted, he would’ve died more peacefully. He wouldn’t have bled, have cracked ribs, have something tied to keep his tongue down in case of intubation. He died suffering from pain and misery. It could’ve been in peace in his sleep.

Family members may feel guilty if they decide to make their loved ones a DNR. They may feel that they aren’t doing the right thing and that they should do everything possible to save them. But in terminal cases, the focus should switch from treatment to comfort. This increases the quality of someone’s end-of-life care.

In my mind, when I die, I would want to die in my sleep. Peacefully. No pain. Just as living is a part of life, death is too. And we should pass with dignity.

Education Day 2: Communication and Delegation

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Today was our second “Education” Day. The first Education Day that happened one month ago covered medication errors and IV insertion. Today, we talked about communication, delegation and the electronic health record.

Communication among the nurses, patients, doctors, and ancillary staff are crucial for good patient outcomes. We communicate to convey  messages to other people. What do you think is the most important part about communication? Take a guess first!

  • Words
  • Body Language (facial expressions, hand gestures)
  • Paralinguistic (the tone; the way that the words are said)

*

*

*

It’s body language, which accounts of 55%. Words account for 7% and paralinguistic accounts for 38%. Body language shows your attitude and shows how you feel.

There are different ways to give and receive information. Even though we spend 7-12 years of our education on learning how to write and read, we spend less than 1-2 years of formal education on how to speak and listen. This is almost counterintuitive, considering that over half of our communication depends on LISTENING to each other.

We broke out into 4 groups and discussed about traits of good listeners vs bad listeners.

Good Listeners:

  • Eye contact
  • Gives feedback
  • Not rushed

Bad Listeners:

  • Interrupts
  • Has a reply or rebuttal before letting the other person finish speaking

Etc, etc, it can go on and on. To show that we care,

  1. Look at the patient in the eye (not at the WOW all the time; let the patient know you’ll ask a series of questions on the WOW so they know you’re not purposely trying to not give eye contact)
  2. Sit down next to the patient to show that you’re not rushed
  3. When they are concerned about something, ask them for more details (especially regarding pain!)

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As for delegation, it is something that new nurses struggle with. The most important takeaway messages I got was:

  • Be specific
    • Example: Take that patient for a walk vs
    • Take that patient for a walk for 80 feet. 1 assist with a walker and oxygen is needed at all times. It’s the first time the patient is getting up so take a pulse ox before and after he goes for the walk. When that’s completed, please tell me what happened.
  • Vital signs and I/O
    • “Please tell me any abnormal vital signs that you see. And for these specific patients (congestive heart failure, post-open heart patients, renal), please document intake and output.”
  • Change priorities as needed
    • Some ancillary staff may think that cleaning equipment or doing the bedtime bundle or whatever it is that they are doing is more important than a patient’s change in condition. Sometimes when you say, “please go do a fingerstick stat” or a “EKG stat” or something else that’s more urgent (such as compromised patient safety aka a patient getting out of bed without supervision especially if they want to use the bathroom or go for a walk but forget or don’t want to call you!), the PCA takes their time to do what you asked them to do.
    • It may help to say: “That isn’t important right now. Right now, it’s more important for you to take a set of vitals on this patient.”
  • If there is an isolated problem (they don’t know or just forgot), it is important to address it right away in private (never in front of the patient!!). Sandwich a compliment, criticism, and compliment. If it is a continuous problem (due to attitude or laziness), then still address it but also bring it up to management.
  • Give feedback. Everyone is valued and needed on the unit. Using their name and saying thanks goes a long way.

 

Best Part About Working Over 4th of July

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  1. Enjoying the Macy’s fireworks with your patients on channel 4.
  2. Enjoying the NY Yankees playing… And the NY Mets.
  3. Less traffic, less patients (who wants to voluntarily go to the hospital on a holiday weekend? Um, no one!!)
  4. More downtime… In general.
  5. Time and a half pay!
  6. Less procedures.

But, you still have to be just as vigilant! Know the emergency call number by heart (no, it’s not 911 at the hospital). It will come in handy when you need it!

Off probation — what does that mean?

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I’m off probation now at the hospital.

That means I passed the series of “tests”—
doing 2 head to toe assessments,
giving out medications through different routes,
going over the chest tube, suction set up, code master (defibrillator, pacer, and cardioversion),
doing drip calculations and entering into the IV pump,
going over the telemetry monitor, and
taking the 50 question EKG exam and passing with a score greater than 90%.

It means no more checking each narcotic.
And trust me, on an ortho floor, a lot of people are in pain, pain, pain.

It means no more checking insulin units.
Yes, I know how to draw up x units of humalog, lantus, and the like.

It means I’ve been doing this for 6 months.
And that means I got 2 weeks of vacation time!

It should mean that I know what I’m doing.
Although I will keep asking questions. And questioning orders that don’t make sense.

It means that I will begin to float to other units.
I won’t be on home turf all the time anymore.
Other med-surg floors and the ER.
I have to admit, I’m a little scared.

It means that I’m ready — and mostly excited!! :)

Donating Stool Isn’t That Weird Anymore

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The first time I came across donating poop from one to another was at my hospital. At first I was a little grossed out but then it made sense— all that healthy bacteria one person could have
— and then transplanting it over to someone who lacks the bacteria (especially those with ulcerative colitis) can work wonders. It helps restore a healthy digestive tract!

Read what a New York Times opinionator did to help save her friend by donating her fecal matter.

I’m almost off probation at the hospital!

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It’s been 5 months since I started on the med-surg telemetry unit and it’s almost time to come off of probation! One of the nurse educators watched two of my head-to-toe assessments and me giving out medications (satisfying the 5 rights for a PO med, SQ injection, intravenous med, and narcotic).

I remember one of my first nursing school classes– doing the entire head-to-toe assessment in 10 to 15 minutes and stating each finding. That was probably one of the most important classes because it’s now kinda easy to recognize something abnormal.

Especially for a cardiac patient, pedal pulses, edema, lung sounds, heart sounds, and neuro checks are important.

Bowel sounds and asking for the last BM is important for surgical patients or for constipated people.

Skin checks at pressure ulcer points (sacrum, heels, back of head) are of upmost important, especially for bed bound and incontinent patients. Is it red? If it’s red, is it blanchable (turn white when you push it)? Could it be a stage 1-4 or a deep tissue injury?

Surgical sites should be monitored for bleeding, leakage, etc.

Urine output of a minimum of 30 ml/hr is also important, especially for those who have a foley! But even knowing how often patients urinate is important. If they haven’t gone all day, then it’s a problem!!

Anyway, I could go on and on. But for right now, here’s an example where the assessment made a different (and trust me, there are many, many examples).

A patient was having a productive cough and felt like he was having a hard time breathing. His O2 sat was 94% on 2L nasal cannula but his lungs had crackles (it sounded wet!) bilaterally (on both sides of his lungs). His feet were puffy (or +2 edema) although pedal pulses were palpable. After calling the PA, I got an order for IV Lasix — which basically works your kidneys to draw in the fluid and excrete it through your urine. Throughout the rest of the night, the patient continued to cough, but his lungs began to sound better. However, due to his surgical site, he experienced a lot of pain too. While I gave him pain medications according to the orders, I noticed that the patient started to get a little more confused by the end of shift. This is when I had to start questioning the type of pain medication given. When giving report to the day shift nurse, I made her aware of my findings. Because of that, she was able to talk to the PAs, NPs and MDs on the floor who are more readily available during the day and make an appropriate decision to treat his pain without him getting confused.

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Anyway, I passed the head to toe assessments and giving out medications portion. Now, there are two sections left.

1) Code master, setting the IV pump, and doing the appropriate medication calculations

2) 50 question EKG test with a > or = 90% since I’m on a telemetry unit. It wouldn’t make sense to work there if I can’t read the rhythms. Even though each month I have to pass a 30 question exam too, they still want us to pass the 50 question exam. It’s ok– I’m ready anytime. :)

How to Study in Nursing School

How to Study in Nursing School

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A couple of people have contacted me to ask how I studied during nursing school. These individuals have completed a bachelor’s already (either recently or it had been awhile since they’ve been back in school), but felt that nursing school was different and wanted some advice.

Of course, this is just the way I studied. It is not the only way or even the best way. Just my way.

On the first day of school, you will receive a syllabus for each class. Right away, write down (or enter in) all of the exam dates and due dates for assignments. Personally, I put them into Google Calendar and have it synced to my phone. That way I have that information all the time.

There are 3 major steps:

  1. Prep
    • Minimum: Print out the powerpoint slides and read through it. This way, you’re familiar with the material and can follow along in class.
    • Maximum: If you have extra time, the syllabus will have readings that you’re supposed to do. Read the headings.
  2. Lecture and Take Notes
    • Go to lecture and take notes on the powerpoint slide. If the professor repeats it twice, then it’s super important!
    • Since you’re more familiar with the material from the prep work, you can ask questions on anything that doesn’t make sense to you.
  3. Review
    • Review all of the powerpoint slides and your notes as soon as you can after class (preferably within 24 hours). These slides are your keys to success.
    • If you still don’t get the material, read the text.
    • Once you feel comfortable with the material, do a group study. If you can teach it and talk about it, you got it.
    • Memorizing the material is helpful. Utilizing it will help you remember it forever.
    • Chances are, the textbook has NCLEX style questions at the end of the chapter or even online on the textbook website. Do them!
      • By the way, NYU has nearly all of the textbooks on reserve at the Bobst library. That means you can borrow it for 2 hours at a time. If no one else has requested that some book, you can re-borrow it over and over again.
      • Some students used additional NCLEX books. The one I liked the most was Prioritization, Delegation, and Assignment by Linda LaCharity.
    • If that doesn’t help, make an appointment with the professor for office time.

Nursing school is really about gathering a working knowledge base. It is not about memorizing something, cramming everything in, and then forgetting everything you learned. Even if you spend 30 minutes everyday reviewing the slides, it will help you retain the information.

Review everyday or at minimum every other day. I did shorter study sessions and even studied on the go when I was busy. I tried to get in 1-2 hours daily. That doesn’t mean it has to be all at the same time. It was just 1-2 hours over the course of the day. Remember, quality over quantity!!

1 week before an exam, I would increase my study hours to around 3-6 hours per day, or even more (yes, I have woken up at 7:30am, got the library by 8am and studied past midnight… only to repeat it again the next day. It didn’t happen too often though… just for Adult and Elder 2 or Med/Surg 2.).

 

Studying on the Go

Traveling on the train is common in NYC. Instead of taking out all of my paper slides on the train, I whip out my iPhone to review the slides. The program I used is GoodReader. I downloaded the PDF version of the powerpoint slides onto GoodReader. You can do this through wifi, signing into the nyu.edu website and downloading it directly, Dropbox, Google Drive, SkyDrive, Google Doc, etc. You can also highlight and write on the document  and create folders using GoodReader.

Anyway, good luck! Let me know what has worked for you.