August 1

There’s less than 3 weeks left before school starts. I finished my last day of work, handed in my garage key card, cancelled my gym membership, and transferred my address from NYC to Michigan this past week. I’ve met with several friends for the last time before I move. I folded all my clothes and placed them into the suitcases. When I looked up and saw a blank white space, my vision started to get blurry and I felt a stream run down my face. I knew this day would come and I’m more excited than anything. 

What I learned and experienced over the last 8 years in NYC is tremedous and something that I would’ve never expected. Sometimes it’s still hard to believe that I’m actually leaving this place now and who knows when I’ll come back. 

Probably the most important thing I found out recently was that I was able to receive in-state tuition, after a 3 month queue and submitting my and my parent’s tax plus more information. 

Anyways, that’s it for now. 

What is Delirium? The ABCDE Bundle

According to my fiancé (yes we got engaged! And yes, he’s not a healthcare guy. In fact, he’s scared of needles), when he hears the word delirium, he thinks of someone being delirious or confused. Unfortunately, this state happens a lot in the ICU and causes a lot of problems.

You can go from being a crazy beast, pulling everything to being super quiet, not making eye contact to someone’s voice. What are the potential causes of delirium and what interventions can be done? Use THINK.

 

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The Gold Standard to determine’s someone state is called the RASS score, or the Richmond Agitation-Sedation Scale. It goes from +4 to -5, as listed below. In conjunction with this, utilizing the Confusion Assessment Method for the ICU (CAM-ICU) determines if delirium is present.

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A lot of times we are using medications for agitation and sedation but studies are showing that using multiple non pharmaceutical methods decreased delirium by 15%.

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In the article, the evidence shows the following will help prevent delirium:

  • Early mobilization.
  • Frequent reorientation.
  • Clinical status updates and schedules.
  • Discuss patient requiring memory recall.

To me, when I read that list, I think most of it is pretty easy. Except for early mobilization. From what I’ve heard, there are patients who are intubated sitting in a chair! In my current ICU, that does not happen. The biggest concern is the stability of the patient. So what can we do?

Implement the ABCDE Bundle,

which stands of Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility. It incorporates the best available evidence related to delirium, immobility, sedation/analgesia, and ventilator management in the ICU. For the ABC Bundle, the nurse and respiratory therapist will go through his or her checklist before the trial.

A stands for Awakening.

The first step is to see if the patient can undergo a Spontaneous Awakening Trial (SAT). The nurse assesses these qualities:

  1. Is patient receiving a sedative infusion for active seizures?
  2. Is patient receiving a sedative infusion for alcohol withdrawal?
  3. Is patient receiving a paralytic agent (neuromuscular blockade)?
  4. Is patient’s score on the Richmond Agitation Sedation Scale (RASS) >2?
  5. Is there documentation of myocardial ischemia in the past 24 hours?
  6. Is patient’s intracranial pressure (ICP) >20 mm Hg?
  7. Is patient receiving sedative medications in an attempt to control intracranial pressure?
  8. Is patient currently receiving extracorporeal membrane oxygenation (ECMO)?

If the answer is yes to any of the above, then there needs to be a discussion with the interdisciplinary team before performing a SAT. If the answer is no to all of the above, then proceed with performing the SAT. Stop the sedation. If the following occurs, you should put the patient back on sedation but try at 1/3 to 1/2 the rate the patient was on before.

  1. RASS score >2 for 5 minutes or longer
  2. Pulse oximetry reading <88% for 5 minutes or longer
  3. Respirations >35/min for 5 minutes or longer
  4. New acute cardiac arrhythmia
  5. ICP >20 mm Hgb
  6. 2 or more of the following symptoms of respiratory distress:
    • Heart rate increase 20 or more beats per minute
    • heart rate less than 55 beats per minute
    • use of accessory muscles, abdominal paradox, diaphoresis, dyspnea

If possible, changing the sedation from propofol to precedex will help patient be calm and it does not depress respiratory status (especially after 24 hours).

B stands for Breathing.

Spontaneous Breathing Trials (SBT) are up next. The respiratory therapist will assess for safety.

  1. Is patient a long-term/ventilator-dependent patient?
  2. Is patient’s pulse oximetry reading <88%?
  3. Is patient’s fraction of inspired oxygen (FIO2) >50%?
  4. Is patient’s set positive end-expiratory pressure (PEEP) >7 cm H2O?
  5. Is there documentation of myocardial ischemia in the past 24 hours?
  6. Is patient’s ICP >20 mm Hg?
  7. Is patient receiving mechanical ventilation in an attempt to control ICP?
  8. Is the patient currently taking vasopressor medications?
  9. Does the patient lack inspiratory effort?

If the answer is yes to any of the above, then it may not be safe to perform the SBT. If the answer is no to all of the above, then the SBT is performed. However, if any of the below occurs indicating signs of failure, then stop.

  1. Respiratory rate >35 breaths per minute for 5 minutes or longer
  2. Respiratory rate <8/min
  3. Pulse oximetry reading of <88% for 5 minutes or longer
  4. ICP >20 mm Hg
  5. 2 or more of the following symptoms of respiratory distress
    • Use of accessory muscles
    • Abdominal paradox
    • Diaphoresis
    • Dyspnea
    • Abrupt changes in mental status
    • Acute cardiac arrhythmia

And of course, who is watching for these symptoms? The registered nurses.

 

C stands for Coordination.

This refers to the coordination mostly between the respiratory therapist and the nurse, although the discussion during the interdisciplinary team will also play a part.

 

D stands for Delirium.

THINK about the causes, use the RASS score every 4 hours and the CAM-ICU score every shift.

 

E stands for Early Mobility.

What I’m interested in is the minimum criteria for early mobility protocol.

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However, if there’s any patient distress, then it’s time to stop. Below are the criteria for stopping early mobility.

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 It’s hard to start something new as an individual as it requires a cultural change and the healthcare team to be behind it. 

But maybe the next time you take care of a ventilated patient, you’ll think of the ABCDE bundle and implement it as a part of your care. 

 

First time jumpstart a Prius

My remote stopped unlocking the 2009 Prius. The remote light lit up red every time I pushed it but the car didn’t respond. 

I went on Google to try to figure it out. I hadn’t driven my car in 5 days. I found out there are 2 batteries in a Prius– one in the front hood to start the engine and the other in back for the hybrid use portion. I was pretty sure the front one was the one with a problem. I looked up how to jumpstart a Prius because I’ve never jumpstarted any car before. 

Thank goodness for YouTube videos. And I parked in a garage. I asked one of the attendants to help me although once he heard it was a Prius, he became skeptical since in the past, he was unable to help another patron. 

First I couldn’t open the door, so I found out that there’s actually a key inside of the remote. After I took it out, I read that it may be difficult to insert the key to open the door on the driver’s side. Thankfully it was easy. 

Next, the attendant drove over a van, left the van on, popped open the hood, and attached the red positive jumper cable to the red, and black negative to the battery. 

Using the other end, he connected the red cable to my Prius (under the fuse V12 battery box on the drivers side, flip the red little box), and connected the black on the hood’s metal latch (it sparked!). We tried turning it on several times by placing my foot the brake and pushing the on button. It didn’t work. 

We sat a little longer– and took the black one on and off the metal connection several times before I saw my car lights go on, and then start emergency honking. The car turned on!

From the Prius? We took the jumper cables off — black then red. Then from the van, black then red. 

Of course, concerned about the health of the battery, we searched up how to check. It was fine. 

Anyways, that’s it. 

It’s getting real

Since I got accepted into the nurse anesthesia program at UM Flint, it’s been an exciting time in my life. I went on my first cruise, got engaged, joined a Community-Supported Agriculture (CSA) and started to really think about what this program will entail. Recently, the previous class invited the Class of 2017 to a BBQ before school starts. For me, it means it’s going to start soon. The program director sent information about what to expect (school = your life for 2 years and don’t let anyone expect you to help around the house but still have at least one evening off to decompress and hang out with loved ones), review material especially in math calculations, the autonomic nervous system and some medications we’re already familar with, and the people I’ll be with for the next couple years. 

Speaking of which, I didn’t expect my picture from the interview to go up. I wished I straightened out my hair a little better but hey, it is just a picture (see above). 

I appreciate that we’re paired up with a mentor from the Class of 2016. It makes it easier to ask questions since they just went through it first (or junior) year themselves.

Sometimes I’ll wake up nervous — but I haven’t even started yet. Then I’ll remember that it’s such a privilege to even have this opportunity. I’m not sure if anyone is ever ready for the massive amount of information that’s expected to be memorized and applied, but here it goes.

One thing I really don’t like doing is writing scholarship essays, or really any essay that involves describing ‘how amazing I am based on the criteria that you’re looking for.’ But it’s a necessary evil. One thing I don’t understand is that if we’ve already submitted our application with letters of recommendation to get into the program, why do we need to duplicate the process of submitting additional letters of recommendation when applying for scholarships? Regardless, I’m thankful to have a NYU faculty member who is not only super supportive of me but also fast in response. 

I’m thankful for everyone who’s supported me. Because life isn’t an individual event. It’s comprised of many people. So thanks.

I’m excited to start this new chapter in my life. There’s 2 and a half months left before school starts. Two more months to save money before I’ll have zero income. But it’ll be worth it.

NYU Accelerated Nursing Program FAQ’s Part II

I recently received an email from a prospective nursing student and thought that it was worth posting my answers.

Hi Jessica,
I came across to your blog while searching for NYU’s accelerated nursing program.  Reading your blog has been very helpful. Congrats on becoming a nurse. Currently I have my undergrad in a business discipline and I am really considering a nursing career instead. I just have some questions regarding nursing, it would be great to get your feedback. Thanks so much if you have the time to answer any of these questions!

1.       Does it matter whether you take your pre-reqs at a community college or 4-yr college when applying to NYU? Do pre-req grades matter? Will there be a higher chance if acceptance if pre-reqs are taken in NYU?

You can take your pre-reqs at a community college or a 4 year college. Pre-req grades matter a lot. Definitely do well on these. I don’t believe there’s a higher chance of acceptance of the pre-reqs are taken at NYU. Majority of students take pre-reqs at a community college or a 4 year college.


2.        What were your credentials when you applied to NYU (eg. GPA, experience)? And did you find NYU to be worth it after working in the field? Is there any other nursing programs you would recommend in NY?

My GPA was 3.84. As for experience, I volunteered at a hospital when I was applying. It’s important to highlight your feelings towards nursing especially after speaking to them and seeing what they do.
NYU is a great school and I’m glad I attended the school. The professors are top-notch and the students are helpful. There’s an interdisciplinary program so med students and nursing students learn about working together and each other’s roles. It is one of the top research institutions as well especially in elder care (NICHE Program http://www.nicheprogram.org). However, it is a really expensive program so I don’t recommend it to everyone.
The other nursing schools in New York / Long Island that I hear good things from include Hunter, Columbia, Stony Brook, Adelphi, Molloy and Pace.

3.       Difficulty finding a job? Did you work part-time while studying in the program?

After I passed the NCLEX, it took about 6 months to find a nursing position. A couple of problems I ran into included not knowing how to interview (because this is a skill you need to practice). I didn’t start my search until after I passed. Some students connected with nurse managers during clinical and were able to secure a position shortly after graduation.

I did work once a week as a swim instructor during school to help supplement the costs. Some students didn’t work at all while others worked 36 hours a week (a full-time job!!). The first and second semester are the toughest so give more time devoted to school before deciding to work.

4.       Do grades matter a lot to employers? Do I need to get straight A’s or can I afford to have a few B’s or even a C?

Some employers require a minimum GPA (3.4, 3.5) before they even look at your application. Some don’t. It’s how you present yourself and your mannerism that matter and whether you retained information from school and can apply it.


5.       What is the starting salary like and is it worth being a nurse practitioner? What kind of nurse do you think is best to become/specialize in if any?

Starting salary differs from location to location, ranging from $40-80k. In NYC, it starts around $70-80k if you’re working at a private hospital.

Becoming a NP is dependent on the person. While I’ve heard that becoming an NP is the greatest thing in the world (I hear a lot of positive feedback), there are still a few who are discontent with the position, as there is more responsibility that comes with the position. Some people don’t want to deal with the higher stress and responsibility but wanted to go back to school and ended up hating being an NP. This requires a lot of self-reflection. What do you think would suit you and are you ready for it?
Personally, I’ve explored many advanced nursing professions. Not only should you look at your duties but also the lifestyle. Where would you want to work, what would you do, when would you want to work, what income would you make, what mobility is there? The best advanced nursing profession depends on the individual and what they want out of life. I picked Certified Registered Nurse Anesthetist. I like the one-on-one direct patient care aspect requiring a high level of critical thinking and autonomy and teamwork.

6.       What’s life as a nurse? What are the difficulties and good parts of being a nurse? Expectations in the work force?

Life as a nurse differs between the environment that you work in. I work at the hospital where there’s 12 hour shifts (7-7:30am and pm), 3 days a week (for full time) and you can choose your schedule (with some limitations such as having to choose at least 3 weekend days, 2 Fridays, etc). Some people choose to do 3 in a row each week and have 4 days off. Other hospitals have it so you work 3 12-hour shifts plus 1 additional day every 4 weeks. Some units, especially in CTICU, PACU and ER, have other shifts from 11am to 11pm or 2pm to 2am.

It’s great having 4 days off because you definitely need it to recuperate and you’ll have time to do something else if you’d like.
Some places have day (7a -3p), evening (3p-11p), and night shift (11p-7a), especially in rehab and nursing homes, and require you work 5 days a week.
At work, you often need to have handoff communication about the patients. Then you assess the patient and pass out medications. You make nursing diagnoses about each patient and use critical thinking. You think to yourself: What’s the goal for the patient today? And then make it happen. You’ll speak to various disciplines to coordinate the care.
There’s a couple of tough parts about being a nurse.
1) Families – Some follow the unit policies and others do whatever they want. Communication is sometimes hard but trying to understand where they are coming from helps.
2) Physicians, MLP – your input is often crucial to the patient’s outcome but sometimes the provider will disagree with you.
3) Patients – some are nice and others are crazy, confused and not so nice.
4) Self- being able to let go everyday of the outcome is tough. At the end of the time, you have to set 1 small goal for the patient and as long as they meet that, you have to be satisfied with the care you provided. Nurses tend to be overachievers and want to always give more but with the number of things that must be done, it’s impossible to do everything you had in mind. You have to remember that nursing is a 24/7 job.
The good parts about being a nurse is knowing that you’ve made a difference is someone’s life. You get to think about an active problem and you get to take yourself and solve that problem. You get to hold someone’s hand and reassure them. It’s an amazing privilege to have to save a life, to have a better life, or to let someone die with dignity.
As for expectations in the workforce, there are several different angles you can discuss but I’ll discuss about your own expectations. There’s a nursing theorist named Patricia Benner who stated that the nursing career is based on the nursing model-
You really do start not knowing a lot, just the basics. You focus a lot on technical skills because it’s something you have to work on. Then as you progress, you build more confidence. Soon you’ll start to see areas in nursing where care can be streamlined or have protocols to standardize care. You’ll be in charge, take on harder assignments, be a preceptor, etc.

7.       Any general suggestions on what I should focus on or do to become a nurse/get into NYU program?

Do well on your pre-reqs, volunteer or work in healthcare, and get to know a few professors who will write a letter of recommendation for you. And write a killer personal statement answering every question asked.

I hoped that helped! Read my first post for more information on NYU’s Accelerated Nursing Program, find out if NYU Nursing is worth it, how to pick a good nursing school, and find out if you can afford an accelerated program. Or if you have any further questions, email me.

Jessica

The Second Career Nurse [Infographic]

While there’s a lot of people who say that nursing was all they ever wanted to do, there’s also a lot of people who doubled back and thought otherwise (including myself!). There are many barriers to commit nursing as a number one career choice. One of the biggest hurdles is our conformity to society. What do our parents, family, friends, and society think about our career choice?

I know personally that I had pressure. I know many male nurses receive a certain pressure too. I know that many immigrants who may look down on nursing get that pressure. Even patients will ask, why nursing?

People get an image in their head and continue to apply that to everyone. A female should be a nurse, a male should be a doctor, some immigrants may think nursing is not a noble profession but rather a dirty one (mostly because of how the nursing profession is portrayed in other countries). We have to break free of these stereotypes and see nursing for what it really is.

Nursing is one of those fields where you get to make a difference in someone’s life everyday– where you combine the science and the art. You will make sure that someone will receive the best possible care, and in the safest way. And when that doesn’t happen, you will start an investigation questioning why that is and what can be done differently.

When we start to have a diverse group of nurses, different ideas abound, different strengths surface, and as a whole, nursing gets stronger.

You can jump over these hurdles by thinking about what is nursing, and how nursing is such an amazing and vast field. There are so many choices and different ways you can contribute, touch another and be touched. You can in one direction and go up as high as you want, or expand horizontally and try out different fields of nursing. You can choose to be by the bedside, or an administration, in research, in an insurance company, etc. Wherever you decide to grow, just go for it. Say it out loud and proud and you will gain social support.

I got in touch with the author of the Top RN to BSN website, who suggested that I include this infographic below on the Second Career Nurse. She did her research and learned more about the characteristics of the Second Career Nurse. I thought it was informative so here it is! If you look at the graph below, you will see that in 2012, 1 in 3 nursing grads are from accelerated nursing degrees.

Now, I have some questions for you as the reader. What made you change your career and how did you get your support for switching into nursing? Comment below to start a discussion. I look forward to chatting with you.

Jess

 

Second career nurses are solving the nursing crisis.

Source: The Second Career Nurse

 

Project GLAM – Start Your Own Dress Donation Drive

project glam

As a part of our unit’s community service project, we decided to do two projects. One of them was Project GLAMGranting Lasting Amazing Memories. Somehow I was assigned to make the flyer and ended up becoming the head cheerleader for this project. WGIRLS Inc started Project GLAM back in 2010 where you can donate your gently used prom dresses (or cocktail dresses or bridesmaid dresses) for underprivileged girls who need prom dresses!

The idea started back in January by my nurse manager where she handed me some printouts from the website. Even Oprah endorsed it, how can you go wrong?

I made the flyer and started talking about it with coworkers a week before our donation drive. I set the drive to a short amount of time (2 weeks) so that people who were interested would bring in their dresses right away. I thought the flyer should be colorful and have spring colors, as well as the logo of the project. The timing of the drive is also important — it just turned spring, just in time for spring cleaning and Earth Day (reduce, reuse, recycle!), and it is before prom session starts. The Project GLAM was also discussed in the local news, which helped bring interest.

It was exciting talking to people about it, and hearing others talk about it with others. There’s a large age range of those working on the unit so many had different ideas of which dresses they should donate — some brought their own cocktail dress or bridesmaid dress, and others brought their own daughter’s prom dress!

We collected about 10 dresses and many accessories. Next, I got in touch with Amy, the president of WGIRLS, who then put me in touch with Kristi, the VP of WGIRLS in Long Island. We decided on a location and I dropped off the dresses.

Overall, it was a successful drive and I hope that other organizations will do the same! It helps to have a group of people donating to bring a sense of community together. However, if you’re interested in donating your own dresses, drop off your dress and accessories at these locations.

Have fun with your own dress drive and make a difference. 🙂

Let’s stop cyberbullying — More compassion please

It’s so easy to say mean and rude things on the internet because often times the person receiving the message is not face to face. This TED talk by Monica Lewinsky shows how bad shame and humiliation can be… To the point where you would rather die than be so humiliated. No matter where she went, people didn’t know her for her but as that other women. It used to only a small community knowing the shame of a person. Now it’s the whole internet world shining a spotlight on an embarrassing moment. To stop this, there are things that need to be done. 

First, be nice. If you see a mean comment, counter it with something kind. 

Second, don’t click on those demeaning links. The more clicks, the more advertising, the more they can make money, and the more they will spend on finding embarrassing stories to tell. People have souls. 

Here were a couple things I learned from the video:

  • Even in small numbers, when there’s consistency over time, change can happen. 
  •  Compassionate comments can abate bullying. Think about the other person on the other side of the headline. 
  • We have a responsibility to the freedom of expression.