He officially passed away this morning
while I was on break. DNR status.
Yesterday his son asked for my thoughts.
“I think he’ll make it tonight.”
Even though he was slowly deteriorating,
Maxed out on oxygen and 3 drips to keep up his blood pressure.
On fentanyl to make him comfortable.
He made it.
I returned last night.
It was a different story.
“Jessica, how’s he doing?” His son asked.
The generic “he’s fine” is off limits. It was time for the truth.
“Last night his respiratory rate was 9 or 10. Now it’s 15-18.
Often when people are nearing the end of life,
it goes from slow to faster and back to slow again.”
“But his heart rate looks ok. It’s 85.”
“Yes that’s true.
But his blood pressure is slowing decreasing.
His heart is still trying to compensate.”
He cocked his head. I tried again.
“His heart is trying to get enough blood to his body
but it’s not working. It will eventually give up.”
Optimism in his voice,
“But wouldn’t the heart rate slowly taper off?
I thought he would live a couple more days.”
“No, his heart can suddenly stop because it’s giving up.
I’m not sure if he will make it through the morning.
His drips cause his blood vessels to constrict.
That explains why his hands are cold
and the oxygen probe to not read well.”
After midnight, his HR was suddenly dropped to 42. RR was 9. SpO2 77%.
“Can you give us an update, doc?”
“Well I’m not a doctor.”
“It’s ok. We’ve promoted you. Just give it to us straight.”
I started to tear up a little bit.
It wasn’t easy for me to tell them what I thought:
He’s on his way out.
They told me that they’ve shed their tears already
and were waiting this.
“Thank you for taking great care of him.
You should be proud of you and your coworkers.
Tremendous sense of purpose and goal and comradery.”
His blood pressures stop reading.
Apnea alarm sounds.
That probably should’ve been my cue.
I still felt a carotid pulse.
I checked my drips.
Gave report and went on break.
I came back from break and looked at the monitor.
His was black.
“Your patient expired.”
Icy cold hospital terminology.
I debriefed with the experienced nurse covering for me.
What could I do better next time?
1. Listen for his heartbeat, not only feel for pulse.
2. Consider the BiPAP machine delivering breaths for him.
What’s the rate set at and what is his RR now?
In the final progress note
Include: heart rhythm- PEA,
who pronounced time of death,
which doctors notified of death.
Family at bedside or contacted.
In the end,
This family was ready to accept their father’s fate.
The son shared his friend’s voicemail message:
“How did they prepare the chicken?
They told him he was going to die.”
Humor can start the healing process.
After I gave report,
I said bye to the family
And they all gave me a hug
And thanked me again.
I drove home
Trying to drown the feeling
By turning up the radio.
I showered, ate, and wrote this down
So that I don’t forget.
Yesterday I wrote about a frustrating moment I had. A reader said that nursing is caring from the heart. I agree with that.
Since going to the ICU,
most of my patients can’t talk to me.
But one was A/O x3, could speak, though didn’t seem normal quite yet.
He was what I called “call-bell happy.”
Too hot, too cold, not comfortable–
it can all happen in a matter of 10 minutes.
1st night- “can I have a sleeping pill?” “Ice, ice, ice” “blankets on, blankets off”
2nd night- slept throughout the night but I’d catch him when he woke up and waved at me to come over. “hurts, hurts, hurts” “your bum?” He nods. I turned him to the other side and boom! He was fast asleep again.
3rd night- he looked like a new man!! Ahh the wonders of a good night rest.
He waved me over to fix him up at change of shift. He proceeded, “thank you. I knew that the moment I looked at you that you’re caring from the heart. You have made a big difference for me.”
I was a little bit shocked that he spoke so normally. We continued to talk and he spoke about another hospital. I asked him about his experience there. His eyes lit up and said, “You should be working there! There’s where you belong. You see that everyone collaborates and works so seamlessly as teams.”
I was taken back a little bit because I felt my unit had members who worked well as teams too. Does that mean he implied that here was worse than there?
He continued, “Leave your information. I’m friends with the head doctor there. I’ll get you a job there. I will. Include your specialty.” And he repeated this several times before he went to sleep.
Unfortunately, he was a step down patient and a critical care patient needed to get transferred into his room. So he left. And a new patient went into his place.
I never did leave my information because I felt that it was a little unprofessional but also, would he really remember? He still has to go to rehab to recover and it would be odd to have my information amongst his personal belongings. I’m not sure if I would’ve gone- I kinda like where I am now. Plus I’m just starting here!!
Another patient- I also had her for 2 nights with a couple days off in between. On the 3rd night she just came back from a procedure. She saw me and reached out for me. The PACU nurse said, “aww she really likes you!” I squeezed the patient’s hand and she squeezed back.
Wow, I just read grrm.livejournal.com blog and it reminded me of how I used to write. Just as myself and not another “list” or really thought out piece. So here’s my start to get back to journaling.
I came across another article about stories– the only stories worth reading are the ones when the human condition is in conflict with itself. You have a set of ideals and yet you’re torn with how you feel.
For example, last night a patient was complaining of pain and her nurse gave her pain medication. 15 minutes later, she’s asking for help. Her nurse is across the room and she saw me sitting at nurse’s station. I knew that her nurse had already attended to her so I ignored her (wow that sounds bad but I was busy catching up!!). After she called 3 more times I walk over and ask her, “what’s the problem?”
“Why didn’t you come over right away?” She probed.
“Your nurse just spoke to you. What’s going on?”
“I’m in pain!”
“Did you tell your nurse?”
“Yes. He gave me pain medications.”
I overheard him say that he gave the pain meds 15 minutes ago. “Ok, then you have to let it kick in.”
“Yes but it hurts!!!”
“Ok but you still have to wait for it to kick in!” I thought to myself, why made her think that complaining to me would make any difference?
I felt sympathetic for her because face it, who likes to be in pain? But I felt the issue was already addressed and that’s nothing left for me to do. Is that wrong? Did I lose my patience?
She ended up falling asleep.
As a nurse, I feel compassion and empathy but there’s only so much to go around. I pour it all on my patients and any patient that has a 3 alarm star going off… Or I’ll help out another nurse “boost” a patient up in the bed. But that’s about it.
We live in a world where money is king. We go to work to make money. Once we have money, we spend it on things that we need and want. Unfortunately, the US school system doesn’t teach us “Money 101.” Most Americans spend more than they make and owe credit card companies money. This is a problem!!!
Whenever I bring up topics about IRAs, 401k, stocks and taxes, my friends are often surprised by how much more I know about it than them. Wanting to help, I looked all over Google for the perfect step-by-step guide. I couldn’t find one. I’ve been thinking about creating one for the longest time now, so that they don’t have to keep saying, “Hey Jessica, can you go over that again?”
This guide is written in the order that I was exposed to them starting from when I was young to now.
My Money Story
Majority of what I learned about money is through my dad. As a 5-year-old kid browsing through the candy bars at the checkout lane, I asked my dad, “Dad, will you buy Twix for me?”
He replied, “No, but you can buy it with your own money. Did you bring your own money?”
Sad, I looked down and whispered, “No…” After I got into the car, I realized that it was just something I wanted, not needed to have. And that things cost money.
Just a couple of weeks prior, he opened up a savings account for me and gave me a weekly allowance of $5 (a dollar amount that matched my age so you can imagine my excitement each year on my birthday). He told me to save half in the bank and the other half in the cash box. In the first year at age 6, I had $120!
At age 10, my dad helped me buy a I Bond to save money at a higher interest rate (currently about 1.35%) compared to the bank’s saving interest rates (0.01%). Right now, there are 2 major types of Treasury Bonds – I Bonds and EE Bonds. Starting at $25, you can buy a Bond from the US Government online for yourself, as a gift, or for a child younger than 18. A ‘Bond’ is essentially lending the government money. In return, your money will go up at the rate of inflation plus a fixed rate that’s determined every 6 months. The purpose is to save for the long-term for up to 30 years. You can pull it out starting at 1 year but anything earlier than 5 years will have a penalty of 3 months of interest. Therefore, you would only ‘cash’ in the bond after 5 years.
Also at age 10, my sister bought a CD, or a Certificate of Deposit, which is another way to save at a higher rate (about 0.9%) but typically for a shorter period of time of about 1 year to 5 years. In case you anticipate to buy a large purchase down the road but you want to save as much as possible now, a CD is a good choice. However, personally I have never had a CD. You want to look for one that gives you the highest rate possible with no fees.
Most banks offer free checking accounts for kids age 13-18. I got my first one in middle school. This became my primary account where money flowed into and out.
Income: I got a job!
At age 15, I started to work part time (less than 10 hours/week). I got to deposit my paycheck into my checking account every 2 weeks. My dad’s word of wisdom is to ALWAYS deposit any check or cash you receive ASAP because you can easily lose it. It also creates a permanent record in your monthly bank statements. If possible, get direct deposit.
Sometimes you will get cash payments. You might think, “Oh great I have cash now, I don’t have to go to the bank.” It’s convenient! However, you need to have a record of how much you earned. Always deposit first before withdrawing it. The bank is your friend.
From the money standpoint, it’s important to have a working income because you need it to get a credit card, have a credit score, IRA, a car, rent, and really anything that you may need or want.
From a personal point-of-view, it builds character, teaches you how to interact with others, and gives you a head-start on your resume.
At age 16, I got my driver’s license and started to drive to school. Sometimes I needed to get gas. My dad got me an additional credit card under his name (with a very low limit of $300). This way I got to practice using credit cards. Here were the rules and the reasoning.
#1 Always pay with credit cards. Why: To have a record of your purchases. Also, most credit cards have purchase protection and warranty extension in case you don’t like your new product and cannot get a full refund. You’ll have less cash you carry. And if anyone steals your credit card, you can always cancel it and not pay for any items that you didn’t buy. With stolen cash, you’re left with nothing.
#2 Always pay in full. Why: Leaving any balance on your credit card means you will have a high interest rate (usually more than 10%) and pay much more. Why would you ever want to give someone more money than they should??! If you currently have any balance on your credit card statements, you have credit card debt. This is considered bad debt. Pay this off immediately.
#3 Always pay on time (or a couple days early if your credit card and bank are two different institutions to make sure you are not late with any payments). Why: Any late payments will result in a ‘late fee’ of typically $35 and decrease your credit score. One way to avoid this problem is to set to ‘automatic’ payments online. You just have to make sure there’s enough funds in your account before the due date each month.
You will probably see a couple of other things associated with credit cards.
Cash back, Miles, Etc
I personally like cash back. For every $100 you spend, you get $1 back (or more!) if it’s 1% cash back. Some have higher cash back percentages. Some cards give you miles. Just remember that you pay in full each month and don’t buy more than you need. This is just a bonus, not a way to make money.
0% Intro APR for Purchases for the first 15 months
This means that you can buy stuff and pay the minimum balance for 15 months. You are borrowing the money. You must pay off the entire balance before the end of the trial period otherwise you’ll get slapped with a APR that is usually more than 20%. That means for every $100 you owe, you’ll owe an additional $20 each year. Holy crap.
0% APR for Balance Transfers until Month/Year
This offer can happen when you first open up a credit card or in a form of a check that credit card companies religiously send to you several times a month (arg they are killing trees and it’s driving me crazy!!!). This offer is helpful if you have something else that you owe at a high interest rate (such as a student loan). Here’s how you evaluate if it’s a good deal.
It will always have a fee and a minimum shown like this: 3% fee with a minimum of $10. The minimum doesn’t matter unless you plan on using the check for small dollar amount. The only time I will consider the deal is if the fee is 1%. That means if I write a check for $5000, I will get charged $50.
The only time I used it was to pay off my student loan, which was charging me 7% interest rate. However, by using this balance transfer check, I paid only 1% on the $5000. That means I only pay $50 to pay back the balance in one year when the 0% APR expires. If I had left the $5000 student loan in the 7% account and paid off the account in one year, I would’ve had to pay $350. I saved $300 by using the balance transfer.
As you get older, try to keep the oldest credit card you have as that increases the length of your credit history. The longer your credit history, the better your credit score.
Free Online Money Management Service
At age 17, I had a checking account and a credit card with two different companies. To keep track of my spending and income, I used a free online money management service. I used Yodlee but now I recommend mint.com. You don’t have to use any of their recommended things. Basically you enter your account information and the service imports the rest of the transactions for you. They even have iPhone, iPad, and Android apps so you can keep track of your spending everyday.
IRAs (Individual Retirement Accounts)
The day I turned 18, my dad took me to Fidelity to open a IRA. “Dad, why do I need a IRA? I just turned 18!! I’m not retiring anytime soon!!!”
He replied, “Yes, but you will retire sometime. And time is the most important factor to make sure you’ll have enough when you retire.” And my, how true that is! You will always have more at the end if you put in (less) money early than (more) money later. Don’t put it off any longer.. get one today!!
To have a IRA, you must have income. For 2013, if you made less than $5500, the max you can put in is your total income. If you made more than $5500, then you can put up to $5500. Fidelity has a great program for people who are just starting out but don’t have that much. I put in $200/month into a Roth IRA through an auto-deduction with my checking account.
There are 2 types of IRAs: Roth IRA vs Traditional IRA. With Roth, your dollar gets taxed now (your paycheck is typically already taxed [net income]. That’s why you only see about 2/3 of what you actually made [gross income]). With Traditional, your dollar gets taxed later.
When you’re younger and not making as much money, put your money into a Roth IRA. This means that your income is already taxed and when you’re 65, the money you pull out will be tax free. If you desired, this account may be passed down from generation to generation.
If you’re making over $100,000, it may be wise to put money into a Traditional IRA, as it will act as a deduction to your gross income and thereby lowering your tax bracket for the year that you put your money in. However, at age 65, you must begin to take out money.
After choosing which IRA you want to put your money in, you have two more decisions.
1. Primary and Secondary Beneficiaries – Who will owe the account in the event that you pass away? You must pick these people and have their social security numbers ready.
2. Which fund? – I recommend putting it into the Fidelity Freedom Fund with the year closest to when you’ll retire. If you don’t pick Fidelity as your investment bank, there are other similar accounts. The Fund will change the percentage of bonds and stocks it holds based on how close you are to retiring. Typically, when you’re younger, the account will be more ‘risky’ and hold more stocks than bonds. Bonds are more ‘stable’ but also have less interest. It’s called a Freedom Fund because it doesn’t require you to do anything and it’ll do the work for you. This leads us to the next topic…
Stocks, Bonds, Mutual Funds, ETFs
I’ve spent over 5 years figuring out the best thing to do with my money by reading books, online material, and doing it with my own money. Here’s what I figured out. For you and me, keep it simple and forget about it. This applies to both IRAs and regular investment accounts.
After picking an institution (listed below), you must pick where to put your money. You can put them into stocks and bonds. You can buy them as an individual stock or bond (for example, if you like Apple and think it’ll grow, then you can buy their stock). Or you can buy them as a big group through mutual funds and ETFs. The good thing about mutual funds and ETFs is that it is already diversified, which means it has many different companies or bonds in that one mutual fund or ETF.
Technically, you should read about each company and you ought you come up with your own feeling about the direction of that company, whether or not it will continue to make profit. Then buy the stock based on that.
You may see in the news that the stock market goes up and down. It does that based on people’s emotions. However, over time the stock market increases, even after the depression. Companies will tend to make more money, as long as it has a sound philosophy and you believe in it.
Anyway, you may have heard to ‘diversify your portfolio.’ Your portfolio is what you own in terms of stocks, bonds, mutual funds, and ETFs. I am a big fan of ETFs because it diversifies for you. Why not mutual funds? Because PEOPLE are managing mutual funds and thus take a bigger cut from you each year (2-3%) whereas ETFs have COMPUTERS managing essentially the same exact thing but for much cheaper (0.05-0.3%).
What’s the difference between Mutual Funds and ETFs?
What is it?
many stocks into one ‘fund’
many stocks into one ‘fund’
Who controls it?
A broker (real person)
How much does it cost?
of the entire investment account
0.05-0.3% annually of the entire investment account
Costs a lot more over time
Free ETFs!! MarketRiders help you pick ones best suited for your situation
In general, you will make 8-10% annually with ETFs. And the best part is there are free ETFs where you don’t have to pay anything to ‘buy it’. Stocks, bonds, and mutual funds all cost a commission ranging from $2.50-$10 per transaction depending on the broker. So what are you waiting for???
The question becomes, which ETFs should I buy?
Here’s the best solution that I’ve come up with and currently use myself: use MarketRiders.
It is an online ETF portfolio manager. It has a 30 day free trial. After that it costs $120/year. It creates your own portfolio based on your needs. Use the free ETFs available through each broker (you can customize in MarketRiders). As of March 28th, if you try it by clicking here, you’ll also get a $25 Visa gift card. Not bad! Here are some choices for brokers.
I got one because I wanted to have some money that I can have easy access to and that wouldn’t have a penalty if I took the money out. Pick one that you trust, has a high interest rate, no minimum, easy to transfer money in and out. Then pick a set amount each month that you want to transfer so that you start to build your emergency fund of $1000.
Free Credit Score — Anytime!
It used to be difficult to find out your credit score. However, now more than ever, your credit score tells others your credibility and ability to pay on time each other. It is essential to know your credit score. You can get it free anytime at Credit Karma (www.creditkarma.com). It even tells you how you got your score, how to improve it, and has personalized scenarios of how the score can be impacted based on your actions.
401k and 403b
After college, I started to work for a company that has a 403b. What is a 401k or 403b? It is another retirement account that is only available through your employer. 401k are available for private companies whereas 403b are available for nonprofit organizations. Some companies will match a certain dollar amount up to a certain dollar. Other companies will simply have it available.
You want to take advantage of this program. You can put in a max of $17,500 in 2013. Personally, I put in $500 each paycheck. It will deduct your income pre-tax so that you will have a lower tax bracket. Also, you would think that taking out that additional $500 would leave you with a paycheck of $500 less. It’s actually only $300 less because it is now taxed at a lower rate. Totally worth it.
Please feel free to share. Let me know if there’s anything you’d like to know more in depth via email or through the comments below. Thanks!
Probably one of the most nerve wrecking things that you have to do as a new nurse is to give a good report to the next oncoming nurse, the charge nurse, the nurse who covers you on break, the doctors, and the ancillary staff. You want to give the right amount of information that is pertinent to each person.
While I was in school, I thought it was a little silly to repeat the information that the instructor just gave me and I thought that I was doing it all wrong. But honestly, it’s good to just repeat the information out loud so you know what’s going on.
SBAR is really comprehensive and is great for the oncoming nurse. Here are the elements.
S : Situation – State Name, Unit, Patient, Problem
B : Background – Admission Diagnosis, Pertinent history, Current treatments
A : Assessment – Current VS, Physical assessment, Test results
R : Request – Needs MD/MLP evaluation, Further testing, Transfer to higher level of care
S: This is Jane Doe, 78 year old female under Dr. So-And-So. A/O x 3 but forgetful. No allergies, No isolation, full code.
B: She came in with pneumonia. Her past medical history includes COPD and diabetes. She came in yesterday (blah blah blah)…
A: (Vital signs) Her vital signs are stable. Afebrile. No pain. (Activity) She can get out of bed to chair with 1 assist. (IVs) She has 2 peripheral IVs in the right AC from two days ago. No drips but gets IV antibiotics. (Skin) Her skin is intact. Palpable pulses. (Lungs) She’s on 2 L nasal cannula sating 95%. Lungs diminished bilaterally. (GI) Active bowel sounds. Regular diet. Last bowel movement was today. (GU) Voids. Good urine output. (Glucometer) No fingerstick. (Labs) She needs a CBC and BMP in the morning.
Current labs Her WBC is elevated.
R: I recommend ID (infectious disease) consult on her.
For a doctor or PA/NP who is new to the patient, do the above but with pertinent past medical history and trending labs if possible.
For the charge nurse, you give report twice. Once in the beginning of the shift and one closer to the end. In the beginning, say the situation, any drips, and the plan for the patient. And if you anticipate that you’ll need help from her, this is a good time to speak up. For the second report, state what has changed since you started your shift (any new labs, tests performed, drips, assessment) and the plan for the patient.
For the nurse covering your break, state the situation, code status (Full code vs DNR etc), mental status, activity, diet, drips, and any abnormal vital signs that has stabilized or anything else to look out for.
For the ancillary staff, state the situation, code status (Full code vs DNR etc), mental status, activity, diet, and any other additional things that they can do (fingerstick, lab work, turn patients, last wash, incontinence).
2013 was the best year of my life.
Independence rang true – new apartment, new car,
new nursing career from the nursing home, to tele and ortho, to ICU.
(wow, I sound like a typical millennial* look at the table below)
My family and friends started new careers too,
life is getting sweeter.
The stats were an all-time high,
Getting emails and comments all the time,
About NYU Nursing
Advising and inspiring future nurses.
To me, there’s no greater praise.
Last year’s theme was ‘New Nurse Blog.’
But now I’m no longer a fresh fresh nurse.
I’ve got one year under my belt!
For 2014 I’m changing it to
‘I wish I knew that before.’ “I” can be me, a friend, or you.
Health, Food, Money and Rights are my passions
So here it goes!
This table is from a Medscape Nurses article about how to manage a 4 generation gap nursing workforce. You can sign up for a free account to read the article.
What They Want
Less demanding schedules (part-time; shorter shifts)
Reduced stress or workload
A job well done
Use a personal touch
Provide traditional rewards
Use as mentors
Offer less physically demanding positions
Recognition for experience and excellence
Positive work environment
Good pay and benefits
Give public recognition
Find opportunities to share expertise (precept, mentor)
Promote “gradual retirement”
Autonomy and independence
Provide opportunities for skill development and leadership
Involve in decision-making
Stimulation, engagement, involvement; multitasking
Socializing and networking
Impatient for promotion
“Move up or out”
Offer a supportive work environment
Begin leadership development early
Provide access to social networks; build on technology strengths
Develop skill base
Here were the topics that we covered in my critical care orientation. While the instructor said that this class is not to provoke anxiety, some of the topics made me a little nervous, but I guess that’s normal for anyone doing something for the first time.
Arctic Sun (Hypothermia therapy)
Hemodynamics I – Arterial lines, CVP
Hemodynamics II – PA Catheters (Swan Ganz)
Insulin Infusion with Delta
TPA for MI
Acute Renal Failure
ACLS Part 1 (BLS + videos)
Intra-abdominal Pressure (IAP) Monitoring
Pulmonary Vein Isolation (PVI)
Crash Cart – Defib, Cardioversion, Pacing
EPIC Code narrator/critical care flowsheet
Intracranial (ICP) Monitoring
Exams (Core and Pharmacology)
PACU Day – recovery from anesthesia
ACLS Part 2 (Respiratory, Tachy, Brady algorithms; Test “Megacode”)
I’m so excited to announce that I was recently accepted into the MICU (medical intensive care unit) at my hospital! Critical care class starts in 2 days and I just finished my last shift on the telemetry med-surg and orthopedic unit!! I loved my team there– the people are truly incredible. The CCPs, PCAs, management, my fellow night nurses and day nurses made my time there truly amazing. It felt like a great teamwork every night, making sure essential things get done and always going above and beyond. 🙂
One year ago, I started at a nursing home for a month. 11 months ago, I started at the hospital on the telemetry unit. My hospital is having some of our ICU nurses go to another hospital in the system to build up their units so this great opportunity came up for me to go work in the ICU.
Fortunately, the interview was a “formality” but it’s no excuse not to prepare! With nearly a year of experience under my belt, it was much easier to come up with experiences showing my leadership. And remember, people relate to specific STORIES more than generalities! Here is a list of questions the nurse manager asked me.
May I see your resume? (Asks questions on the resume especially regarding additional schooling aka your future plans and previous experience)
What made you interested in coming to the ICU?
How has your experience prepared you?
What kind of drips have you used?
Have you called a RRT or a neuro RRT or code before? What happened? What was that like?
Describe a busy night for you.
If you have several things going on, how do you deal with that? (Delegation and priority- give specific examples where this came in handy!))
How do you keep your ancillary staff accountable? Do you always or only sometimes have huddles? Do you meet up with them again? How do you make sure they do what you asked them to?
What do you do when you’re unsure of something?
What is a strength you have? A weakness?
What have you heard about this unit?
Do you have any questions for me? (The answer is always yes and you ask questions!! Such as the type of patients, the ratio, the professional nursing organization, scheduling, etc)
I hope this helps! If you have heard of additional questions, I’d be happy to add in more to get a more comprehensive list. And happy thanksgiving to everyone!! I have a lot to be thankful for, including the readers who have given me positive feedback through emails, comments, and likes. 🙂 so thank you!!!