Nursing Update

Hi there! Oh my word I can’t believe it’s been so long since I’ve written anything. A little over a year now! I never did get around to writing a post about a typical shift in the cardiac stepdown unit. Obviously this blog is no longer a big priority since I started it to record my journey through school and well, I’ve been graduated for a little over 3 years now.

3 years.

Wow. I can’t believe I’ve been finished with nursing school and have had a degree for 3 years already! And as of about a week ago, I’ve been a registered nurse for 3 years!

I appreciate all the comments in my absence and I’m so glad that this blog is still helping nursing students.

A word of encouragement: being a new nurse is tough and scary. Being responsible for lives and handling medicines that could potentially cause disability or death is not something to be taken lightly. But the experience and knowledge that is gained as time goes on at the bedside makes the job feel easier and the anxiety lessens and going to work suddenly becomes a privilege and no longer feels like a heart attack waiting to happen.

I transitioned into a medical/surgical ICU almost a year ago, and I finally feel like I’m HOME in the world of bedside nursing. I absolutely love being an ICU nurse. I feel like I’ve found my passion and this is where I belong and where I make a difference. I feel like my nursing world has a purpose. Friends, if you don’t feel like this in your unit, it may be time to shake things up.

My ICU handles many different surgical and medical conditions. Some of the more frequently seen medical conditions are sepsis, pneumonia causing respiratory failure, strokes, DKA, acute kidney injury/acute renal failure, post cardiopulmonary arrest, afib/aflutter, and hypertensive crisis/emergency, among others. And some of the surgeries we get are craniotomies, exploratory laparotomies due to bowel perforations, and laminectomies. We don’t see as many surgical patients as medical patients for sure, but I’m ok with that because I prefer the medical patients. We have the ability to care for patients on rotoprone beds for ARDS, CRRT (continuous renal replacement therapy – a slower, continuous form of dialysis), patients who have had ventriculostomies done and have EVDs (external ventricular drain) to decrease intracranial pressure, and hypothermia for post cardiopulmonary arrest patients who are eligible. And of course we have the usual hemodynamic monitoring through CVP lines and arterial lines.

It’s a busy ICU and our acuity stays pretty high. For example, about a month ago, we only had one patient out of the whole ICU that wasn’t on a ventilator (and our census was full, with PACU and ED holding patients for us!).

I’ve been able to take care of almost every type of patient with the exception of a hypothermia patient (we don’t get them TOO often) and a CRRT patient. I’ve taken the CRRT class and technically can have a patient on CRRT, however it’s just never worked out that I’ve been working when we’ve had a CRRT patient or they’ve been too unstable for me to take as my first CRRT patient. Hypothermia, CRRT, and organ donation patients are always 1:1 patients in my ICU which is nice because they’re usually very busy assignments.

I’m pretty sure I’ve learned more in just a little under a year in the ICU than I did in the two years I worked on the cardiac stepdown unit! Although I have to admit that I’m so thankful I didn’t start out as a new nurse in the ICU. Obviously it works out well for many new nurses but I think that it would have been detrimental for me. Not only are you learning how to take care of patients as a new nurse, you are also learning how to chart and learning how to navigate hospital life and hospital culture. I’m grateful that I had those two years prior to the ICU to get my basic nursing skills and assessments down, because when I moved into the ICU I hit the ground running and it has been a fast pace ever since! Also on the plus side, I really learned a lot about cardiac nursing and management of cardiac patients which I really appreciate because the ICU I’m in doesn’t really handle many cardiac patients (our hospital has a CVICU where the majority of the cardiac patients go).

There are some big differences between the cardiac stepdown unit and the ICU. In the stepdown unit I was responsible for 4-5 patients per shift. We didn’t usually have more than 2 patients at a time who were on a cardiac drip such as amiodarone or cardizem; in fact it was more common that my patients were saline locked other than scheduled IV antibiotics or maybe had continuous normal saline running. We rarely had patients with NG tubes or other invasive equipment. Most of our patients could get out of bed independently or with assistance. They were monitored remotely with telemetry. Our patient care technicians got all of the blood sugars, did baths, emptied foleys and urinals and toilet hats, recorded vital signs every 4 hours (unless a patient was on a cardiac drip), and helped feed and otherwise assist patients when the nurses weren’t available. Because the nurses had so many patients, we were responsible for medication, assessments, educating the patient when possible, and charting.

In the ICU we have 1-2 patients (sometimes 3 if we’re really short) per shift. Our patients are usually critically ill and on several drips to manage/treat their condition; in fact it’s rare if the patient is only on maintenance fluids or saline locked. They can have central lines, PICC lines, NG/OG or PEG tubes, foleys, rectal tubes, EVDs, chest tubes, wound vacs, etc. Every patient is monitored from the room with vital signs being taken every 15min-1hr; those vital signs then populate into the chart automatically (other than temperature, unless the patient has a temperature probe in their esophagus, rectum, or bladder). The nurse is responsible for total patient care, including baths, turns, feeding (when they’re alert enough to have a diet – which is rare), etc. We have patient care techs in the ICU and they’re available to help, but many of them also act as unit secretaries, stock the unit, transfer patients, etc. They are also responsible for blood sugars (unless the patient is a DKA patient, in which case the nurse usually does the blood sugars or the nurse and patient care tech alternate every hour). Nurses are completely responsible for the intake/output record per patient and so therefore must empty foleys/drains and record the intake from food trays. Patients don’t get out of bed often in the ICU (unfortunately) and when they do it’s usually with PT. Nurses are responsible for drawing blood for labs/blood cultures and taking the patients to MRI/CT.

There are other differences but this explains the biggest differences between the two units for me. And of course, in the ICU, the patients are sicker and so I do maintain MUCH more contact with physicians and family members. My assessments are much more thorough and I have to recognize subtle assessment changes quickly because most of my patients aren’t alert or able to communicate well with me. And in the ICU we rely on teamwork way more than I ever had to in my previous unit.

I can’t promise any posts any time soon but I will try to update a little more regularly. My upcoming plans in my nursing career this year are to study for, take, and pass the CCRN certification. I also want to take a preceptor class at my hospital and begin precepting new nurses and new employees. And I’m beginning to seriously think about beginning DNP school; the program I’m really interested in only takes applications every December though so I’ve got some time before I have to make a decision about that.

If y’all have any questions or would like me to write a blog post about something in particular, please let me know!

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Two Years a Nurse

Two years ago today I was officially listed on the Texas Board of Nursing website as a registered nurse!

The past two years have been good, bad, hard, fun, and such an expansive learning experience as a new nurse. Nursing school did NOT prepare me for what it’s actually like to be a nurse at the bedside, completely responsible for my patients for a 12-13 hr shift. Of course I knew that the reality of being a nurse was going to be different than what I was able to observe and practice in nursing school, but being a “real world” nurse is SO much more than I expected.

In my residency program I was given 16 weeks to orient to being a nurse. I honestly felt like it was the perfect amount of time…in the beginning I thought I’d never get to the point where I was comfortable taking patients on my own and fully taking care of them, but then by the end I was so ready to not be hovered over anymore, haha!

Of course in the beginning my preceptor and I started out with just one patient, and it was basically me learning how to develop and follow a routine, tackle time management, and take care of a patient with the guidance and help from my preceptor right there beside me. And then as time went on and I was comfortable with completely caring for one patient, another patient was added to the mix. Gradually of course the patient assignment increased until I was doing everything for 3-4 patients with only occasionally needing guidance and help from my preceptor.

About 6 months after I came off orientation the realities of bedside nursing, hospital politics, short staffing, and various other things started to catch up to me and I found myself frustrated and bitter with work on a daily basis. I dreaded going into work. I really enjoyed being with the patients and the patient care that I gave but everything else weighed me down. I was (and am) afraid of making a mistake. I was (and am) afraid that I wouldn’t catch something that I should have. Plus a part of me was angry with myself that I didn’t hold out for an ICU job right out of school like I wanted (even though in retrospect I think starting out on the stepdown unit was the perfect first job for me!) I found myself disillusioned and dissatisfied.

And I was frustrated because nursing had been my passion for a long time. I worked hard for my degree and I didn’t want to lose that zeal and that love for the profession.

Well thankfully I was able to take 3 months off for maternity leave in September. It came at just the right time and surprisingly when the time came to go back to work I actually found myself excited again and ready to get back into nursing. And while I still have bad shifts and days when I don’t want to go to work, I have found that the extended break really help “reset” my emotional self and somehow gave me my love for nursing back.

I’ve learned a lot in the past two years and have built the foundation for being a good nurse. I still have a TON that I want to accomplish and I know I will forever be learning but I’m so glad that the first couple of years of being a nurse are behind me. And I’m so excited to be continuing my career as a new ICU nurse starting in March!! In the middle of January I interviewed for a CVICU and a general medical/surgical ICU and actually got offers for both! I surprised myself – I really thought I’d go for the CVICU (considering I LOVE the heart and I’m familiar with the cardiac system the most since I work on a cardiac stepdown unit) but I ended up accepting the offer for the general ICU. I like the fact that it will give me more experience with the other body systems and I will have a wider knowledge base. Especially because I want to become an acute care nurse practitioner in the future and I want to have a good understanding of more disease processes than what just affect the cardiac system.

I’ll put a blog post up somewhat soon (as soon as my 4.5 month old will allow me the time to write it!) summarizing a typical shift and what my nights generally look like. For now let me just end by saying I’m happy to be back and I’m super excited for the new experiences to come! 🙂

Entering Week 12

It’s the start of week 12 already!!! In a little under 5 weeks I will be graduating!! (And just in case you’re wondering, only 29 days until my last final and only 32 days until pinning!!!)

I’ve had some changes with my CCI schedule…in the middle of October I got an email stating that I was no longer allowed in the ED at the VA due to them taking precautions with potential Ebola situations, so I was given a new preceptor and a new floor – a med-surg floor. Honestly I wasn’t thrilled, for several reasons. I had grown to love being in the ED and I knew what was expected of me, I LOVED my preceptor and we got along really well, and I was scheduled to be done with my shifts on Halloween. Due to the timing of when I was able to get ahold of my new preceptor and begin shifts with her, plus the fact that she works 8hr shifts instead of 12hr shifts, meant that my CCI shifts were stretched out a bit further into November. Instead of only having 4 (12hr) shifts left to complete, I now had 6 (8hr) shifts to complete.

I also thought that I wouldn’t enjoy this new change due to the fact that I’d be on a med-surg floor, but honestly I’ve really had a good time with my new preceptor and on this floor with these patients!! I’ve done a TON more charting and medication administration, as well as looking at lab trends and looking into the H&P of these patients, which I really didn’t do in the ED because our patients were with us for such a short amount of time. At this point I’ve taken up to 3 patients, I’ve given report on 3 patients at the end of the shift (not very successfully, but thankfully the nurse I was giving report to was kind and gave me tips for how to do it better next time), and I should be taking 4 patients on my next and last shift which is this upcoming Wednesday. I can’t believe my VERY LAST CLINICAL IN NURSING SCHOOL is this Wednesday!!!

Tomorrow after our leadership and management test, our entire class is going to be taking a class picture for our pinning ceremony, so we get to wear our scrubs but actually look pretty in them for once, being that we can wear our hair down and wear makeup. Everything is wrapping up so quickly now that I feel like I can’t keep track of it all! I can’t believe that we are so close to being done.

A couple of days ago I bought my graduation announcements, all my honor cords that I will be wearing at graduation, bought my diploma frame (it’s gorgeous!) and registered with Pearson Vue to take the NCLEX. AHHHH.

I took my exit HESI about two weeks ago but I made a 904 on it (which converted to an 83%) so I’m going to re-take it. I don’t feel like I NEED to retake it since I made over an 850, however I figured it’d be good practice, plus I BARELY have a chance at making an A in CCI with that score so if I can get a better score the second time around, then my chances of making an A are much higher (they take the higher of the two scores – they don’t average them out, thankfully!).

So here’s what’s left in this semester and then I’m DONE!

  • 2 tests (L&M tomorrow, Communities next Monday)
  • 2 quizzes (Communities quizzes before each exam)
  • 2 projects (One in Communities, one in CCI)
  • 1 clinical (last one on WEDNESDAY!)
  • 1 clinical log (for Communities)
  • 1 HESI
  • 2 finals

I can’t believe it! I’m so close it’s insane!!

I’m Back!

Hello everyone! I had to make my blog private there for awhile during the whole Ebola situation due to the fact that I had journalists tracking me down at my house to try and get information out of me. I just decided to make everything private for the time being.

But I’m back now! There’s been a TON happening with school that I haven’t written about and that I will get around to writing about soon! (This week!) But for now I have to begin studying for my 2nd Leadership and Management test on Monday…so blogging will have to wait a bit.

BTW, the countdown is ON folks!! Only 30 days until my LAST FINAL of college!!!

Keep Calm, I’m…

Going to be a Cardiac Nurse!!!!!

After my PCU and CSU interviews a couple of weeks ago, I was called back for final interviews for both, as well as an interview on my floor and an interview at a CVICU. The interview on the CSU (cardiac step-down unit) was first, and I went to that not expecting much more than to get some great practice with a panel interview and practice with the type of questions that I would be asked.

As it turned out, I met several of the staff and charge nurses on the unit and got great vibes from them, was asked if I wanted to tour the unit after my interview  (which I did, and LOVED), and left the interview feeling like I REALLY wanted to stay on the unit as a new grad nurse. That night found me tossing and turning in bed wanting to be chosen for that job and yet feeling conflicted as to the fact that if I chose that job I’d be leaving a great unit and people that I love at my current job.

I got a call from the manager of the CSU the next day offering me a night position on that unit…a call that I missed and had to listen to on voicemail because I was getting ready for my interview that day, the interview on my floor with my boss!

I wanted to call her back right away and accept the position – in my gut, I had a great feeling about the job and  I just KNEW that I wanted to start my career as a nurse on that floor. But I called my mother-in-law and then best friend first to get some advice on what to do, especially since I was about to go interview for the position on my floor, and they both told me to at least interview with my boss first and see what she had to say about the position on my floor.

So I went to that “interview”, which really was more of a Q&A session with my boss (she wasn’t interested in a formal interview since she already knew me) and I ended up telling her about my job offer and the war going on in my heart and mind as whether or not to accept the position I was offered at a different hospital or stay where I knew the unit, the managers, and the coworkers I’d be with as a new nurse. The biggest reason I told her that I was even considering the other job is because the new hospital is 15-20 min away from my house whereas my current hospital is about an hour and 15 min away from my house. I didn’t tell her that I was also considering the other position because the acuity of the floor is higher than the floor I currently work on, and I’m somewhat nervous about staying on my floor and transitioning from a PCT to a nurse; how would the other PCTs react to that?

After I left my interview with my boss, I just knew that I had to call the other manager back. I knew what my decision was and I’d known even before my interview with my boss. I wanted to take the other position.

So I called her back and I accepted her offer to be a new grad nurse in the CSU!!!

The residency starts in February of next year, so that gives me plenty of time to study for and pass the NCLEX once I’ve graduated. And then my life as a real nurse will begin!!

Here are some of the criteria that the CSU deals with:

  • Patients with a primary cardiac diagnosis, or patients with a medical/surgical diagnosis that develop cardiac issues during their stay requiring high acuity cardiac monitoring and/or care.
  • Acute MI (heart attack) patients with or without cardiac cath lab interventions – including post intervention with/without arterial sheaths in place.
  • Patients requiring inotropic pharmacological support.
  • Patients requiring blood pressure support – either for hypertension or hypotension.
  • Post-op cardiovascular surgical patients.

I’m so freaking excited!!! I just want to graduate already and start my job as a cardiac nurse!!!

Office Space

Cleaned up my office yesterday…filed and everything. (I absolutely hate filing. Seriously…worst chore EVER.) I still have a bunch of stuff to shred, but I’ll get to that one lazy afternoon when I have nothing better to do than to watch ER. 😉

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I ordered my books for my Community Health class, but I still don’t have a book list for the rest of the classes. 😦 I also still have no idea what my schedule will be for the first few weeks of school…which is crazy considering the fact that the beginning of the semester is only a little over 3 weeks away. EEK.

I also do not know yet where I will be precepting within the VA Hospital. My instructor asked if I had a preference for critical care, ER, or med-surg; I of course answered that I’d prefer to work in critical care but I haven’t heard back about that and I’m not sure when I’ll know. It’s frustrating when I don’t have any answers because it’s harder to prepare myself…but such is the way of things.

I seem to be consumed lately with the thought of applying to jobs and I’m trying to imagine myself getting call backs for interviews. The nerves are building and it feels much the same way as it did before I was able to apply to nursing school. The ANTICIPATION!! I’m not quite ready to apply because I don’t have any cover letters made yet (need to do that SOON!) but I’m mentally ready to get this show on the road.

And that about sums up my thoughts for now! I think I’m still in denial that this semester starts so soon…

 

Adult Health Simulation, Round 2

Yesterday (Friday) I participated in my last simulation for Senior 1. It was the exact same simulation that I participated in as a Junior 1, only this time I was on the other side of the same coin. It was terrifying…especially after hearing stories of my classmates breaking down into tears on Wednesday (some of us went Wednesday, some of us went Friday).

I had nightmares about this simulation on Thursday night. I dreamt that I froze and couldn’t do anything…and then I dreamt that we were notified that the simulation was canceled due to SNOW! That’s how badly I didn’t want to participate. I knew that I would be all by myself (the instructors had released the wrong schedule to us – the schedule that showed us who we’d be paired with and which patient we’d have) and the pressure was intense. Most of my classmates were paired with another S1 and everybody had two J1s. Except for the lucky few of us that they decided would be alone with their J1s. I was told later that they specifically picked the strongest of us to participate on our own (a blessing and a curse!).

So when I got to campus yesterday morning I reviewed some of the paperwork that we had to chart on and steeled my nerves as best I could. I didn’t feel at all prepared but I had to do it so I just had to deal.

The first thing we did was practice with IV pumps for about 45 minutes. This was EXTREMELY helpful to me since I’d never been able to practice on one in simulation OR clinical. So I actually feel like I could work an IV pump for the first time! I had a lot of fun doing it and I think it really helped me calm down.

Then we moved on into the “ER-triage” part of the simulation. This time, instead of being stationed at one patient to get a thorough history and assessment, the S1s were paired off (except me) and rotated amongst the five patients in order to do a quick assessment and move on. We were supposed to be able to get enough information to be able to prioritize the patients afterward. I thought this part was a bit harder than I was anticipating. Completing a “quick” assessment is not an easy thing for me to do, plus I think I was so nervous and scatterbrained that I did not ask all the right questions or get all of the information that I needed.

After the ER we spent a bit of time together as a group prioritizing the patients, and then we moved into the ICU lab in order to take care of our patients for the actual simulation part of it.

I was paired up with two J1s and was given a CHI patient (closed head injury). At this point in the simulation, since everything had been happening in “real time” since Wednesday, my patient had decompensated quite a bit. His GCS (glasgow coma score) was 3 which is usually an indicator of brain death (although it’s not confirmed until other tests have been performed), he was intubated, his ICP was 22 and climbing, and really we were there to make sure his body remained viable.

I really wish we were given more time than 45 minutes in the actually simulation to get things done. I had been told in report that the patient’s ICP was 22 and if it was above 20 for over 5 minutes the physician needed to be called. So the first thing I did was check the patient’s safety equipment, vent settings, IV fluids, and took a quick look at the monitor to make sure that there weren’t any pressing concerns other than his ICP. Then I set about trying to call the physician about his ICP. And after the physician gave me orders to give the ordered Mannitol, it took me FOREVER to give that med! I wasn’t sure how long to IV push the med so I had to call the charge nurse. Well the charge nurse told me it couldn’t be IV push so I had to dilute it and give it IVPB. Then she says “wait, let me double check that,” after I told her the only form we had the Mannitol in was for IVP. Meanwhile the J1s are doing a thorough assessment (thank God) and checking the patient’s blood glucose.

Finally I’m given the go-ahead to give the Mannitol as IVP so I have to draw it up and prepare it, and then give it. Well, while I’m giving it, one of our instructors walks in and goes “that’s enough interventions for now! Time to start cleaning up and preparing for the next shift to come in!”

WHAT?! That wasn’t enough time at all! I didn’t even have time to get anything else done!

At least I didn’t walk out of there crying. I thought I just might. But I really should’ve managed my time better and I should’ve been able to get more done during our shift than just give the Mannitol. Ugh. I’m disappointed in myself.

But hey, that’s the purpose of these simulations, right? Figuring out how to be a nurse and manage time and take care of the patient?

I just hope that next semester when I am (hopefully) following a preceptor around that I will learn very well how to manage time and take care of my patients. I’m ready to be a nurse but I don’t want to feel like I can’t organize well enough for this job!

 

Close Call

I just barely scraped by. BARELY.

That adult health final was rough. I just can’t even put into words how hard that final was. It made me feel like I hadn’t learned ONE thing all semester. I certainly thought I was prepared…but let me tell you after having received As on all my previous tests, this final felt like a punch in the gut. I LOVE learning about adult health, but this final certainly wasn’t reflective of that.

I took the test and then, even though it was online, I didn’t get my grade right away. 😦 About an hour later, a classmate posted on Facebook that the grades were up so I booked it onto our blackboard site and scrolled down to the bottom.

I made an 80.

I felt my heart drop. I needed an 82 to get an A in the class. It was the same exact scenario from last semester with my Assessment final!!

But then I remembered that I got 2 points for my final grade due to my HESI score. So I texted my instructor to ask her if the grades had our HESI points added to them already or not.

THEY DIDN’T!!!

So I ended up making an 82 and getting an 89.5% overall course grade, which rounds to a 90, which equals an A!

Seriously, scraped by. Barely. But I’m super happy that I made an A and super excited that my Adult Health 1 class is OVER!

50 Years…

Today is the 50th Anniversary of the day that President John F. Kennedy was shot.

Living in the DFW area, I have grown up with this history and have many times been on the street on which he was shot. This semester, I stepped foot in Parkland hospital for the first time and was able to stand on the site of Trauma 1 and the place where he was declared dead.

I would have to honestly say that it was JFK who began my desire to have a career in the medical field. How is that possible? I certainly wasn’t alive when he was shot…in fact my own father was a young toddler when that occurred and not even my mother was alive!

When I was about 6 or 7 my parents gave me the booklet that they had received from the Dallas memorial for JFK. In this booklet (which I still have) there were interviews and information about the day when JFK was shot. And pictures. Many many pictures, most of which I do believe are false, but it was these pictures that spurred my interest in the medical field. They were autopsy photos and descriptions of where the bullets had entered and exited the President’s body. And the descriptions were so full of medical jargon…none of which I understood. I poured over those gruesome pictures and was enthralled with the human body and what could happen to the human body in the span of 5 seconds that would cause death. And I looked up the words that I didn’t understand. And I remained so interested in the anatomy and the mysteries of the human body that from then on I knew I wanted to be involved somehow in medicine.

My interests have certainly evolved from that point…when I was younger I wanted to be a doctor or maybe even a coroner due to my love of the human body. But for me now I realize that there is so much more than the human body, diseases, and medicine. There is also the human spirit. And the human spirit is why I am so interested in and passionate about nursing. I still LOVE the human body and am interested in the tragedies that can occur with it (which is why I think I’m so interested in trauma/ER nursing), but I also really want to be involved in the soul and spirit of the patient and their family.

Call me weird if you must (it’s certainly true) but that is my origin story. And it all revolves around JFK’s death.

 

 

Can’t Wait!

Yesterday I went to the hospital and signed all my papers for my job! I also had my TB testing done, and completed a physical and drug screen.

And today I bought pretty teal scrubs (PCTs wear teal) for work and I actually found a pair that I LOVE. Can’t wait to wear them!

Now all I have to do is return to the hospital tomorrow to get the TB skin test read for results, and then orientation starts on Monday!