Archive | November, 2009

lazy nurse go learn something

12 Nov

I am lazy and neglectful around my brain. It was several months ago that my beloved hospitals education department tempted all the nurses on the telemetry floors to study for PCCN certification and I was super motivated. I showed up for the classes, did all the homework , and took home the ten audio lectures on my flash drive and the worksheets and said to myself I can do it.

What happened? The first section is Pulmonary which comprises 14% of the test, second to Cardiac which is 36% of the test (thankfully). So here I am still studying Pulmonary, I keep dwelling there, not because I am not comfortable there but because the next lecture, the next section is Neurology. It is not that I do not like the neuro, hell I know I have a whacked out limbic system, but it is just that it just does not excite me that much. I have one fave neuro MD, but only because he likes to chew pink bubble gum and blow bubbles in the halls like me when no one else is looking (busted); I like to slip him some gum when he is unaware to be accused later when he finds it, “How did you get that gum in my pocket?” and I reply, “While you were assessing my patient of course.”   I might be neurotic, he might know that. That is about the only thing I like about neurology so far. I feel terrible caring for the stroke patient that comes in rapid atrial fibrillation and find a history of atrial fibrillation and blood work that reveals a sub-therapeutic INR.  I just do not have the answers to: when is this going to get better? to the families of patients who are presenting with stroke. I am not saying that I always have to know the outcome, I can deal with the un-predictable factor, but maybe I just need some more education and here I am delaying the studying by writing this in the first place; procrastinate I do. I should get into it, after all I am caring for stroke patients, especially the ones with arrhythmias. I know what I have to know at the minimum. Yes I certified to score the NIH on admission, but I just do not like it, and still have to get out that little assessment book to score the patient appropriately. I am being pessimistic but I should reveal that I have seen patients actually have an acute stroke after admission to the hospital that received tPA and have had good outcomes. I should lighten up about this predicament I find myself in.

I could happily skip from Pulmonary to Cardiac and then on to the Nephro because there is something I like about the way the dialysis machine spins and smells. I know it is strange loving, but I get a thrill out of chemistry and Renal is filled with it.  I loved chemistry in school and I still rock (like some other person I know) like a tetrahedrally bonded carbon atom with a strong covalent bond, adamas: a diamond.  The first thing I really noticed about ABGs was if all the values went up or down in the same direction you see a metabolic disorder, sick way of learning, I know.  I will think about nephro when I get tired of spinning on IV poles in the halls, and that is going to be a good long while I am sure.

After that I will study the rest, or maybe I will just go take the test because after all this might just be one more way of being lazy. I did not do horrid on the pre-test. I do not know what I am really waiting for. Maybe because I know that I am a good test taker but if I pass does not mean I really know anything!  This way I just keep on learning; sick way of learning, I know.

Let me do it

2 Nov

After two something years out of nursing school and rolling on telemetry with all its PQRST intervals and drugs and QTc intervals and heart sounds and lung sounds and optimal electrolyte goals for cardiac patients.  AND  yes  to the Pharm D, I am aware that the MD just ordered Levaquin IV and the patient is on an Amiodarone gtt so I will call for a different antibiotic because I know after numerous phone calls from pharmacy that the Levaquin IV and Amiodarone IV may prolong the QTc interval and perhaps lead to torsades de pointes, and we all know to watch for those R on T– PVCs. Oh and I love the medical patients that get transferred to telemetry so that they can receive haldol IV because that too may prolong the QTc interval. *sighs*

I am  backtracing here like a regular sinus rhythm strip erasing backwards from right to left to the original pacer  of my heart.

What I want to write about is clinical can do skills. I just like clinical stuff. I would much rather start IVs and insert tubes and talk to my patients then to sit at a computer all day and chart check  (b o r i n g).   And I got a reputation for that in just 2 short years.

How did it start? Luckily for me I had a great clinical preceptor. This man nurse who orientated me for some 18 weeks on the floor is an older nurse from India (note: not to be confused with fave man nurse).   He actually went to medical school in India, and then came over to the USA, never completed residency and then just decided to go to nursing school. So he has been around for a while. He has great clinical skills. There is not an IV that he can not start on the poorest of veins. He is calm and relaxed all the time, even in a crisis and he just can do. I consider myself  lucky to have been precepted by him and I am lucky to obtain some of his calmness. He has the ability to differentiate a crisis  requiring help from others or we can fix it here and now situation. He was there when my first patient coded and actually inserted a femoral central line under the supervision of the intensivist during the code, so that the intensivist could manage the code! imagine that!

Starting IVs. After my orientation was over I deliberately scheduled myself on the days that he worked just so I could keep him a  resource. For every hard stick that I could not get the IV catheter inserted, he would be there for me. The thing about me is that I never left the room when he started my IVs, I wanted to stay to see what he was doing. He took a really long time on those who had poor vasculature. He sat down in the chair, looking , searching, palpating. Sometimes he would find a vein and show me and tell me to do it while he stayed with me and I would get it!

I was never the nurse to ask some other nurse to start an IV for me and then go do other things, even if I was busy and I never asked someone else to help me unless I failed on my own attempts. And now I am the nurse that other nurses ask to start IVs that they can not get! Practice.

And after two years, I get it mostly every time. How? Well, I had a great teacher and I start IVs alll day for everyone. When I am not busy or my work is done at 1800  hours I ask every nurse if they need any IV starts and then I make a list and get a bucket and go inserting. I love when I introduce myself and tell the patient what I am here for and they tell me, “I have been poked so much you will never get it.” and I just take a long long look and then get it in one stick, the patient gets so happy and relieved and it feels good hearing, “you are the best aren’t you?”   I blush and say no I am not the best, but inside I feel real good, as if at least I am good for some things.

I am not limited to IV catheter insertion. There is nothing more that I loathe more than gastroenterology and all of its aspects. The patient coming in with the huge distended belly either from a bowel obstruction that is probably septic or ascites from liver failure, it just worries me so much. I once had a patient code that I am sure was originally related to abdominal compartment syndrome. I mean the belly was so big and distended it appeared to suck up all the lung space! I mean how can one breath with a belly like that?  Here I am backtracing my ECG.

It is pretty darn bad when Belly Surgeon tells another nurse to find me to insert the NGT that she could not get in. I remember inserting my first NGT, I was in ICU still as a student and the cool nurse grabbed me and I was all shaky and nervous, and he just held my arm while he told me keep advancing, so I did, shocked at what started sucking out of that patients belly:  coffee grinds. The second NGT I inserted was equally nerve scraping. I asked my clinical coordinator to come with me, she held my hand, and I got it in.

Now my clinical coordinator wants to know why is the surgeon calling asking me to insert an NGT when just 2 years ago I was so afraid I could have peed my panties. I give all the credit to her by telling her remember you are the one who showed me how Miss. Reality check: I am just always around, if someone says out loud they have to do this, or have to do that, I just get up and say, I can go try it no matter how gross it is.  So doing it over and over again gives me this confidence that I would not have if I just waited around for it to always be my patient only that needs whatever intervention.

And just like it is always easier to clean someone elses house as opposed to your own, it is much easier to shove tubes into the orifices of  someone elses patient other than your own for some reason.

One thing about tubes that drives me into an irritated frenzy is this: Patient comes in with a bowel obstruction or something like that and night nurse puts in a spaghetti noodle for an NGT and then tells me in the morning there is no output from the tube on low intermittent suction. I mean why bother inserting the slippery soft 12 french? Of course there is no output, that little tube is clogged probably with fecal matter silly and I am not about to mess around with it all shift. I learned this by going  in with the 18 french and getting a whole liter out immediately; I am not surprised as I watch the belly slightly decompress.

And decompression queen I be, and I kinda dislike that reputation given to me by Belly Surgeon.  It is sort of gross and I wanna be pretty darn it! *sighs* I mean if a surgeon wants to make up pet names for me I would pleased with the cute smart nurse or something like that. I do not like GI. That is why I work on telemetry to reduce the number of GI related patient care. Unfortunately I get them anyway, for whatever reason, electrolyte imbalances: transfer to telemetry or whatever other reason attending MDs can create.

I once had a patient with Ogilivie Syndrome. The patient was very sick from other illness but this problem was very discomforting to say the least, and seemed like one Kcl rider after another, I never infused so much potassium in my life as on this patient. Needless to say I called Big Belly Surgeon who informed me that when the potassium levels return to normal it will get better for the patient and also insert a large-bore NG tube and try inserting a rectal tube, the kind used for fecal containment on c-diff patients. Well I inserted the tubes and the belly went down. wow and gross. it worked.

If you work with me, I got your tubes, lines, and stat blood work, your ECGs too. If your patient is crashing, I got your 18 gauge in quick and the defibrillator pads on just in case. I just like to move, I can not sit for long and I got that reputation, let me do it. Even if it means speed charting at the end of the shift. My only distraction would be that darn dictator, I could sit for that and press 3 for short rewind a few times.