Goals

Each week of orientation we are supposed to work towards some goals.  They start out pretty basic such as find various supplies in the unit, identify where the medication resources are, care for one patient from arrival to discharge.  I have two preceptors that I am working with, both wonderful nurses but with very different styles.  This is a good thing for me as it gives me the perspective that there is more than one way to do things.  One of my preceptors is also a nursing instructor at one of the local colleges so she is very much into writing out my goals and how well I accomplish them each shift.  At the end of the shifts though, the last thing I want to do is organize what happened into a list of goals fulfilled!  But I try.  I am getting to the end of week four in my training and my goals are a little harder to reach. This week I am supposed to care for respiratory and cardiac patients, take two patients with increasing complexity, and improve my assessment skills.  I did get a baby with croup this week and if you have never heard the cough that these little one produce when they have croup it will scare you to death! It is a loud dry bark, and it sounds like they are not going to be able to get their next breath in.  I settled mom and dad in the room with this baby and tried to listen to his lungs and he started screaming.  A good sign that plenty of air was getting in, he was pink and warm too. So I rushed off to get some Albuterol and set up a blow by nebulizer, and pretty soon he was sounding better and playing with his dad.  Then I had to get some IV Decadron in him by mouth. This stuff tastes terrible, I am told, but I did manage to get it in (kind of like getting a cat to swallow a pill) and rewarded him with some nice cold apple juice.  We treated him with some humidified air for an hour or so and sent him home with instructions for his parents to use a humidifier or a shower to help him breathe.

I never got a cardiac patient, but I did get quite a bit of experience tracking down the responsible MD for my two admitted patients that were staying with us while we waited for beds to open up. They ended up staying the entire shift and I spent a lot of time paging MD’s to come see them and write some orders so I alleviate their pain while they waited. I learned about tracking down surgeons and advocating for my patients.

Then last night I had a dream that I totally screwed up the computer charting by departing my patients in the computer while they were still here! I was getting yelled at by the clerk and the MD’s to not ever depart patients and  I woke up woke up trying to figure out how I was supposed to get them off the tracking board without departing them?  And feeling frustrated that I don’t have a good grip on all the logistics of using the patient tracker.  Ahhh!  Just got a call from the nurse educator that is running our orientation and we are being pulled from the floor to do some more training on the computer tomorrow.  I hope to get a better grip by the end of tomorrow.  Whew!

We saved your life, now you take over

The shift started out calm enough, my preceptor and I were taking report on a patient that had been there all night and was being admitted. We were just waiting for a bed.  Then at 0755 they rushed him in from triage.  He had come in with his mom because he had started vomiting the night before, had acute abdominal pain, was short of breath and he was losing his vision.  With that chief complaint and a history of diabetes and pancreatitis, the triage nurse recognized  this 30 year old patient was in DKA crisis.  The lack of insulin (he wasn’t controlling his diabetes) causes hyperglycemia which leads to osmotic diuresis, dehydration and electrolyte depletion. The free fatty acids are converted to ketone bodies which  release hydrogen ions leading to metabolic acidosis. This drop in pH causes increased respirations to try to compensate and the breath smells fruity.  This was the case with this patient.  His vitals were BP 88/62, HR 146, R28. The teamwork began. The MD was asking him questions while several nurses started working, inserting 2 large bore IV’s , drawing labs and pouring fluids in. I got his finger stick blood glucose level and it was critical high, which means over 500! He was shaky, weak and still vomiting. We got a urine sample, a portable chest xray, and drew some arterial blood for blood gases.  He admitted he had been drinking a lot (1-2 pints/day) and his last drink was 9am the previous day. We gave him zofran and 10 units of insulin, someone got an EKG and soon his heart rate shot up to the 180’s and the rhythm started looking whacky, widening and looking like SVT. The MD decided to cardiovert.  In a flurry of motion we moved him into the trauma bay got him hooked up to the crash cart administered some versed (5mg, wow) and shocked him with 150 joules. He cried out and jerked on the gurney, and his heart rate dropped to 120. Whew! At this point I was designated as the recorder, my preceptor gave the medications, and a couple of other nurses were managing the IV fluids, and all the other tasks.  By this time we had gotten 4 liters of fluid into him, squeezing the bags or hooking them up with the pressure bags used in  hemodynamic monitoring. The doc ordered some metoprolol to bring his heart rate down since it was starting to creep up to 145.  She ordered 5mg, and asked that only 2.5mg be pushed first as we all watched the monitor to see his heart rate drop.  It would be risky to use too much because his blood pressure was so low 104/57 and we didn’t want him to bottom out.  His heart rate dropped to 87 in about a minute, it amazed me how fast these medications took effect. We were starting to take a breath here, it was about 0840 and his lab results were in.  Blood gases showed pH 7.02, pCO2 <15, pO2 150, HCO3 3, base excess -25.6  Whoah! this guy is really sick. Tox screen came back positive for benzos and opiates, electrolytes were completely out of whack with potassium at 8.3, CO2 at 6, and anion gap at 33. Glucose came in at 966.  He was complaining of belly pain so we gave him 4mg of morphine, and his heart rate was creeping up again, so we pushed another 1mg of metoprolol and gave him an albuterol breathing treatment.  Usually in DKA the patient has hypokalemia however this patient had hyperkalemia, K level was 8! The MD ordered 1gm of calcium gluconate which quickly overcomes the cardiac toxicity of hyperkalemia, it increases the cardiac muscle tone and force of contractions.  More zofran for the nausea  and a banana bag to replace electrolytes and vitamins.  We had him chew a 325mg aspirin with a few sips of water, I think the doc was worried about a clot forming in his heart through all that fibrillation before the cardioversion.  An amp of sodium bicarb (50mEq) IV push slowly, 20mg of kayexalate by mouth, trying desperately to drop his potassium level and raise the pH of his blood.  By now it was about 0910 and nurses were all working together to get these meds in him, through the right IV lines avoiding any incompatibilities.  Everyone was thinking out loud and checking what they were doing withe each other, the teamwork was amazing to me. I was still busily recording everything with the time that it was happening. Normal saline bag #6 went up, a triple dose of albuterol was given with a nebulizing mask, D5W was hung with 2 more ampules of sodium bicarb.  An insulin drip was started at 10 units/ hr, at the same time RT started continuous albuterol 10mg/hr.   After all this fluid was poured into him, he needed a catheter to drain his bladder and this was something that struck true fear in this young man.  He had just been at death’s door and had his heart shocked back into beating properly, yet he was freaking out about having a catheter put in.  Well, my preceptor calmed him, in the midst of the chaos and using lots of lidocaine got the foley in and drained about 200ml of urine.  Lab took a sample, and got more blood. Another IV was started in the hand with insulin going in one IV and bicarb in another we needed a third for the banana bag and other meds.  His blood pressure was beginning normalize at 122/66 and heart rate at 98.  He was needing more pain control so we gave more morphine slowly, titrating to his blood pressure.  Then some lasix to get his kidneys to flush through that fluid and RT to draw more ABG’s .  Results came back and his pH was up to 7.22, pCO2 22, HCO3  was now 9, and base excess -17.  Glucose had dropped to 666, K to 7.1, CO2 to 8 and anion gap to 23. We were going in the right direction. The MD decided to stop the wide open fluids and halt the bicarb drip, now just keeping the banana bag and insulin drip.  It was 1030 and we were liking his vitals of BP 137/64, hr 107, R18, O2 sat of 100% and pain 8/10. We started to talk about admission to the ICU.  Our patient was beginning to come around and the MD was talking to him about what had just happened.  She had a very serious and forceful talk about how close he had come to dying and that he absolutely had to get control of his diabetes and stop drinking. The young man’s mother had been hovering around the outskirts of the activity the whole time quiet tears dropping and looking very frightened. The doctor pointed at her and said to the pt, “you have someone here who loves you and wants you to live, can you at least try to stop drinking and take care of yourself for her?”  He started stammering about all the stresses in his life and my preceptor looked at me with a look of “you know he’s not going to change.”  We sat down to chart everything from the notes I had been taking. while the other nurses worked on getting him a bed in the ICU.  He was not out of the woods yet, for the next couple of days his glucose, insulin, electrolytes would have to be carefully monitored and balanced while monitoring his heart and respiratory function. He was an extremely lucky young man to have been brought in to us when he was and that triage nurse and ED team acted so quickly. As we wheeled him up to the ICU he was beginning to realize what had happened and was thanking us for helping him and saving his life…… I responded with a hand on his arm and looking straight into his eyes “you are welcome, it is our job to save your life, now it is your job to take over.”

patients from door to door

The first awkward moment was in the med room, with my preceptor needing her H1N1 shot and not wanting me to give it to her. ouch.  Nothing personal, ya sure.

My goal for the first week in ER was to take care of one patient from start to finish. Today I managed four! No, not at once, one after the other, never more than one at a time. I was working the blue side, less critical patients, mostly things like abdominal pain, fever/ flu, alcohol intoxication, UTI and the like. I managed to get an IV in an intoxicated patient on the first try, even thought the guy had some pretty tough leathery skin from spending many a night sleeping under bridges. I learned how to mix a banana bag, saline with vitamins and minerals added that rehydrates and replenishes the nutrients a chronic alcoholic desperately needs. All the while our fabulous social worker was trying to find a place for him to go to detox, I was trying to convince him to stay long enough to get rehydrated and stable.

I greeted my 15 month old patient in the lobby and she was all smiles in her mom’s arms until we walked into the exam room then she grabbed her mama’s neck and screamed. No way was she going to let me listen to her lungs and take her temperature. I was actually glad to see her respond appropriately to a stranger, and thankful I didn’t have to give her an injection.

I stood by observing a patient brought in by ambulance having a seizure. The patient was having trouble breathing, swelling in her eyes and face, and her skin was quite red.  The MD looked at me and started firing questions as if I were her med student

MD: what do these symptoms indicate?

Me: anaphylactic shock?

MD: good, how do we treat it?

Me: uh, give epinepherine

MD: perfect, how much and how do we give it?

Me: (in my head, aaaah I have NO idea how much, why is my mind blank?) um, 1mg I think? IV?

MD: no! that is for ACLS, the dose for anaphylaxis is 0.3 mg and we give it IM, where?

Me: in the thigh ( suddenly remembering EPIpens that you stab into the thigh)

MD: yes! go get it, you are an RN aren’t you?!

Me: I am!  (rushing off to the med room feeling like, wow, I AM an RN, I CAN go get this med and help this patient ) I felt like I was really on the spot and really I was just observing why did the MD turn to me?  I guess, I did okay. And the patient came out of the situation and in a couple of hours was sitting up and ready to be discharged with her very own EPIpen in case this ever happened again.

I was starting to gain some confidence, learning the routine, knowing where to find supplies I need, even helping another nurse put a foley in.  Then came another awkward moment one of the MD’s made a comment that she could tell I was new to the unit because I had the chart ready in the slot for her to take in to see the patient to write her orders. And another nurse quipped “yea, and she doesn’t have a bad attitude yet.”

And I hope I don’t, it is not in my nature.

ER at last

After what seemed like an eternity of preparatory training I am finally in the ER. This has been my dream since I started nursing school and here I am on the job in a busy county ER. I am  working with a preceptor that is very experienced but not that happy about having someone to train.  Luckily I don’t need much hand holding and I don’t take her reluctance personally, she is just overworked.   We worked on the “blue” side which is the less acute side, seeing patients that are triaged as level 3 or 4.   Two patients stood out for me because we weren’t really able to help them.  One was a woman with chronic back pain who had suffered a fall, she had used up all her pain meds and was not able to refill her scripts  before the first of the month. She got some new RX’s but could not fill them due to lack of money.  She came in looking for some pain relief.  We were able to give her some pain relief, and take an x-ray,  but could not give her medication samples to carry her over till the first of November when her scripts would be available through her basic medical insurance. We provided her with a new cane and a cab ride home, she was not happy.  The other patient broke my heart.  A young woman doubled over in pain came in with her husband.  The history looked like this could be a chronic bowel issue, or a kidney stone. She was nearly hysterical in fear of what was wrong with her and not being find relief from this pain.  The MD immediately pegged her for a meth user and ordered a urine tox screen and pregnancy test which came back negative for everything. We gave her Ativan to calm her and some dilaudid to ease the pain and 3 liters of fluids. She went for an abdominal CT which was negative and she was discharged with a script for go-lytely and donnatal and instructions to come back if she did not get relief.  She was not a happy camper, she felt we were ignoring her needs and not listening.  She wanted to get to the bottom of what was causing her pain and I have to say I agree with her. In the end she left without signing the discharge papers, without taking her prescriptions or instructions, and telling us she was going to go to another hospital for help.  I felt like we didn’t listen well, I don’t know if the MDs and other nurses misjudged her, I am too wet behind the ears to see what they see. but my gut feeling is that we missed something, and it broke my heart that she left feeling frustrated with her care.  Both the charge nurse and my preceptor talked about how you have to be firm with these kinds of patients and not be caught up in their drama, I just don’t see the category of “these kinds of patients” yet and I am not sure I want to.

ICU perspective

I take report from the day shift on patients and they are immediately mine, they are here in this moment needing my care regardless of what came before or what might come in the future.  It is not my place to question if they are deserving of my care and the expense of the procedures that we provide in ICU, those decisions were made in the admission or transfer to the floor, once here, I do everything within the scope of my practice to ensure the safety of the patient and improve their condition or make them comfortable.  Those issues don’t cross my mind until in relating a story to Hero (aka hubby) brings to my attention that many might question whether we should be providing this level of care to undocumented immigrants or incarcerated individuals. This boggles my mind, I try to clear the faces of these human beings from my mind and erase the direness of their condition to get a glimpse of the perspective that might deny these people care.  I can’t.

The septic patient we saved the other day who I took care of again just before he was transferred to the med/surg unit, looked at me with grateful eyes and said (through his son, interpreting) “you are pretty.”  Okay, flattery will get you everywhere with me, and at my age I don’t hear this particular one very often, but those words told me lots more than their face value.  They told me of a 73 year old man that has come through the worst of his illness with enough alertness and humor to even make that comment, they told me he was feeling better and on the way to being mended.  His sons; one or another of them were at his side every moment through his days in our unit, holding his hand and searching for reassurance from us, his nurses that their father was going to be okay.  He and they needed my care.

Another patient, came to us after collapsing in his jail cell, coding in ER, being resuscitated and placed on a ventilator.  He had taken a months worth of his blood pressure medication at once, and was in septic shock as well. In spite of the ventilator, being sustained with fluids, levophed, versed, insulin, bicarb, and fentanyl the sheriffs had him chained to the bed at the ankles with heavy chains and two of them stood guard at the door.  This guy was not responsive let alone an AWOL risk.  His pupils were fixed and pinpoint and he did not respond to painful stimulus.  The day I took care of him he was on a two nurse to one patient ration because he was getting CRRT.  We monitored and titrated all his drips to keep him hemodynamically stable, took care of the ins and outs, and basically tried to keep his vitals as stable as possible.  His perfusion was so bad that we were unable to get pulse-ox readings so we were constantly drawing blood gases. They were reassuring, 94-96 PaO2.  For some reason the lab was never able to get a good PTT reading on his coag panel that we were concerned about giving his heparin. We would draw blood from his art line, pulling off the first 10-12 mls before taking our sample, and still no reading. Finally the lab came and tried to draw a venous sample but they couldn’t get anything out of any veins they punctured. The central line was full of all of his drips so not useful for drawing blood.  We never did get a good PTT on him.  His platelets were steadily dropping from 250 to 91 to 37 over the last 48 hours and that had us worried.  During this shift this patient’s brother came to see him and was not allowed in, his mother called the nurse’s station and we were not allowed to give her any information.  At one point the brother was allowed in for a few minutes, and was clearly distraught about seeing his brother this ill.  I spent some time in the hall with the brother just listening to him and being a caring presence.  I’m pretty sure that when I am no longer orienting I will not have the luxury of time to spend with family members.  This patient needed our care and so did the family. I don’t know what he did that put him in jail, I can only imaging why he might want to end his life, but he deserves to be cared for as a human being and his family deserves to a compassionate ear.

The last patient I want to mention was the organ donor we took care of while the transplant teams got ready to recover her liver, kidney and lung.  By the time she was under my care, the family had made their decisions, said their goodbyes and left the hospital.  Although her body was being sustained medically, she was clearly gone.  I kept focused on the people her organs were going to help and how important it was to maintain perfusion and keep these organs healthy.  Even in death the patient and future patients need our care. And I do my best to provide it.

ICU case

I am beginning to see that in nursing, schedules and plans are never firm. It turns out my preceptor in the ER isn’t ready for me yet so I have spent this week in the ICU. As anxious as I am to get to my ER training, this week has been incredibly enlightening for me. I see the value of being oriented to the different units and getting a feel for how they work and what their challenges are. It will help me be more understanding and better prepared to transfer patients there from the ER.
On my first day I hit the ground running. I met the nurse I would be working with as we were receiving a patient from one of the medical floors who had come in through the ER the night before. This patient had come here from Mexico a few days earlier to celebrate his birthday with his nine children now living in CA. He came into ER with pneumonia and abdominal pain and was admitted. Then his labs came back showing he had a raging infection and his lactate was 6.0 and PPT of 107! Yikes he was going into septic shock. CT scan of his abdomen showed stones in his common bile duct and the MD’s suspected ascending cholangitis. When he arrived on our unit his blood pressure was in the 60’s and his extremities were cold and cyanotic.  Our first task was to get fluids into him fast. He had one IV running Lactated Ringers which we turned up to 1200cc/hr, and quickly got another large bore line started, more lactated ringers 1200cc/hr.  At this point the room was swarming with residents and an attending, all trying to get an arterial line started so we could measure his blood pressure internally which is much more accurate.  The main goal being to keep his organs perfused to prevent organ failure. The poor patient was stuck numerous times since the blood pressure was so low it was hard to get the art-line in. They all kept asking for supplies which I would run to find, BUT it was my first hours on the floor I didn’t know where stuff was kept, OR the code to get in the room!  I caught on quickly though and soon was grabbing supplies, opening sterile packs, handing out 4×4’s and tape, and most of all trying to comfort the patient as he was being poked and prodded. They finally got the arterial line in, and we got some blood gases drawn and set up the pressure monitoring.  We hung two units of FFP to help his clotting, and more fluids. They also started a levophed drip which can raise blood pressure after fluid replacement in hypotensive shock  and a versed drip, and IVP fentanyl to sedate him for the procedures, He started to have some fluid in his lungs as they were about to take him to radiology for an ERCP, so they intubated him and put him on a ventilator. I was able to go to the ERCP and observe.  The MD found the stones blocking the bile duct and flushed them out, releasing a slew of pus and debris.  Then it was back to the ICU, next a central line and a foley catheter.  The central line used was a special one called a presep catheter, it has a fiberoptic tip to allow measurement of SvO2, or oxygen saturation which is important to measure in sepsis. By this time it was 10pm and we were starting to see some improvement in his blood pressure and hoping he was out of the woods.  He hadn’t produced any urine yet, due to some kidney failure and we were quite worried about that. As we gave report to the night shift and reflected on the evening I really saw how the nurses and MD’s work  well together, everyone stayed focused and helped each other as we worked.  The residents and attending MD discussed the plans and procedures in detail so I learned a lot just listening in and observing.  It felt great and exhausting to be part of the process.  I hope this patient improves through the night and that tomorrow is calmer.

whirlwind med surg training

I have one more shift to go on my med/surg portion of training before I FINALLY get to the ER. The floor I have been on has a wide variety of patients, mostly medical with diagnoses of alzheimers with extreme dehydration, to CVA, cancer, wound abcess, brain mass, cellulitis and more. My goal working in this unit was to understand the criteria for admission, learn the equipment in less chaos than the ER, and get a perspective of what it is like for the RNs receiving the patients we will be sending from the ER for admission. This is a new approach for our ER training, I am gathering based on the questions I have been getting from the nurses. They all want to know why we are being oriented in their unit if we are going to work in the ER, then they chuckle that we will soon forget their perspective once we have been in ER for a little while. I have to say the main question I get is, “how did you get hired as a new grad?” It seems that this new grad program I managed to get into was not only a well kept secret on the job boards, it was not on the radar within the hospital either. I really am fortunate to have found out about it and gotten hired.
I have been working mainly with one nurse but tagging along with any nurse that is doing an admission from the ER so I see the process once the patient comes to the floor.
It took me a day to figure out where things are, and get a feel for the routine of the shift, most of the nurses have been very friendly and eager to welcome me to the hospital. It is the patients however that confirm for me that I am on the right path. I love working with them, even the cantankerous ones. This is one place where my age is to my advantage, they assume I have been a nurse for years and don’t seem to notice my clumsiness with equipment or nervousness inserting an IV. I have had several successes now so that nervousness is lessening.
On my second day we had a patient die at shift change. She had just come to the floor from ER a few hours earlier and her friends had just left to arrange hospice care for her. We were getting report when the nurse taking over this patient’s care went to meet her and discovered that she had died. I helped carry out the death protocol which involved notifying the appropriate people, getting the MD to fill out the forms, calling the organ donation network, and preparing the body. The thing that always catches me by surprise is the change in skin color that happens, the skin takes on a definite yellow tone. We washed her, changed her gown and linens, and tucked her in the bed for when her friends returned. It turned out that she was not approved for organ donation due to her liver disease. We moved her roommate to another room without revealing the death had occurred so as not to freak her out, and talked with and comforted the two friends as they said their goodbyes. Then we wheeled her body down to the morgue. Wow, I felt a mixture of emotions through the evening from sadness that she died alone to the profoundness of the end of life, to the the confidence that came from the self discovery that I can handle the process in a professional way and be there for the patient and family. I know I will be dealing with patients dying while working in the ER and I was glad to have gone through this experience.
Another patient that moved me was a gentleman with end stage colon cancer who has not been able to control his pain. He was extremely dehydrated and constipated, had gotten a few doses of morphine in ER but came to the floor with an infiltrated IV, pain level of 10/10 and respirations of 36. I tried unsuccessfully to place a new IV, but another nurse was able to get one in and we gave him some more pain medication. In spite of the excrutiating pain he was in, this patient was pleasant and patient as we tried to make him more comfortable. In contrast another patient I had that same day, a demanding former meth user with neuropathy in her feet and legs and suffering from panic attacks, yelled for her pain meds constantly, became combative on several occasions, and left the floor against advice to smoke. If one nurse didn’t give her what she wanted she yelled for another nurse or MD.
I could go on about each patient, they each presented situations that I learned a great deal from. (I know, my learning curve is steep at this point in my career, I have so much to learn) I am grateful for the chance to work in this unit for a couple of weeks, it has confirmed that I have made the right career choice and makes me even more excited to get into the ER. Next week!

Onto the floor!

This afternoon I start on a med/surg floor with a preceptor.  For two weeks I will work with her to learn the basics before I go to the ER.  The plan is to learn in a less chaotic environment so we have time to absorb what we are learning. Seems like a good idea, I hope it goes smoothly. The last three weeks have been spent in classrooms and in the ancillary departments. It has been useful, but I am anxious to start working with patients. Stay tuned.

Day one

Eight hours in orientation, ughh. When will people realize that reading powerpoint slides to your audience just makes them sleepy. Kick me if you are ever in a class of mine and I start droning on from my slides.

New ER nurse

I don’t know if I can call myself an ER nurse yet, but today at the end of my interview for an ER position the nurse manager said to me, “I am very impressed with everything you’ve done and what we talked about today. The August group of new hires is full, but we have room in the September group if you would like the position.” My ears did a double take, what! really?! You are willing to take a chance on me? wow, yes! It is a job in the ER in the hospital 6 blocks away from me. What could be better, my dream job! I am definitely doing the happy dance.