If you’re new to this blog…

WELCOME! Maybe you’re here because you’re starting nursing school, dreaming of nursing school or just getting ready to buckle down again for another semester. For all the newcomers, I thought it would be handy to give a brief overview of what you’ll find here…since this blog is SO MUCH more than a blog. Ready?

In this section of the blog you will see all the posts that I do periodically on a variety of nursey related topics, and it is always the first thing you’ll see on this page. But wait, there’s more!

At the top of the page, you see a menu bar with some headers…explore your heart out because this is where you’ll find notes related to nursing school and some of my pre-reqs such as A&P, printable reference sheets, study aids, goodies to buy, a link to my e-book and loads more. So, this site is MUCH more than just a blog…it is your ultimate resource for kicking some nursing school bootay! NOTE: Some items may be temporarily unavailable as I am currently updating all my files…if you don’t see what you need, CHECK BACK in a few days :-)

You will also occasionally (if you’re lucky) see a picture of the cat I stole from my neighbors. Well, “steal” might be too harsh a word. He sort of stole me…his name is Oliver and he loves nursing school!

Oliver says, "Dude, welcome to the best time of your life."

Oliver says, “Dude, welcome to the best time of your life.”

Have fun this semester, and be safe out there!

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Resources page is back up!

I finally fixed the links for the resources page…so please go crazy! Also, if you see any other bugs, please let me know :-)

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Did you think I forgot about you??

So sorry for the huge lag time in between posts…grad school is taking up all my spare time. Boo! For those of you who have left comments in the past month, I finally got around to responding…thanks for visiting!

I also finally got around to proofing the printed copy of the Nursing School Thrive Guide, and it is now available on Amazon…woohoo! It looks great, if I do say so myself! In fact, I’m hosting a giveaway on my FB page, so come on over there…join the group and leave a comment to introduce yourself. I’ll choose a lucky winner Oct 26th to get a brand-spanking new copy all of your very own :-)

Thanks for sticking around guys…as soon as the semester is over, I’ll get more goodies up for you! Maybe a Thrive Guide for grad school? Haha…just kidding!

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The Thrive Guide Lives!

My quest to get the Nursing School Thrive Guide into your hot little hands as a printed book is almost complete! I received my proof copies today and if everything looks good (PLEASE let everything look good!), then I will be selling it asap on Amazon :-). I may also sell through this site, but for now we’ll start with what’s easy. Can’t wait to have it available for you guys!

Screen Shot 2014-09-11 at 6.05.17 PM

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The site is “sort of” under construction!

Hey everyone, in order to accommodate the amazing growth of this blog, I transferred over to a new host. With that said, things may look a little different while I re-do all the bells and whistles. Everything should be here as it was, except for the pre-nursing files (which I am in the process of updating).

Not to worry! The Straight A Nursing Student website you know and love will be back looking like it’s usual awesome self in no time! Or who knows…maybe it will look even better???

Thanks for sticking with me during the move…we’ll get the boxes unpacked and the pictures hung back on the wall in no time!

Nurse Mo

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Our First Guest Post! Doing a Head-to-Toe Assessment

I am super excited to announce our very first guest post! This one is brought to us by Courtney author of the website From New to ICU a great resource to help students navigate the often confusing educational pathway from taking their pre-requisites to choosing a nursing school. Courtney is here today to share with you her best advice for doing an amazing head-to-toe assessment. So, without further ado…take it away, Courtney!

Worried about Doing a Good Head to Toe Assessment?

I remember when I was in nursing school that I was SO nervous about doing my head to toe assessments! The first head to toe assessment I did, I forgot to listen to lung sounds. Pretty embarrassing! Have any of you felt this way as you’ve done your assessments?

I now work in an intensive care unit and do head to toe assessments at least every four hours. Practice definitely helps to make your assessment a habit! There are so many details to keep track of.

Being able to communicate all of this information to the following nurse can be just as daunting. I have created a report sheet found here titled, “Basic Head to Toe Assessment: Overview.” Doing a thorough assessment and giving a good report are both very important skills to develop!

What I’ve learned is that the best assessments are organized by body systems. Here is an example of a head to toe assessment narrative. All of this information should be gathered during your assessment. Here’s my advice for each body system and how to approach your head-to-toe assessment:

Neurological: There is a HUGE variety of neurological tests that can be performed. This is my basic testing that I do on all of my patients regardless of why they are in the hospital. If any of these are lacking, more investigation should be done into why the patient has this deficit. 

  • Is the patient in any kind of pain? Where and what type?
  • Are the patient’s pupils equal, round, and reactive to light?
  • Is the patient alert & oriented to person (ask their name), place (where are you?), time (ask the month and year), and situation (do you know what brought you to the hospital?).
  • Can they move all extremities well?
  • Can they squeeze your hands tightly with both of their hands?
  • What about applying pressure with their feet?
  • Is their speech clear?
  • Do they have any numbness or tingling?

Respiratory: Respiratory can be either a very simple or a very complicated body system to discuss. It can be as simple as, “This patient’s lung sounds are clear and they are on room air. No respiratory deficits noted.” It can also be as complicated to include ventilators, chest tubes, and oscillators. For your basic respiratory assessment, here are the questions you should be asking yourself: 

  • Assess their lung sounds. Do they sound clear, coarse, wheezy, rhonchorous (it sounds like there is a LOT of fluid moving around), or decreased (not much air moving)?
  • Is their respiratory rate normal (12-20 breaths/minute)? Are they having difficulty breathing?
  • How much oxygen is the patient requiring?
  • Do they have a cough? If so, what are they coughing up?
  • Do they have a sore throat?

Cardiovascular: The heart can be a very complicated organ if it wants to be. There are your four heart valves, four chambers, septums, and arteries and veins attached to complicate things even more. The heart is also one of the most fascinating organs because of the ability it has to pump thousands of gallons of blood through your body every day. Here are the things to think about in your basic cardiac assessment:

  • Assess the patient’s heart tones. Is there a clear S1/S2 (meaning the “lub dub” sound)?
  • Are there any murmurs (not a clear “lub dub” from issues with heart valves), rubs (sounds like friction of heart rubbing), or gallops (sounds like a horse galloping)?
  • What is the patient’s heart rate and rhythm?
  • How is the patient’s blood pressure?
  • Are they on any medications to affect their blood pressure?
  • How are their radial and pedal pulses?
  • What is their capillary refill time?
  • Do they have a temperature?
  • Are they flushed?
  • Does the patient have any edema?
  • Are they wearing sequential compression devices to prevent deep venous thrombi from forming?
  • What IVs does the patient have? What is infusing through them?

Gastrointestinal: Isn’t the GI system just our favorite? I have realized that the ICU is full of GI. Don’t sign up for my specialty unless you are ready for lots of secretions and fluids!

  • Assess bowel sounds. Are they present, hyperactive, hypoactive, or absent?
  • What is the patient’s diet order?
  • Are they having any nausea or vomiting?
  • Do they have an nasogastric (NG) tube or gastrostomy tube (G-tube)?
  • If he has tube feeds infusing, what have the residuals been? (Residuals are checked by putting a 50 mL syringe into the NG tube and pulling back whatever contents are in the stomach.)
  • When was their last bowel movement? What did this look like?
  • Do they have a colostomy or ileostomy? 

Genitourinary: How much urine output a patient has tells you about a variety of different things. The causes of low urine output could be because of acute kidney injury, low blood pressure, infection, and ureter obstruction among other causes. If a patient’s urine output has decreased, once again ask yourself, “Why?”Some basics in your assessment include asking the following:

  • Does the patient have a Foley catheter in place?
  • If so, what is their urine output? If not, then when did they last urinate?
  • Any pain with urination?
  • What does the urine look like?

Integumentary (Skin): During my assessment, I look over the patient’s skin. Note that the most common places for skin abnormalities and breakdown are where bony prominences come into contact with surfaces. 

  • Are there any rashes, bruises, or other abnormalities?
  • How is the temperature of their skin?
  • Do they have any drains?
  • What is draining and how much?
  • Do they have any wounds or pressure sores?
  • What dressings are in place for these wounds?

Psychological/Social: Depending on the unit you are working on, the psychological assessment may be very short to very in depth. If you are taking care of a suicidal or bipolar person then your assessment will be much lengthier. 

  • How is the patient coping with their situation?
  • Are they calm, aggressive, anxious, combative, frightened, etc.?
  • How is their family coping with this situation?

Good luck to all of you as you do your head to toe assessments! Practice makes perfect! For more information about nursing basics, check out www.fromnewtoicu.com. This has lots more information just like this head to toe assessment post whether it be chest tubes, how to start an IV, or how to insert an NG tube! If you are looking for a nursing program, there are also hundreds of nursing school reviews with information about prerequisite courses, GPA requirements, tuition, and much more! Good luck with your nursing searches!

 -Courtney
From New to ICU

 

 

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ABGs Part 2 – Compensation

In my last post about ABGs, you learned how to do a basic analysis of uncompensated acid/base disorders. If you need a review, check out that post then come back here. I’ll wait. 

Now that you’ve got uncompensated gasses figured out, I’ve got some bad news. Most of the time you won’t be handed a nice clear-cut ABG like that and will, instead, be dealing with compensated and partially compensated acid/base disorders…sorry. The good news is, once you’ve got the basics down you will have no time taking it a level deeper to understand compensation. 

Let’s look at Partial Compensation first.

You take report on a patient with the following blood gas: pH= 7.33, CO2 = 55, Bicarb 30, PaO2 = 80. If you do the tic-tac-toe method here, you’ll end up with a diagram that looks like this:
Partially Compensated Respiratory Acidosis

What are you noticing that’s different about this tic-tac-toe diagram from your uncompensated diagrams? If you’re saying, ‘there’s nothing in the NORMAL column’ then you are correct!  In PARTIALLY COMPENSATED acid/base disorders everything is abnormal…don’t worry, we’ll go step-by-step.

1) What is your pH? Is it acidotic or alkalotic? In partial compensation, your pH will always be abnormal. If it were normal then that would be considered fully compensated (more on this later). So, look at your pH and decide if it is acidotic or alkalotic. 

2) In this example, it’s acidotic at 7.33 (getting close to normal, but not quite there yet). Now look at your CO2 and Bicarb. Which one is also acidotic? In this example, it’s the CO2 that is also acidotic so this means we are working with a RESPIRATORY ACIDOSIS. 

3) Now look at the Bicarb…if it’s normal then you’d have uncompensated acidosis meaning the kidneys are not altering their production of bicarb to try to change the body’s pH. In this case, the kidneys are producing MORE bicarb than usual to help buffer all that acid. So what we have is an abnormal Bicarb that is alkalotic to try and balance out the acid. So we know we are dealing with some degree of compensation.

4) Is it partially compensated or fully compensated? Look again at the pH…if it is abnormal (which it is), then it is only PARTIALLY COMPENSATED. Making sense?

Let’s try another one:

pH: 7.47, CO2 = 31, Bicarb = 18, PaO2 = 78

Screen Shot 2014-09-03 at 3.02.46 PM

In this case your pH and CO2 are both alkalotic which tells you we are dealing with a RESPIRATORY ALKALOSIS. When you see that the Bicarb is also abnormal this clues you in to the fact that it is PARTIALLY COMPENSATED. 

OK, one more: pH: 7.26, CO2 30, Bicarb 12, PaO2 86

Screen Shot 2014-09-03 at 3.08.30 PM

In this case, you start by determining that you pH is acidotic. Next, you notice that between the Bicarb and CO2, one of them is also acidotic and that’s the Bicarb…so you now know you are dealing with a METABOLIC ACIDOSIS. 

Is it compensated or uncompensated? Look at the CO2. Since it is also abnormal (and the opposite of the acidosis), you know the CO2 is trying to compensate for all that base, so it is PARTIALLY COMPENSATED METABOLIC ACIDOSIS. 

Now, let’s look at Fully Compensated acid/base disorders. A little harder, but you got this!

The thing to know about FULLY COMPENSATED acid/base disorders is that the pH will be within the normal range of 7.35 to 7.45. We are going to have to now look a little closer at this number to determine “the lean.” Don’t fret…you’re doing great!

pH: 7.37, CO2 28, Bicarb 17, PaO2 60. When you initially plug these numbers into your tic-tac-toe diagram they look like so:

 Screen Shot 2014-09-03 at 3.22.12 PM

Hmmm….the pH is normal. Do we even have an acid/base problem here? Now is when we need to look a little closer. Take a peak at the pH. It’s 7.37, which is a perfectly acceptable pH. But, the astute nurse knows these other abnormal values aren’t going to be ignored so s/he looks a little closer at the “lean” of the pH. What is the “lean?” Recall that a normal pH is 7.35 – 7.45, with a pH of 7.40 being right smack dab in the middle. We are going to look at where our pH lands on either side of that perfect 7.40…it will either be less than or greater than, leaning to acidic or leaning to acidotic. To be more precise, a pH of 7.35 to 7.39 “leans” toward acidosis, while a pH of 7.41 to 7.45 “leans” toward alkalosis. 

So, now let’s draw our diagram with the “lean” taken into consideration. 

Screen Shot 2014-09-03 at 3.25.39 PM

Because our pH is “leaning” toward acidosis, we have a tic-tac-toe of METABOLIC ACIDOSIS…and because the pH is within the range of normal, we have a FULLY COMPENSATED METABOLIC ACIDOSIS. In this case, the body has adjusted CO2 levels to balance things out. 

We’ll do one more, then you’ll have this down solid!

pH = 7.36, CO2 = 55, Bicarb 30, PaO2 60. Be sure to take the “lean” into consideration as you draw your diagram!

Screen Shot 2014-09-03 at 3.29.59 PM

Looking at your diagram, you see that you have a FULLY COMPENSATED RESPIRATORY ACIDOSIS. 

Now, doesn’t that all just make perfect sense?

Be safe out there!

 

 

 

 

 

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ABGs….easy as 1 – 2 -3

I was chatting with some nursing students recently and asked what their most challenging subjects have been so far…someone piped in and said that ABGs were a real pain in the neck… and no wonder! Her professor had suggested they just try to memorize the values. Sorry, but that’s not going to do squat to help you analyze an ABG at the bedside of your critically ill patient in renal failure with COPD and pneumonia.

So, I thought it would be nice to do a little post about ABG analysis, mainly the tic-tac-toe method. Now I was going to link you to the original article, but it’s only available on EBSCO (or other subscription services) so if you have an EBSCO account through your school I highly recommend the article titled, ‘Turn ABGs into Child’s Play” by Doreen Mays and Eileen O’Connor.

Since this brilliant article was written, lots of folks have jumped on the tic-tac-toe bandwagon. If you google it, you’ll find videos and powerpoint slides galore. I haven’t gone and looked at them all, so I can’t tell you if they’re amazing or not. I do know the original article is amazing, so next time you’re at the library or logged in through your university’s site I highly recommend you read it. It will change your life ;-)

Of course, you know I’m not going to leave you hanging…so basically, it boils down to this. You know your normal ABG values, right? If not, then you do need to memorize that part and you need to know if the value is acidic, normal or basic/alkalotic. So, let’s review:

pH: 7.35 – 7.45 (lower than 7.35 is acidic, higher than 7.45 is basic)
CO2:  35-45 (lower than 35 is basic, higher than 45 is acidic)
Bicarb: 22-26 (lower than 22 is acidic, higher than 26 is basic)

The next thing you need to understand is that CO2 has to do with the lungs, and Bicarb has to do with the kidneys…so CO2 is respiratory related and Bicarb is metabolic related. Got it?

Ok, so now I’m going to get artsy…forgive me please! Let’s say you have a patient who has a bad pneumonia who suddenly isn’t looking so spiffy. You are super worried so you get an ABG. Your results show the following:

pH = 7.16; Bicarb = 24; CO2 = 59; O2 = 60. 

I can tell you right now that’s a pretty crudtastic ABG. Let’s figure out why it’s such bad news. Ready? The first thing you’re going to do is draw a tic-tac-toe grid, like this:

Step 1

Step 1

So, did you remember his crudtastic ABG results? Start with the pH…it’s 7.16. Is that acidic or alkalotic? Think about it for as sec and you’ll remember that a low pH is acidic. Good! Write “pH” under the acidic column like so:

Step 2

Step 2

The next value we’re going to look at is the Bicarb, which is 24. Is that acidotic or alkalotic? Think about it! Think carefully. Yes, it’s a trick question! That bicarb value is totally normal, so we’re going to write “Bicarb” (or you could write HCO3 if you wanted to be fancy) in the middle column like this:

Step 3

Step 3

Actually, you can look at Bicarb or CO2 after your pH, it doesn’t really matter…but this just happens to be how I set up my art show, so we’re doing it this way. Now let’s look at your CO2. It’s 59. Is this acidic or basic/alkalotic? Hmmm….high CO2 is acidotic, you say? Yes, you’re right! So, let’s write CO2 in the acid column just like this:

Step 4

Step 4

And then you step back and admire your tic-tac-toe board because guess what? You’ve got three-in-a-row…you win! 

Tic-Tac-Toe!

Tic-Tac-Toe!

Because your three-in-a-row is in the acidic column, you know you’re dealing with an ACIDOSIS. Now, is it respiratory or is it metabolic? Easy. Respiratory acid/base is determined by the CO2, while metabolic acid/base is determined by the Bicarb. So which one is in your column? The CO2, right? That means, this is a RESPIRATORY ACIDOSIS. 

The next question you’re going to ask yourself is, “Self, is this compensated, partially compensated or uncompensated respiratory acidosis?” Well, self, it’s a good thing you’re so smart because that’s an easy one for you, too. To determine compensation, we look at the pH first. Is it abnormal? Yes…so we are definitely not compensated. Now we look at the Bicarb…the only number we have left (except for O2, which we’ll get to in a minute). The Bicarb is normal…so what does this mean? This means the kidneys have not yet had a chance to kick in and start buffering that acid. If they had, the Bicarb would be high. But in this case, it’s totally normal, which means your poor patient has some acidic blood coursing through his little ol’ system and his dumb ol’ kidneys haven’t done a darn thing about it. So in this case we have UNCOMPENSATED RESPIRATORY ACIDOSIS. 

Now we’re going to take note of his O2 and his clinical presentation (which is as crudtastic as his ABG). This dude needs to be intubated RIGHT AWAY!!! Get the team in there now (and what supplies do you want to have handy? Hmm? We’ll save that for another post.) Want to do another one? Of course you do!

Let’s say you’ve got a patient who’s on a vent, zonked out on paralytics and breathing at a set rate of 16. He’s suspected of taking an overdose of antacids, thinking they were ecstasy pills. So, he’s not the brightest bulb in the pack…welcome to nursing. So, anyway his ABG results are such:

pH = 7.56; Bicarb = 32; CO2 = 37; O2 = 90

So, first draw your tic-tac-toe grid. I’ll wait. Now, let’s look at our pH. Is it acidotic or alkalotic? It’s alkalotic, so let’s write it in:

So far so good!

So far so good!

Your next value is the Bicarb of 32. Where does that go? Yep! You got it…his Bicarb is high so he’s alkalotic. 

It's getting easier, huh?

It’s getting easier, huh?

Even though you have tic-tac-toe already, you still need to analyze the CO2 to see if we’re compensated or not. So, his CO2 is 37. Where’s that go?

You're rocking it!

You’re rocking it!

So, what do you think? You have a tic-tac-toe with the Bicarb matching up with the pH…so you have a METABOLIC ALKALOSIS. Is it compensated or not? Have the lungs adjusted CO2 to balance things out? Nope. So it’s UNCOMPENSATED METABOLIC ALKALOSIS. Since he’s on paralytics his body isn’t going to breathe at a rate to naturally compensate for the alkalosis…so we need to make those vent adjustments ourselves and turn his rate down…maybe to around 12 or so. We’ll keep an eye on his CO2 and O2 as well…but most folks tolerate a rate of 12 just fine.

So now go watch a few YouTube videos. Let this sink in and then we’ll tackle compensated and partially compensated acid/base disorders. Then we’ll tackle mixed acid/base disorders. Then you’ll be even more amazing than you are right now. 

Be safe out there!

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Save your neck with a bookstand!

So I am in full back-to-school shopping mode…my favorite time of year! In a previous post you may have noticed me singing the praises of my wooden book stand. Well, guess what? It’s so nice I bought it twice!Screen Shot 2014-08-10 at 8.06.32 AM

Actually, I loaned my original to my sister-in-law for her adventure through nursing school and now that I’m going back for my MSN, I found myself in need of something to make it easier on my neck with all the reading I’ll be doing. So…with that said, I loved this book stand! It’s only downside is the price ($35) which admittedly does seem a little high, but when I compared it to other book stands, it seems to be the most sturdy and the little clips make it easy to turn pages and then clamp them down again. Considering how much I used it the first go around, I’d probably still buy it even if it were priced higher…did I mention I loved it?

Here it is, if you want to click through to Amazon and check it out!

 

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Save your neck with a bookstand!

So I am in full back-to-school shopping mode…my favorite time of year! In a previous post you may have noticed me singing the praises of my wooden book stand. Well, guess what? It’s so nice I bought it twice!Screen Shot 2014-08-10 at 8.06.32 AM

Actually, I loaned my original to my sister-in-law for her adventure through nursing school and now that I’m going back for my MSN, I found myself in need of something to make it easier on my neck with all the reading I’ll be doing. So…with that said, I loved this book stand! It’s only downside is the price ($35) which admittedly does seem a little high, but when I compared it to other book stands, it seems to be the most sturdy and the little clips make it easy to turn pages and then clamp them down again. Considering how much I used it the first go around, I’d probably still buy it even if it were priced higher…did I mention I loved it?

Here it is, if you want to click through to Amazon and check it out!

 

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