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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A puzzle for you.

For some reason I get super excited about IV compatibility problems, and I had a good one recently. Let’s assume this is your patient…she is on 8 continuous infusions and has IV piggyback meds to give at regular intervals.

The continuous infusions are: Epinephrine, Fentanyl, Insulin, Levophed, Nimbex, Sodium Bicarbonate, Vasopressin and Versed.

The IVPB and IV Push meds are: Flagyl, Levaquin, Protonix and Vancomycin.

She has a triple lumen central catheter and she’s so edematous you can’t get a peripheral in. How are you going to run all your meds? Think about it and I’ll post a solution in a few days :-)

Y-Site

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Put your ACLS fears to rest

If you’re a student nearing graduation, or a new grad then you’re likely looking at taking ACLS. First of all…reeeelaaaaax. I guarantee you will not be the only student or new grad in the room, and I guarantee you will not be the most clueless person there. So let that sink in as you take a few deep breaths in and out.

Every ACLS class I’ve been in has been about 1/3 to 1/2 students and new grads. So you will be in excellent company! The rest of the group is a mix of experienced medics and nurses from all clinical areas…ED, ICU, dialysis, PACU…mainly the places where ACLS is required. In the last class I took, one of the nurses worked at a Medi-Spa and just wanted to keep her skills sharp. We even had one physician in the group…and, not to toot my own horn or anything, but when a question came up about the compression to ventilation ratio …he was wrong and I was right (just goes to show that just because you perceive someone as being “smarter” than you, doesn’t mean they always have all the answers!). If you’re lucky, there will be a good number of paramedics in the group…these guys run codes all the time. Like All The Time…so they usually know ACLS from front to back (SLCA?).

If you’re new to the whole ACLS thing, take the class with a buddy or two, and get together a few days before the class to run mock codes. As you go through the ACLS code algorithms, you’ll notice that the heart can really only do one of four things…go too slow, go too fast, not go at all, or spaz out. If you can keep that kind of simplicity in your head and refuse to freak out…you’ll be fine! The thing about codes is that it’s rarely the heart doing just one thing the whole time. It will switch around, for example, from v-fib to astystole, from asystole to bradycardia, from bradycardia to something else…it likes to keep you on your toes, that’s for sure! When the rhythm switches around like this we call it a Mega-Code, and that’s what you’ll be signed off on in your ACLS check off. Here’s how the Mega-Code works:

You will be placed in a group of usually 5-6 people, and the instructor will have a Mega-Code scenario for each of you (oh joy!). What this means is that each of you will take the roll of Team Leader and run the code…you basically get to tell everyone in the group what to do…how fun is that? If  you’ve never taken the class before, try not to be the first one running a code as the Team Leader…watch a few and then step up to the plate. You’ll learn a lot just from those few scenarios, and also see that it’s not as scary as you thought after all.

For starters, the patient isn’t going to die if you take a little extra time to ponder the situation (in real life, this may not be the case…but we’re in a Safe Place here!). Next, your team mates will help you, and some instructors even allow  you to use the notes you took in class if you need a little memory boost.

Depending on the simulation capabilities of your facility, you may have the opportunity to actually practice hands-on skills such as placing your patient on the monitor, putting on the oxygen, applying the patches and listening to lung sounds. In other cases, your data will come through the instructor who is running the scenario. Whatever the situation may be, always start your code off with getting some data…get the patient on the monitor right away, then get a blood pressure and an O2 sat. If the scenario involves a homeless person in the winter, get a temp. Order a tox screen so that later on you can go through your differential diagnosis.

The code will usually start with your patient presenting with some kind of complaint or abnormal heart rhythm. Grab a set of vitals, get ‘em on the monitor and figure out what the heart is doing (too fast, too slow, not at all, or wackadoo). As you perform interventions based on each algorithm, you’ll notice the heart will change rhythms so that you eventually go through most (if not all) of the algorithms. And that’s it! You (and your patient) survived!

So, if you’ve been nervous about ACLS, I hope you feel a lot better and go in there and have fun :-)

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Idiot-Proof your Patient

One of the most useful skills you will utilize as an RN is organization. In fact, if assessment is your King-Daddy skill, then organization is a close second. An organized, orderly room is a much safer (and more pleasant) place to be than a chaotic mess. One of the things I like to do is something I call “idiot-proofing” my patient. This has nothing to do with the intellectual capacity of my patient, but more to do with setting things up so that anyone (ANYONE) could walk into my room and know what’s what. Here are a few things I do to make sure that if someone walked into my room while I was away, they would know what they need to know:

Label label label
When you go into your room to do your initial assessment, take some masking tape and a sharpie with you. You will want to trace each med from the bag, to the pump, to the patient. You will label each IV pump. “But wait,” you say. “Doesn’t the pump display the name of the drug?” Yes, it does…but the scrolling takes several seconds and I don’t have several seconds to stand there and try to figure it out. Just label it. You will also label each IV just above the Y-site. Why there? Because the Y-site is where you will be attaching an IVP or another primary line…so that’s where you’ll want your label.

So, what should you label your lines? It depends. If it’s a drug, that’s easy…label with the name of the drug (insulin, levo, fentanyl, neo, nitro, etc…). If it’s IV fluids that you are also running your piggybacks through, label it “NS w/IVPB” or “LR w/IVPB” whatever…so that anyone walking into your room knows where they can hang your clindamycin or whatever.

If you’ve got a flush line running (more on this in a bit), label it accordingly. The last thing you want is someone to piggyback your antibiotic into a line flushing insulin, for example. I always label my flush lines with the drug they are flushing “Insulin Flush” or “Levo Flush”. That way anyone (even an idiot) knows RIGHT AWAY that this particular line is mixing with insulin or levo at some point and they probably want to steer clear. If you had just labeled this line as “NS”, then chances are someone could easily come along and “help you out” by hanging your Flagyl and piggybacking it in. No bueno.

Clear up compatibility confusion
There is nothing I love more than an IV compatibility conundrum. Oftentimes your patient will have three lumens and 7 or more gtts. This is where things get fancy. Run your IV compatibility report with every IV drug your patient is getting…people will often just run the continuous infusions and forget about the piggybacks. Run those, too…sometimes you’ll be surprised what you can Y-site together (or what you can’t!). Print two copies of this report…one for the bedside and one to put with any patient paperwork (if your facility still uses paper!). If the puzzle is particularly complex, I will write on the report what I have Y-sited together…if they have three lumens, then I’ll label them A, B, C and write out what is running together. For example: A= proposal, levo, fentanyl; B=Lasix, Acyclovir, Cefazolin; C=NS w/ IVPB (disclaimer: please consult a pharmacology reference at your facility before infusing these particular drugs together!).

Along those lines, if you have something that you absolutely DO NOT want to run with anything else EVER…cap off those ports somehow. Cover them with tape and label them DO NOT USE. Remember, we are ‘idiot-proofing’ our patient with the goal that anyone walking into the room would know the score immediately and not have to spend half an hour figuring things out.

Ins/Outs
If your patient has multiple suction canisters, it is a nice idea to label each as well (OGT, ETT, Yankauer, etc…) This way it’s easy to see which should be on intermittent LWS and which should be on continuous. Also, don’t forget to mark the canister level at the end of your shift…if you don’t then the next shift can’t accurately do their I/Os.

As for measuring the intake, this is easy if your patient is NPO and just receiving IV fluids. If they are drinking it gets trickier to keep track. One easy way is to put a piece of masking tape on their water pitcher and just mark off  how many times they empty it. If they are on a strict fluid restriction, then one method is to pre-label the paper cups and put them in the room. For example, let’s say your patient is on a fluid restriction of 1200 mls for 24-hrs. Make sure you account for his antibiotics, and then determine what his PO intake can be…let’s say it’s 900 ml…which is about 4 of those paper cups. Label them #1 of 4, #2 of 4, #3 of 4 and #4 of 4. I’d also put the date on there as well (IDIOT-proof, remember?). This way both the patient AND the next nurse knows how much fluid he can have and help ration it out over the 24-hr period.

Titrating gtts to protocol
Some gtts you will titrate according to a specific protocol. Insulin and heparin are two that come to mind. Do yourself and your buddies a favor, and put a copy of the protocol AT the bedside. This way as you check your blood sugar, you have the information right in front of you and know exactly how to titrate the gtt, without having to walk out of the room to go look at it. We usually tape these to the sides of the IV pumps, but you place anywhere, as long as its accessible.

A word about flush lines
Flush lines are often overlooked and it drives me bonkers! You will want to use a flush line in the following instances:
– you are infusing a drug at a very slow rate (less than 5-10ml/hr)
– you are infusing a drug that you will likely be turning on/off

If you are infusing a drug at a very slow rate, it’s probably not enough to keep the line open. A flush line ensure the line stays open and that the drug you are dripping in is carried in to the patient effectively. The most common drug in this scenario is insulin or maybe a vasopressor that you are weaning off.

If you are infusing something that you will probably be turning on/off, a flush line ensures you don’t have to manually flush and lock the line each and every time you turn the infusion off. Flushing a line that is running a powerful drug is a pain in the neck because in order to do it SAFELY you should withdraw any drug that is sitting in the line, and then flush and lock it. A common drug in this scenario is insulin, heparin, or any vasoactive gtt such as levophed. If your line is persnickety and refuses to allow withdraw, then you are in a pickle, aren’t you? A flush line avoids this and helps keep your line open to boot. (Along those lines, if your line ever acts up and won’t allow blood return, this is a sign you need to TPA it…don’t wait for it to become so sluggish it clots off…no fun!).

I hope these tips help you keep your patients safe and happy regardless of who follows  you or walks into your room to help while you’re off on a much-needed break!

Be safe out there!

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1. Emergency or Not?

Emergency or Not?
This podcast discusses some common situations that will require your urgent attention: blood pressure, neuro, cardiac, respiratory and loss of peripheral pulses. Enjoy!

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Are you prepared for the shock of your life?

As you are traveling along your nursing school journey, you are undoubtedly having conversations with your classmates that start with the question, “Why do you want to be a nurse?” or “What drew you to nursing?”

The reasons people choose such a demanding vocation vary from person to person, and range from the pragmatic (as was the case with my friend, a single mom, who needed a stable job that would enable her to provide for her family) to the altruistic…those who get into nursing to help others.

Many pre-nursing students embark on this journey with only the most basic idea of what a nurse actually does on any given day. I, for one, had visions of starting IVs, holding hands and changing dressings. I had no idea what being responsible for the care of a critically ill patient would entail, the level of vigilance it would require, or the amount of stamina required to stay “ON” for 12 hours straight. I had no idea how much information I would be required to know in order to do my job safely, no inkling of how much gosh-darn paperwork I’d have to fill out, or how alone you can feel when you’re by yourself, bagging a patient who suddenly starts having a grand mal seizure. I had no concept of what it would be like to watch someone die, how rewarding it would be to see someone walking the halls when I thought they were “for sure” going to die, or how much I would want to hug my coworkers at the end of the day. It’s a crazy job with more highs and lows in one shift than most people experience in a lifetime.

Probably the biggest shock for me as a new-grad was just how dang hard the job is. As a student, I’d say I was exposed to about 25% of what a nurse does…so however demanding you think it is as a student, go ahead and quadruple that and you might not be in for the shock of your life. You’ll still be shocked, but hopefully you’ll at least know it’s coming! So, with that said, I leave you with this beautiful piece of artwork I created ;-)  It inspires me when I am feeling depleted by the demands of my job…and reminds me why I chose nursing in the first place…

Be safe out there!

ICU Nursing

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The Metaphor of Illness

This is Marda*
I had been a nurse in the ICU for about two years when I received report on a patient with end-stage metastatic lung cancer.  She was approximately 25 years old, married, and the mother of three young children.  The patient, referred to by the alias Marda*, had come into the emergency room the day prior complaining of shortness of breath.  At the time of this writing, I do not recall if the cancer diagnosis was new, but my impression of the day’s events is that this woman and her family were blindsided by the news that there was nothing more that could be done.  The damage to her lungs was extensive, and the cancer had spread to her liver, brain, and lymph nodes.

When I assumed care of this patient, she was on a non-rebreather mask at 100% with oxygen saturation levels that indicated she would need to be intubated if she were to survive.  Because intubating her was futile in the face of her cancer, the patient and her family were confronted with the difficult decision of withdrawing care.  My role that day shifted from the usual of trying to keep someone alive to doing everything in my power to grant this woman a peaceful death.

As the physician made her rounds, I noticed Marda had the misfortune of being assigned to a resident, someone who had not yet polished the delicate skill of communicating devastating news.  She delivered the message with a clinical detachment that completely disregarded the emotional and social impact of its weight, and its effect was obvious.  The patient was inconsolable.  I knew that as the nurse, as the gentle shepherd on this woman’s final journey, I must provide the sensitivity and warmth missing from that particularly cold interaction.  Because of my inherent compassion and the heartfulness with which I infuse my practice, I had the power as well as the duty to soften the hard edges of the doctor’s words, “you are going to die today.”

Some things you never forget
This experience stayed with me mostly because of the way I felt while I cared for Marda.  It was just one day, but it is one I will never forget.  Her situation, her anguished cries, her fear, and her sorrow cut through my clinical exterior and touched a place of deep sadness in me that I still feel today.  On the one hand, I did feel powerful in that I knew I could alleviate her pain, I could connect her with a spiritual advisor, and I could help ease her transition from the kingdom of illness into the quiet peace of death.  But in some regards, I felt ultimately powerless.  A thief had entered my practice and robbed me of my confidence to assuage her fear and enormous sense of loss.

When I think about this woman’s kingdom of illness and her battle against cancer, the defeat she felt was obvious.  She cried out over and over again, “I don’t want to die, I’m not ready, I don’t want to die,” and I knew she felt she had lost the fight.  It was agonizing to be in the room with her and I had to resist my own urge to run.  As Sontag stated in her 1978 writing, Illness as Metaphor, “a large number of people with cancer find themselves being shunned.”  In that moment, I could understand why.  The rawness of watching someone face death hits so close to home, and unless one is accepting of the eventuality of their own mortality, the desire to flee can be great.

The fight is over
My most powerful moment came when Marda and her family ultimately decided the fight was over.  Marda shook visibly with a fear so strong it was contagious, but I knew I owed it to this woman to join her army and be a courageous presence.  She asked me what her death would be like and I promised her it would be peaceful.  She asked me if it would hurt and I promised her she would feel no pain.  I talked with the resident about the medications she would need, I arranged for a priest to perform last rites, and I ensured her family had the privacy and support needed to grieve together and say goodbye.  I started her on a morphine infusion and provided medication to relieve her anxiety.  I comforted her with every interaction and communicated openly with her husband at the bedside.  My goal of care was to change the dynamic in that room from one of fear to one of acceptance and peace.  My power that day came from honoring the promises I made.

Lessons learned
I learned that my own fear of mortality should not hold me back from providing heartfelt, supportive care to patients in their times of need.  I learned that I have the inner strength to stay when I want to run. I learned how to maintain enough emotional distance to do my job while showing the compassion and courage needed by someone facing their ultimate fear.  I learned that taking care of people who know they are dying requires a special set of skills and that I often find it difficult to choose the right words when difficult questions are asked.  Most importantly, I learned that taking care of dying patients will never get easier, nor will I want it to.  The landscape, however, will become more familiar each time I visit the kingdom of the ill.

Sontag believed “illness is not a metaphor,” yet it is difficult for me to grasp the concept of illness without it.  How do we rally the energy needed to navigate disease without feeling we are heading into battle, and how do we graciously admit defeat when the fight is over?  These are questions I will continue to investigate as I work with patients like Marda and develop the emotional competency to understand what these interactions mean to me as both a human being and a nurse.

How this experience changed my practice
This experience helped me address, to an extent, my own fear of caring for dying patients.  I have been able to be more direct with them about their experiences and anticipate their physical, social, and emotional needs well in advance.  I do find that each time I work with a patient at the end of life, I become more accepting of my own eventual demise. As such, I  have noticed the desire to flee becomes less as I gain experience and confidence that I will say and do the right thing.  As someone who works extensively with patients inhabiting the kingdom of the ill, I hope to understand its complex landscape and use this insight to help my patients view their inhabitance not as Sontag’s  lurid metaphor, but one in which they possess the power needed to live, and ultimately die, with grace.

References

Sontag, S. (1978). Illness as metaphor. New York: Farrar, Straus and Giroux.

*Patient age, name, disease and other identifiers have been fictionalized to protect patient privacy.

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Happy New Year

Welcome to 2015 everyone! Hope you are all enjoying your winter break and gearing up for an awesome semester! You probably have noticed that I haven’t posted in awhile…I’ve been on a bit of a break as I’ve been dealing with some health issues and have focused all of my energy and attention on moi. The good news is, I am doing better and hope to continue on an upward trend. As we embark on the new year, I am renewing my focus of providing you with excellent educational content, organizational tools, and yes…more books!

I am working on taking all of my notes from nursing school and revamping them, updating and turning them into a book. Not sure when this will get done as it’s a monumental task, but it’s something I’m super excited about! I am also looking into offering a premium subscription service that includes video tutorials and more in-depth tutoring…what do you think? Just some of the things I’m pondering for 2015!

If you are a new nursing school student, or prepping for nursing school, I invite you to check out my book, “Nursing School Thrive Guide.” It’s chock-full of information about organization, study tips, clinicals, test-taking…basically all the goods you need to know to thrive in nursing school. You’ll love it!

Stay safe out there!

Nurse Mo

 

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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!

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