Complete Care

At one of my job interviews, I was asked, "What is a disadvantage about nursing." The answer was easy and obvious to me. The continuity of care was missing - especially since I was used to working with an expecting couple before during and after birth as their doula.

So, I was pleased this week when I was able to provide somewhat continuous care with one particular patient. I was assigned to "catch" her baby in the delivery room. Then, the next two days I was assigned as her postpartum nurse, along with my preceptor. I even got to do her discharge teaching the day of discharge.

Today was a significant day for me as a new nurse. It was my first day assigned to a patient as primary nurse. My preceptor was available to help and answer questions as I needed her; but, she totally let me run the show and really feel what it is like to have to organize your day, make accurate assessments, chart everything necessary, medicate on time, do appropriate teaching, AND provide compassionate care.

It kept me busy having just one patient.... I admire the nurses who can do it with 3 or 4.

Oh and it was my first time that I had to work on a weekend..... My kids are less than happy... But Mark helped explain to them that women do have babies on Saturday's, too.

Semantics

I can't say enough how happy I am at this job. This week just flew by. The days at work go so quickly. There are continuous clinical tasks to do followed by never-ending charting; I like to keep busy. There were two days this week that we had every room on the unit filled with either antepartum, labor or postpartum mothers. I can surely see why they hired a new nurse. They really need the additional help...Unfortunately, I'm not at the point where I feel very helpful yet, though, as I still have to ask people so many questions... even silly ones like "How do you transfer a telephone call?" So, I'm not saving anyone much work at this point, but can't wait to be more independent and am able to actually be of some real help to everyone.

I'm starting to become familiar with the protocols and standing orders, etc. But, there are many more to learn.

A funny story. My first day on the unit, my preceptor said to me - very matter of factly - "We're going to go catch a baby now."

Coming from my world (doulas and midwives, etc), "Catching a baby" means actually delivering the baby as it is born in a gentle manner. SO, I was a little confused... Why are we going to catch a baby? Do they want to prepare me in case the doctor can't make it one day? Why aren't they calling the doctor? WHY IS MY PRECEPTOR SO CALM?!?

So, I ask with obvious confusion, "Why aren't we going to call the doctor to deliver the baby?"

She kindly only giggles slightly as she explains to me that in Nurse-Lingo, "Catching a Baby" involves receiving the baby from the doctor after delivery to assess it, aid in any resuscitation needed, clean it and give it initial medications.... NOT Actually Catching it. :)

Ok, so I'm finding out my transition to "nurse-hood" is going to involve a lot of re-thinking and re-defining of things I've previously looked at differently.

It's fun, though.... Everyone is super nice and very welcoming. The doctors are already calling me by name and today I got a phone call from a doctor asking for me specifically. I was nervous, but was able to provide the doctor with the needed assessment information on the patient and was able to suggest appropriately what test might need to be ordered.

Another funny thing: Recently I've developed some mild rosacea, and it manifests itself as bright red cheeks anytime I exercise or get nervous or stressed out. Sometimes it also appears for no apparent reason at all.

Anyway, it is a dead give-away for when I am nervous at all...whether I appear calm on the outside or not... So during incidents like talking on the phone to the physician about a patient or while inserting IVs or foley catheters, I have bright red cheeks... Like I let Raggedy Ann apply my make-up or something.

Hopefully I'll be more comfortable soon enough with the routine clinical tasks and interactions that I won't light up like rudolph ten times a day.

Transitions

I just gave away my nursing school uniform to a friend who is starting my old nursing program this fall. I have this pile of old school stuff just lying in my bedroom... taking up space. I was only too glad to give some of it to someone who could put it to good use. But, it was strangely .... sad? Shutting the door on my first nursing degree; having the memories and my degree as a reminder of the hard hours put in there. Leaving the materials and uniforms behind - I don't know - it was strange.

It's funny. A couple times this week on the floor, I felt like saying, "Do you know how hard I worked to get here?" Then, it occurred to me that each and every one of the nurses on the floor worked just as hard as I did. Yes, they know. I almost feel like I'm in a dream and at some point it will all fade away - when I wake up. I'm just so excited to be doing what I am doing.

It's been a great week! I did so much already. The floor is so busy. Lots of great opportunities to learn. My orientation has classroom components as well as on the floor learning experiences. I spent a whole day in class learning their computer order entering system - which was painfully long and boring - but necessary.

I got to assist with an external version and was so surprised at how rough it was. I was literally cringing during the procedure. I could only imagine how difficult it was for the dad to observe .. A compassionate hand on his shoulder was instinctual from my years of doula-ing.

There were nursing students on the floor today. It was surreal having the nursing students reporting to me; while it was just over a month ago I was the nursing student... Just plain odd. I have to get used to my new role.... and I will.

The staff is super supportive and never makes me feel overwhelmed, although it would be easy to feel that way. My preceptor and I were assigned 4 patients today. But, my preceptor is knowledgeable, and able to multi-task WHILE teaching. She is very reassuring that with exposure and practice, I will be just as smooth. One can dream, right? (Just don't wake me up if I am dreaming!)

Birthdays

Today was my first official day on the floor, working as a Labor Nurse. Was it by design that the first birth I attended as a RN was on my son, Isaac's 10th birthday? It made it even more memorable.

Isaac is my "little Mark." He not only looks like a mini-mark, but he acts like him - TO THE T. He is gentle and kind. Would never be mean to anyone. He is sensitive. Artistic. Creative. Musical. He loves Garfield comics, reading books and doing karate. He's a great brother and one of the best sons a mother could ask for.

Happy Birthday, Isaac. Just imagine what the next ten years could bring!!

Orientation Update:
So far, not surprisingly, there are things that impressed me and other things that didn't. Overall, I feel welcome and the unit is quite busy, lending to many learning opportunities. My preceptor has a kind, gentle manner about her...willing to answer my many questions. I got to spend some time in the NICU today, as well.

Speechless

Article: Baby survives abortion

Hot?

Cool off with this yummy summer treat (recipe is up at Here).

Fathers

Coming from a dysfunctional family (who doesn't, really), Father's Day isn't at the top of my list of holidays that bring a fuzzy, warm feeling. But, I'm beginning to appreciate it in a whole different way, each year more than before as I partner with my husband to raise our children together.

In stead of being nostalgic and remembering fondly all of the moments with my family of origin while growing up, It's become a great way for me to help the kids shower their dad with some of his favorite things in an effort to thank him for being all that every child deserves: a caring, loving father.

Not perfect. We, as humans, don't need perfection. But we do have a void filled only by a caring, loving father. I treasure Mark's commitment to our children and the real ways he shows them he loves them and is interested in each of them.

It has been an unexpected pleasure that I have been able to watch Mark and others (during my work as a doula) become fathers. Some are hands on and right in there, practically catching the baby themselves. Some are pale white and ready to faint. My personal favorites are the ones who cry at the birth of their child. Seeing a grown man cry is truly touching...it's hard for me not to sob right along with them.

I'm glad that every June we are able to pause and think of the many fathers (not necessarily our own) that have made an impression on our lives and the ones that we love.

Orientation Evolution

It's been almost a full week of orientation. Whew. The best one-word to describe it is: whirlwind! I'm tired and am most certainly finding out that my learning is far from over, even though I just graduated and passed the NCLEX!

Some of the nurses from 15 or 20 years ago have told us about their orientation that basically consisted of someone giving them the keys to the medication drawers and showing them where the lounge was before setting them loose to do their job as a new RN. Quiet different from the orientation I am privileged to be a part of today!

It is such a comprehensive, intense orientation. I'm sure my next couple posts will be focused on the orientation process, as it will go on for at least 90 days. Right now I'm still doing the general hospital orientation. I will start my unit specific orientation next week. I will go through classes for specific topics related to my specialty: postpartum hemorrhage, gestational age assessment, PIH, etc. And will work with a preceptor closely during this period.

This is the largest orientation group the hospital ever hired. There are 63 new employees with about 30 of them being new registered nurses. I am the only one that was hired into obstetrics, however, which makes me feel honored as a few of the other RNs there told me they requested obstetrics as well.

I'm tired. Today we focused on IVs, IV therapy, pumps, central lines, etc. Tomorrow will be epidurals and pain management.

They feed us very well! Each day we get bagels, yogurt, fruit, coffee, etc. for breakfast, a complete hot lunch spread and snacks and drinks throughout the day. I am feeling valued and appreciated. Something I've not experienced before at any job I've had before.

That's the general overview. I'll write more later as I regain my stamina... The week is wearing me out. But, in a good way. I'm truly excited about the beginning of this next leg of the journey!

Announcing....

RN !!!!!!!

(I passed!)

Mads' Grad

Madeline's school had a "6th grade promotion" for the kids getting ready to enter Jr. High. I still can't believe my little baby girl is going to go to Jr. High!!!

Anyway, she got several awards at the "graduation" ceremony, including the Presidential Academic Fitness Award for maintaining at least a 90% average in all core subjects since 4th grade.

She reminded me so much of myself, it wasn't funny. She was so stressed out about the possibility of not receiving the award....I felt like I was waiting at my pinning ceremony all over again waiting to see if I would receive my honor cords. We gave each other the thumbs up when her name was called.

She worked hard. We are proud.

Here's a picture of her after her ceremony.











Here is one of a work of art she created that was hanging in her school's hallway. She's smart and artistic!

After the NCLEX

Well, all of this studying is over. Whew! I went to Erie yesterday and took the boards early this morning. While I cannot comment on the content I encountered, because it is all "TOP SECRET," apparently, I can tell you a little about how I prepared for it and what I thought was helpful.

After classes were over, my studying comprised of solely doing NCLEX style questions. I did about 200 questions a day. If I missed a question, I would find out why and make notes about the content I was weak in.

I found it very helpful to know
-All of the normal laboratory values
-Pharmacology - inside and out: uses, side effects, and therapeutic effects of meds
-Your major systems: Endocrine, respiratory, cardiac, and renal
-Prioritizing care

The results will not be available for a couple days. But, I feel pretty good about it. The test is computerized and can give you anywhere between 75 & 265 questions. The computer shuts off when it is 99.9% sure you have or have not met competency. Mine shut off after the minimum 75 questions. So, I'm taking that as a good sign. It could either mean that I proved to them really fast that I know my stuff or that I showed them quickly that I was so far gone there was no saving me with further questions. I like to think it was the former. :)

Anyway, Mark came with me to Erie. After the exam we drove out to the Presque Isle Peninsula. We rented bicycles and biked around the peninsula. It was an absolutely perfect day for it, too. The sky was clear, there was a light breeze, and Lake Erie's scenery was beautiful. Here are a couple pictures from the ride.

Monday I start my new job! The beginning of a new chapter!

Crunch Time

Only 2 days before I take state boards!! NCLEX ? Crunch time.

Here are some Obstetric Pharmacology NCLEX questions:

1) In assessing a premature neonate, which assessment finding should the nurse anticipate as a result of the ritodrine (Yutopar) therapy?
A. Respiratory distress
B. Hypertension
C. Hypothermia
D. Hypoglycemia

2) A client is scheduled for induction of labor at 40 weeks gestation. The nurse knows the safest technique for the antepartum administration of oxytocin (pitocin) is:
A. In an IV bag diluted per protocol
B. In an IV bag piggybacked into the main IV line
C. In two separate IM injections
D. IV bolus slowly over 20 minutes

3) Which assessment must the nurse make prior to the safe administration of IV oxytocin (pitocin)?
A. Cervical dilation
B. Fetal station
C. Maternal blood pressure
D. Fetal position

4) A client receiving magnesium sulfate for treatment of severe pregnancy induced hypertension (PIH) begins to show manifestations of magnesium intoxication, and the decision is made to administer calcium gluconate. The nurse will use which of the following methods to administer the calcium gluconate? Administration via:
A. Rapid IV push
B. IM injection
C. IV drip
D. Slow IV push

5) Which clinical finding would indicate to the nurse an adverse reaction to betamethasone (Celestone) in an antepartum client?
A. BP of 90/52
B. Muscle weakness and cramping
C. Temp of 103
D. Blood sugar of 64

6) Which does the nurse understand to be an action of dinoprostone (Prepidil)? It is a:
A. Vasodilator which can be used to stimulate contractions and induce labor in post-term clients.
B. Vasoconstrictor which can be used to delay the onset of premature labor contractions.
C. Vasodilator which can be used to ripen and soften the cervix in term clients.
D. Vasoconstrictor which can be used to increase uterine contractility in postpartum hemorrhage.

7) The nurse determines that administration of magnesium sulfate would be contraindicated for the:
A. Mildly pre-eclamptic multigravida client at 38 weeks gestation.
B. Severely pre-eclamptic multipara client in the first stage of labor.
C. Mildly pre-eclamptic primigravida client in preterm labor at 34 weeks gestation.
D. Primipara client with severe pre-eclampsia during the first post-partum day.

Answers: 1) D 2) B 3) D 4) D 5) B 6) D 7) A
Questions from Meds Pub Online Review

Good to Know

While going over my new benefit package with the hospital yesterday, they told me about an interesting "perk" available to full-time employees. It is kind of like an employee discount one would get if working for a store like Walmart or Sears. Only it is a discount on surgeries. No lie. If anyone in my family receives medical treatment of any kind (including surgeries) from my new hospital employer we all get 25% off.

Weird. But good.

CRUD

Another shot!

Just met with my new employer. Went over tons of paperwork. And I have to get yet another vaccine! I wrote about this when I started nursing school and needed a series of three Hep B vaccines, a Rubella booster and a Tetanus booster. Well, it turns out that I should have had the Tdap Tetnus booster which includes Pertussis.... But I didn't. So, I'm getting another Tetanus shot. Out of all of them, that one was the bugger that left my arm aching for a week afterwards! Darn it, anyway.

So, for any new nursing students, just save yourself some misery and get the Tdap Tetanus booster - even if they say you don't need it. You may, depending on where you work.

What Do Nurses Do?

My children and I were talking recently about what a nurse does. I asked the kids if they knew what a nurse does. This brought an interesting response from Isaac. He said, "Nurses help the doctors by doing what the doctor says to do."

Wow.

I was blown away that that is what my children thought a nurse does. But, to be honest, before nursing school, my knowledge of what nurses did was fair, at best.

So, I thought it would be interesting to try to list some of the responsibilities of nurses. I will follow each with an NCLEX question relating to that responsibility because I am in NCLEX study mode still.

In no particular order except what comes to my mind:

Nurses must prioritize care and decide which client needs medical attention first.

1) After receiving report, which of the following clients should the nurse see first?
A. A 14-year old client in sickle-cell crisis with an infiltrated IV.
B. A 59-year old client with leukemia who has received half of a packed red blood cell transfusion.
C. A 68-year old client scheduled for a bronchoscopy.
D. A 74-year old client complaining of a leaky colostomy bag?

The nurse must delegate safely and appropriately to LPNs and Nurse's Aids, taking into account their education, skill level and scope of practice - while retaining final responsibility for delegated tasks.

2) Which of the following assignments, if made by the registered nurse, would be appropriate for an LPN?
A. A 34-year old woman with low back pain scheduled for a myelogram in the afternoon.
B. A 41-year old woman in traction with a fractured femur.
C. A newly diagnosed 43-year old woman with type 1 diabetes mellitus.
D. A 56-year old man with emphysema scheduled to be discharged later today.

Nurses must be knowledgeable about specific medical & surgical complications and be watching for them in the patients. If complications are seen, the nurse must alert the physician.

3)The nurse is caring for a client who had a thyroidectomy 12 hours ago for treatment of Graves' disease. The nurse would be most concerned if which of the following was observed?
A. Blood pressure 138/82, pulse 84, respirations 16, oral temp 99 degrees F.
B. The client supports his head and neck when turning his head to the right.
C. The client spontaneously flexes his wrist when the blood pressure is obtained.
D. The client is drowsy and complains of a sore throat.

The nurse should also be aware of expected medical & surgical side effects so she can treat them directly and not alert the physician, unnecessarily.

4) A client receives 10 units of NPH insulin every morning at 8am. At 4pm, the nurse observes that the client is diaphoretic and slightly confused. The nurse should take which of the following actions first.
A. Check vital signs.
B. Check urine for glucose and ketones.
C. Give 6 oz. of skim milk.
D. Call the physician.

The nurse must be knowledgeable about the patient's condition/surgery so she can provide the necessary care and interventions to the patient.

5) A client is admitted to the hospital with a diagnosis of chronic bronchitis. He has a 10-year history of emphysema. The nurse should place him in which of the following positions?
A. Side-lying
B. Supine
C. High-Fowlers
D. Fowlers

The nurse must know expected laboratory normals and the use of the laboratory tests in order to monitor the patient's condition and alert the physician if necessary. If a lab tests comes back and the value is abnormal it is the nurse's responsibility to communicate that to the doctor. If it is not told to the physician, then, it is the nurse who is at fault.

6) The nurse is caring for a client with an acute myocardial infarction. Which of the following laboratory findings would most concern the nurse?
A. Erythrocyte sedimentation rate (ESR): 10 mm/h
B. Hematocrit (Hct): 42%
C. Creatine kinase (CK): 150 U/ml
D. Serum glucose: 100 mg/dl

The nurse is involved in educating the community in general about medical issues.

7) A parent asks why it is recommended that the second dose of the measles, mumps, and rubella (MMR) vaccine be given at 4 to 6 years of age? The nurse should explain to the parent that the second dose is given at this age for what reason?
A. If the child reaches puberty and becomes pregnant when receiving the vaccine, the risks to the fetus are high.
B. The chance of contracting the disease is much lower at this age.
C. The dangers associated with a strong reaction to the vaccine are increased at this age.
D. A serious complication from the vaccine is swelling of the joints.

The nurse is responsible for being knowledgeable about medical conditions so that she can educate patients about their specific conditions.

8) The nurse is caring for a woman at 37 weeks' gestation. The client was diagnosed with insulin dependent diabetes mellitis (IDDM) at age 7. The client states, "I am so thrilled that I will be breastfeeding my baby." Which of the following responses by the nurse is best?

A. "You will probably need less insulin while you are breastfeeding."
B. "You will need to initially increase your insulin after the baby is born."
C. "You will be able to take an oral hypoglycemic instead of insulin after the baby is born."
D. "You will probably require the same dose of insulin that you are now taking after birth."

The nurse must make appropriate room assignments so that the health of the patient, their roommate, and others is protected.

9) The nurse is caring for clients on the pediatric unit. An eight-year old client with second and third degree burns on the right thigh is being admitted. The nurse should assign the new client to which one of the following roommates?
A. A two-year old with chicken pox.
B. A four-year old with asthma.
C. A nine-year old with acute diarrhea.
D. A ten-year old with MRSA.

The nurse must be knowledgeable about matters of nutrition and its impact on medical conditions in order to provide basic dietary counseling to patients related to their specific needs.

10) The nurse is preparing discharge teaching for a client with a new colostomy. The nurse knows teaching was successful when the client chooses which of the following menu options?
A. Sausage, sauerkraut, baked potato, and fresh fruit.
B. Cheese omelet with ban muffin and fresh pineapple.
C. Pork chop, mashed potatoes, turnips, and salad.
D. Baked chicken, boiled potato, cooked carrots, and yogurt.

The nurse needs to be knowledgeable about antidotes for specific medications in order to provide for the safety of the client in case of toxicity.

11) The nurse is caring for clients on the medical unit. A client is admitted with a diagnosis of deep vein thrombosis (DVT). Admission orders include heparin 2,000 units per hour in 5% dextrose in water. The nurse should have which of the following available?
A. Propranolol (inderal)
B. Protamine zinc
C. Protamine sulfate
D. Vitamin K

The nurse must be aware of medications the patient is on and possible interactions that would affect the patient.

12) A client returns to the clinic two weeks after discharge from the hospital. He is taking wafarin sodium 2 mg PO daily. Which of the following statements, if made by the client to the nurse indicates that further teaching is necessary?
A. "I have been taking an antihistamine before bed."
B. "I take aspirin when I have a headache."
C. "I use sunscreen when I go outside."
D. "I take Mylanta if my stomach gets upset."

The nurse needs to be aware of specific physical/physiological conditions that would affect medications and be prepared to make critical decisions about the administration of those medications.

13) A client is receiving digoxin. His pulse range is normally 70 - 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should initially:
A. Call the physician for orders
B. Withhold the digoxin
C. Administer the digoxin
D. Notify the charge nurse

The nurse must be knowledgeable about medications in order to do accurate patient teaching about their medications.

14) A client asks the nurse how long she has to take her medicine for hypothyroidism. The nurse's response is based on the knowledge that:
A. Lifelong daily medicine is necessary.
B. The medication is expensive, and the dose can be reduced in a few months.
C. The medication can be gradually withdrawn in 1 - 2 years.
D. The medication can be discontinued after the client's thyroid-stimulating hormone level is normal.

The nurse is responsible for all nursing actions she preforms. Mindless "helping the doctor by doing what he says" as my son put it, is not an option. The nurse must double check all orders for all patients, ensuring that the treatment, test, or medication is appropriate and safe for the patient.

15) A client with acute pancreatitis has been admitted with the following physician orders. Which would the nurse question the doctor on?
A. NPO
B. Naso-gastric tube insertion
C. Morphine sulfate 5mg every 4 hours PRN pain
D. IV of D 5 1/2 NS at 125ml/hr

Lawsuits against nurses for negligence and malpractice are on the increase. Prudent nurses will stay abreast of current research and practice evidence based nursing.

Yes, we help the doctors, but nurses today are autonomous, and they take pride in their profession.

Answers: 1) a 2) b 3) c 4) c 5) c 6) c 7) a 8) a 9) b 10) d 11) c 12) b 13) b 14) a 15) c
Questions from:
NCLEX-RN Strategies for the registered nursing licensing exam 2007-2008 edition &
NCLEX-RN Exam Cram

D.C.

Our family took a long weekend jaunt down to Washington D.C. We wanted to get a mini-vacation in before I started working (NEXT WEEK!!), because I'm not sure if I'll be able to take vacation right away this summer. And, we've all worked hard these last few months and deserved a little down time together.

It was really nice.. I remember going on a field trip there once as a 5th grader...but don't remember much about it. Everything was very clean and well maintained. Beautiful trees, plants and flowers all over.

We went to The National Zoo, and saw the pandas.











We visited most of the monuments, memorials and famous buildings.











And we toured two Smithsonian museums: The National Museum of Natural History & The National Air and Space Museum. All of these were absolutely free! Our tax dollars at work, no doubt. We stayed at a nice hotel right next to a metro stop that made getting into the city a breeze.






Although the kids were old enough to appreciate the city, their favorite part was swimming!