The kids are alright

This is my last week of shadowing in the PACU. I’m ending my week in pediatric pre and post op.

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I have been a grown up nurse my whole career. Med surg, small ICU, STICU, that’s what I know. I know how you fix an adult. I know nothing about children.

I am not good with kids. I’m uncomfortable around them. I’m not used to kids. I am out of my element.

I feel so freaking awkward!

I am so useless in here. It’s not because the nurses aren’t teaching me. The PACU nurses have been amazing. I just don’t know how to handle kids. I have none of my own. I don’t want any. I have no maternal instinct. I have little patience for crying. I’m just not good with kids and I’m well aware of that.

So here I sit, on my phone, typing up this blog while on lunch, hoping I survive a few more hours so I can go back to my adults in radiology on Monday…

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OR 4

I’ve been shadowing in the pre and post op unit for the last week. I am still a radiology nurse but I’m up here learning a few things. In MRI we give some of our patients propofol to sedate them so they can tolerate the scan and then we recover them afterwards. My department has me floating in PACU to evaluate how PACU recovers patients to see if there are things we need to bring back to our department. I’ve been enjoying myself so far. Today I am following the sedation nurse. We are in OR 4.

OR 4 is where they are doing all the abortions today.

I wasn’t prepared.

I have no children and have never been pregnant. I have no desire to have kids. Honestly I’m not fond of them. I am pro-choice. I consider myself pretty liberal. I don’t judge women who choose to have an abortion.

I was still not prepared.

I’ve read about abortion. I know people that have had them. However, I have never actually seen an abortion and after today I don’t need to see anymore.

It’s emotional.

One was because of fetal deformity. Most were not. The reason didn’t matter. You could see the anguish in some of the faces of the patients. Some were stone faced and I couldn’t really tell how they were feeling. A 16 year old seemed not to really have a full grasp of what was really happening. One lady cried and expressed her feelings of guilt the whole procedure.

It’s was a lot to deal with.

The procedure itself was different than I expected. Mentally I has to steady my nerves to watch how the fetus was removed. Typically I stayed at the head of the table with the patient for their comfort… And my own. I tried to focus on the patient and not the procedure so I could keep my emotions out of it.

This is definitely something I could not do on a regular basis, if I could ever do it at all. This experience is something I definitely won’t forget.

I still remain pro-choice even after today. Now I understand what women go through not just physically but emotionally when having to make this choice. It’s so much deeper than what I understood.

The complainer

Don’t be the complainer.

You know the one, nothing ever goes right for this nurse. They are the ones that come in and start complaining before they even clock in. They always have the worst assignment. They always have the worst shift. Everything is always wrong.

Two total care patients that only really need repositioning? “OH MY GOD WHY DO I HAVE TWO TOTAL CARE PATIENTS????”

Four walkie talkie patients that are self care? “GREAT THEY ARE GOING TO DISCHARGE SOMEONE AND I’M GOING TO GET AN ADMISSION!”

Float to an easy unit with cool ass staff? “WHY IS IT MY TURN TO FLOAT???”

Go home.

Why are you even here? Why are you even a nurse? What did you expect from the health care field? No, our jobs are not a roses and sunflower fields every shift. Sometimes our jobs suck, horribly. Honestly though, if every shift is your worst shift ever and it’s like that no matter where you work… I hate to be the bearer of bad news but it’s not the job, it’s you.

I mean, you’re the common denominator here. It’s time for you to face the facts: you’re miserable at your job because you’re just miserable as a person. Maybe you should work on that…

Preceptor behavior (how not to be an asshole)

I have been the orientee and I have even done a little precepting. I lucked out so far and had wonderful preceptors (except for one but anyway…) but I have seen some TERRIBLE preceptors.

One thing that I noticed from a few of the preceptors that I would definitely label as “assholes”, is that they take pride in being intimidating to their orientee. I have¬†witnessed this behavior and have had other nurse confide in me about their preceptors after they were out of orientation. Some of the things I heard were appalling.

It is NEVER okay to make your orientee feel “dumb” or “stupid”. You were a new nurse at one time and you didn’t know everything when you started, you had to be taught as well. You know what else is not okay? It’s not okay to just leave your orientee to fend for themselves. You are not on vacation, you are responsible for teaching this new employee the ways of your unit. Get up and check on them, make sure that they are actually alright. STOP USING THE AMBUSH TECHNIQUE!!! For those of you that don’t know what the ambush technique is, let me fill you in on this bs. Basically what happens is the preceptor ambushes the orientee when they aren’t prepared for it and starts hammering them with questions of “things they should already know” in the eyes of the preceptor. Do I know the normal range for a CVP? Yes, I do. Do I know the normal range for a CVP when you show up out of nowhere,¬†while I am catching up on charting¬†on a patient that I just had to start on norepinephrine and give two units of blood? No, absolutely f*****g not! This does not mean I am less intelligent than you, it means I was focused on my charting and not expecting a nursing ambush! The ambush technique neither proves nor disproves someone knowledge, it just makes you look like a douche. While we are at it, stop making your orientee feel like they are bothering you when they ask you questions. They don’t know. You do. Spread the wealth of knowledge. Learn how to give constructive criticism¬†and praise. A lot of preceptors seem to miss that last part. Your orientee is already paranoid and trying to be a close to perfect as possible. Let them know you notice the good things they do along with the things they may need to work on. Your orientee will be much more receptive of your criticism, trust me.

Look, i’m not asking for a lot. I am simply asking you to remember what it was like when you were orienting. Remember how stressed you felt. Remember how confused you were. Remember how intimidating it was. Remember that you aren’t perfect.

n00b

So you’re the newest person on the unit. You may not be new to nursing but you are new to this place. Don’t let that freak you out.

As the newbie I was always really quiet and reserved. What I didn’t realize was how off-putting that was to others. It never failed, once I got to know my coworkers they would all say the same thing “I thought you were so mean when I first met you!” For the longest time I didn’t understand why that seemed to be the case. You know me though, if I don’t know then I’m going to ask. That is when I found out that I sort of appeared unapproachable because of how I tended to distance myself from my new coworkers. I changed that once I started the new position I am currently in.¬†This time I made a conscious effort to get to know my coworkers.

Here are a few steps to transition into your new work environment:

  • Introduce yourself to your new coworkers. If you know of a good ice breaker then use it (having the name Shaunelle but being called Fred is one hell of an ice breaker, everyone loves the story of how I got my nickname.)
  • If you are an experienced nurse understand this: your experience is much appreciated but you are the new nurse¬†on the unit. Don’t walk around like you already know everything there is to know. You may know cardiac ICU but you don’t know how they run¬†their cardiac ICU. Have a little humility (ran into this with a new coworker, she didn’t last long).
  • Don’t be afraid to ask questions. It is safer to ask than to¬†assume you know what you are doing and then do it wrong. Your new coworkers will remember that screw up, trust me.
  • If you are a super proactive person, join one of the committees. You are bound to meet your coworkers that way.
  • Become familiar with your physicians and introduce yourself to them. Let them know you are new to the unit, I mean you will be working with them too.
  • Know that not everyone is going to warm up to you immediately and that’s okay. They may still be “feeling you out” so to speak. That is not your problem, that is theirs. They’ll either come around or they won’t. It’s not the end of your world. However, DO NOT allow bullying behavior towards you. You may be the newbie but you deserve respect and if they want it from you then they should earn it. Forget that “nurses eat their young crap”!

Those first few weeks, hell even first few months, are a weird time. You’re trying to adjust to a whole new setting. Things may feel off and that is normal. You may feel a little out of place at first, and that’s normal too. Give yourself time to get acclimated to your new surroundings, you are going to do great!

ABG’s, what do they mean?

Arterial blood gases… Chances are if you work in a progressive care or intensive care unit you have seen ABG results or you will.

If you’re like me in the beginning, you have no idea how to interpret the results. For the longest time I had no idea what I was looking at. I knew the pH was indicative of acidosis or alkalosis, and that was the end of it. Once I started working in an ICU I wanted to really understand what the results meant. I made one of our respiratory therapist teach me how to understand the results (he was awesome and was happy to help). It turns out ABG results are not too terribly difficult to interpret. You are trying to obtain three key pieces of information:

  • Is the patient acidotic or alkalotic?
  • Is this a respiratory or a metabolic issue?
  • Is the body fully compensating, partially compensating?

While there is plenty of information on the ABG slip (or in the chart if your unit doesn’t have an ABG machine available) you can come up with the answer by looking at three key results: pH, paCO2, HCO3.

One of the ECCO learning modules I did had this handy little chart that made it easier to interpret the results. I thought I would share it with you all in case there is someone out there confused like I was, but may not have a quick resource available.

That’s it. This little handy chart has helped me a lot. It took what was, for me, a larger amount of overwhelming information and broke it down into something I could use. Here’s how to use it:

Look at the pH, is it <7.35 (you’re acidotic) or >7.45 (you’re alkalotic) or is it normal? Circle which side of the chart your value falls in. Then look at the PaCO2. We are looking at carbon dioxide in the blood here. Repeat the previous steps and circle where your value falls. Then look at your bicarb, HCO3. Circle where that value falls.

Remember pH tells you if they are acidotic or alkalotic. Now that you’ve figured that part out, it’s time to figure out if this is respiratory or metabolic. Look at your chart, is the CO2 circled on the same side as the pH? If yes, it’s respiratory. Is the bicarb circled on the same side as the pH? If yes, then it’s metabolic. Now, are we compensating? If you are partially compensating then you will have one value on the other side of the grid. If you are fully compensating then your pH will actually be normal.

I’m a person that needs to see something in action so let’s do a couple of examples:

Note let’s break out the chart:

pH is low so we know the patient is acidotic. The CO2 is on the same side as the pH. The bicarb is on the opposite side of the grid so the body is trying to compensate. We have respiratory acidosis, partially compensated.

Let’s do one more:

Bust out the handy dandy chart!

The pH is high so we know it’s alkalosis. The bicarb is on the same side of the chart as the pH but the CO2 is on the opposite side. Here we have metabolic alkalosis, the respiratory system is partially compensating, that’s why the CO2 is high.

I would like to mention one thing, if all your values are on the same side of the chart then it most likely means the one of the systems of the body aren’t compensating.

Hopefully this post is able to help someone out. If you have any other hints, tips, tricks let me know!

Teach back

Get your patients to “teach back” what you have taught them. Get them to repeat what you have taught them. You may be surprised at how little information your patient has absorbed from the education you have given. Using the “teach back” or “repeat back” method can help you gauge just how much information your patient is retaining.

With the “teach back” method, it’s exactly as it sounds. You get your patient to teach you what you taught them. This method is really effective for education that involves hands on training. Things like changing a colostomy bag at home, changing a wound dressing, giving tube feeds, doing peritoneal dialysis, etc all require a lot of teaching. These are thing you want to make sure your patient understands before they return home. When you get them to teach it back to you then you know that they have an understanding of the information they have received. As they are teaching it back, you can correct them if necessary and give them little hints to help them with the process.

“Repeat back” works well with information that may not require as much hands-on work. I found that it works well with my patients that are being sent home with multiple prescriptions,¬†especially different inhalers. I had a patient with COPD and asthma (and yes, she still smoked, how did you know?) that had both Symbicort and an albuterol inhaler. She ended up on our unit from a bad asthma attack. When she started to get wheezy I took her the albuterol inhaler to help open her up and she refused. I couldn’t understand why. She said “that’s not the one I need for my asthma, I need the other one”. Confused, I asked her if she was referring to her Symbicort. She said yes, that’s the one she takes when her asthma flares up. She took her Symbicort whenever she felt tight or wheezy and took her albuterol twice a day. OH, nooooooow I know why you’re in here. I tried explaining to her that the Symbicort is for her COPD, not asthma. She argued with me for a good 10 minutes that I was wrong. I had to not only print out information on Symbicort but also have the doctor talk to her before she accepted that she has been using her meds wrong this whole time and that is why she was in the hospital. Upon discharge I made her repeat the education I had given her and show me which inhaler was her twice daily inhaler for COPD and which inhaler was for her asthma. I felt comfortable that she understood her meds upon discharge.

I think this teaching our patients about their health is where the medical system is lacking. Often, we are in such a rush to get people out so we can get people in that we just assume the patient understands because they didn’t ask any questions. Often, it’s the opposite. Some are embarrassed to say they don’t understand. Some can tell we are in a rush and don’t want to bother us by asking us to repeat what we have told them. It is up to us to make sure our patients are leaving with a full understanding of their health and their medications.

TJC

So The Joint Commission is here this week…

Yay.

If you don’t know, TJC is an accrediting body for hospitals that makes sure we are doing things according to acceptable standards. In all honesty, it’s a good thing. It makes sure we are on our sh!t. I am okay with that.

However…

When TJC visits it turns every unit into chaos! What do I mean? Well, each hospital gets a “heads up” that TJC may be visiting within a date range. This sends every manager and compliance officer into a panic. Typically it goes a little something like this:

“Is this dated?”

“When does that expire?”

“Move this stuff out of the hallway and even though we have no true place to store it, FIND SOMEWHERE!”

“Do you know where the evacuation plans are for this unit?”

“Where are the fire extinguishers located?”

“How long does it take the purple wipes to disinfect?”

“What about the gray wipes?”

“And the red ones?”

“What is the temp on the fridge?”

“Where is the temperature log?”

“Where is the check sheet for the code cart?”

“Is there an expiration date on the Accucheck controls?”¬†

“All cups must have a lid on them or I am throwing them away!”

This continues for the entire week that TJC is in the hospital. All those things that we should have *technically* already been doing, we are going to do them all RIGHT NOW. I have been lucky. For eight years I worked 1900-0700. TJC is not in the hospital at night and neither is management so I avoided most of the shenanigans. Now I work days and evenings. I am now in the line of fire. I have been on my toes all this week just waiting to see the group of them come around the corner. So far I have avoided them. Let’s hope my luck continues!

Holier than thou

Hello holier that thou nurse and/or doctor on med Twitter.

We are so glad you came to join us and tell us how wrong we are for sharing our experiences when they aren’t all “rainbow and unicorny”. Let me see if I can explain something to you:

Sometimes it can suck being a nurse. Sometimes it sucks being a doctor. Sometimes it sucks being a CNA. Sometimes, the medical field just sucks.

I know this is shocker for you since your days are only sunshine and blue skies. For the rest of us, however, we deal with patients every day. We see death, abuse, addiction, cancer, and disease progression on a daily basis. We see tears, we get hit, we get verbally abused, we witness (and then somehow get involved in) family drama, we get spit on, we get called racial slurs, we go THOUGH it. Sometimes, we take to “med Twitter” to vent to those that understand us. We don’t do this because we get a kick out of bashing patients. Majority of us in the medical field are in this field because it’s what we love and we couldn’t see ourselves doing anything else. We love what we do but sometimes it’s a bad day and we need to talk about it to other people that have been through what we are going through. We get encouragement. We get advice. We get a picture of a puppy to melt away the stress. It’s our own little online bar where we get to sit and talk to the bartender. We need an outlet.

What we don’t need is your pretend internet holiness and your pretentious “I’m more of a patient advocate than you are” attitude. We would never do or say anything to harm or patients. We are, contrary to your belief, compassionate and caring medical professionals. We use these outlets to keep from losing our minds. So how about you hop on down from atop that high horse, ok?

One year!

So we have hit the one year mark with Barelysanenurse.com!

Thank you to all of you that have read my blog, commented, and shared.

When I started this blog it was sort of just a little hobby to talk about nursing life. Surprisingly I am enjoying this! I’m glad there are people out there that want to hear my opinion lol.

Let’s see how long we can keep this bad boy going!