Step one

So…

I’ve done step one. I’ve applied to a nurse practitioner program.

I’m terrified!

Am I smart enough?

Can I handle this?

Can I afford this?

Is it worth it?

Will I be able to find clinical sites?

Is this the right decision?

This is a really big committment. A lot of my time and finances will be going into this and I wonder if I’m ready for it. I have been bouncing back and forth between career paths and decided that I can do what I would like to do with an advanced practice degree.

Patient education is my passion and I know that as an NP I will get the opportunity to try and make a difference. By working in the “clinic” setting I will be able to try and prevent admission to the hospital by providing care and education on their health. I want to stop patients from being observers in their health care. I want patients to be a participant in their care plans. An educated patient does better. I love when patients comes into my current job and tell me all about why they are getting their scan. It let’s me know they are involved in their health. Those patients area typically in better health than my patients that have no idea what’s going on.

I know I’m doing this for the right reasons. I just don’t know if this is the right time. Then again, when is the right time? I can always find a reason to not do something. Life is always throwing me curve balls. I might as well step up to the plate, swing with all my might, and hope to God I knock it out of the park!

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Look at me when I’m talking to you!

I am going to vent for a moment so bare with me okay?

I ABSOLUTELY HATE WHEN MY PATIENT DOES NOT LOOK AT ME EVEN ONCE WHEN I AM SPEAKING TO THEM!

This has nothing to do with eye contact. I know for some people, eye contact is uncomfortable or unusual in their culture. I get that. However, when I call someone into my IV chair and they can’t bother to put their  phone down long enough to raise their head and answer my questions it burns me up! I just feel like it is so disrespectful! Is that how they converse with everyone? No, I highly doubt it. I think *that* is what bothers me the most. I am simply trying to provide care within my environment. I didn’t force them to come to this hospital, nor did I force them to make an appointment for whatever reason they are here. I feel like the least someone can do is acknowledge that a human being is standing in front of them providing care.

There have been times when I am trying to go over information with a patient and they are so engrossed in whatever is happening on their phone that they have a hard time answering my questions. Typically this statement will get me the acknowledgment I prefer: “Let me know when you are done on your phone and then I I’ll continue.” After that I take a step back and wait. Patients will typically put the phone down and pay attention.

In all honesty, I don’t need their undivided attention the entire time they are in my care. Since I am the radiology nurse, I am going to be the one to go over the contrast questionnaire with the patient and then I will obtain vascular access. This isn’t dramatic stuff here. I really only need the patient to pay attention when I am asking them questions, after that I actually prefer they occupy themselves because most often it means they’ll focus on their phone and not on the 20g I am about to stab them with.

I don’t know, maybe I’m just getting old or something but a little acknowledgment wouldn’t hurt.

Uniform… Acceptance…

The hospital I work for has a uniform policy. As nurses we wear ceil blue and/or white. I hated the idea of uniforms… At first.

Now, I kind of like the fact that each department in our hospital has a uniform.

Yeah, it surprised the hell out of me too!

It helps me know who I’m talking to or who just walked into my patient’s room. I’ve often had patients say, “the doctor said I can have something to eat!”, however I haven’t seen the docs come onto the unit. Now I’m trying to figure out who my patient was actually talking to so I can find out what was actually said. With everyone being in uniform I can ask my patients “what color uniform were they in?” I cannot tell you how many times I’ve asked that question and then find out it was xray technician that came in to do the morning portable chest xray that the patient talked to! For a lot of our patients, anyone in scrubs is a doctor.

The fact that I can identify a department just by their scrubs is a real help and as much as I hate to admit it, uniforms made things a lot easier. I only have one big complaint, THESE COLORS!!!!

I despise the ceil blue/white combo. I would really prefer a darker color. Something like a hunter green or a navy blue would work for me but it is what it is.

So tell me, what policy did you initially hate that you’ve learned to accept and perhaps even like?

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.

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.

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?

Vitamin C and sepsis

You may or may not have heard about some new studies coming out that show some positive results adding vitamin C to sepsis treatment.

If you haven’t heard anything about it, don’t worry, you will.

This is what really kind of started it all. It was a retrospective study, not one you could really take back to your ICU and make evidence based changes on, but it provides some interesting factors to think about. This study gives some information about some of the preliminary findings. So far, (cautiously) it looks positive.

However, don’t think doctors around the world are ready to jump on the vitamin C boat just yet. There hasn’t really been a what I would call a “large scale” scientifically sound study completed just yet. It’s safe to say the idea remains controversial. Here is a really good article addressing the controversy surrounding the treatment. I did notice one thing when I read this article: while doctors may not be ready to jump on board do to a lack of evidence, most of them really hope vitamin C treatment does turn out to be beneficial. The health care field as a whole really wants a better treatment for sepsis, especially since what we are doing now is only partially successful.

I am hoping someone decides to do a large scale study and really put vitamin C to the test. I would love to know if this could potentially be an adjunct sepsis treatment or if it is time for medicine to go back to the drawing board. Trying new things is what helped the medical field advance this far, let’s not stop now!

Motivated?

I’m strangely motivated to do a lot of nursing related things that I had no desire to do before. All of a sudden I want to go back to school to get my Master’s. I want to join our shared governance committee. I want to advance on the clinical ladder up to a Clin III. I want to cross train in other parts of our department.

What the hell is happening?

Where did I get all of this motivation from?!

Is… Is this what happens when you’re happy at your job?

I mean, honestly, these are all things I know I can do if I put forth the energy to do it. I’m still (relatively) young, unmarried, no children… I have the time so why not?

I need to sit down and prioritize all of these new goals. Time for me to become Super Nurse!

Wish me luck!