ACLS

This week I’ve spent my time studying in bed while fighting a nasty cold.  I had ACLS (learning to run a code) class all day yesterday and the test today.

The test includes being the team leader during a practice code, then taking a written test on reading EKG’s and another written test about what to do during codes.  It’s pretty stressful with a lot to learn, but thankfully it was some what of a review for me since I had a quicker version of this class back in Cincinnati.

Now, heaven forbid I ever find myself the only person who is ACLS certified at the scene of a code I will know what to do.  Hopefully, if I don’t forget it all!

How I passed the NCLEX-RN

The two most popular posts on my blog have been one about Hillary Clinton and another about my experience taking the NCLEX.  Well, since the one thing the world doesn’t need more of is one more person blogging about politics, especially someone who hates politics.  I thought I would make another post about the NCLEX.  Sorry to those of you who could care less.

My first tip is for people trying to pick a nursing school.  Get on-line and look up their passing average for the NCLEX.  I think how well your school prepares you for the ultimate test has a lot to do with you passing.  I believe my school did an excellent job preparing me for the NCLEX.  In 2006 my school’s average rate was 93%.  I would love to know what it is now because they now require all students to take a practice HESI exam every 9 weeks.  I work with several girls who all went to the same school and none of them have passed boards after several tries.  They are all REALLY smart, but the school just did not prepare them for the NCLEX.

For those who are not required to take the HESI, let me clue you in.  It’s basicly a longer harder version of the NCLEX.  If you can pass the HESI you are supposed to be able to pass the NCLEX.  It is also on a computer and the questions are just as hard, if not harder.  I believe a full length HESI is around 300 questions.  We took a short version every 9 weeks at the end of each term.  We also had a full length HESI before graduation that we were required to pass before graduation.

My second tip is to practice, Practice, PRACTICE!!  We were required to buy this book for school.  It comes with a computer disk with practice questions on it.  We were required to do a certain number of practice questions while we were in school, and we had to get over 80% correct or we had to keep doing them over and over again.  The book is not broken down by subject, the point is to get your brain used to jumping from subject to subject.

This is the only book I studied from for the NCLEX.  After graduation I took this book everywhere.  To the dog park, training classes for work, on my lunch break from work.  Every spare minute I had I was doing practice questions.  At home I would put the CD in my laptop and do practice questions on commercial breaks while watching TV.  I would mute the TV and do questions until my show came back on.

The disk has several options.  You can break the questions down into subjects, or have them mixed together.  You can do one question at a time, meaning it tells you the correct answer as soon as you pick your answer.  You can take 10 question quizes and then get the answers at the end.  Or you can take 100 question tests.

I did a little bit of each.  I liked getting the answer as soon as I answered the questions because I would still be thinking about why I answered the question the way I did when the correct answer came up.  However, the 100 question test builds up your endurance.  After doing several of these 100 questions will fly by in no time.

For the most part I did tests with the subjects all mixed together.  But I also  did tests with questions from each section individually.  You can also choose to do every single practice question from each subject.  The most important one for this option is the prioritizing section.  There aren’t that many questions in that section on the disk, but it will teach you to think like the NCLEX people think.  Do them ALL!!  I promise it will help on test day.

That is what you need to pass the boards.  You don’t need to know everything word for word out of the text book.  You need to be able to pick out the most important part of the question and figure out what answer it is pointing too.

Almost EVERY SINGLE  QUESTION on the NCLEX exam was about something I had never even HEARD of before, let alone knew anything about.  It was all about knowing what they were looking for,, and what the question was trying to get me to think about.

Some big things that I and others have been tested on very strongly:

1. Stages of isolation.  I had a question wanting to know what kind of isolation I would put a patient with some plague I had never heard of before in.  Well, obviously if it has the word PLAGUE in it, it is bad.  They are in the strongest isolation possible.

2.  I had a TON of those mark all answers that are correct questions.  ICKKK!!  MAJOR ICCCKKK!!  I SUCK at these because I can always talk myself into marking them all.  You can pick all of the questions like these from the disk and do just them.  DO THEM ALL!!!  Out of the 75 quesitons I got on the NCLEX I had at least 7 of those dumb things.  My other advice on these, don’t spend too much time on them.  Just pick the answers that pop out at you as correct and move on.  That way you don’t talk yourself into marking them all.

3.  And of course, the lovely priority questions.  Yes, it’s true, there are tons of these.  Remember  your ABC’s, but also remember that sometimes ABC’s aren’t always what they are looking for.  If all of your patients are stable who do you see first??

4.  Oh, something else I had a lot of.  Study the Black, Red, Yellow, Green triage system.  I couldn’t find a great website about this, so hopefully you can find something better in your nursing books.

Three or Four days before boards cut back on studying and try to relax and take some time to let your brain rest.  Spend some time with your family, go see a funny movie, get out of the house.  I still did a few questions a day, but not hundreds a day like the weeks before.   Drive by the testing center the day before so you aren’t stressed about finding it the next morning.  Get a good nights sleep.  Wake up early so you don’t have to rush to get there.  The Sunday before my NCLEX I went to church and had an amazing experience.  I had been so stressed before then that I would almost retch every time I thought about the test.  At church this amazing peace swept over me and I just KNEW I was going to pass.  I hope you can have this feeling going into boards.

In the front of the book are tips on studying for boards and tips on what to look for in the questions.  I read through the tips on what to look for chapter the day before, just as a refresher.

Oh, and our school told us to take snacks and water to the test.  Don’t, you will have to lock everything up and can’t get back in your locker until the test is over.  Take the ear plugs they offer even if you think you won’t need them.  There were others in the room taking court recording tests, so people were typing a mile a minute all around me and it was distracting.

Let me know if you have any questions.  And GOOD LUCK!!!  I hope you will have the letters RN (or LPN) after your name soon!

Oy Vey!

I originally started a blog in order to record memories about my nursing career.  I couldn’t let one of my patients get away with out blogging about her.  In the morning when I got report from the night shift nurse she told me this little old lady was so cute and sweet and that I would love her.

Yeah, thanks for the warning.  I walked into this patients room unprepared for the psychotic out lash that I would get all day.  I walked in to find her laying on her side away from the door with her bum hanging out for the world to see.  I explained that I was her nurse for the day and that I needed to take her vital sings.  She rolled over and sat up on the side of the bed.  I put the blood pressure cuff on her arm.  She had come in with arm pit pain that she thought may be a heart attack, so I had asked which arm she wanted it taken on to make sure I wouldn’t hurt the arm that was already bothering her.  Now, I know the cuffs get tight, but not as tight as a machine compared to manual cuff.  And her pressure was sky high, so I had to pump that puppy up to about 275.  With in seconds of pumping she was flailing around and screaming.  The nurse in the room across the hall came in because she thought the patient was going to punch me.  I couldn’t even take her blood pressure because I couldn’t hear anything above her blood curdling screams.  I let the cuff deflate, then squatted down in front of her and explained that I understood that it gets really tight, but that I’m not hurting her on purpose and I had to take her blood pressure.  Then I asked if she wanted me to try using the other arm.  She then gave me a lecture about how medical science sucks and that the scientists and hospitals won’t find a different way to take someone’s blood pressure until patients start refusing to let us use a the blood pressure cuffs that cause excruciating pain.  I guess I could have started an arterial line to monitor her pressure with, that would be less painful right?  I finally got her blood pressure, which she never let me take again the rest of the day.

It wasn’t even 8 AM yet and she was also complaining that she didn’t know why she bothered coming to the hospital because we couldn’t figure out what was wrong with her.  She had been there since 3AM, the hospitals don’t do non emergency tests between 3 and 7AM.  She was scheduled for a stress test that would start around lunch time.  I already knew the stress test wasn’t going to happen since it requires taking her blood pressure multiple times through out the test.

A few hours later she called out saying she needed help to the bathroom and I was standing outside of the room next to hers, so I helped her walk to her bathroom with her walker.  On the way out of the bathroom she started screaming about the plate thing in the threshold.  You know that gold or silver or wooden thing on the floor between rooms.  She said that if her walker got caught on it and caused her to break a hip she would be suing St. Luke for millions of dollars.  I could understand being upset if the thing was hazardous, but there was nothing wrong with it and her walker slid right over the top.  We called the maintenance man anyway and when he got there he walked back out of her room and asked what he was supposed to do about a non broken floor plate.  He ended up putting a piece of bright duct tape over it to remind her it was there.

When the aid from the stress test department came to help her fill out paper work and make sure she was a candidate for a test I knew this thing was never going to happen.  They ask questions to make sure the patient hasn’t eaten since breakfast and hasn’t had any caffeine since the night before, both things that could alter the results of the test.  They also try to find out if you can run on a treadmill to decide what kind of stress test to perform.  When the clerk asked the patient if she could ask her a few questions she responded “Yes, but if they are stupid questions I won’t answer.”  Good gravy, what makes people so hateful?  Especially to people that are trying to help.

About an hour later we got a call from the stress test lab saying that the patient had refused to complete the test.  When she got back we called the Dr who told us to have her sign out AMA (against medical advice) if she was not going to cooperate with her care.  I did the paperwork and went in to have her sign the paper and to send her home.  She refused to sign the the paper or to leave.  The only thing she had wanted to do all day was to go home and now that she could she wouldn’t leave.

She said that she didn’t refuse to take the test but that she couldn’t lay flat on the table any longer during the test.  My charge nurse went and talked to her and determined that each test that we could perform involved something that she said she couldn’t do.  We called the Dr back, who is a Dr who usually screams any time she gets a phone call.  And she didn’t let us down, she screamed at us (like Dr like patient I guess).  She said to just discharge her and to make sure that we charted about her refusing the tests we offered.

Of course it would be hours before her son would come.  Actually at first she had no number for her son and the number in her chart was her daughter’s work number.  But, the daughter was out of town for the next week and we only got her voice mail saying so.  Thankfully her daughter called her room while I was in there and she was able to call patient’s son and told him he could pick her up.  Several hours later he showed.

Usually with this kind of patient their family is apauled by their behavior and appologises profusely to us.  I was expecting the same with her son.  Unfortunatly he was just as nasty as her.  When he got there I was in the middle of taking care of a new patient that was having chest pain.  The patient and her son where standing out side of her room ticked off that I wasn’t in her room the second he showed up to take her home.  He had only been there about two minutes when I went and told them that I was in the middle of an emergency with another patient and that I would be there as soon as I could.  About 10 minutes later I went in to discharge her.  As soon as I walked in her son said “Well, it’s about time.”  Whatever, I gave her the discharge forms, took out her IV, took her heart monitor off and told her to go ahead and finish getting dressed.  I told her I would call for a wheel chair to take her down stairs.  The sons comment????? I’m sure you can guess.  “Well, that will probably take another hour or two like it took you to get in here.”  This man hadn’t even been in the hospital for more than 15 minutes.  I grabbed the aid and asked her to get a wheel chair and get them off of the floor as fast as humanly possible.

This woman needed a psych consult.  No joke.  She would go from bawling her eyes out, to turning into satin woman woman with glowing red eyes, to bawling again in less than 1 minute.

I’m sure she’ll be back.  Lord help me to be a patient understanding nurse!!

Waiting for D/C

Just a little education for those of you who don’t work in a hospital.  When it is your day to be discharged, don’t expect it to walk out the minute the Dr leaves your room.  I’m suprised at how many patients get huffy when five minutes have passed since someone mentioned going home and they are still here.  I try to be understanding that they are anxious to get the heck out of here, I am too.  But several things have to happen after the Dr leaves the room.  Here’s a short lesson for you.

If you have more than one Dr seeing you, you may not be leaving just yet anyway.  Such is the case with my patient today.  Not only does she have a primary Dr, but she also has GI on her case.  Primary told her yesterday that he would be in before noon today to D/C her.  (I hate it when Dr’s do this, they get the patient all excited to go home when really they can’t).  Anyway, if you have more than one Dr then they ALL have to say it’s ok, not just one of them.  Some of our more critical patients have up to 6 different specialists seing them, they all have to write discharge orders, not just one or two of them.

After the Dr leaves your room they still have to write in your chart.  This could take an hour or longer, depending on how big of a hurry they are in.  After the Dr is finished with your chart the secretary has to do some work on it.  Sometimes this can also take awhile depending on how many charts are waiting in line in front of yours.  Then, after she is finished your nurse has to do paperwork.  I personally try to get to it as quickly as possibly, because I know by now you’ve been waiting awhile.  But, patients don’t understand that sometimes their nurse is wrapped up with another patient not being able to breath, a code going on, or other such emergencies that just simply are more important than finishing your paperwork so you can go home.

So, please, be patient and understanding.  We want you to get home too, but sometimes it just can’t happen right this  very second.   I can’t count how many times I’ve been screamed at and cussed out over this.

Oh, stay tuned for an announcement of my new photography blog.  Hopefully tomorrow I can get pictures posted from yesterday, then I will post new the address here. 

I must be crazy

Yesterday I sent away for information about finishing my bachelors degree. I’ve requested information from NKU and UC. I have an appointment next month to tour NKU. Honey, are you reading this?? I forgot to tell you, I made a reservation for you to go with me if you want. :0) At the moment I’m more interested in NKU. It’s closer and a lot less traffic over there than trying to get to UC. Someone at work said “Why do you want to go back?” I was like “I’m stupid I guess.” I’m not really ready to go back. I’m still learning so much at work and attending classes at work to get some certificates that I need. But, I need to start researching and getting ready now if I want to start in the fall or next spring. I might be able to take some classes that I need at the junior college that I graduated from, it will depend on what I still need. I have most of my courses finished, just a couple prerequisites and then the nursing courses.

Speaking of learning at work. Isn’t it scary that I’m already training people?? I’ve had an orienty with me every day for the past week or so. Some days I feel like I’m doing a pretty good job of teaching them. Other days are so crazy and busy that they just run along behind me for the ride. I just try to tell them like everywhere some days are good and some days are bad. Of course our bad days usually mean that we’ve got one or more patients that should be in the ICU, but aren’t.

I wonder who we need to write to about getting a law passed to set nurse to patient ratios in Kentucky?? In California TCU nurses are not allowed to have more than four patients, even at night. On our floor we can have up to 5 during the day, 6 in the evening, and 8 at night. That is s0000 no safe. We’re considered a critical care floor, but I have to take care of 6 patients?? And that’s not just patient care. The evening is the worst time for getting slammed with admissions. So, I’m doing all of that paperwork, filing, signing off orders, putting information into the computer, printing care paths off, and trying to keep up with six critical patients. Plus we don’t have a charge nurse at that time to help with any of it. Sometimes we luck out and have a float nurse to help, but she has to help two different floors at once. So, we usually end up doing it on our own anyway.

OK, I need to get ready for work. Thanks for listening to me complain. Two more days of work and then LAS VEGAS!!! WOOHOO!!

chUrch

I wish I had a recording of a pastor from a church that I used to go to saying “chUUUrch”. It was a yelling, whooping, speeking in toungue church. And you didn’t just go to church, you went to ChUUURCCCCH!

Anyway, church was awesome yesterday. We’re still going to the new church plant near our house that we checked out a few weeks ago. It meets in a building owned by the city for events. The room that the service is held in has two walls made of windows that face out towards a park. There’s nothing like singing “The Earth is filled with HIS glory!”

At the very end of the service when the pastor is praying we all open our eyes and there are three deer standing literally right outside the front wall of windows. It was so cool to watch them after having an amazing worship service.

I had a really rough week at work last week and I’m still not ready to go back. I’m probably going to have a patient that I have had every day that I’ve worked since he was admitted, unless he’s in ICU now. Today he is supposed to have surgery, the same surgery he was supposed to have Friday but kept refusing. The problem is, if he doesn’t have the surgery he’s going to die, and soon. But, he also isn’t ready to agree to being a DNR either. So, either he has the surgery or he ends up on life support, that will probably never come off with out him dying or having the surgery. I’m not looking forward to the emotional roller coaster of that again today.

Friday I dealt with that all day. Thankfully the Dr on the case is as nice as she can be. So, I wasn’t afraid of paging her the 1 million times I had to that day. At the same time I had a prisoner who had been released from jail, so he no longer had a guard. He had um, lice, impetigo, Hep C, and who knows what else. Plus, he was going through DT’s (confused and crazy) and refused to wear any clothing. Lovely. And at the exact same time my other two patient’s heart rhythms changed, and not in a good way. One was going south (and not to Lexington) and no Dr’s would return my call. The other one ended up being fine, but there is still charting and calling of Dr’s when rhythms change.

God please help me to have a good attitude at work today!!!

Ahhh, exhaustion

I’m so glad I have the next two days off.  This was my third day in a row, so like 32 out of the past 50 hours I have worked.  I’m exhausted.  The three days actually have been pretty good.  Yesterday and today we had student nurses on the floor, which takes some of the stress off.  Today at 3:00 all of the students left, and all hell broke loose.  I got one admit, raising me to five patients.  When she got on the floor her family was already mad and anxious.  They had just had a death in the family, so they were all on edge and taking everything a little over the top, understandably.  Then an hour later I was informed that I was getting another new patient.  Thankfully she still hadn’t shown up when I left.  One of my patients was VERY sick and his family was very anxious, but nice.  Plus I had another patient pacing the halls and not happy with me because he wanted to go home, but needed cardiology to sign off on him.

So, I’m staying home in my PJs for the weeend, don’t try to call me in to work!

To code or not to code??

Something that is surprising and interesting about nurses is how we react to our patients not being a DNR.  This was came up one day that I worked last week.  I was getting morning report on a 90 something year old patient who had been sent down to ICU three different times in the past two weeks or so because she isn’t getting enough oxygen to her body.  Her O2 stats keep steadily dropping no matter how much oxygen we pump into her lungs.  Surprisingly she was not a DNR.  I was flabbergasted.  Now, don’t get me wrong, I think everyone has the right to decide if they want to be resuscitated or not.  But, coding someone is rough.  Bones break, lungs can collapse.  Very few patients ever leave the hospital after needing CPR, at least at her age and state of health.  She was VERY sick and was going down hill.  At the time she was so out of breath she couldn’t even speak.  I would guess she weighed around 80 pounds, if that.  I’m not sure if it was her wishes to be coded, her families, or if her doctor refused to write the order.

The ironic thing was every other patient I had that day was a DNR, and all of them were in much better shape than her.  The only saving grace was that her family was always with her, and hopefully they would have told us to stop if we had started working on her.

I was very upset about her code status and was dreading getting out on the floor to start working.  It would have broken my heart if I would have had to code her and feel her ribs break under my hands while I did compressions.  Thankfully she made it through the shift with no incident.  The last I heard of her she was back down in ICU.

And Hillary thinks nurses make too much

The is a rumor going around the nursing world that Hillary thinks the problem with the Health Care system is that nurses make too much money. Lately she has been spending a lot of time with nurses. She recently job shadowed a nurse for a day and spent time with nurses at a hospital in Las Vegas. My personal opinion is that all of that time is being spent trying to earn back nurses’ trust now that the election is coming.

On a day like today, you couldn’t pay me enough money to stay on the floor. But, I know that other patients and the other nurses on the floor need me here. I came into work in a good mood because I had a great group of patients yesterday and I was looking forward to spending the day with them again. Unfortunately, my group got split up. I still have my one “problem child”from yesterday and picked up another one. One of my patients has been leaving the floor to take extra pain medication and I would bet a million dollars that he’s also shooting up illegal drugs. He’s also been caught smoking in the bathroom. I have been called every name under the sun by him today for not giving him his pain medication earlier, even though I did give it to him.  He’s just hoping someone is stupid enough to give him a second dose.  The charge nurse, hospital supervisor, and security have all been in his room numerous times. Thank goodness it looks like he will be going to another floor as soon as we get a bed there for him.

I’m sorry if I’m inpatient and unsympathetic, but I have patients who are sick (not that he isn’t) who want to get better, are willing to follow the rules of the hospital, and need my time and attention.

Hey Hillary! Wanna spend a day with me in a hospital in a poor part of town? I’ll even let you change my patient’s poopy diaper!!  Um, make that a C-Diff poopy diaper!

Should’t we get hazard pay for taking care of patients and days later find out they have a serious communicable disease?  I once took care of a patient for a week before they found out he had tuberculosis.

My first code

I experienced my first code last week. As a TCU nurse I have been to several rapid responses (including one on my own patient) and one code, because our floor is part of the code team and I try to go along for the ride if I’m not swamped, because eventually I will be charge nurse and have to respond to them. But, this was the first real code on our floor and the first time I have been one of the first people into the room. Thankfully, it was not on my patient. It was first thing in the morning, I was still getting report. I was in the break room behind the nurses station listening to taped report, so I didn’t even know it was going on until it was paged over head and even then I had to turn off the tape to hear the room number the second time she said it. I shut off the tape and walked into the station “Did she say our floor?!?” Everyone responded yes and said room 10. I hurried into the hall to see the patients nurse running towards me telling me they needed a back board. She is still in training and had no idea what to do. I ran and grabbed it and went running to the room. Our charge nurse and one of the night shift nurses were already in the room when I walked in doing compressions and trying to get oxygen going. We ushered the wife out who was sitting in the corner and a nurse went out to sit with her. We cleared out the chairs and got the overhead trapeze off of the bed. I have no idea why it was on there. After several attempts the Dr finally got him intubated and there was a slight rhythm, but not enough to generate a pulse, so we were still doing compressions. I ended up stepping in and doing compressions on him. I don’t remember what drugs we pushed. But eventually his pulse was strong enough to stop compressions and he was sent down to ICU. Unfortunately the last I heard he was posturing and they didn’t think he would make it.

Some quick tips for new nurses scared about your first code. The biggest relief is if your hospital does it right about a million and 1 people will be in the room to help you very quickly. You’ll actually have to send people away because they are just in the way. Things to do until the code team gets there. 1. Have someone working on the airway. A lot of codes that I have been too are because the person is choking. Do they need suctioned? Start bagging them if not. 2. Get someone on compressions. 3. Get the crash cart in there. 4. Get an IV started if they don’t have one. 5. Get the head board off of the bed so the Dr and respiratory can intubate if needed. 6. Clear as much out of the room as possible before the swarm of people arrive. Obviously you can’t do this all alone. The nurse aids can be clearing the room, getting the cart, and trying to get the headboard off. The RNs should be doing airway, compressions, and IV. Stay as calm as possible.