Tuesday, March 13, 2012

I'm finally breaking up with my Mirena

I'm finally breaking up with my Mirena (for the update since taking it out head over here). For 5 months I've been told to just hang in there, wait it out, deal with the beyond annoying side effects and I'm finally calling it QUITS! Dun-zo. For any MEN out there, STOP reading now. Trust me, this is girl stuff to the max and you don't want to hear about it... any of it, seriously. I also understand that there are tons of women out there who have had no problems with the Mirena and love it. I happen to fall in the other category and I'm posting this info for anyone else out there who is in the same boat, I believe the side effects are HIGHLY under-reported and therefore unknown to most of the women  considering it as their form of birth control. It takes only a few minutes of good old Googling to find a million stories of women who have had serious problems with their Mirena, and lots of side effects that are not even listed on the information packets provided to the general public. I believe it is in need of review by the FDA, personally.

One other quick note, Mirena which is advocated as essentially a 'hormone free' birth control option actually does deliver 20 mcg/day of Levonorgestrel, the same thing as Norplant, the birth control arm implant that has since been discontinued in the US... not to mention the thirty some thousands of lawsuits filed due to the side effects which patients were not warned about (ie-  weight gain, nervousness, anxiety, nausea, vomiting, mastalgia, dizziness, dermatitis/rash, hirsutism, scalp-hair loss, headache, depression, acne and SO many more)... not a good correlation. In fact there are numerous similar pending lawsuits for Mirena. In 2010 the FDA sent a warning letter to the manufacturer stating that their claims are misleading and that they minimize the risks associated with the IUC. It's just not looking good folks...

For those who like Cliff Notes, the following is a concise list of side effects that I've experienced causing me to finally STOP trying to "wait it out" and have it removed as soon as possible! It has been the combined extent and severity of these symptoms that have led to my decision. For those who want the whole details... continue reading for the full story.

- Bleeding... excessively and consistently for 5 months. FIVE months with only a couple of days here and there of reprieve
- Cramping. On a daily basis for the past 5 months ranging from mild to as painful as early labor contractions.
- Bloating, severe bloating folks. Horribly uncomfortable, not to mention the puffy distended abdomen that makes me appear 5-6 months pregnant ALL the time.
- Weight gain. Outside of being pregnant this is the highest the scale has ever read in my life, roughly 5-7 lbs higher than my pre-pregnancy weight.
- ZERO sex drive. Literally zero... for the past 20 weeks!
Wacky mental state & mood. I am either just flat.. blah... or high or low, there's no gradual inbetween. And no patience for anything. At all.
- Depression. Mild yet still noticeable looking back.
- Fatigue.

5 months may not seem like that long in the grand scheme of things... I suppose I could wait it out until 6 months... 9 mos... or even a year...but things have gotten to a point that they are affecting my daily life in a bad way, to me this means that it's time to throw in the towel. If things were improving I may have a different view but they aren't. I have given it this long PURELY for the fact that it will cost me $800-$1000 to get it re-inserted if I chose to remove it prematurely and changed my mind later.
When I was researching about getting the IUC put in I stumbled across some interesting information about tons of side effects women had experienced that are not reported or under-reported. This article was one that I stopped and thought... hmmm... but I went ahead with it anyway. I figured, if anything, I'd now be aware that there were other side effects possible and just be on the lookout for them. Everything I was told about Mirena from the vast majority of folks including my doc was that it was great, you dont have to worry about anything until you decide to have another kid.

Sounded great, I had always had mild issues with birth control pills in the past, I'm extremely sensitive to the hormones, spent a couple of years trying different ones out. Finally landed on a low dose, monophasic (just one dose the whole month) and I would take it continually (overlapping each month) so that I never got a period. Not too big of a hassle... worked fine but I thought if I could get the Mirena and just pop it in and never think about birth control again until we were ready for another baby that would be fantastic. And we also had the whole clotting issues that I have that may or may not effect my risk of blood clots from standard birth control pills. So with all of that it made perfect sense to go with the Mirena.

I had mine put in at the end of October 2011 when Baby D was about 5 months old. No problems there. I went home expecting to have some severe and annoying bleeding for about a month or so, maybe 6 weeks at most. Well that came and went... it was consistent heavy bleeding every day for around 8 weeks. I just thought well damn I guess I'm one of the outliers that experienced symptoms for longer. Everyone assured me to just wait it out a little bit longer, it'd get better, etc. So I kept waiting.

Well finally the bleeding stopped... so I thought... I then started the never ending spiral. I would get a reprieve for a few days (the longest period of time being 1 full week, and that only occured once) and then the bleeding would be back. Rarely it was light, usually it was heavy (like clots ALL the time as if I was back in my post-partum days after having my kids) I had never experienced that in my life! And you'd throw the cramping in there with it. I would have consistent cramping on a DAILY basis to varying degrees regardless of whether or not I was bleeding at the time. Several times a month I would have cramping so severe that it was identical to my early labor contractions, not your average run of the mill cramps. And of course to go along with all of that you have the bloating. My stomach so distended if I'm not actively flexing and sucking it in that I easily look 5 months pregnant at any given time. At this point I literally weigh the most I ever have in my life outside of being pregnant. I'm not talking 50 lbs but I did seem to jump up to a consistent 5-10 lbs higher than my pre-pregnancy weight, for no reason. My diet hasn't changed, my activity level hasn't changed (if anything I'm more active dealing with 2 kids) the weight has just appeared and hasn't gone anywhere. I have also increased my activity level, changed my eating/drinking habits and decreased portion sizes over the past month and the scale hasn't moved. In a normal world this would at least give me a pound... maybe 3 but nothing is changing. These have been the glaringly obvious side effects... there are more subtle problems (see below) but I keep hearing 'just ride out the storm, it will stop, hang in there.' So I have been.

After the 3 month mark I started thinking Ok seriously... WHEN the hell is this going to let up, this is becoming miserable. What happened to 4-6 weeks of misery... we were going on 12+ and NOTHING had changed, it's not like things were gradually improving, not at all. Talk about beyond annoying, I wasn't even able to use tampons for fear that they may yank the strings out (which I thought had happened back at the 6 week mark) so every day pantiliners... disgusting.

As 3 months turned into 4 and now going on 5 I have started realizing the other more subtle side effects going on. Lack of sex drive would be a total understatement, we're talking ZERO... less than zero... zilch... nothing. And this is NOT like me. I just justified things thinking- well if you constantly felt like you were on your period for 12 weeks you'd have no sex drive either. But really the lack of interest isn't solely due to the annoying cramping, bleeding, and bloating going on... it is clearly mental/hormonal whatever you want to call it. There's nothing coming from my brain to even remotely put me in the mood. That doesn't even touch the awful body image going on with my huge fat belly and weight gain, feeling ugly and crappy is putting it mildly. Mind you, this has been going on for MONTHS now... it has really done a number on my mental state and has been grating on my nerves.

Along the same lines has been some mild depression... I wouldn't say this has been anything overtly obvious, but looking back it is clear for me to realize there is some slight depression going on too. My mood is just wacky... I am either listless and blah with no energy or I have almost bi-polar type of emotions going on, lots of highs and lows, no gradual progressions, just all over the board... pretty much like being pregnant :) I have a lot less energy and less drive to enjoy things that I normally enjoy... not consistently at least. A lot of fatigue, granted I do have a lot on my plate that would wear anyone out but it seems like I'm more tired than I really should be. Everything seems like a hassle a good majority of the time and I feel like I have to gear myself up to do normal tasks. Or I'll be the opposite and completely gung-ho to get things done, it's like there is a limited middleground. I have ZERO patience for even the littlest of things (not that this is a forte of mine anyway) but the smallest things drive me nuts, piss me off, and iritate me to no end. I kind of feel like I'm constantly on edge... Clearly this has provided a challenge for my relationship with my husband and our children. Lack of patience + 2 year old + high needs baby= bad for mommy!

I have tried to take all of this with a grain of salt realizing that the added stress in my life from business/school/new baby et al are undoubtedly contributing to my lack of patience, my fatigue, etc. But I keep thinking back to that info I had read prior to getting the Mirena and keep wondering... hmmm.... If anything I think it's a result of both issues. At least I can control one of these by taking the dang thing out and getting part of me back to normal, right? And bottom line I know that I can take the Mirena out and see if things improve, if not, we'll go from there. I will say that I would not have it inserted again, after the next baby I will not be going back to Mirena.The fact that, even in a small way, it is negatively affecting my every day life is enough to call it quits. Not to mention, the random bleeding ALL the time for MONTHS on end is enough in itself to make me never want to deal with it again. Feeling this crappy for this long is just too much, I can't do it anymore.

I suggest anyone out there wondering the same things that I have been start here (http://mirenadiaries.wordpress.com/)

and then read through some of this other stuff....

For people experiencing severe enough symptoms to want to persue legal action this is where I'd go here. http://www.motleyrice.com/medical-devices/mirena-iud-lawyers

To report negative side effects to the FDA-
Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

And here is the UPDATE after I stopped using the Mirena- the weight came off, the symptoms disappeared, click for the whole story Read more!

Monday, March 12, 2012

How to Prepare for the CPNE

The pictures & info below contain copyrighted content from Excelsior College, this information is meant for demonstrative purposes. No replication of this information is permitted.

The following is what I did to prepare for the CPNE. Some tips and tricks I learned along the way that may help. I've also included a timeline of how I prepared. Disclosure: I am a professional procrastinator, I did spend a lot more time preparing for this than I originally thought I would but it is probably no where near the amount of time that I'd advise someone else to take. I am lucky to have a photographic memory and an ability to retain a lot of information, it has served me well in school my entire life but I will warn anyone else attempting this, DO not underestimate the amount of preparation needed. You know your own strengths/weaknesses by now, make sure you plan accordingly for this exam, it would be an EXPENSIVE mistake to show up unprepared...

I basically spent 1 month studying in increments. I unfortunately procrastinated as I figured I would but I work well under pressure. I took small bites not really sure what to do or study and solidified my understanding of this finally at the workshop 2 weeks prior to my date. I really started hammering down the last week before I left. I spent my time at the airport and hotel cramming (this works for me) since it was truly the first opportunity I had away from ANY distractions (kids, work, phone calls, business, etc). 

November 1: finished FCCA & submitted app to CPNE
Beginning of December: received my CPNE date of March 1
Mid January: finally printed study guide, ordered lab supplies, started watching YouTube videos from former CPNE students.
Feb 1: started reading/highlighting/tabbing study guide making notes on questions and practiced using lab supplies a couple of times. Signed up for Sheri's online workshop and started watching videos on labs & PCS's.
Feb 7: finished reading study guide, had phone call with EC to clarify some questions, submitted PCS 1 to EC for review. Created/modified my mnemonics and memorized them this week.
Feb 8-10: attended Sheri Taylor's CPNE workshop in Atlanta
Feb 11-20: intended to study, didn't. Week off for family wedding festivities. Submitted PCS 2 to EC for review, participated in EC monthly chat to clarify more questions.
Feb 21-27: Had final phone call with EC for last questions. Spent a good 8 hours total over this time running through labs exactly as I would at test, attempted to do 2 practice PCS's on my husband. Fail. Submitted several careplans to Sheri and wrote corresponding grids for each, timed myself exactly as it would be at test.
Feb 28: Headed to Wisconsin for CPNE. Re-read my previous notes in the entire study guide at airport and on plane. Reviewed more careplan resources/books on plane. Set up lab stations around my hotel room and ran through labs 3 times. 
March 1: Lab checkoff day. Watched videos on labs, practiced labs 3 times each, ironed scrubs, off to checkoffs. Got first PCS assignment, back to hotel, wrote careplan, watched videos on my assigned AOC's, ran through mnemonics for 10 mins, practiced wound station (for repeat) 3 times, to bed.
March 2: Wrote out mnemonics while eating breakfast. PCS 1 & 2 at hospital. Back to hotel. Went through several mock kardex info to rattle of careplan diagnoses practicing for day 3.
March 3: Last PCS, finished 3 for 3 no revisions.


If you haven't printed out the study guide yet, yes you SHOULD print it out. Yes it is expensive because it's 8 million pages long, so avoid placed like Kinkos & Office Max because they charge about a buck a page. Head over to www.BestValueCopy.com, they are the cheapest place around (I checked everywhere!) and have a handful of options you can pick in addition to printing if you want (add a cover, get it drilled with 3 holes for a binder, have them bind it for you, etc). Also Google some coupon codes for them and you can end up getting the thing for around $25 shipped.

Practice, practice, practice! Keep inventory along the way of what areas you need more help with. DO THE PRACTICE PCS's from Excelsior, this is the only way to get feedback on whether you are doing things right or not. Clearly I recommend signing up for Sheri's workshop so you can continue to practice and get feedback. If I could do things differently, I'd have practiced mock PCS's at home a LOT more than I did, I just didn't have the time or energy to get people together to help me with this aspect. We had SOOO much going on at the time that it just didn't happen and this is the area I was most concerned with since I hadn't done direct patient care in over 3 years. Sheri's videos were crucial because of this, there is no way I would've known what to do in the room without these videos. I also would have had NO clue what to really study, how to organize things and practice succinctly without attending the live workshop. To me this is critical, I will advocate spending the money on a workshop to ANYONE.

Show up and execute!! Cram at the last minute if that works for you. I brought ALL of my supplies with me, checked a bag just to do so. I brought my study guide, books, laptop, everything! Some people need to relax and forget about things prior to testing, if that's you, then do it.

Remember one step at a time. Take a little bit at a time, write out a schedule for your practice so you can see where you need to be to make sure you're getting it all in in time. As my Dad always says, "make a plan, and work your plan". 

This is part of my post series on Excelsior College's ADN nursing program and the CPNE experience. See all related posts over here. Read more!

Thursday, March 8, 2012

We have a word.

Ok 8 months in and I'm ready to finally call this Baby D's first official word. The kids been saying Dadadadaa forever, probably since he was 4 months old, has recently thrown out some mamamamamaa but I kept saying that until he uses it intentionally and deliberately I wont call any of his babbling "real" words.

So after a week I'm finally ready to say that THIS is Nugget's very first word..... I mean phrase...

"UH- OH!"

Thats it! Kid drops stuff on the floor on purpose all day long and looks at you and says UH OH! It is too darn cute, I have to get it on video some time. So although it isn't really a word, it is a phrase, and he uses it deliberately so it's goin down in the baby book folks! Read more!

I have twins.... born 18 months apart. No really!

I still laugh about it because they really look exactly alike... Go ahead, see if you can tell them apart!!
Snoozing boys just a couple weeks old
Who's on left... who's on right? The Dudes at 2 months old.

2 of these cuties are Baby D, the other is HL, which one?

All bundled up, both about 2 weeks old

With the momma, oddly enough I am wearing the
same necklace in both pics...weird!

My little turkeys

See I told you... scary isn't it :) Read more!

Wednesday, March 7, 2012

CPNE Mnemonics

The pictures & info below may contain copyrighted content from Excelsior College, this information is meant for demonstrative purposes. No replication of this information is permitted.

The only way in my mind to even come close to remembering all of your "critical elements" for each area of care assigned and THEN remember to document the appropriate elements is to use mnemonics. I have pretty much a photographic memory and even I wouldn't have chanced the idea of forgetting one little thing either in implementation or documentation. You would want to rip your own head off if you got to the end and left off one tiny thing and failed the whole shabang...

There are 23 Areas of Care- 19 of which, in my opinion, you should have mnemonics for.

I got all of my mnemonics from Sheri Taylor's workshop (if you are wondering who this lady is that I keep referring to, head over here). I sat down one afternoon with my set of EC flashcards and her studyguide with mnemonics and I went through each critical element with each mnemonic making sure that the one I picked included ALL of the critical elements not only for doing the AOC but also for documenting it. I tweaked them here and there and re-did some to fit my brain better.

Enter Room
Wash hands
Introduce self
ID patient

Vital Signs(you don't necessarily need a mnemonic for this since they are listed on your PCS recording form but I decided to do it anyway just incase)
GT PRB WOPR (Get PRegnant Belly a Whopper, lol, it worked for me ok)
Gloves (for oral temp)
Pulse (apical/radial)
Weight (if assign)
02 sats (if assign)
Pain (what scale)

Fluid Management (20 Min Check)
Hydration status turgor/muc membranes
IV type/rate/amt
Palpate site temp/edema
Pump settings
Inspect tubing air
Check enteral feeds
Oral intake- explain
Write it down

Mobility status
Observe devices
Balance abnormalities?
Implement activity/increase support
Log patient response

MAR (get the mar)
Meds (check meds)
ID patient
Special assessments?
Administer meds
Sign MAR

Abdominal Assessment

Pain any?
Pee need to?
Position flat
Look distention
Listen x4
Feel tender/rigid
Reposition patient

Neurological Assessment

Level of consciousness x3
Observe pupils
Grasps- hands
Inspect fontanel- child
Check dorsi/plantar flex
Stimulii noxious- unresponsive
Symmetry of movement- child

Peripheral Vascular Assessment
Compare bilaterally
Pulses distal
Refill cap
Inspect sensation eyes closed
Pale/Pink color
Hot/cold temp

Respiratory Assessment

Position upright
Instruct to breathe normal
Breathing abnormalities?
Resp rate/rhythm
Equipment clean
Auscultate x4
Tell patient breathe slow/deep
Hear x4
Evaluate 02 if assign

Skin Assessment
Temp hot/cold
Integrity intact?
Color red/pink
Reposition off area
Evaluate for pain
Do 2 areas

Comfort Management

Assess level of comfort (ask)
3 things
Reposition (I usually stopped writing after this point because I knew a bunch of things I could offer for comfort by heart, so I'd just rattle them off if I needed to)
Dental hygiene
Change linens
Hygiene activities
Comfort rub
Environmental controls- lights
Record patient response

Musculoskeletal Management
Mobility status

Apply heat/cold if ordered
Range of motion
Evaluate tolerance

Oxygen Management
Best position
Resp rate/rhythm
Ears nares
Assess tolerance to activity
Triggers to combustion
Evaluate 02 if assign
Assess cap refill/color/clubbing
Evaluate &

Pain Management

Pain level
Assess location
Intensity sharp/dull
Guided imagery
Temp hot/cold pack
Reassess after 20 mins
Response & record

Respiratory Management
(said peebray purp, no clue... but it worked for me)
Position upright
Breathing abnormalities?
Resp rate/rhythm
Auscultate x4
Explain resp activity
Provide receptacle
Repeat as ordered (x10)
Reassess lungs x4
Patient response

Wound Management

Wound location
Observe drainage type/amount
Unique irrigation supplies
Need clean or sterile field
Dressing change or pack
Evaluate pain/tolerance

Drainage & Specimen Collection
Drain ACT, Spec OCLC (said ock-lock)
  Assess color and amount
  Clean area if assign
  Tube replace as found
  Obtain specimen
  Correct container
  Label date/time
  Correct location (to lab)

Enteral Feeding
Feeding type
Low fowlers
Orient patient
Warm (room temp)
Select device
Total amount
On time +- 30
Measure/calc gtts
Aspirate AND air
Check residual & reinstill
Have baby burp


Select solution
Temp (room)
Obtain special equip
Position for drainage
Aspirate AND air (NG's)
Flow rate slow gentle
Look at return solution
Observe patient response
Write it down

Patient Teaching

Learning readiness
Evaluate prior knowledge
Activity of learning
Reassess understanding
Need to document

Read more!

Tuesday, March 6, 2012

CPNE Documentation: Narrative Notes and documenting with mnemonics

The info and/or pictures below contain copyrighted content from Excelsior College, this information is meant for demonstrative purposes. No replication of this information is permitted. This is part of my post series on Excelsior College's ADN nursing program and the CPNE experience. See all related posts over here. 

I have re-written all of my narrative notes and evaluations as best as I can remember. They may have flowed a bit less smoothly during the weekend, I'd add in a mnemonic that I forgot at the end sometimes and it didn't sound perfect but it hit the important parts. I tended to overdocument a bit rather than just hit the required critical elements. I charted right from my mnemonics on the grid but worded things out of order occasionally so that they sounded better. I'll be honest I didn't write much down on my grids during implementation. I had every intention of doing it in a different colored pen but it became awkward to keep stopping to write things down and take my paper in and out of my pocket 100 times. So I reverted back to waitress days and just remembered everything. I DID write down vitals and I'd write a thing or two here or there after I did about 10 things but I've got a pretty good memory so this worked for me. Wouldn't recommend that to anyone if you're worried about forgetting!

I'll post mnemonics on their own page but I devised mine by taking Sheri Taylor's and comparing them side by side with the critical elements on my EC flashcards. I tweaked them and made a few new ones that worked better for me that hit every single element and reminded me of how to do that particular AOC. (ie. adding in C periph for pva which stands for compare bilat, otherwise I thought I'd forget to document BOTH limbs compared to one another which is a critical element. Just little things like that)

PCS #1

Oxygen management
My Mnemonic: BREATHE sAFER (little S because I didn't use it)
Best position, resp rate/rhythm, ears nares, assess cap refill, triggers to combustion, humidity, eval 02 sats, assess tolerance to activity, finally evaluate & record.
Patient on oxygen at 1L/min via nasal canula, respiratory rate even with slight retractions noted, respiratory rate 18/min, capillary refill less than 3 seconds in both hands, oxygen saturation at 92% on oxygen. No skin irritation noted to ears or nares and patient denies discomfort from oxygen tubing, states that the humidity makes it more tolerable. Patient complains of dyspnea with exertion but states that it is much improved today. Patient positioned upright in bed to facilitate oxygenation, no triggers to combustion noted, oxygen tubing and humidity assessed to be running appropriately as ordered.

Respiratory Assessment
My mnemonic: PI BREATHE
Position upright, instruct to breath normal, breathing abnormalities, resp rate/rhythm, equipment clean, auscultate x4, tell patient breathe slow and deep, hear x4, evaluate & record.
Patient sitting upright in bed on oxygen 1L/min via nasal canula and noted to lean forward at times to breathe easier, respirations are even with slight retractions noted. Abnormal lung sounds in bilateral upper and lower lobes posteriorly. Respiratory rate 18/min.

My mnemonic: MOBIL
Mobility status, observe devices, balance abnormalities, implement activity & increase support, log patient response.
Patient ambulatory with no use of assistive devices other than standby x1. Patient does utilize oxygen at 2.5L/min via nasal canula during ambulation.No balance abnormalities noted, steady gait. Encouraged patient to use controlled breathing techniques and to move slowly during activity to improve dyspnea but patient states that he likes to keep a "quick pace". Oxygen saturation dropped to 81% during ambulation but patient denied offers to take rest periods. Patient ambulated the full hallway back to his room with increasing dyspnea towards the end. Patient returned to his bed with difficulty breathing and states that he is surprised that he got that tired walking and agrees to go slower next time. Oxygen saturation returned to 91% after a few minutes and patient resting comfortably in bed.

PCS #2

Respiratory Management
My mnemonic: PBRAE PRRP (said pee bray - purp, I dont know? But it worked lol)
Position upright, Breathing abnormalities, resp rate/rhythm, ausc x4, explain resp activity, provide receptacle, repeat as ordered, reassess lungs, patient response.
Patient positioned to right side, posterior lung sounds clear in bilateral upper and lower lobes, no breathing abnormalities noted, respirations are even and unlabored. Patient completed incentive spirometry x 10 repetitions without complaints of dizziness or dyspnea. No cough or mucous production noted during respiratory hygiene. Posterior lung sounds reassessed and continue to be clear in bilateral upper and lower lobes.

Pain Management
My mnemonic: PAID MGMTTR
Pain level, assess location, intensity sharp/dull, duration, massage, guided imagery, meds, turn, temp hot/cold pack, reassess response.
Patient rates pain level 4 on 0-10 scale but states that it is much better than before. Patient describes pain in the abdomen as constant and aching and worse on the lower right side since surgery. Patient encouraged to use the PCA pump at regular intervals to maintain tolerable pain level. Patient repositioned out of bed to chair and states that it feels "wonderful" and can't believe the difference in pain in just one day. Patient denied offers to give back rub and change linens and stated she was very happy and feeling great. Patient later changed her mind and primary nurse notified of patients request for a new sheet and gown.

Abdominal Assessment
My mnemonic: 4P's LLF RR
Privacy, pain, pee, position, look distention, listen x4, feel tender/rigid, reposition, record.
Patient privacy provided, no complaints of unusual pain, foley cath in place, patient positioned supine as tolerated to about 35 degrees. Abdominal binder removed and slight distention noted. Large midline incision and JP drains to right and left lower abdomen covered in occlusive dressings. Bowel sounds present but hypoactive in all quadrants, moreso in the left upper and lower quadrants. Patient recently changed from npo to clear liquid status. Abdomen palpated to be soft with more rigidity noted on left upper and lower abdomen. Patient denies pain with light palpation. Abdominal binder re-secured.

My mnemonic: Drain ACT (Spec OCLC "ock-lock")
Drainage: Assess color and amount, clean skin if assigned, tube replace as found (spec: obtain specimen, correct container, label date time, correct location/lab).
Right JP drain emptied into designated measuring container. 30 mLs of serosanguinous fluid noted with some clots present. Drain reattached to tubing with suction in place as found.

Patient is on fall precautions and transfers out of bed to chair with 2 assists. No use of other assistive devices but utilizes oxygen. Some balance abnormalities noted, gait is slow and slightly unsteady. Patient instructed to sit and dangle feet prior to ambulation and to move slowly to improve hypotension. Patient transferred to chair with no signs or complaints of dizziness or hypotension and states that she is feeling much better and stronger today.

PCS #3

Oxygen Management

Patient on oxygen 1.5L/min via nasal canula. Oxygen saturation 92% on oxygen. No humidity running, oxygen tubing and rate running appropriately. No signs of skin irritation to ears or nares and patient denies discomfort. Patient states that oxygen is helping her dyspnea in the hospital. Patient states that she uses oxygen occasionally at home with increased activity. Respiratory effort is even and unlabored, respirations 18/min. No triggers to combustion present and patient states prior knowledge of oxygen flammability. Patient positioned upright out of bed to chair to facilitate adequate oxygenation.

Peripheral Vascular Assessment
My mnemonic: C-PERIPH
Compare bilaterally, pulses, edema, refill cap, inspect sensation eyes closed, pale/pink, hot/cold
Bilateral lower extremities are warm to the touch, pink, with no signs of edema. Strong bilateral dorsal pedal pulses present with capillary refill less than 3 seconds in toes of both feet. Patient is able to move extremities freely and can identify tactile stimulation to both feet with eyes closed.

Patient is ambulatory with oxygen to decrease dyspnea. Instructed patient to sit and dangle at bedside and to use controlled breathing techniques during activity to improve dyspnea. Patient transferred out of bed to chair with 1 assist, no balance abnormalities noted, slow and steady gait, no other assistive devices needed and states that she feels much better today. No signs or complaints of dyspnea during or after transfer.

Patient Teaching with fluid management
My mnemonic: LEARN

Learning readiness, evaluate prior knowledge, activity of learning, reassess understanding, need to record.
Patient ready to learn and states that she has some prior knowledge of limiting salt intake to help with CHF but admits that she cheats occasionally. Patient encouraged to continue to watch her salt intake, to elevate legs throughout the day, and to increase fluid intake within dietary orders to help with swelling and symptoms of CHF. Patient states that she will try to keep working on these things at home and says that she finds it easier to keep hydrated during the summer.

Patient assessed to have a relatively low BP reading 109/36. Consulted primary nurse about any orders regarding holding Amlodopine and Lasix with low BP reading. Primary nurse stated that there were no indications to hold the medication and to administer as ordered. Second BP reading taken prior to administration 127/49, both medications administered 0920.

**Evaluations are rationales over here

Read more!

CPNE Careplans: My actual careplans, tips & advice

The info and/or pictures below contain copyrighted content from Excelsior College that may be confidential in nature, this information is meant for demonstrative purposes. No replication of this information is permitted.
Here are my careplans written verbatim (at least as best as I can remember) and my PCS Kardex info and AOC's. I was able to use activity intolerance with all three patients and believe that this is highly likely for anyone's weekend, so I'd remember to think of that one first every time and see if it can fit before trying to think up something else.

The way I wrote my care plans was to look immediately at the areas of care assigned, based on that I started to think of my priority diagnosis- the important one and highest ranked according to Maslow's. So I immediately looked and sorted info in my head- Airway, Breathing, Circulation, Pain. I didn't even look at their admitting diagnosis, or any other relevant info until I had perused the AOC's and had my priority, then I'd use the other info to validate my choice (this is where my AEB came from).

So for example I look down at the Kardex- I have oxygen management and they are indeed on oxygen, I immediately think Impaired Gas Exchange, then I look up to their admitting diagnosis which says pneumonia- BINGO, we're good. Impaired Gas Exchange r/t ventilation perfusion imbalance aeb dyspnea. If I was unsure about any of the r/t or aeb I would just leave it off until I had a chance to either check the chart to be sure or get report from primary to validate.

***For my priority picks I NEVER continued to use a label without perfect evidence of the r/t and aeb because I knew that this would be the diagnosis that I'd use for my evaluation and I would HAVE to have this info, if I wasn't 1 million percent sure I didn't go with it***

That being said for my second pick I would go with something that would work and if I didn't have clear evidence of an r/t or aeb I'd just leave that off of the planning care plan (it's not required there anyway). AND I would pick an outcome that fit the diagnosis even if I didn't know or really think that my patient would be able to achieve it. I did this because you don't have to rationalize your outcome or interventions for your second pick, ONLY the first, so who cares if they didn't meet the outcome or if they refused your intervention! Chart it and who cares, it's only the first pick that I wanted to be sure was bulletproof, that had interventions that I could get in without problem, that had an outcome I could easily meet. Because by doing this I avoided revisions and avoided the dreaded thought of marking the "unmet" or "ineffective" boxes on the evaluation. I didn't want to open the door for ANYTHING there that could fail me.

Along the same lines I worded my interventions in a way that I would be able to complete them with or without patient cooperation for the most part, again avoiding revisions. For example "Encourage patient to use controlled breathing techniques during ambulation" instead of putting "Nurse will have patient use controlled breathing" because if your patient says no or doesn't do it you have to revise. Same with outcomes to an extent- "Patient will participate in ambulation without complaints of dyspnea" instead of saying "Patient wont have dyspnea" because it's easier to lead the patient with what you want them to say "you feel good right? you didn't seem to have any trouble breathing with that, that's great huh!" "Much stronger than last time right?" You can't argue with subjective information when it comes from the patient, if they say they're good then they're good. I figured this was a safer way to do things to pass...

I picked every outcome, related to, intervention, and as evidenced by DIRECTLY from the Mosby's book. You are only required to use the label verbatim but I picked every single thing straight from the book so that there was no way the CE could look at me and say "show me where this intervention is under that label??" Even if the intervention was completely appropriate, if it wasn't in the book I didn't even try it. I did pick appropriate interventions, outcomes, and things that fit that particular patient so that I was still specific to the patient but I used the book exactly.

For example: One of the interventions for Activity Intolerance is (pg.169 3rd edition) "Instruct and assist a COPD client in using conscious controlled breathing techniques during exercise including pursed lip breathing" So for my patient that had COPD I went with this. For my patient with the hernia who also had activity intolerance I did NOT use this, since it was mentioned specifically in connection with COPD. Sure that intervention could work with her too, breathing slowly, controlled, etc but she didn't have COPD so I didn't use that one. That was my rationale for taking the precise interventions and tailoring them to my specific patient.

****HIGHLIGHT YOUR BOOK with your go-to typical defining characteristics (aeb's), related factors (r/t's) and interventions. You don't have to highlight them all, just the ones that you can expect to see frequently. This will save you precious time in planning!****

PCS #1: 
-History of COPD, re-admitted after just being released 2 days ago with pneumonia, complaints of dyspnea.
-Areas of Care Assigned: Vitals, Intake & Output, Fluid Management (with IV access but no IV fluids present), Respiratory assessment, Oxygen management (on 2L/min NC), Medications 0900 (Lovenox, Prozac, Aspirin), Mobility: ambulate hallway.

Dx #1: Impaired Gas Exchange R/T ventilation perfusion imbalance: COPD (including COPD made this part patient specific) AEB patient complaints of dyspnea and fatigue (this was all charted & reported from primary so I knew I was good for eval)
Outcome: Patient will have a capillary refill of less than 3 seconds in both hands during PCS. (I chose cap refill instead of 02 sats because the CE didn't check 02 sats under oxygen management, it was checked under vitals and I wasn't sure if I could use it or not in management, so I went with cap refill instead to be on the safe side).
Assessment: Assess patient's capillary refill in both hands during PCS.

Intervention #1: Nurse will continue to administer oxygen as ordered via nasal canula during PCS. (pg.389) *Notice I didn't say oxygen at 2L/min because his orders kept changing and I didn't want to revise, so I changed the wording.
Intervention #2: Nurse will offer rest periods during ambulation during PCS. (pg.390) *Notice I said OFFER, so even if they decline I still did my intervention.

Dx #2: Activity Intolerance R/T imbalance between oxygen supply & demand AEB complaints of exertional dyspnea and fatigue (I could've left these off but I had report of them so I included them)
Outcome: Patient will participate in ambulation with no complaints of dyspnea during PCS. *Notice I took what Mosby lists for an outcome and worded it to fit that patient. (I didn't care if he ended up complaining of dyspnea because I wasn't evaluating this label as my priority, and obviously he had a bit MORE than just dyspnea during the PCS ha!)
Assessment: Assess patient for signs and complaints of dyspnea during ambulation during PCS. *Putting 'signs AND complaints' allowed me flexibility to get objective AND subjective info, more options for charting and/or eval if you need it
Intervention #1: Nurse will instruct patient to move slowly with activity and during ambulation during PCS. (This was my version of "slow the pace of care. Allow the client extra time to carry out physical activities" pg. 169).
Intervention #2: Nurse will encourage patient to use controlled breathing techniques during activity and ambulation during PCS. (pg. 169).

***Notice that most of my interventions literally require me to simply SAY something "hey you should go slow, try and take deep breaths before doing any activity", this means it will take you seconds to complete and you can be off and running (or your patient can start running ;) Be conscious of your time the WHOLE time by thinking this through ahead of time***

PCS #2
Recent post op abdominal surgery, hernia repair with extensive adhesions. Was having trouble with pain but not so much once I got to her. JP drains, 2 IV's running fluids & meds, oxygen @ 2L/min, PCA pump, epidural pump, foley, SCD's, abdominal binder. Had been having major issue with hypotension (90/50). Overweight but otherwise pretty healthy.
Areas of Care Assigned: Vitals, I & O, Fluid management, Respiratory management with I/S x10, abdominal assessment, pain management, drainage for JPs, mobility: out of bed to chair

*I immediately wanted to hit my "airway" priority and saw respiratory management, but had nothing else relevant, she had no history of breathing issues, and no other risk type issues so that was out even though she was on 02 I was NOT assigned oxygen management. No circulation even though I could've stretched for tissue perfusion issues with tissue trauma but I knew that was a bad idea and I wasn't assigned a PVA. So next priority was pain which I WAS assigned.*

Dx #1: Acute pain R/T tissue trauma: abdominal surgery AEB patient states pain level 4/10 (I was  not crazy about using this one since she wasn't rating her pain very high over the past couple of readings, BUT she had a PCA pump AND an epidural and acute pain was relevant for being newly post op so I ran with it).
Outcome: Patient will rate pain level 3 or less on 0-10 scale during PCS.
Assessment: Assess patients pain level on 0-10 scale during PCS.

Intervention #1: Encourage patient to use PCA pump at regular intervals to better manage pain during PCS. (pg. 550)

Intervention #2: Reposition patient out of bed to chair x1 during PCS.

Dx #2: Activity Intolerance (I left off the R/T since I didn't have a crystal clear picture, I could've probably put imbalance between 02 supply & demand but didn't chance it). I also left off the AEB even though I knew she had hypotension because this wasn't my priority dx and I didn't put it unless I was 200% sure.
Outcome: Patient will participate in transfer out of bed to chair with no signs of hypotension *Notice I used hypotension for her since I knew this was a problem she was having, making it patient specific.
Assessment: Assess patient for signs of hypotension and complaints of dizziness during transfer out of bed to chair.
Intervention #1: Nurse will instruct patient to sit and dangle at the bedside prior to activity and transfer out of bed to chair (pg. 167). *This is not only appropriate for transferring any patient to chair but is mainly to help with orthostatic hypotension, the precise problem she'd been having (patient specific).
Intervention #2: Nurse will offer rest periods during care activities and transfer out of bed to chair during PCS. (I could've used reposition out of bed to chair as an intervention which would count as "mobilizing the patient as soon as possible" pg. 166, or "position client upright several times daily" pg. 166 but I had used this intervention for pain and didn't want to chance it.)

PCS #3
Admitted with severe dyspnea, history of CHF, COPD, diabetes, lupus, depression, and a few other random things.
Areas of Care Assigned: Vitals, Intake & Output, Fluid Management (she had an IVAD but no fluids currently running), Medications 0900 (Prozac, Lasix, Amlodopine, Lovenox, Mucinex), Flush IVAD, Peripheral assessment lower, Mobility- out of bed to chair, Patient teaching with fluid management.

*I had my airway priority obviously with 02, could've tried to use tissue perfusion problems for circulation with the PVA and diabetes but I no supporting data so I steered clear (good thing too because she was fine in that department!)*

Dx #1: Impaired Gas Exchange R/T ventillation perfusion imbalance: COPD AEB: patient complaints of severe dyspnea (sound familiar?? Don't re-invent the wheel, same problem same history, same diagnosis even on different patient)
Outcome: Patient will have an oxygen saturation of 92% or higher on oxygen during PCS. *I used 02 sats this time since it was checked off under oxygen management this time.

Assessment:Assess patients oxygen saturation on oxygen during PCS.

Intervention #1: Continue to administer oxygen as ordered via NC during PCS.
Intervention #2: Nurse will position patient upright out of bed to chair x1 to facilitate oxygenation during PCS (pg. 388). (I included the tidbit about facilitating oxygen so she knew I was using positioning to help oxygenation, not just positioning for the heck of it).

Dx #2: Activity Intolerance R/T imbalance between oxygen supply and demand (duh, that's why they have her on oxygen) AEB exertional dyspnea and fatigue (this was reported by primary)
Outcome: Patient will participate in transfer out of bed to chair without signs or complaints of dyspnea. (once again, didn't care if she ended up having dsypnea since I wasn't evaluating this one, plus I could probably get her to report an improvement in the dyspnea at the very least if I led the questioning the right way)
Assessment: Assess patient for signs and complaints of dyspnea during transfer out of bed to chair.

Intervention #1: Nurse will instruct patient to sit and dangle prior to transfer out of bed to chair (pg. 167).

Intervention #2: Nurse will encourage patient to move slowly and use controlled breathing during activity and during transfer out of bed to chair (pg. 169) 


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Monday, March 5, 2012

Resources For My Fellow Nursing CPNE Friends

Dear fellow Excelsior nursing friends from afar,

I have put together this info to help anyone going through this journey in hopes that something anything here may help someone out there. I was lucky to have the support and encouragement from previous students who paid it forward and I hope to offer the same to you. I had this "mommy" blog already so I figured why not add on a section for CPNE-ers try to share this info that I would've died to have myself while I felt so completely lonely and lost during this program.

My CPNE test date was 3-1-2013 at Meriter Hospital in Madison Wisconsin. I've adjusted dates here to make these posts more seamless for the blog. 

Below are various links to posts about anything from my careplans to my PCS's in depth. I will add to it as I can about my entire journey with Excelsior. Hope some of it helps, best of luck to all of you on this wild ride!

The posts include information that worked for ME, these things may not apply to you or to the current version of the study guide. I tested under the 19th Edition. Please confirm any info you find with an advisor as I would feel awful in steering you the wrong direction with any advice I offer that worked for me specifically. ALWAYS confirm info you find anywhere with an advisor, preferably on email so you have a paper trail.

Where to start?? If you're new here, start with the Preparation post. If you want to know about what the weekend is actually like start with the various hospital days. If you're near your test date read up on all the documentation/careplan posts to help fine tune. It's a lot of info, so bookmark it and come visit again :)

NO I DO NOT GET PAID or compensated in any form of anything for this ha I wish! I don't get Google Ad money, traffic or per click money. I averaged 100+k page views a month prior to my cpne journey, so be sure that I have no hidden agenda, my blog sponsors deal with diapers, not nursing school so they don't care heh! Just here to help.

Some of the info and/or pictures included contains copyrighted content from Excelsior College which may be confidential in nature. No identifying patient data is included and this information is meant for demonstrative purposes. No replication of this information is permitted.

A brief history of how I got here. Graduated as an LPN in 2007 tried to move right into the bridge program but long story short school was a mess lost accreditation, etc. Worked in pediatrics, started my own biz around the same time on a whim. Eventually quit my job, had both of my Dudes and intended to finish my degree at some point. Realized that my pre-req credits would be expiring soon (meaning re-taking 2 years worth of A&P, micro, and such) and said uh oh. Stayed away from a traditional nursing program since it’d cost $2000/mo just to put the Dudes in daycare and chose Excelsior instead. If I’d only known then what I know now…. Decided to finish the program as fast as humanely possible. Signed up for all 8 theory exams right away, bought some previous students study notes, not one textbook and passed all exams in just over 6 weeks. Enrolled in both sections of the FCCA immediately, got stuck with the full 8 week computer version. Passed those and submitted my CPNE app the next day. Got my date about 4 weeks later (beginning of December) for March 1. Signed up for Sheri Taylor’s workshop 2 weeks prior to my test date and attempted to study in the meantime. Finished reading the 500 page studyguide about a week before the workshop. Finally got my head around what I was doing at the workshop and came home to study for my final 2 weeks. Submitted careplans and practiced labs for my final week and jetted off to Wisconsin. Went 3 for 4 in labs, passed #4 the next day, went 3 for 3 on PCS’s, flew home and started writing this for all of you before I forgot details.
Click away folks....

What is the CPNE?
All about what I call The Gauntlet.

CPNE Day 1 Labs & PCS 1
My lab advice, equipment differences, what to do/not do, and my first PCS that got things off with a bang.

Another interesting patient experience with the bionic woman and dashing down the hall to hand in my paperwork with 2 minutes to spare in the end.

CPNE Day 3
My final PCS and what it feels like to walk out with that magical letter

The careplans I used for my PCS’s and all of my AOC’s

Documentation Galore
My narrative notes and how to document using your mnemonics.

Evaluations & Rationales
My evaluations for all 3 PCS's and examples of rationale statements.

How to remember all 23 areas of care, the mnemonics that I used.

The CPNE Weekend In Pictures
A photo montage of the weekend starting out with nearly getting arrested at the airport

Preparing for the CPNE
What I did to prepare, my notecards, the workshop, how I set up labs, etc

Why I chose Sheri Taylor over Excelsior to prepare for the CPNE and what the workshop was like.

NCLEX & Licensure
My crazy road to finally signing that RN after my name! Including getting all 265 questions.

WGU: Western Governors University
Life after the CPNE exists! My road to getting my BSN and MSN!

WGU: Single Terms Tricks & Tips
How to finish your BSN in a single term

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