Sunday, March 4, 2012

CPNE Adventure Begins: Labs and PCS 1

The info and/or pictures below contain copyrighted content from Excelsior College that 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. This is part of my post series on Excelsior College's ADN nursing program and the CPNE experience. See all related posts over here.

My CPNE was in Madison Wisconsin at Meriter Hospital this past weekend (3-1-2013). Some general info, nice hospital and the staff I dealt with were very friendly. Had patients on 3 different floors, general med/surg, a cardiac floor, and an ortho floor. Couldn't find any particular "specialty" for the hospital so I expected any type of general patient. Pediatric unit is brand new and located by the ER, I get the impression that they want any type of 'student' as far away from their new unit as possible.

Day 1 Labs-
Show up and meet the CA, Lynda, who was absolutely wonderful! This woman was a true angel and I feel so fortunate to have had her even though I didn't end up needing her 'intervention' during my weekend I know that she would've made things so much more pleasant if I had. Great vibes from this lady, she truly wanted to see us all succeed, like a surrogate mother to all of us. Go through the orientation and she hands us a book that their staff has put together to offer encouragement to the students testing. It's a notebook full of wisdom and happy thoughts from prior students who had passed their weekend at the moment they finished. She told us that any time we needed some encouragement to take the book and soak in all the positive energy, such a nice gesture! We get our orientation to the lab stations and I notice a handful of differences between the supplies I'd been practicing with and their supplies. When we were offered 15 minutes to look over things I ran around and opened every package and inspected everything I could, this is CRUCIAL.
IM/SQ station had syringes and separate needles, you had to attach the needles since nothing came prepackaged. The needles also had a couple of different needle guards that I'd never seen before so I made sure to practice with each of them. We were told that we HAD to use the table to engage the needle lock and I practiced this as well. I immediately noticed that there was only one kind of 1" needle available, they also 1 1/2", and also 5/8".
IV meds station the mini bags have a different type of 'plug' where you attach the tubing, it's not the soft blue rubber like I'd been practicing with, it's a beefy old yellowy rubber thing. I made sure to yank one off to see how difficult it would be since I knew this would be an easy way to contaminate tubing if you had to yank it hard enough, and it was hard to get off! SHOULD'VE played a little more with the roller clamps and practiced counting for a few seconds. (Do this after you've browsed other stations and have time left over) the roller clamps were very touchy, tiniest adjustment and the drips would go WAY off up/down. Due to this I took nearly twice as long to get my drips right during checkoff which was fine since I still had about 5 mins left over at the end but if you take close to 20 minutes in practice this WILL throw you a curve. I also ended up with air in the tubing and had to backprime, the CE didn't notice the air at all, I could've probably skipped it but I didn't take the chance. After back priming I STILL ended up with another set of bubbles in the secondary tubing (again barely noticeable) but I wasn't exactly sure what to do at that point. I decided to try and flick the bubbles up to the drip chamber, had no idea if that'd even work, but it DID. This took time obviously. I thought I had those drips perfect 2 separate times, they were dead on at my 15 seconds and 30 seconds and then when I hit the full minute they were off by 6 drops. Still not sure what was happening, all I know is that you had to be much more precise with the tubing/clamps that they had than I had to be with my practice ones at home. So watch that!!
Wound station. Main thing that was waaaay off were the gloves. They had vinyl ones, not latex, these are MUCH HARDER to put on because they are less stretchy. Practice with them (green aloe ones). And the sizes were waaaay off, I assumed a small would be fine but couldn't even get my fingers in them, wasn't expecting that, and SO glad that I tried them on ahead of time to find that out. Medium gloves good, they were a bit bigger than I'd have preferred but I made due since there was no other option. Next up, the 4x4 to put under the abd pad, all of my practice supplies had a SINGLE 4x4, the packages here had 2 in the same package. I didn't know if we were supposed to use both so I opened up the wound that was already dressed and they had used 2 so I made a mental note to use both. They had 2 different wounds (actually 2 of each station for all of the stations) and I had only looked at one earlier, big mistake. Should've looked at both and I ended up getting the one that I hadn't checked out. There is a difference between the two wounds, same general shape and idea but differences. When I pulled that dressing off I went uh oh, ok it's fine just roll with it. Next difference was the wound apparatus was smaller than the one I'd been using and they had it wrapped very "skinny", envision wrapping your wound around a pop can (It was some mannequin part, a forearm or something small/skinny and round and it WOBBLED!).

Did my wound flawlessly in about 7 mins, went to get the 4x4 and placed it on top, then abd, then started to tape. They had vinyl/clear tape, not the paper opaque tape I'd practiced with and their tape would NOT stick to the damn wound. I kept trying to stick it and worried she was going to fail me for it if it popped off or fail me for pushing too hard and 'injuring' the patient or something. I made the other 2 pieces of tape longer hoping that would help, still a pain in the ass but finally I got it to work for the most part. Turned to say ok, I'm done and she said to me in an odd voice "are you sure you have completed all of the critical elements"... I took this as a sign that something was effed.... looked back over everything, stood there puzzled and said "well yes I have??" and off she went to get the CA. F@&^@***, not good. CA comes over and says "you can't have any of the 4x4 poking out underneath the abd pad" and I looked down and said "what are you talking about?" She lifted it up in the air and rolled it over and sure enough a tiny piece of the 4x4 was sticking out past the abd pad. I wouldn't have even seen this regardless unless I had picked the wound up and spun it around but the CE had been sitting in a chair eye level with the wound so she could see it. The problem..... that extra damn 4x4, while I was messing with the tape the extra 4x4 was slipping around under the abd and managed to sneak it's way out, barely.I could've probably tried to fight this for a variety of reasons but chose to hold off, repeat tomorrow and see what happens.

On my repeat I chose to again use both of the 4x4's from the package, I would advise anyone else to clarify this with their CA and see what the protocol is. I didn't want to try and only grab 1 from the package and risk contaminating something so I grabbed both carefully and SLOWLY dropped them both on top of the wound, then I SLOWLY adjusted that abd pad to the perfect spot and dropped it. I anchored the abd while I got the tape on to make sure the extra gauze didn't slip this time and I taped that baby up, I went OCD this time, I pulled the tape up a little, made sure it was perfect in all ways, I got down and stared at EVERY angle of the wound before I stopped and thank you god- pass!

IV Push Station. Ended up with 4mg of Zofran, which was 1 mL over 1 minute. This is a pretty touchy push since you're only working with 1 mL total, hadn't practiced that volume in that time before. I opted for a twist and push motion, similar to flicking a lighter? FYI some of the bottles are overpressurized from people screwing it up, one of my flushes went nuts and sent fluid shooting everywhere, it was dripping down the syringe and I was sure she'd try to fail me for something because of it.... because this is all that goes through your head the whole weekend! It made it harder to see bubbles and made the syringe slippery but it worked. I also bumped my last syringe when I took it out of the package to draw up my med, I'm sure it wouldn't have been a failure point but I didn't know so I stopped to get a new syringe. Other than that it went fine, I knew I'd be pushing the time limit on this one so I hauled butt drawing everything up. Don't freak about bubbles, yank that fluid back, whack it around like you mean it because you don't have a needle to bend, pull out an extra .2-.3 and then get the bubbles out after you take the syringe off the leuer lock, you can always draw up more if you have an issue since you aren't mixing in this one so don't waste time on this like the IM station.

So Day 1 and was 3 out of 4. I was ok with it, clearly I wanted to hit 4 for 4 but I figured one to repeat wasn't horrible. But the more I thought about it over the night I freaked out a bit more considering how many easy points of failure there are in the wound... had to put that out of my head and say oh well, it is what it is.

Headed over to meet our CE's and get our first patient after labs. My first CE was less than 'friendly', hopefully she never stumbles onto this blog because I'd feel bad but I think it was just her personality, she wasn't warm, she wasn't sociable or fun, she was very "business". Of the few questions I asked her she gave me answers that I knew were not right according to what Excelsior says and I chose not to argue with her unless I ended up needing to. I asked where the "clean" area is designated in the patients room that we are allowed to place our paperwork and she said "That would be considered a teaching question, I can't tell you that".... I was thinking, uh wtf, that is NOT teaching... but I smiled and said ok fine and shoved my papers in my pocket (and that's where they stayed the rest of the time!). She handed my Kardex to me, gave me about 4 seconds to look at it and then went to the computer and said 'well what do you want to look  at in the chart' I was like dang give me a second to digest it here and I'll let you know but she was already opening the computer and kept kind of hounding me to look at what I wanted to see. She started going over a couple of vitals and screens in the computer, then says "here's the nurses notes, but I'm not allowed to show you care plans" and closed the screen down. Again I could've argued that I was allowed to look at anything in that chart that I wanted to but I kept my mouth closed. I logged it in the back of mind as ammunition incase the need arose to use it, fight time would be Sunday... I figured I'll do as I'm told for Saturday but come Sunday the gloves come off if I have to fight to stay here.

Care plan for this guy was cake to me- I saw oxygen management and respiratory assessment and saw that he had COPD and pneumonia and said sweet- Impaired Gas Exchange, boom done. The only other thing I had for him was meds so nothing to work with there. He was on bedrest and so I went with Activity Intolerance, cake folks. I questioned a few things in the chart, his 02 kept changing from 2L to 1L to something else so I opted NOT to include the specific amount in my careplan until the next morning when I could verify his current order. I also noticed that he had rated pain at 8 on the last shift but the CE said 'agh, no, he always rates his pain a 0' she seemed to not care about the current rating implying I should ignore it but this made me uneasy. I was afraid I'd walk in the room, he'd rate his pain an 8 and I'd be screwed fixing pain somehow (when it wasn't assigned) end up having to revise the careplan AND use the special scary box on documentation ha! He was also noted to refuse any prn pain medication so I thought, wonderful.... omg. Tried to ignore this and went back to the hotel to plan out how I was going to do his care. I was very concerned with the order I would do things in because I hadn't done any direct patient care in years, I was worried about the flow of things without having to go in and out of the room a million times. Wrote a logical order of events on my practice grid at the hotel that I'd replicate in the morning. Watched some videos on the AOC's I had to do to make sure I had it fresh in my brain and went to bed about midnight.

Day 2 Begins
Woke up and ran through mneumonics, hit the hospital ready to go.  Got report from the primary while I finalized my careplan and that's when the fun began. Half the things on my Kardex had to be changed since his status changed, now all of a sudden he was ambulatory, not on bedrest. Now she wanted an apical pulse instead of a radial. She changed from a tympanic to an oral temp, and his 02 order had gone down. Minor glitches, had to adjust my interventions to ambulate patient rather than reposition in bed, and changed my interventions in activity intolerance to instruct patient to move slow and use controlled breathing while walking. Turned in paperwork and after several minutes we were ready to go. 20 minute check was nothing, just skin turgor and oral intake/output. He had no fluids running in his IV but DID have an IV placed, I asked 4 times whether I needed to assess the site condition and was told no each time, even though I believe you are indeed supposed to check it. I asked about this the night before when I saw it in the chart, I asked that morning, I asked right before going into the room, and I asked right before I handed in the 20 min check. So okie dokie, no IV site check fine. Good thing I had nothing to do for the check because as I walked in the door respiratory was in there giving him a neb and asking him questions. I thought GREAT and tried to wait patiently for a few moments after washing/gloving/ID'ing. Finally I got the impression that RT lady wasn't going anywhere soon so I made the choice to interrupt her and get my 20 minute check done, she wasn't doing anything to help me out and gave me the vibe that I was in her way and I wasn't having it. Sorry lady, I'm on the CLOCK, tick tock.... I nearly removed the woman from the room in order to get my stuff done and hand it in. No friends made there but too bad. She kept telling him to be quiet and do his neb treatment while he was explaining his intake to me, it became somewhat comical. I told him I was going to end up RE assessing every single thing she was doing since they were my management areas, luckily he didn't mind but I could see a patient getting very irritated about this.

Vitals time, I go to do the apical heart, she hands me the double stethoscope, I note that it's a Litman, which was great, I shouldn't have any issues hearing. I listened to his 'apical' rate for over 5 minutes and did not hear ONE HEARTBEAT. I'm not joking. The stethoscope was working fine, it was placed appropriately, it was on the right side, the guy had no audible heartbeat. For real. I moved the stethoscope finally away from the normal area to several other areas, nothing, nada, zilch. I started freaking out, I kept looking at the CE for feedback and she was stone-faced, not an inclination of anything there. She did tell him to turn his TV off but it didn't help. Finally I didn't know what to do at all so I took the stetho off and said, I absolutely cannot hear ANYTHING. I waited for her to take me out of the room to fail me but she didn't. She obviously felt the same way and was just as confused to what was going on so she said to hook him up to the machine so we'd have something to put in the chart and that she'd "term" that part for me. I wasn't really sure what that meant but crossed my fingers that it was fixable somehow. Machine read 66 BPM... I'm still convinced the guy was a robot alien. Got the rest of my vitals, I was all discombobulated, I think I only took 1 resp rate, but then 2 BP's, and then 1 temp... I started to forget my numbers before I could write them down it was a mess. I had to stop and take a deep breath. It didn't help that my super nice patient wouldn't shut up ha! Any other time I'd be happy to engage but I couldn't focus on anything I was doing. I finally looked at my watch trying to decide how long it would take to do meds and whether I could walk him now or later. I said this outloud and apparently the guy was PUMPED to go walking which I thought was great, so I said ok we probably have a little time before your meds to walk now. I started to give my speech about non skid socks and planned to quickly state my interventions to go SLOW and use controlled breathing when the guy shot out of the bed and lept across the room to go walking!! As non-skid socks came out of my mouth he looked back and said "NAH I don't need em" and whipped his oxygen off, put the portable one on, hooked his 02 sats on and ran out the door. RAN. My jaw dropped to the floor, I thought for sure I was finished. I didn't know what to do... was I supposed to tackle the guy back into his bed and put socks on him??!! OH my word. I didn't get a chance to verify the 02 L/min on the portable tank before he ran off so I chased him and bent down to verify as he was walking. The CE didn't know what the heck to do either, I just gave her a look like WHOA you better catch up because I'm going!! HAAA, it was soooo NOT funny at the time. I started to shout out my interventions so that the CE could hear me down the hallway, I figured I'd try to sneak them in there whether he listened or not. "You know you really should try to move nice and SLOW to help with your shortness of breath, that is really important when you're doing any kind of activity" "NAAHH! I like to keep a quick pace!" (as he continued to race around the floor). I tried to grab the oxygen tank for him and he shooed me away, I've got it! You don't have to to hold it! Next intervention :::shouting::: "You should try to use nice controlled breathing while you're doing activity, blowing out of your mouth like you're blowing into a straw will really help you!" Next intervention "Why don't we take a little break real quick, let you catch your breath for a minute, it helps to take frequent breaks" NO, I'm good. Are you sure??? YEA, but I think I'll only do one lap.... yea geeze I thought I'd be able to do more.... At this point I notice things are going south and he's breathing hard so I ask him to stop again and he refuses and continues to keep breathing harder at the end of the hallway. I reach over to grab the oxygen as I look back at the CE trying to hint to her that she better get ready the guy is about to go down and faint in the hallway. She was as much of a deer in the headlights at this point as I was and I said one final time let's just STOP and take a break for a quick second, he couldn't even talk at this point and pointed to his room which I steered him into quickly and he collapsed on the bed gasping for air! His 02 sat machine was reading 81%.

You can imagine the thoughts in my head..... lots of expletives.... and I wanted to just whack the guy one and say THANKS for doing this to the STUDENT for crying out loud WTF??!!!! I TOLD you to go SLOW!! But instead I continued to kneel next to him telling him calmly to take deep breaths and sit forward on the bed, nice and slow, relax. He tried to yank the oxygen and 02 sats off and I said NO, we're going to leave that on for a bit. After about 10 minutes I felt comfortable switching him back to his 1L wall 02 over the 2.5L portable, and laid him back in bed and said we're going to go get your meds now so you need to CHILL and rest buddy!

Meds are in a med locker right outside the room which is great, they have a barcode system so it makes it a little trickier to administer because the CE has to go in ALONE to scan meds and barcodes with the patient, THEN they come back out to get you to go in and give it to them. You have a little makeshift MAR that they give you and the most important thing is to remember to ID patient with the MAR, NOT your Kardex for meds. Easy to forget since it's just a regular handwritten sheet of paper in your stuff. I had to give Lovenox which I'd never actually done, was all concerned about the bubble situation, then heard my patient had been refusing it. I thought SCORE! But I heard my CE in the room convincing him to take it, I wanted to say shuusssshhhh he doesn't want it, I don't need to do it :) Well THEN we had trouble. Lovenox beeped in the computer, wrong dose, had to do all this verifying with the primary, get a hold of doc and pharmacy, etc. Syringe had 40mg and he was on a new order of 30mg. While CE is telling me to calculate the titration to downgrade the dose I am flipping out about how this will work and how I'm supposed to get the bubble BACK into the syringe, and how many cc's of bubble and and and.... thank the lord the primary looks at her and says Oh NO, we're calling the pharmacy to send the new dose up, no need to try and do that. WHEW! Thankfully I didn't have to deal with dosing the Lovenox but the problem now was that the clock was ticking away while she went and did all of this verifying and reordering. CE looked at me as she ran down the hallway to figure out the med situation and said, "well don't waste any time, do your documenting or something" and I didn't even get a chance to tell her that she had my paperwork so I couldn't document!!

So improvise.... I got an alcohol swab out of my pocket and started writing in elf letters my mobility narrative so I could just copy it over once my paperwork was back. Once she arrived she had to re-do the whole scan barcode thing while I waited outside the door so I took this chance to scribble down my O2 management narrative using my leg as a table.

Finally give the meds, give the shot (don't forget to bring a 2x2 with you for this)! I did and went to use an alcohol swab which probably would've failed me when the patient just ripped his shirt back down and said I'm good and brushed me away. So alrighty I walked away to the Sharps container and no one was the wiser. I had lost about 15+ minutes of time with the med ordeal (I probably could've asked for this time back but didn't want to chance it) so I was down to the wire documenting and handed my paperwork in with about 5 minutes to spare. Sat in a room for about 20 minutes having a heart attack going back over in my head what I had written... Did I include all the elements? I didn't skip any part of the mneumonic right? Did I write the intake in the right column? You second guess every single thing waiting there. She walked in the room finally and said.... "Ok. Sorry that took so long, I had to wait for Lynda (CA)." :::GULP.Oh God.::: You passed, I just had to verify the change with that apical pulse, that was my fault since I switched it on you at the last minute.

Oh my goodness thank GOD!! One done. What a special first PCS, couldn't have gone LESS smoothly. I look back now and realize this was a blessing, if I could handle that one first then any would've been fine. And luckily it prepared me for PCS #2, which was equally as crazy in it's own way.

Day 2 over here

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