Wednesday, March 24, 2010


     So many things happen in a day. Two shifts since my last blog and I am already loosing details that I'd wanted to share. Hopefully they will come to me as I sift through my short term memory.
         I've worked with a couple of patients that have been considered challenging by those who worked with them before me. I am considering more and more the effect of how a report is given, the words, tone of voice, emotions used, on the person receiving the report and their subsequent care of the patient. It has to have some effect.
    How much of our own prejudices are we passing on? Do we consider this before we spread it around? What are we projecting onto those we are caring for? Are we aware of it? Are we honest with ourselves?
     These are the kinds of questions and topics I'm considering, although I have not had a lot of time to put into their consideration. I would love to think more about it. It's a topic that really interests me and I think a lot can be learned from looking into it further.
       I find, when I interact with people directly, meeting them where they are at, offering them my time, my presence, and my attention, it goes a long way toward gaining their trust and respect. Although I have my own thoughts and feelings about the choices people make, and sometimes my empathy for them causes me to feel some grief, I do not feel burdened by judgement of their actions, choices, etc. I feel as though those type of things become suspended, somewhere away from my interactions with individuals, and I am able to truly be with them as they are, and show up as my best self. I am really grateful for this.
      I try to listen to what others say about others and allow my experiences with them as individuals and as a unit (nurse/patient, Dr/patient, etc.) to filter out what is needed and what is not. I find much of it is not. How much do I really need to know about someone before I can walk into their space and provide the best care for them? Good question. Like everything else it probably depends on the particulars of the moment.


Thursday, March 18, 2010

feeling like a "real" nurse

        Yesterday, during my fourth shift on the mother baby unit, I began to feel like a real nurse. I started the day by assuming care of two mother/baby couplets (that means two moms and two babies in two seperate rooms). I knew where to go to listen to report. I knew to start off by looking through their charts, signing everything that needs to be signed, beginning to plan my day. I wrote myself notes: when each patient had their last medications and when they needed their next ones, which forms I needed to go over with them and have them sign, what things needed to be taken care of before they could be discharged, etc.
        I felt at ease. I asked questions of my coworkers and received friendly responses. Everyone seems to be helpful, willing to take a bit of time out of their busy schedules to assist one another. It's wonderful!
My preceptor checked in with me regularly but, mostly, I sailed through my day on my self made raft of competence! What a great feeling. I felt like a "real" nurse, managing multiple tasks at a time, working with CNA's, volunteers, doctors, midwives, RN's, social workers, unit secretaries, as part of the "health care" team. I answered the unit phone and called my patients' care providers to make requests, using SBAR of course!
     During one of my breaks, sittiing with CNA's and RN's around a lounge room table, we talked about our families, food, caring for patients, etc. It feeds me to be around people, to talk with them, to listen to them, to laugh with them! I am so blessed to be in this place, at this time, at this point in my life. Thank you, thank you, thank you!
    One of the highlights of my day came when one of my patient's was preparing to have their son circumcised. (don't freak out yet!) Circumcisions are hardly ever performed where I work. There is one doctor that does them every once in awhile. My preceptor said she thinks she's only participated in one since she's been working there. Another RN took a call from my patient's pediatrician. He had called to say he was coming in 10 minutes to perform the circumcision and wanted lidocaine cream placed on the baby's penis.
    Finding the cream was quite a tadoo. There was discussion amongst the nurses about how long the cream should remain on the penis before the cut was made? How long would it take the pharmacy to send the cream up to our unit? Did the nursery have the cream on hand? (No, they didn't). The nurse who took the call from the doctor scanned a STAT order to pharmacy and suggested I call pharmacy to let them know we needed it ASAP. I did call, that's when I found out from the other nurse that she had scanned it as a STAT order, and I was firmly told by the pharmacy tech that "You do not need to call if the order is STAT, this phone call is unnecessary". I thanked her very much and went about pulling together the circumcision supplies and paperwork with my preceptor.
    A few minutes later the doctor arrived. Another RN, who had done a circumcision with him a few weeks earlier and run into the same problem with not having enough time for the cream to properly numb the baby's penis, spoke to the doctor at the nurses stattion. She suggested, in the future, he write orders for the cream in the patient's chart the day before the procedure so that we could have time to procur and place it. He was receptive to the idea. It was a good exchange for me to witness.
    The DR then went into the patient's room to go over and sign the informed consent for the circumcision. I came in a few minutes later, with the cream, to apply it. The doctor was finishing up an examination of the baby and was still chatting with the parents about the procedure. He asked me where we would be performing the procedure. I responded that we were preparing to do it in the patient's room, unless he would rather do it somewhere else. The DR then asked the parents what they thought. The mom said she was fine with being in the room but that the dad did not want to see it. So it was decided that dad would step out and the circumcision would be done in the room. The DR left the room then, saying he would be back in about 15 min.
   After placing the cream on the baby and bundling him back up I asked the parents if one of them wanted to  hold him.  I went over some of the paperwork with them, aftercare, etc. Dad was looking anxious and asked me,
      "So how much do you know about this procedure? I know it was started as a religious thing, but what are the benefits of doing it?"
     Thus began a lengthy discussion about informed choice. I encouraged them to take the time to gather more information if they felt they needed it. I told them there is a lot of information about circumcision available, that from what I know, there is not a lot of evidence supporting the physiologic need to remove the foreskin. That in America it seems to be mostly a cultural and religious choice. I also said that they did not have to do the procedure today. That they could take more time to think about it and do it at another time if the chose. Just as we were finishing our discussion, and Dad seemed to have decided he wanted more information, DR came in.
      I said something to the effect of "perfect timing, we were just discussing their desire for more information", as I was leaving I heard Dad say, "I think we've decided not to do it today...."
    Several minutes later the DR came out of the room and stated they had decided not to have the circumcision done today. He did not seem at all put out by it. I was relieved. While he was in the room, after I had left, I wondered if he was giving them contradictory information to what I had. I wondered if he would think I had fed them false information or tried to pursuade them one way or another. He made no indications that any of that was the case. That was also a good experience for me!
    I went back into the patient's room, to remove the cream from baby's penis, remove the circumcision supplies, and check in with the parents. Dad said they had had a good talk with the DR. That DR had told them he couldn't give them any really good reasons to circumcise their son. That the only issues he really sees in practice have to do with hygiene. (Which was something I had also mentioned to them).
    The whole experience had the staff and nurses talking. Some had very strong opinions about it, some were for it, some were against it, some were undecided. For the most part I kept my personal opinion out of it. Even when chatting with my coworkers. Although I did mention feeling happy for my patient, the baby, that he gets to keep his penis intact, at least for a little while longer. I left feeling like I had saved a penis! My good deed for the day!
   But what was even better was encouraging the parents to take the time they needed, to gather as much information as they needed, to make an informed choice, that they would feel good about. My being there for that, listening to their concerns, offering evidenced based information, supporting their unveiling of their own power as parents, was another precious moment that I am so glad I was present for!!!

Monday, March 15, 2010

Keeping myself up at night

    Last night I had a difficult time getting to sleep, visions of patients flowing through my mind, stress hormones circulating through my blood stream. I kept running over my day:
                               *Did I forget to chart her edema?
                              *What if I misinterpreted her bleeding and she hemorhaged after I left?
                               *That blood pressure cuff and machine didn't appear to be working correctly....
                               I was going to get another machine and come back to retake her BP, but the end of
                               my shift got busy and I forgot... what is she develops Eclampsia? More women develop
                               it after birth than before!!!!!
                              *Why didn't I go into that patient's room more often?
                              * There really are people who won't feed their baby unless you remind them?
                              *What if that baby goes home and gets even more dehydrated? There's nothing I can do
                              about that, is there?

         Yesterday I began to get a real felt sense for the importance of having a routine. There are so many details to keep track of when things follow an expected course. When they deviate from that course there are even more details to be aware of, to be responsible for! I will have to work at developing my own routine, integrating elements from those I've observed, those I work with, to provide the best, most coherent care for the patients I work with.
        I am going to forget things. I will most likely make many mistakes. If I am diligent they may not cause any gross damage to those I am caring for. I need to remember I am not doing it alone. I have a host of team members available to assist me. It doens't help to think that if I make a mistake when I'm in the orienting phase my poor preceptor will be responsible too! Even when I am the responsible party I can still stop, take the time to ensure I am making the best choice for my patient and for my self. Otherwise I will not be getting any sleep. Then I won't be any good to anyone!   

Friday, March 12, 2010

2nd Shift

    Obviously if I am going to blog about the details of my residency experience I am going to have to do it more immediately following an experience. It's too easy to forget the juicy details if I put it off for a few days.
        This past Saturday I did my second shift on the postpartum unit and had a great day! It was a 12 hour day shift. It started out nicely, several patients (mother-baby couplets) to work with. I chose one couplet to work with more on my own. My preceptor observed me doing some of the tasks, pointed me in the right direction, helped me get my charting in the right place, helped me get into the medication system, etc. I did quite a bit on my own and felt good about it.
     Working with the patients is the best part, it comes pretty naturally for me. When I don't know something, fumble while removing sticky tape from an IV site, or drop something on the floor, I often make light of it, smiling, bringing appropriate humor into the situation. I think my air of easefullness helps patients feel comfortable with me, even though they know I am new and don't know everything!
     My third shift on the unit is this Sunday. I will be working with a different preceptor and am interested to see how her approach differs from those I've worked with so far. I look forward to the opportunity to gain new perspectives, insights, and learning new ways of doing things.

Wednesday, March 10, 2010

First 12 hour shift on the unit part 2

     During my first shift I had the opportunity to add some information and offer education to a few patients here and there. One of the most rewarding elements of my day involved aiding a new family in breastfeeding. The patient was interested in breast and bottle feeding. The newborn baby had received formula in a bottle after birth, before coming to the postpartum floor.
     When my preceptor and I were first in the room the patient indicated a desire to breast feed for the "first week or so". After listening to her for a minute or too I began to feel as if she could use some more in depth education about infant feeding. We offered her a bit of information before moving on to the next task.
      A bit later, at the nurses station, we had the opportunity to chat with the Lactation Consultant  (LC) on the unit that day and asked her if she would be willing to offer some education/support to our patient. She was able to chat with our patient and later told us that she seemed interested in trying to breastfeed and the LC thought the patient would ask for help if/when she needed it.
    Later I was in the patients room and was able to support her in latching the baby onto her breast, support them both, and offer a ton of information/education at the same time, but one of the best things I was able to do, the thing that appeared to have an impact on my patient, was the way in which I spoke to her about her baby, her breasts, and her ability to feed/provide for her newborn.
   I said things like:
    "Look at your colostorum, you have so much of it!"
   " He knows just what to do, what an intelligent baby"
   "See how his lips are flared out, that's just right!"
    "Hear that puff of air sound? That means he is swallowing, getting just what he needs"
   "Isn't it amazing how your body just knows how to provide this food that is just right for your baby?"
    "You are both doing it. Look at what you're doing? You are both so amazing!"

      It may sound over the top, but I assure you I was sincere, and my patient appeared to appreciate it. Every time I was with her throughout the course of the afternoon I offered her tidbits of information about caring for her baby, feeding her baby, her baby's amazing talents, relexes, and needs. I shared with her the wonders of colostorum and never even mentioned formula. ( I would have if she had asked/brought it up, but she didn't). I didn't say anything about bottle feeding. I focused on the moment, on what was happening right then, between that mother and that baby! I encouraged her to ask for help, even if it was for every time she wanted to latch her baby on, to use the resources available to her in the hospital, to ask questions, etc.
    And you know what, she did! Once, I was at the nursing station, and she came out of her room ,walked up to me, and asked me if I could help her latch her baby on! It was so awesome! I did help her and the next time she asked me to come into her room to help her, I talked her through it and she was able to get that baby on effectively all by herself!
   Watching her face, seeing the pride and awe eminating from her was magic!
   From the first time my preceptor and I spoke to her about infant feeding until my shift was over, her demeanor and attitude regarding feeding her baby seemed to change completely. From my perspective, she went from vaccillating and unsure, to confidant and committed!
   I can't explain to you how much this experience filled me. Even thought I've helped many, many women to feed their newborns,  I walked around full and satisfied that evening. I came home walking on clouds. I had truly made a difference in the life of my patient, her baby, and her partner. Whether or not she chooses to continue breastfeeding, switches to formula, or does some of both, those moments she had with her baby, the opportunity she had to successfully feed him from her own body, with a supportive woman by her side, will always be with her. I have no doubt she will view herself and her baby differently from now on, consciously or unconsciously, in a big or in a small way...
  It doesnt' matter to me. I know my being there changed something in her, uncovered something in her that she may never have known, or maybe had forgotten, and that is a miracle to me!!!

Friday, March 5, 2010

First twelve hour shift on the unit Part 1

       This past Tuesday I did my first shift on the unit.
        I arrived about 15 minutes prior to the beginning of my shift. I had no idea where to go to meet my preceptor. I went to the staff lounge, waited for a bit, didn't see her come in, then walked around the unit. I asked a few people if they knew where she was, nobody did. A few said she hadn't come in yet.
So I went back to the lounge and asked a few more people. Someone finally suggested I go to the Charge Nurse office upstairs and ask.
       By this time it was a minute past the beginning of my start time so I decided to clock in on my own. I had never used  the clock in system before, but I figured I could do it by myself. What I wasn't sure of was the protcol about clock in time, which machine to use, etc.
       Then I went upstairs, went to the door of the Charge Nurse office, and found 4 nurses sitting around a desk, giving/taking report. They all looked up at me, and despite my desire not to interrupt, I told them I was supposed to be orienting with &* today and asked if  they knew where she was. The Charge Nurse replied, "And she's not here today." She looked at a sheet of paper and said a name, which I only caught the last name of, and told me to go back downstairs to B Quad to find her.
       So I went back down stairs and asked if anyone knew where &* was. Someone directed me to the Unit Secretary's office. I went into the office and stood against the wall, listening to three people getting report from a tape recorder. Then another nurse came in and gave report directly. It turned out one of the people was a nursing student from PLU, I think there were about 6 of them on the floor that morning.
After report I asked one of the nurses if she her last name was &*. It was, so I introduced myself and told her I had been assigned to follow her around for the day.  I think I said something to the effect of "I've been pinned on you for the day".
        &* was very gracious. As she prepared herself to go out onto the unit ,she asked me if it was my first shift on the unit. I said that it was, and she said it would probably be a "follow her around and observe" type of day. I told her that was fine with me and I followed her out onto B Quad where she had been assigned.

Report and Patient Assignment:
    It appears that report is given via tape recorder. The out going nurses on a particular quad take turns going into a private room, an empty patient room, or an open office, and record report for each of their patients onto a tape recorder. Then the oncoming staff go into the room and listen to the report via tape recorder. Then the oncoming nurses choose which patients they want to work with and receive "live" patient updates from the outgoing nurse of that particular patient.
  I'd never encountered report given this way before. I will have to experience it some more before I have a sense of how it really works.

         Apparently it had been a "crazy" night shift. Nurses were behind on charting, patients needed lots of things done, and everyone seemed pretty frazzled and overwhelmed, understandably. I pretty much hung out to the side of things, listening and observing. A nursing student was assigned to one of my preceptor's patients, whom my preceptor had worked with the day before, and she had three other patients as well.
       We spent much of the morning preparing two patients for discharge. There was some teaching to do, some paperwork to fill out, but much of it had been done by the night shift. As I mentioned before documentation is all done via paper charting, and all doctor's orders are via paper charting as well. It is an interesting excersise to read various forms of handwritting, some of it requires a great deal of "interpretation", which I am not exactly comfortable with. It seems as if the nurses become familiar with doctors' handwriting and establish some degree of exerptise in interpreting their orders, but the room for error is still unnerving for me. We shall see how/if this changes for me over time.
That's it for now. More on my first 12 hour shift on the unit to come.......

Tuesday, March 2, 2010

12 Hour Shift Brain Drain

Today I worked my first 12 hour shift on the Mother Baby Unit. I basically followed a preceptor around and contributed here and there. It was a great day and I have so much I want to share here on the blog, but right now my brain is completely drained. My eyes are heavy and I can barely put two words together effectively. So, the detailed blogging will have to wait.
I have education classes to attend tomorrow and thursday so it may take awhile to get to it. But I'm planning on sharing!