Just kidding.

I got some spam email from a company that wants me to advertise their stuff for free. They linked an ebook and I was perusing it with a smirk.

Then I happened upon this golden advice for nurses:

Listen carefully. Sometimes physicians can give orders so quickly and it could be hard to keep up. If you don't understand, make them slow down and go over it, but don't second-guess the doctors. Part of your nursing job involves carrying out the orders of the physician, even if you feel another course of action might be best.

Words from the pros, people. Your professional opinion is worthless. DO NOT QUESTION THE PHYSICIAN.

Now fetch me a cigarette, the chart, and a hot toddy, stat! And pick up my dry cleaning!

Blech. I've written 3 care plans this year, one for each of my clinical rotations. They are essentially full-sized research papers worth a huge chunk of my final grade.

Care plans are fickle creatures. We never had a proper care-plan-class, which really irritates me. I mean, I had to take English (again) to ostensibly learn how to write papers, but I don't have to take a care plan class to learn how to write care plans? Especially when I have never seen a care plan in my life and said care plan has the same impact on my final grade as any research paper had?

So because the learning curve was kind of steep (last semester we were briefly introduced to the nebulous concept of writing a care plan, and all of a sudden this semester we were told to Write A GOOD One Because It's Worth 30%), I had a lot of self-learning to do. Something I do frequently, it seems...

As part of the framework required to write the care plan, my school assigned the following guidelines:

• Patient's age, gender, marital status, religion, allergies, admission date, diet, activity, code status
• Current medical diagnoses including pathophysiology
• Past medical hx and health problems
• Applicable surgical/other procedures and their most common complications
• The patient's context of health, including (my personal favorite... lol) ye olde Determinants of Health and the principles of Primary Health Care
• The patient's developmental and social hx, including family and their influences on the pt's health
• Ordered tests, treatments, and interventions, including agency protocols and policy
• Recent diagnostic tests and results
• The teaching/learning needs of the pt
• How other members of the interdisciplinary team are involved in pt care
• Strengths & capacities of the pt
• Ordered medications including rationale, classification, side effects, and nursing considerations specific to the patient
• And, finally, 3 primary patient needs to address in the care plan. Each must include:
• Nursing diagnosis (NANDA stem, etiology, and manifestations)
• NOC labels 'SMART' goals (specific, measurable, appropriate [person-centred], realistic, & time limited
• Nursing interventions (NIC labels)
• Rationale
• Evaluation

Physical environments. “The physical environment is an important determinant of health. At certain levels of exposure, contaminants in our air, water, food and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness and gastrointestinal ailments (Public Health Agency of Canada, 2003).” Jane has lived in Alberta for her entire life. The urban health regions have a much lower mortality rate for all causes of death for females from 2006 to 2008. Calgary has 419.43 deaths per 100,000 population and Edmonton has 427.59. The mean for Alberta is 443.65 (Alberta Health and Wellness, 2009). Jane’s physical location is positively impacting her health simply by virtue of health accessibility and active living opportunities.

I also got very detailed with my NANDA-specific nursing diagnoses (this was the first of 3):

Priority need. Ineffective coping related to loss of vision, personal vulnerability, perception of inadequate control, impaired adaptive behaviors, and problem solving skills, as evidenced by flat affect, social isolation, inability to meet role expectations, poor self-esteem, uncertainty about choices, and deference in decision-making. Jane’s history of dependent behavior is making it a challenge for her to adjust to life as a visually impaired person. It is easier for her to surrender decision-making responsibility to John and rely on him to perform the roles of partner, guide, and caregiver than to accept her blindness and find ways to manage with it and go on with her life. Jane instead copes by isolating herself and being the passive member of their relationship.

Apparently it paid off, because I scored 18.9/20 on it. I was floored. I NEVER expected that kind of mark on the last paper of the year. Yay, me!

If you struggle as much as I do with writing care plans, I STRONGLY recommend investing in a good care plan book. I really, really like Gulanick & Myers' Nursing Care Plans: Nursing Diagnosis and Intervention. The book was very well rated on Amazon and with good reason. It has the NANDA, NIC and NOC labels for all included care plans as well as oodles of online resources and plenty of interventions and rationales. I am very happy with it. So is everybody who keeps 'borrowing' it every time a care plan comes due. At $40 it has been way more valuable to me than the freakin APA guide I spent an embarrassing amount of money on in first year.

Also keep in mind that your campus library, hospital library, and often hospital unit have really good (and really specific, in the case of on-unit material) references available. That's how I found specifically psychiatric care plans such as the one I used for my 'Ineffective Coping' diagnosis.

Another really good free online source I found is the Care Plan Constructor which I have linked on my Resources list. It's not as detailed as a book would be, but it gives you some more interventions and rationales to cite. It's also faster to navigate than a book, IMO, so it can be really handy to peruse for diagnosis ideas.

If I think of any other good things to add, I will. If you need help with your care plan I'd be happy to try. If you have any questions, fire away!

Typically, I hate them, because I've never felt like the group did a better job than what I could have done by myself.

I'm working on my last project for the year (!) which is a group presentation with myself and another girl. It has been AWESOME because we had a total mind meld and worked together like magic. We both contributed equally to the project and helped each other completely.

Project, start to finish = 4 hours.

For the first time, I think I *enjoyed* a group project. Don't tell any of my instructors. I have an image to maintain ;)

[/profound]

That's Mental Illness, not myocardial infarction, except those are pretty common too.

One of my oldest, bestest friends, who actually completed half of her nursing after-degree and quit because she hated it, may very well be suffering from major depression. She's one of the most amazing people I know. When she feels like herself, she's funny, SO intelligent, adventurous, and free-spirited.

I spent an hour on the phone with her this afternoon talking about nothing much and then we started talking about her life and where she is with it.

She's not happy or remotely satisfied with her choices and she feels like she's 'running out of time' to pull her shit together. We're the same age. This same conversation has been happening for years. She's opposite of me - where I went globetrotting after high school, she went straight to university and took a degree in something that doesn't interest her, hoping she'd find herself. She still hasn't.

Anyway it started with a regular girlchat and morphed into me using my psych skills on her. She expressed fear and doubt about whether she was ever going to be happy and questioned the validity of seeking medical help. I told her in no uncertain terms that antidepressants and mood stabilizers were just one small piece of overall therapy. They would help her feel well enough to start seeking ways to get more from her life. They would provide the boost.

I then heard her out and repeated parts of her narrative back to her to really emphasize some of the self-defeating thoughts she was having. We then discussed how regular exercise might really help her feel better. I really promoted some of the AMAZING psych programs I've seen while I have been on my clinical rotations.

I finished the conversation with this:

I care about YOU. I could give a shit whether you stay in school for the rest of your life or never step foot in a classroom again. I don't care whether you go be a carpenter or a business executive or a drifter. All I have ever wanted is for you to be happy and it kills me that you haven't found that.

She agreed to seek help.

I still consider her a suicide risk if she doesn't get help soon. If there's nothing else in the world that I learn from nursing, I am grateful that I learned just enough to help my friend feel hope.

Mental health issues are everywhere, people. Don't sleep though your Psych classes.

Hopefully it works. I had a lot of fun designing it and the wonderful iPod-wearing Flo was feeling a little tired up there. The graphic was designed by myself so please don't steal it ;) Let me know if there's anything broken...

I had to remove my blogroll and links until I can get them working again.

I was up since 3 AM this morning finishing my last care plan for this rotation (mental health). It's a very cool specialty and I'll describe it for you in another post.

The big thing on my mind right now? I FINALLY got the last piece of my application today, from the instructor who so frustrated me on Friday.

This is the position I applied for. I *just* sent the email with my completed application package. It's been over 2 years since I went through the process of applying for a new job and it never gets any easier.

This is actually way worse because it's, like, the real me I'm sending out into the great unknown. It's not some crap job I'm getting to tide me over until I'm ready to start my career. This is my first contact with my future employer, assuming they're still hiring RNs when I graduate and pass the boards.

This IS my career.

The fluttering in my chest is just like it was 2 years ago (nearly to the day - just... wow) when I realized what I was getting myself into:

It's the searing excitement in my chest - I am going to Be. A. Nurse. After so long trying to find a place for myself in the healthcare industry, this is it. I am standing at the very beginning of my chosen path and I am so incredibly ready.

Now I just watch and wait and hope I said all the right things.

*stares at the clock*

The deadline for my UNE submission has been changed to April 15 (Thursday). I still have a fair shot. I'm getting the form from my instructor tomorrow when I turn in my third and final (!) care plan for this semester.

I'm feeling a lot more positive and relaxed now. I've got a huge emotional investment riding on being accepted into AHS. I'm scared and excited and hopeful.

When people ask me what I do, I am so proud to say I am in nursing school.

Every day I am making a difference to someone and I am so, SO, in love with my profession. I have never had a doubt in the last 2 years that I was making the right choice. Everything that I see and do has been inspiring and challenging to me. Menial tasks like fetching water or changing linens have never bothered me. I have been privileged to help people in their times of medical and emotional need. I am in a trusted position and people listen to me, really listen, when I speak to them. I work hard to hear what they have to say.

It has been a long journey and I'm only halfway there, but this opportunity to begin embracing my chosen role is one that I have been waiting a lifetime for and I am so ready to get started.

I am applying for an undergrad nurse position. It's a very competitive spot, as you can imagine. I needed several forms to complete including one mandatory reference from school. I think I have a pretty good chance... EXCEPT:

• My instructor, who is my reference, agreed to fill out the required form on Tuesday
• She lost the form 3 times and I keep reprinting it for her
• My school decided YESTERDAY it would put in a new procedure on requesting references
• Said reference request has a form required (of course)
• I can't get the form because I am at clinical and not at the school, and it's not available online (of course)
• I have EVERYTHING ELSE I need for the application including a very thoughtful resume and cover letter that took me hours
• My instructor refused my offer of sending her the form as soon as I got home if she'd just give me the completed reference today (Friday)
• She stated the earliest she could get it to me was Monday
• The posting closes Sunday

I've started this post about 5 times now on different days but kept having to try again later. My days are just sooooo busy. I guess having too few hours in the day is a good thing, given the alternative!

My second rotation started in mid-February just before the Reading Week break (that's our Canuck version of Spring Break... only it's in the winter and less associated with drunken bingeing ;) Man, let me tell you, at the end of my first rotation on Medicine I felt a degree of competency I could hardly believe. The nurses on that unit trusted us to do good work. I assumed all aspects of care for my patients and at the end of the rotation I had three. I was pouring meds independently (although we had to get an RN to cosign narcotics and insulin, and our instructor to cosign Coumadin/Heparin). Basically the only time I saw my instructor was a daily check-in to verify my assignment. I felt very comfortable with my patients and their needs and saw and did a lot.

So I had a certain expectation that I would only be improving on the skills, independence, and decision-making that I had been developing over the past 5 weeks.... well, not exactly.

My instructor for the second rotation was an older nurse who'd had her masters for longer than I've been alive! She had been a nurse manager/administrator for more than a decade. Compare that to 3L where my instructor was maybe 10 years older than me and was still in bedside care in the CCU.

This new instructor had a totally different attitude towards teaching. She considered herself more of a facilitator and did not give concrete expectations about anything. It drove us CRAZY. We'd ask what she needed to directly observe, or what meds we could pour, or what expectations she had for the care plan.

Her answer to everything? "It's not about me. It's about your learning."

Um, thanks. Wait, what?

Anyway it ended up that my I-think-I-can attitude from 3L was completely shot because for the entire 5 weeks she insisted on watching every med poured, every dressing change, every bladder scan, every foley/straight cath/IV line prime/etc, (almost) every assessment, and so on. The real problem with that was that we were split between 2 units she would take FOREVER getting from one unit to the other to observe all of these things.

The big difference between the two rotations, I guess, is that on 3L it felt like we were actually somewhat useful to the unit. Handy to have around.

On 6R we were just a pain in the ass. Because she insisted on watching *everything*, that meant a lot of things had to wait. Sometimes hours. Sometimes those things were meds. Some days I didn't pass 0800 meds until 0930. A lot of times I had to ask my buddy nurse to do things that should be Really Freaking Basic because I didn't have permission from the instructor to do them without her and it was something that was urgent.... perhaps a fresh post-op was at 8/10 pain, or the initial dressing was not holding, or something like that. Boy, did I feel great making excuses all the time for why my patient care seemed so crappy. Luckily the patients were really understanding. The nurses? Not so much. Apparently the charge RN took it to the dean (not sure) of my school saying that it was unethical for patients in pain to wait for morphine because the instructor wanted to see it. Especially because school policy says that all we need is ANY nurse to cosign - RN, LPN, whoever is handy! I totally agreed with the charge's opinion. Complete BS, IMO. No patients should have to suffer in pain for ANY length of time just because they have a student assigned to them.

I will say, though, that as much as the instructor's (ahem) 'teaching' style grated on me, she had really valuable insight into people and behaviors. At my midterm evaluation, I was amazed at all the things she had noticed about me. She had things written down from the first day on the unit. She was incredibly perceptive and it was actually really good to hear what she had to say. She said I was a good nurse and that she would hire me if she were still a unit manager. I was completely honored, given her background.

Well! Venting aside, let me describe the unit :)

I think we usually had 19 beds open. The patient population was mostly 60+ and in for elective hip and knee arthroplasties. MOST of the time they were post-op but we did have a few people come in before their surgeries. WOW, what a difference from Medicine! These patients' average lengths of stay were less than 5 days. We would get a post-op in at about 1400, often still numb from the spinal block, and by 1900 physio would have them up walking. I COULD NOT believe how fast their recoveries were. I guess I still had the perception that there was a certain period of convalescing after a major surgery like that - not so, at least not for joint replacements.

Patient care usually consisted of neurovascular assessments and vitals q shift (depending on how recent their operation had been), hygiene, encouraging mobility, assisting with transfers, pain assessments and interventions, and prophylactic meds like Fragmin. And drains. And dressing changes... omg! Dressing changes! Part of me thinks wound care is SO AWESOME!!

I took a picture of the giant Wall O' Dressing Stuff. That was a HUGE learning curve for me. There are dressings for every type of wound. Occlusive, silver nitrate, hypotonic, absorbent, moist packing, protective, nonadhesive... the list goes on and on. I spent literally hours in here (this is the clean utility room) going through all the bins and researching what type of dressing was best for what type of wound. I absolutely loved it. Most patients with a healthy surgical wound, typically and depending on drainage, got their wound aseptically cleaned and dried with normal saline, a layer of Adaptic to prevent adhesion, Cavilon to protect the surrounding skin, and either gauze and abd pads taped down with the sheet tape or Mepore all-in-one bandages. Sometimes I had to get creative and splice together bandages to fit. My instructor had her own ideas about how I should do it, and I usually followed her advice, but when I started sneakily doing dressing changes on my own I did it my way and it looked (and lasted) much better. My sterile technique is completely second nature now. I worked a sterile field sometimes 2 or more times per shift, and it was often awkward as hell with a huge pile of dressing packages and a tiiiiiny little dressing tray for space... I also got to do a dressing change on a central line. The patient thought I did such a great job, he wrote me a letter of commendation! *sniff*

The drains were also pretty cool! I drained and primed a lot of hemovacs. It's amazing to see just how much post-operative goo can come out of someone. The pic on the right was about 300 mLs, I think, drained only about 4 hours after I had already drained 400. She was a fresh post op and quite the bleeder. It looks like straight blood but it isn't; there are tiny bits of bone in there and lipids and lymph. It's quite the cocktail ;) Strange smell to it, too. It smells very strong and very chemical, like a hair perm might.

6R was all about teamwork. All us students got letters when we orientated, stating the rules of the unit. One of the big ones was that we were to NEVER risk our backs. All lifting and heavy patient care was to be done in teams. I was totally impressed with how well everyone worked together. There was always someone ready to help you. The NAs seemed to be everywhere at once.

One of the NAs was a dear older Brit who used to nurse in England. When she came to Canada, her licence did not transfer, so she chose to work as an NA instead of upgrading to LPN/RN. She said she loved patient care more than anything else a nurse was expected to do, and she was really, really good at it. She appeared at my patient's bedside on the first day and helped me give a bed bath, just because. She then instructed me on how to give a really freaking good bed bath. My pt was just about purring by the time she was done. She said that chances were excellent that if you give really excellent nursing care in the morning, patients would be feeling very content and not likely to ring their callbells for the rest of the day. She also said it was very therapeutic for the family as well to see their loved one comfortable and cared for. I completely appreciated her help all throughout the rotation. She was great. I wish SHE was my instructor...

It was amazing how the whole unit acted as a team. EVERYONE went to report, including the unit clerks, NAs, manager, staff nurses, students...

Really the only 'downer' during my stay on 6R was my instructor's desire to see and do everything even though that wasn't physically possible. I'm a pretty gung-ho student. I keep my eyes and ears open for opportunities and make the most out of my rotations. I really liked the unit itself. It seemed like a great place to work, given the helping atmosphere and the fact that most of the patients were there for elective surgery and WANTED to get better and get the hell out of there so they were very motivated and active in their own recoveries. Don't get me wrong, Medicine had its moments, but Surgery didn't have the same atmosphere most of the time.

The other negative about the unit, and it really wasn't about the unit at all, was regarding one of the patients. I really should call him a resident. Actually, I'll call him Mark ;) He was a 60-something man with some severe congenital cognitive impairments. He yelled inappropriate things and was aggressive and immobile. Apparently he had a fall at his group home, fractured his hip, and was sent to our unit after surgery. This was OVER A YEAR ago. The group home refused to take him back (!) because he was so difficult for the staff to handle. Because no one could find him a place to go, he stayed right there on Orthopaedics, probably one of the most ill-equipped units to have a guy like Mark. Everything was so busy that there was no time to just sit and spend time with him and give him the quality care he needed to reintegrate him back into a group home. He was just strapped into a Broda chair most days. You could hear him yelling obscenities from the other unit, and my heart cringed every time I saw a child pass near his chair with no one to make sure he wasn't going to strike out. The hospital did the best it could by assigning an NA to be with him 1:1 as much as possible... but really, he shouldn't be there. Mark is a perfect example of a guy who just fell through the cracks.

I saw a couple of interesting cases during my last week on the unit:

• One pt was a trauma who was flown in from very, very north (~200 km north of the Arctic Circle). He was, like, the embodiment of the Determinants of Health. He was remote, poor, uneducated, male, and Aboriginal. My Foundations in Health class would have had a field day. He had gotten into some kind of snowmobile accident and shattered his tibia. I was trying to do a thorough neurovascular assessment on him (big risk for compartment syndrome - challenging because of the cast he had on his leg), and there was a whole freaking med team in there discussing his surgery, and the surgeon was pushing consent forms in his face, and my primary nurse was attempting a dressing change. He was a pretty neat guy though. He told me about hunting polar bears and seals and carving traditional bows and knives. He had some epically beautiful pictures on his laptop too. Wow. Kinda makes me want to be a Northern nurse................. lol, yeah right. Maybe if they had sun 12 months a year ;)

• One of my few sub-60 year old patients was a younger mom with a spindle cell sarcoma in her upper arm. She was in for her second resection to try and remove the tumor. She had gotten a skin graft taken from her ventral thigh, and that was pretty awesome. I couldn't believe how much fluid wept from it. No wonder people with burns are at such a high risk for dehydration! I had to do a dressing change on it because the one done 3 hours prior had already sprung a leak. I ended up putting a medium-sized Tegaderm on it, taping it all around, and then putting a huge Tegaderm over that and taping that all around too to try & seal it up tight. My dressing held quite well actually! She had it on still after I was done my rotation. I was very proud of myself :) I also had a really awesome Nursing Intervention moment. She had her initial dressing on her upper arm for over 5 days. Well, by the end of the 5th day she had a crazy case of the itchies. She looked really uncomfortable. I noticed she had Benadryl ordered for nausea so, with the consent of my instructor, I gave her 50 mg of that. Lo and behold, it worked! Total self high five! No more itching, and she pretty much loved me from then on.

• My other Really Cool patient ended up being the guy I wrote my care plan on. I got to go into the OR and follow one person through the entire hospital experience. I got to Same Day Admit at about 0800. The first thing that struck me was how young he looked. Comparatively, I mean. He appeared in his late 60s and he was in for a total hip replacement. Turns out he was actually nearly 80!! He had been very physically active for his entire life and now was getting joint replacements because of the osteoarthritis from his sports-filled past. The guy was seriously the fountain of youth. He lived in the mountains and biked 5km every day. He and his wife were adeptly maintaining their home. He looked decades younger than my own grandfather. No lie.

Wow, the operation!!! That was so cool! He was awake through the procedure. I followed him down from SDA to the operating room where I changed into OR scrubs and a hair net. We wheeled him into the theatre and slid him onto the table, and the anesthetist gave him a spinal block (SO COOL - the catheter was massive!!). The anesthetist threaded the needle between the disks and into the spinal column while the pt was sitting leaning forward. Then they laid him down while he could still move, put in a foley, and proceeded to drape the hell out of him. The surgeon was very particular about pressure points from the catheter tubing and clamps etc, which I approved of. I got to stand about 5 feet away throughout the operation so that was very exciting for me. I wanted to be as "in" the action as they'd let me and if I were any closer I'd have contaminated their sterile field :)

They rolled the pt onto his side and clamped him, so to speak, in that position. Then they cut through his skin and down to the acetabulum. And then, oh my god, the surgeon and the resident grabbed onto the pt's leg and popped the head of the femur out!!! It made this nasty thwwwwwwwOP sound that just hit the pit of my stomach and made it churn. Nothing else in the entire surgery hit me quite like that. Once the femur was out (shudder) the surgeon took a bigass bone saw and cut the head of the femur off. I mean off. He plucked it out of the wound and plopped it onto the instrument table. Mmmmmmmmm ;)

Oh! The instrument table! MASSIVE! I was amazed at how the scrub nurse knew what to get and when. There were about 3 tables pushed together, all covered with sterile drills and bits and screws and saline and cloths, oh my!

It truly was like being at a mechanic's shop. The surgeon and the resident and the product suppliers were all talking about the pt's leg and fitting different-sized cups and heads into him. They were moving his leg all around and using power tools on him. It was kind of surreal.

The thing that really got me, though, was how the OR was not really about the patient at all. At that point he was just a Hip that needed fixing. No one talked to him throughout the procedure and really no one censored their conversation to accommodate him. The scrub nurses and the surgeons were talking about some kind of masochistic x-rated somethings at one point. I kind of thought the surgeon was a dick, actually, but he was kind enough in teaching me various things. He was only a little chauvinistic towards me ;)

They sewed up the pt without putting a drain him because he didn't bleed very much, and then I got to care for him for the rest of the week, and I wrote my care plan on him as well. It was great, actually, for both of us. I think he appreciated knowing that I would be there when he woke up in the morning and I knew all of the ins and outs of his surgery given that I had seen it with my own eyes.

Well I guess I'd better wrap up this rambling. Feels like I've been typing forever!

Summary: I definitely liked my surgery rotation. If there's one phrase to describe me, it is Morphine Fairy. I loved giving people pain medications to control acute moderate-severe pain. I loved seeing them grit their teeth while I prepped them for a sub-Q or IM injection and then watching them drift off to sleep within half an hour. I'm not sure if I'm a med/surg nurse, but I learned a TON. Really, I've enjoyed all of my rotations because I'm the kind of person who goes into an experience with an open mind and a humble, 'teach me' kind of attitude. Not like some of the ice queens in my class, but that's a story for another day. Good night, nurses and nurses to be :)

You may remember all of the textbooks I bought for first year – I spent close to $1000 on books alone. Then I went hungry but not *quite* hungry enough to eat a textbook. Well, surprise! Some of those books I barely even cracked open. Here’s what I did for this year:

I didn’t buy a damn thing. Not one.

I know, I know, I can hear you WTFing from here! “But I’ll fall behind on my readings!” you say? I hear you. This is what I did, and I didn’t fall behind on my readings – all it took was a little ingenuity.