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We had our first exam out of 5 (not including the cumulative final) this week.  It covered chest traumas, heart dysrhythmias, cirrhosis, and hepatits, plus some math questions.  (There are always 3-5 math questions, which are usually guaranteed free points as long as you round the answer correctly and include the correct units.)  I did really well on the exam, which is a nice way to start the semester!  The nature of the questions is getting somewhat more difficult (as they've told us all along would be the case).  For example, a complication that can occur with cirrhosis is the formation of very fragile blood vessels (varicies) in the digestive tract.  These can rupture easily, leading to hemorrhage.  A question from our first semester might have focused on either identifying the phenomenon or basic management (like "don't eat irritating foods").  A question from our second semester might have focused on a medication and teaching the patient what it does (the right answer would be something like "this beta-blocker will lower your heart rate and blood pressure so that the blood isn't putting so much pressure on the vessel.")  One question on this exam was something like "The nurse assesses the effectiveness of metoprolol in controlling varicies by:  a) noting that the pt's blood pressure has decreased, b) making sure the pt takes his pulse each day before taking the mediaction, c) assessing for bloody stool or emesis, d) ...something else I don't remember."  With this question, 'a' is a correct interpretation of what this medication does, and 'b' is something the patient should be taught to do when taking this med (which is a beta-blocker).  But the correct answer is 'c', because it addresses the actual problem that occurs with varicies--they bleed (sometimes profusely) into the GI tract.  If blood is still appearing, the drug isn't solving the problem.  So, on reading this question, we're now expected to automatically know and identify the type and action of the drug, as well as the danger associated with the varicies, and then put these pieces together to evaluate the effectiveness of the drug. 

We didn't have any new theory in class this week, which I think is a little weird, but that's the way they wrote the schedule.  We start to learn about the renal (kidney) system next week, as well as management and delegation.  We also have the first of our mandatory math tests for the semester.  These don't count towards our grade, but we must get 100% or take it again.  If a person fails to get 100% after 3 tries, they have failed the entire semester.  I'm not actually aware of anyone who has had to repeat a semester because of this, but I'm sure it has happened.

We had our second week of clinical this week, which I thought went better than last week!  Our instructor has warned us, though, that she's going to start expecting more and more of us--I think not so much in terms of "more tasks" but "more thought, more assessment, and more problem solving."  The idea is that by the end of the semester, we need to have developed at least a rudimentary amount of "nursing judgement," whereby we identify an abnormal finding, assess all of the pertinent information, and then decide what to do--which might include calling the doctor or NP, but that's not the first step.  So, for example, if a patient suddenly complained of being short of breath after walking a short distance, we'd need to measure their pulse oximetry (that little finger clip with the red light), listen to their lungs, identify whether they were in pain, and check the level of oxygen they are receiving (if they have external oxygen).  Then based on those findings we might decide "the lungs sound okay, but the patient needs to use their inspirex (a device they breathe through that promotes fuller lung expansion), and needs to wear an oxygen bottle when walking around" or "there are some crackles in the lungs where there weren't before.  This could mean fluid is building up.  The patient needs to walk a lot, deep breathe and cough frequently, and use their inspirex."  or (maybe) "I can't hear any breath sounds on the right hand side, and I could earlier.  We need to notify the doctor right away."  But most likely, this is not the case, and the nurse is the one who needs to gather the information to make this call.  Even though this sounds kind of simple, it's definitely a habit we need to actively develop.  In part, this is because for the last 3 semester we've been taught to come to our instructor immediately with any abnormal findings.  This is because we didn't necessarily have the knowledge yet about what these findings might mean.  But by now, we should have the knowledge base to understand/interpret the data we gather when doing our assessment.  (Of course, we still have to let the instructor know!  But we need to come to her with *all* the information, not just "my pt is short of breath.")


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