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Nursing School week 2/#13
Apr. 22nd, 2012 09:50 amOnly one more "real" week left! This past week was actually relatively relaxed, except I didn't feel well on Wednesday afternoon and had a terrible headache all of Thursday--this made it very difficult to get my "self-reflections" written on time. (They also weren't 7 pages long this week.) But we didn't have any exams this week, and I didn't have a simulation scheduled (the last one is next week), so it was mostly just classes, reading, and clinical prep work.
We tried a new thing in clinical this week--she paired us up with another student, and on the first day one student did all of the assessments, patient care, and documentation; the other student handled medications. On the second day, we switched roles. Together, we shared 3 patients each day (we've been having 2 patients by ourselves up until now). It was an interesting way to change things around, and it forced us to work on skills like prioritizing and communication, but overall I wasn't crazy about it. There were too many times when I thought "I'm about to give this medication for....whatever...and I don't really know what the patient's baseline is right now because I didn't do the assessment." Between the 3 patients I was assigned, there were 63 medications prescribed! This did make my day of passing medications very busy, especially around the 1000 hour (when most once-a-day medications are given), when each patient had an IV medication. The instructor has to supervise us when we do anything with an IV, and she can only be in one room at a time!
This coming week we get a bit of a break on our clinical paperwork, but let me give you an outline of what exactly I've been writing up most weeks:
For every patient, we have to write up all of their medications. This means looking in the medication book to see what they've been prescribed, how much of it, what route (oral, IV, topical, etc...), how frequently it's given, and any note present with the order (like "hold if systolic blood pressure is < 100." We take this information and go to our trusty medication books to look up the type of drug (ex: an ACE-inhibitor, or an opioid analgesic, or an immunosuppressant), how it works in the body, major side effects and things to assess the patient for before giving the medication, any other information or teaching we should give the patient (ex: this could cause dizziness, or this might make your urine red, or tell your doctor if you develop a cough). Lastly, we look at the patient's chart and lab data to determine why this patient is taking this medication. We are allowed to use pre-printed "Med Cards" (which are published exactly for this purpose) but the card, of course, doesn't know why this patient has been prescribed this medication, or how much of it they're taking, and there isn't a pre-printed card for every medication in the world. I prefer to write mine out on a spreadsheet that I can fold up and put in my pocket. When we go to give a medication, our instructor checks what we're about to give (to make sure it's right!) and then asks us what it's for.
For every patient, we also have to write up a brief analysis of any abnormal lab values. These, obviously, depend on the patient and how long they've been in the hospital. Some patients have blood drawn for a Comprehensive Metabolic Panel and/or Complete Blood Count every day; some don't. Sometimes the doctor adds an order, so they'll get a CMP with an Iron Panel, or a CBC with a Lipid Panel, or whatever... When someone's in the hospital, it's rare that all of their lab values would be normal. We look at the list and write out "the pt's Red Blood Cell (RBC) count is low because they have a GI bleed" and then write interventions that might be appropriate for this patient, such as "assess for signs & symptoms of anemia; cluster care to preserve patient energy; anticipate stool tests for blood; possibly anticipate blood transfusion." Some labs are more inter-related than others. If a RBC is low, it's likely that the hemoglobin and hematocrit will also be low. If potassium is low, sodium might be high (they are usually exchanged for each other in the kidneys).
Writing up the lab values and meds is a very inter-related process. I had a patient a few weeks ago who was admitted with hyponatremia (too little sodium) because the pt's pituitary gland was putting out too much anti-diuretic-hormone (this was caused by too much pressure in the brain because of a recent stroke). Too much ADH = not enough urine, but all the fluid has to go somewhere! the pt had a lot of edema in the legs, but more importantly, all the fluid had diluted the blood too much and s/he now, effectively, had too little sodium. This causes confusion and can eventually lead to coma (too much fluid in the brain). The patient was prescribed Lasix, a diuretic, to relieve the fluid load. However, Lasix also wastes electrolytes. So the pt was also prescribed potassium supplements, magnesium supplements, and salt tablets (sodium and chloride). Lasix doesn't actually waste sodium, but they needed to raise the level anyway.
If any patient has a surgical procedure, we have to write up a short sheet on why they had it, what the surgery entails, and what important post-op care and assessments might be.
Generally, we do all of the above on 2-3 patients each week (it's not uncommon to have a patient be discharged on Tuesday and we get assigned a replacement on Wednesday morning). We also have a longer packet to write up on one patient each week. This packet focuses more on creating nursing diagnoses and looking at the patient's condition as a whole. There are questions about the patient's support system (who do they live with? how will they get around?), discharge planning (will they go home after this? to a rehab facility? back to the nursing home they live in?), education (what learning needs have been identified? did we provide any teaching?), prioritization of care and assessments (you're going to assess the respirations of a pneumonia patient before you worry as much about their bowel sounds), an extended write-up of their primary and (at least one) secondary diagnosis, with some analysis of how the two influence each other, and then development of nursing diagnoses (at least one in 3 different categories). The point of the nursing diagnoses is really to provide a framework for looking at/understanding a patient's condition. I had a patient with a COPD exacerbation, who could barely catch his/her breath while sitting quietly, so "Activity Intolerance" was an appropriate nursing diagnosis. I had a patient who had very poor management of diabetes (and lost a leg because of it); "Impaired Health Maintenance" was one dx. Each diagnosis needs to be supported by subjective and objective data (COPD: Subjective-Pt reports "I feel so short of breath;" objective-respirations are 32 per minute); (Diabetes: Subjective-Pt states s/he "wasn't very good about checking blood sugars at home and would forget to take insulin," objective-pt's A1C level was >13% on admission [target range for diabetics is <7%] with an estimated average blood glucose of 344 [target range is 70-99; maybe 110]. Pt has 4 necrotic toes on R foot which will be amputated on ____)
This coming week, we don't have to do the long packet, just the medications and labs. Woohoo! That's all for now, though--time to get ready for church.
We tried a new thing in clinical this week--she paired us up with another student, and on the first day one student did all of the assessments, patient care, and documentation; the other student handled medications. On the second day, we switched roles. Together, we shared 3 patients each day (we've been having 2 patients by ourselves up until now). It was an interesting way to change things around, and it forced us to work on skills like prioritizing and communication, but overall I wasn't crazy about it. There were too many times when I thought "I'm about to give this medication for....whatever...and I don't really know what the patient's baseline is right now because I didn't do the assessment." Between the 3 patients I was assigned, there were 63 medications prescribed! This did make my day of passing medications very busy, especially around the 1000 hour (when most once-a-day medications are given), when each patient had an IV medication. The instructor has to supervise us when we do anything with an IV, and she can only be in one room at a time!
This coming week we get a bit of a break on our clinical paperwork, but let me give you an outline of what exactly I've been writing up most weeks:
For every patient, we have to write up all of their medications. This means looking in the medication book to see what they've been prescribed, how much of it, what route (oral, IV, topical, etc...), how frequently it's given, and any note present with the order (like "hold if systolic blood pressure is < 100." We take this information and go to our trusty medication books to look up the type of drug (ex: an ACE-inhibitor, or an opioid analgesic, or an immunosuppressant), how it works in the body, major side effects and things to assess the patient for before giving the medication, any other information or teaching we should give the patient (ex: this could cause dizziness, or this might make your urine red, or tell your doctor if you develop a cough). Lastly, we look at the patient's chart and lab data to determine why this patient is taking this medication. We are allowed to use pre-printed "Med Cards" (which are published exactly for this purpose) but the card, of course, doesn't know why this patient has been prescribed this medication, or how much of it they're taking, and there isn't a pre-printed card for every medication in the world. I prefer to write mine out on a spreadsheet that I can fold up and put in my pocket. When we go to give a medication, our instructor checks what we're about to give (to make sure it's right!) and then asks us what it's for.
For every patient, we also have to write up a brief analysis of any abnormal lab values. These, obviously, depend on the patient and how long they've been in the hospital. Some patients have blood drawn for a Comprehensive Metabolic Panel and/or Complete Blood Count every day; some don't. Sometimes the doctor adds an order, so they'll get a CMP with an Iron Panel, or a CBC with a Lipid Panel, or whatever... When someone's in the hospital, it's rare that all of their lab values would be normal. We look at the list and write out "the pt's Red Blood Cell (RBC) count is low because they have a GI bleed" and then write interventions that might be appropriate for this patient, such as "assess for signs & symptoms of anemia; cluster care to preserve patient energy; anticipate stool tests for blood; possibly anticipate blood transfusion." Some labs are more inter-related than others. If a RBC is low, it's likely that the hemoglobin and hematocrit will also be low. If potassium is low, sodium might be high (they are usually exchanged for each other in the kidneys).
Writing up the lab values and meds is a very inter-related process. I had a patient a few weeks ago who was admitted with hyponatremia (too little sodium) because the pt's pituitary gland was putting out too much anti-diuretic-hormone (this was caused by too much pressure in the brain because of a recent stroke). Too much ADH = not enough urine, but all the fluid has to go somewhere! the pt had a lot of edema in the legs, but more importantly, all the fluid had diluted the blood too much and s/he now, effectively, had too little sodium. This causes confusion and can eventually lead to coma (too much fluid in the brain). The patient was prescribed Lasix, a diuretic, to relieve the fluid load. However, Lasix also wastes electrolytes. So the pt was also prescribed potassium supplements, magnesium supplements, and salt tablets (sodium and chloride). Lasix doesn't actually waste sodium, but they needed to raise the level anyway.
If any patient has a surgical procedure, we have to write up a short sheet on why they had it, what the surgery entails, and what important post-op care and assessments might be.
Generally, we do all of the above on 2-3 patients each week (it's not uncommon to have a patient be discharged on Tuesday and we get assigned a replacement on Wednesday morning). We also have a longer packet to write up on one patient each week. This packet focuses more on creating nursing diagnoses and looking at the patient's condition as a whole. There are questions about the patient's support system (who do they live with? how will they get around?), discharge planning (will they go home after this? to a rehab facility? back to the nursing home they live in?), education (what learning needs have been identified? did we provide any teaching?), prioritization of care and assessments (you're going to assess the respirations of a pneumonia patient before you worry as much about their bowel sounds), an extended write-up of their primary and (at least one) secondary diagnosis, with some analysis of how the two influence each other, and then development of nursing diagnoses (at least one in 3 different categories). The point of the nursing diagnoses is really to provide a framework for looking at/understanding a patient's condition. I had a patient with a COPD exacerbation, who could barely catch his/her breath while sitting quietly, so "Activity Intolerance" was an appropriate nursing diagnosis. I had a patient who had very poor management of diabetes (and lost a leg because of it); "Impaired Health Maintenance" was one dx. Each diagnosis needs to be supported by subjective and objective data (COPD: Subjective-Pt reports "I feel so short of breath;" objective-respirations are 32 per minute); (Diabetes: Subjective-Pt states s/he "wasn't very good about checking blood sugars at home and would forget to take insulin," objective-pt's A1C level was >13% on admission [target range for diabetics is <7%] with an estimated average blood glucose of 344 [target range is 70-99; maybe 110]. Pt has 4 necrotic toes on R foot which will be amputated on ____)
This coming week, we don't have to do the long packet, just the medications and labs. Woohoo! That's all for now, though--time to get ready for church.
