![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
Nursing School week 3/#15+
Well, this is a little delayed, but better late than never, I guess...
On Tuesday and Wednesday of Week 15, I took my final exam in OB, then the computerized exam (which was harder than I expected) and also the computerized exam in Mental Health (which was also harder than I expected!). I had my evaluations with both clinical instructors, which went well. I assume our grades have been posted by now, but our online registration site has been defunct since the middle of the semester so I can't check. (This made registration for Spring of 2013 really easy, lemme tell ya!)
So, that officially marked the end of the semester. 3 out of 4 complete!
Thursday and Friday I did...something...which probably related to getting Christmas presents ready to mail? I really don't remember, and it was only 2 weeks ago. Maybe I slept a lot... My vertigo continued to slowly go away, and by Saturday the 15th I wasn't very aware of it any more except when trying to keep my balance or moving with my eyes closed.
Saturday I started a Clinical Elective, where we get to spend 5 days on a floor with an instructor and just hone our skills. I'm really glad I did this! It brought back to mind all kinds of management and organization issues I need to keep working on, and gave me a chance to practice some skills I haven't used in a while. I got to give my first intramuscular injection, too. (It's flu/pneumonia vaccine season!).
The Elective met on Saturday, Tuesday, Wednesday, Thursday, and Friday. On Monday, I mailed all the Christmas presents, having spent Sunday making fudge and bread to go in the boxes. I can't say I really did a lot on Tuesday-Friday after Clinical--it's pretty exhausting, and I had to be there at 6:30 in the morning. I definitely think that evenings will be my preferred shift (if I get a choice!).
My brother arrived from the midwest on Saturday the 22nd, and we had a really nice week with him. We went out to Rochester to visit a family friend on the 24th, and then had Christmas at our house. On the 27th we did a lot of shoveling, but it wasn't too bad since the only pressing engagement we had was for PoC to go to work each evening. (I so wish we were in a position where he didn't need to work nights, but it's a paycheck...) My brother left on Saturday the 29th, and we left a few hours later for a very short trip to VT to see PoC's family. The drive took about an hour and a half longer than usual, but we made it safely and returned home safely on the 31st. Two days there is really about enough, anyway! Now I'm enjoying relaxing at home for a few days until I really start to feel like I must study for next semester (the syllabus comes out next week; classes start on the 15th). Maybe I'll write our Christmas letter!
Behind the cut, for length, a recap of some of my clinical work this semester (Pediatrics, OB, Mental Health; I already talked about the Community-based nursing stuff). As usual, excuse the fact that I can't indicate age or gender!
Pediatrics--I spent a total of 6 days on a floor at a Children's hospital. In general, the patients on this floor were fairly stable--it wasn't the ICU or the oncology floor. Many were post-surgical patients, but not all. The turnover/discharge rate was pretty high, so I rarely had the same patient on 2 days in a row. Our focus on this floor was supposed to be not only the medical/physical assessments related to the illness, but also observations of normal/abnormal growth and development, and family coping patterns.
I had a preschooler with a broken femur from an accident--surgical repair. Only the father really spoke English; the patient watched and listened attentively, but never spoke to me. The mother was protective and worried (naturally!), and wouldn't let the patient try to bear weight or get out of bed, even though both were allowed. They were discharged the next day; I just hope the patient got up and started moving around at home.
I had a gradeschooler with a tear near the rectum caused by a fall in the shower. This patient was doing really great until it came time to put bacitracin (painless ointment) on the wound, at which point s/he broke down in tears out of fear that it would hurt--apparently the initial exam before the stitches had hurt a lot. I got through it without causing pain (a lot of parental comforting helped, too!) and was then able to write one of our long write-ups about my actions and assesments of the patients reactions (for example, we're supposed to recognize that reaction formation is a common coping mechanism in this age group--the child will present the 'expected' reaction--ie: bravery--while really feeling scared. So, I wrote about this concept and the reassurance that I gave the patient and the physical actions/interventions I took to reduce pain.) After this, the patient was cheery again and was released that evening.
I briefly had a teenager who came in late in the day in anticipation of surgery the next morning. The surgery (necessary, but not emergent) had already been delayed by the fact that the patient had 2 STDs the last time they had attempted the surgery. The patient admitted this time that s/he had continued to engage in unprotected sex after the last round of treatments, and thus the patient needed to be tested again before any further preparation could take place. This patient was an older teen, but it still made me sad to see that s/he arrived at the hospital unaccompanied--and obviously wasn't getting a lot of guidance at home.
I had a toddler who had been burned in a kids-playing-with-matches-and-gasoline accident (yes, this really does happen). The wound care team did all of the dressing changes, so I just needed to do my 'normal' assessments. The mother was with the patient the whole time and obviously very devoted--and felt terrible about the accident. The patient was very chipper and played and smiled--despite the full-length bandages on both legs.
I had a younger-gradeschooler who was having a bone problem in the hip bones repaired. One hip had been done a couple of years prior, and the second hip was now completed. Even with a surgery as involved as this, the patient was sent home 2 days later!
I had an infant who had been born 2 months pre-term and had spend most of his/her life (to date) in the NICU. One week after coming home from the hospital, s/he was admitted with 'Failure to Thrive' which can mean a lot of things, but basically means s/he wasn't gaining weight and was spitting up everything. Eventually, reflux was diagnosed (I got to watch the stomach scan!), but it seemed to me that the larger issue was a pair of young, underprepared parents who had really not had any time with their baby to figure out stuff like 'how to hold it!' I was really hoping when they were discharged that being able to spend a little more time with their baby would help them learn to meet his/her needs! It wasn't that they didn't care; they just didn't know what to do...
OB/Maternity--we spend a total of 6 days here as well, but it was broken up into 3 days on the labor/delivery floor, 1 day devoted only to the nursery, and 2 days on the post-partum floor. The first day in L&D we mostly learned about the floor, the birth process (we hadn't had this content in lecture yet) and certain procedures (such as the external fetal monitoring equipment that gets belted around the mother's abdomen). The next day, I got to watch a birth! This was an amazing experience! It was the mother's first baby, and the husband, some sisters, and both grandmothers were at the bedside. (There were actually a ton of people in the room--in addition to family, there was the OB, an OB resident, a medical student, me, the RN, an RN who was being trained on this floor, and after the baby arrived, another RN!) I was present when the mother got an epidural, and then her labor progressed fairly quickly over the next few hours. The RN had a lot of experience on this floor, which was a great thing to watch. The baby was healthy, though needed a little help to start breathing at first (lots of suctioning with a tube down the trachea, and slapping of the feet. They don't hold babies upside down and smack their bottoms anymore, though.) After the baby was breathing, I got to participate in the initial assessment (overall shape & function of limbs, posture of body, presence of reflexes, right number of parts, etc...) and put the erythromycin in the baby's eyes. Then we wrapped him/her up and placed him/her in mom's arms!
My last day on the L&D floor I shadowed a RN who was working triage that day--any pregnant woman who comes in with a complaint is usually sent here (unless it's a broken leg, or something). We had one patient who seemed to be in early labor but was only at 37 weeks--after determining that she wasn't progressing too quickly (ie: the cervix wasn't opening), she was given medicine to slow/stop the contractions and sent home to rest. The general philosophy is that the baby should stay inside unless it is definitely more dangerous inside than out! Another patient came in to have pre-eclampsia ruled out--her blood pressure had been high at her last appointment, but she was otherwise healthy. (If positive, this would be a case where the baby might need to come out rather than staying in; eclampsia doesn't resolve until the birth, and it affects the circulation that supplies the baby.) A third patient was in a lot of pain that seemed not to be related to early labor--the doctors were trying to figure out if she possibly had pancreatitis.
On the nursery day, we spend time assessing healthy infants. Not everyone in the group actually got to watch a birth, so for some this was their first time. We were also about to watch a circumcision, but the doctor realized that the baby's foreskin was partly adherent (not loose) and the baby's urethra wasn't at the tip of the penis--called a hypospadias. In both cases, the baby can't be circumcised. The hypospadias needs to be surgically repaired for normal sexual function later in life, and the foreskin tissue might be needed in this repair. After this, though, the baby can be circumcised. This was an interesting case, because the problem was obvious to the eye. An assessment at (or shortly after) birth should have identified it--I'm not sure why it was missed!
On the PostPartum floor, I had the same patient for 2 days because she had been a drug abuser so she had the baby needed extra monitoring for withdrawal symptoms before discharge. I wished I could have had her a 3rd day, because on the 2nd day her blood pressure started to rise--eclampsia can occur after the birth, too. Of course, I didn't want her to have eclampsia (which can ultimately lead to seizures and coma), but the blood pressure changes probably wouldn't have been caught if she'd been send home 48 hours after the birth. I would have like to learn the eventual resolution of it all.
Mental Health. We spent 6 days on an inpatient floor of a local hospital (but I only did 5 because of the vertigo issue). The floor is a locked, secure floor--mostly to protect the patients from the world, not the other way around. Patients must give the staff a password for anyone who calls requesting information about them; otherwise floor staff cannot even acknowledge the presence of a particular patient on the floor if someone inquires. The floor treats patients as young as 17. In general, most patients we saw had been admitted involuntarily because they had threatened to hurt themselves. Some were brought by family members; a few had been picked up off the streets by EMS. However, many had then converted their admission to 'voluntary' status, which means that they request further treatment.
I found this floor to be interesting from an intellectual point of view, but not a place I'd like to work. Mostly, we spent time talking with patients--which isn't a bad thing, but I think I need more activity in my practice. Some other students loved it, though! We weren't assigned specific patients--we were expected to try to talk to as many as we could, and use our therapeutic relationship skills to the extent of our ability and the patient's level of orientation/rationality/anxiety. Among the patients I spent the most time with were a patient with severe anxiety (who was discharged our first week and had been readmitted by our last week)--when something triggered this patient's anxiety, it was like flipping a switch. All of a sudden s/he was in severe-anxiety mode--unable to concentrate on anything else, requiring direction and assistance rather than making decisions for him/herself. Another patient had an eating disorder and was going to be transferred to a hospital specializing in this as soon as his/her suicidal ideation was under control. Another patient had severe depression and was nearly inert. A college-age patient had been admitted after being found stuporous by his/her roommate. The staff was trying to determine whether s/he had taken some bad drugs (which s/he denied) or whether this was possibly the first psychotic break in schizophrenia (which manifests itself in teen/young adulthood).
This floor did not have padded rooms or beds with leather straps for holding patients down. It did have a couple of low-stimulation/isolation rooms (with no furniture other than a bed on the floor, and a set of locked double doors so the patient can be constantly observed from outside the room). I did not see any patients placed in these rooms, either--the goal is to prevent an escalation. All patients were checked at minimum every 30 minutes; patients who are checked every 15 minutes are also not allowed to have belts or shoelaces. There was one patient who was under constant observation but allowed freedom to move around. S/he was in such a delusional state (making phone calls claiming to be the President, etc...) that the one-on-one observation was clearly for the patient's protection.
I think my biggest issue with feeling like I could be really effective on this floor was the integration of 'therapeutic communication'--in which we're supposed to facilitate a stable patient identifying their concerns and then identifying some things they could do to address them; not making suggestions--with personality disorders. Personality disorders are ingrained patterns of behavior, and are classified differently from mental illnesses (perhaps in part because they really can't be treated except perhaps by long efforts of therapy after the patient recognizes the fact that their behavior is a problem). A frequent common theme in patients with personality disorders is an external locus of control--ie: the patient attributes almost every bad thing in their life to an external problem, and doesn't see any action that they could take themselves to change anything about their circumstances. Thus, it's pretty much impossible to assist them via therapeutic communication! About 20% of the population is believed to have a personality disorder--many are never diagnosed--and in the inpatient population, it's a much higher rate. Sometimes the patient's chart would list a diagnosed disorder, but usually it would just indicate that one was suspected. At any rate, several of the patients I spent a lot of time with were likely personality-disorder patients in addition to their mental health disorder(s). Thus, I kept feeling like I wasn't getting anywhere (especially since I often didn't realize this disorder until well into the conversation--I think this is an issue of experience, more than anything).
I think the tools learned on this floor will be useful--plenty of medical/surgical patients also have mental health issues after all--but I'm definitely more comfortable in the medical/surgical realm so far.
On Tuesday and Wednesday of Week 15, I took my final exam in OB, then the computerized exam (which was harder than I expected) and also the computerized exam in Mental Health (which was also harder than I expected!). I had my evaluations with both clinical instructors, which went well. I assume our grades have been posted by now, but our online registration site has been defunct since the middle of the semester so I can't check. (This made registration for Spring of 2013 really easy, lemme tell ya!)
So, that officially marked the end of the semester. 3 out of 4 complete!
Thursday and Friday I did...something...which probably related to getting Christmas presents ready to mail? I really don't remember, and it was only 2 weeks ago. Maybe I slept a lot... My vertigo continued to slowly go away, and by Saturday the 15th I wasn't very aware of it any more except when trying to keep my balance or moving with my eyes closed.
Saturday I started a Clinical Elective, where we get to spend 5 days on a floor with an instructor and just hone our skills. I'm really glad I did this! It brought back to mind all kinds of management and organization issues I need to keep working on, and gave me a chance to practice some skills I haven't used in a while. I got to give my first intramuscular injection, too. (It's flu/pneumonia vaccine season!).
The Elective met on Saturday, Tuesday, Wednesday, Thursday, and Friday. On Monday, I mailed all the Christmas presents, having spent Sunday making fudge and bread to go in the boxes. I can't say I really did a lot on Tuesday-Friday after Clinical--it's pretty exhausting, and I had to be there at 6:30 in the morning. I definitely think that evenings will be my preferred shift (if I get a choice!).
My brother arrived from the midwest on Saturday the 22nd, and we had a really nice week with him. We went out to Rochester to visit a family friend on the 24th, and then had Christmas at our house. On the 27th we did a lot of shoveling, but it wasn't too bad since the only pressing engagement we had was for PoC to go to work each evening. (I so wish we were in a position where he didn't need to work nights, but it's a paycheck...) My brother left on Saturday the 29th, and we left a few hours later for a very short trip to VT to see PoC's family. The drive took about an hour and a half longer than usual, but we made it safely and returned home safely on the 31st. Two days there is really about enough, anyway! Now I'm enjoying relaxing at home for a few days until I really start to feel like I must study for next semester (the syllabus comes out next week; classes start on the 15th). Maybe I'll write our Christmas letter!
Behind the cut, for length, a recap of some of my clinical work this semester (Pediatrics, OB, Mental Health; I already talked about the Community-based nursing stuff). As usual, excuse the fact that I can't indicate age or gender!
Pediatrics--I spent a total of 6 days on a floor at a Children's hospital. In general, the patients on this floor were fairly stable--it wasn't the ICU or the oncology floor. Many were post-surgical patients, but not all. The turnover/discharge rate was pretty high, so I rarely had the same patient on 2 days in a row. Our focus on this floor was supposed to be not only the medical/physical assessments related to the illness, but also observations of normal/abnormal growth and development, and family coping patterns.
I had a preschooler with a broken femur from an accident--surgical repair. Only the father really spoke English; the patient watched and listened attentively, but never spoke to me. The mother was protective and worried (naturally!), and wouldn't let the patient try to bear weight or get out of bed, even though both were allowed. They were discharged the next day; I just hope the patient got up and started moving around at home.
I had a gradeschooler with a tear near the rectum caused by a fall in the shower. This patient was doing really great until it came time to put bacitracin (painless ointment) on the wound, at which point s/he broke down in tears out of fear that it would hurt--apparently the initial exam before the stitches had hurt a lot. I got through it without causing pain (a lot of parental comforting helped, too!) and was then able to write one of our long write-ups about my actions and assesments of the patients reactions (for example, we're supposed to recognize that reaction formation is a common coping mechanism in this age group--the child will present the 'expected' reaction--ie: bravery--while really feeling scared. So, I wrote about this concept and the reassurance that I gave the patient and the physical actions/interventions I took to reduce pain.) After this, the patient was cheery again and was released that evening.
I briefly had a teenager who came in late in the day in anticipation of surgery the next morning. The surgery (necessary, but not emergent) had already been delayed by the fact that the patient had 2 STDs the last time they had attempted the surgery. The patient admitted this time that s/he had continued to engage in unprotected sex after the last round of treatments, and thus the patient needed to be tested again before any further preparation could take place. This patient was an older teen, but it still made me sad to see that s/he arrived at the hospital unaccompanied--and obviously wasn't getting a lot of guidance at home.
I had a toddler who had been burned in a kids-playing-with-matches-and-gasoline accident (yes, this really does happen). The wound care team did all of the dressing changes, so I just needed to do my 'normal' assessments. The mother was with the patient the whole time and obviously very devoted--and felt terrible about the accident. The patient was very chipper and played and smiled--despite the full-length bandages on both legs.
I had a younger-gradeschooler who was having a bone problem in the hip bones repaired. One hip had been done a couple of years prior, and the second hip was now completed. Even with a surgery as involved as this, the patient was sent home 2 days later!
I had an infant who had been born 2 months pre-term and had spend most of his/her life (to date) in the NICU. One week after coming home from the hospital, s/he was admitted with 'Failure to Thrive' which can mean a lot of things, but basically means s/he wasn't gaining weight and was spitting up everything. Eventually, reflux was diagnosed (I got to watch the stomach scan!), but it seemed to me that the larger issue was a pair of young, underprepared parents who had really not had any time with their baby to figure out stuff like 'how to hold it!' I was really hoping when they were discharged that being able to spend a little more time with their baby would help them learn to meet his/her needs! It wasn't that they didn't care; they just didn't know what to do...
OB/Maternity--we spend a total of 6 days here as well, but it was broken up into 3 days on the labor/delivery floor, 1 day devoted only to the nursery, and 2 days on the post-partum floor. The first day in L&D we mostly learned about the floor, the birth process (we hadn't had this content in lecture yet) and certain procedures (such as the external fetal monitoring equipment that gets belted around the mother's abdomen). The next day, I got to watch a birth! This was an amazing experience! It was the mother's first baby, and the husband, some sisters, and both grandmothers were at the bedside. (There were actually a ton of people in the room--in addition to family, there was the OB, an OB resident, a medical student, me, the RN, an RN who was being trained on this floor, and after the baby arrived, another RN!) I was present when the mother got an epidural, and then her labor progressed fairly quickly over the next few hours. The RN had a lot of experience on this floor, which was a great thing to watch. The baby was healthy, though needed a little help to start breathing at first (lots of suctioning with a tube down the trachea, and slapping of the feet. They don't hold babies upside down and smack their bottoms anymore, though.) After the baby was breathing, I got to participate in the initial assessment (overall shape & function of limbs, posture of body, presence of reflexes, right number of parts, etc...) and put the erythromycin in the baby's eyes. Then we wrapped him/her up and placed him/her in mom's arms!
My last day on the L&D floor I shadowed a RN who was working triage that day--any pregnant woman who comes in with a complaint is usually sent here (unless it's a broken leg, or something). We had one patient who seemed to be in early labor but was only at 37 weeks--after determining that she wasn't progressing too quickly (ie: the cervix wasn't opening), she was given medicine to slow/stop the contractions and sent home to rest. The general philosophy is that the baby should stay inside unless it is definitely more dangerous inside than out! Another patient came in to have pre-eclampsia ruled out--her blood pressure had been high at her last appointment, but she was otherwise healthy. (If positive, this would be a case where the baby might need to come out rather than staying in; eclampsia doesn't resolve until the birth, and it affects the circulation that supplies the baby.) A third patient was in a lot of pain that seemed not to be related to early labor--the doctors were trying to figure out if she possibly had pancreatitis.
On the nursery day, we spend time assessing healthy infants. Not everyone in the group actually got to watch a birth, so for some this was their first time. We were also about to watch a circumcision, but the doctor realized that the baby's foreskin was partly adherent (not loose) and the baby's urethra wasn't at the tip of the penis--called a hypospadias. In both cases, the baby can't be circumcised. The hypospadias needs to be surgically repaired for normal sexual function later in life, and the foreskin tissue might be needed in this repair. After this, though, the baby can be circumcised. This was an interesting case, because the problem was obvious to the eye. An assessment at (or shortly after) birth should have identified it--I'm not sure why it was missed!
On the PostPartum floor, I had the same patient for 2 days because she had been a drug abuser so she had the baby needed extra monitoring for withdrawal symptoms before discharge. I wished I could have had her a 3rd day, because on the 2nd day her blood pressure started to rise--eclampsia can occur after the birth, too. Of course, I didn't want her to have eclampsia (which can ultimately lead to seizures and coma), but the blood pressure changes probably wouldn't have been caught if she'd been send home 48 hours after the birth. I would have like to learn the eventual resolution of it all.
Mental Health. We spent 6 days on an inpatient floor of a local hospital (but I only did 5 because of the vertigo issue). The floor is a locked, secure floor--mostly to protect the patients from the world, not the other way around. Patients must give the staff a password for anyone who calls requesting information about them; otherwise floor staff cannot even acknowledge the presence of a particular patient on the floor if someone inquires. The floor treats patients as young as 17. In general, most patients we saw had been admitted involuntarily because they had threatened to hurt themselves. Some were brought by family members; a few had been picked up off the streets by EMS. However, many had then converted their admission to 'voluntary' status, which means that they request further treatment.
I found this floor to be interesting from an intellectual point of view, but not a place I'd like to work. Mostly, we spent time talking with patients--which isn't a bad thing, but I think I need more activity in my practice. Some other students loved it, though! We weren't assigned specific patients--we were expected to try to talk to as many as we could, and use our therapeutic relationship skills to the extent of our ability and the patient's level of orientation/rationality/anxiety. Among the patients I spent the most time with were a patient with severe anxiety (who was discharged our first week and had been readmitted by our last week)--when something triggered this patient's anxiety, it was like flipping a switch. All of a sudden s/he was in severe-anxiety mode--unable to concentrate on anything else, requiring direction and assistance rather than making decisions for him/herself. Another patient had an eating disorder and was going to be transferred to a hospital specializing in this as soon as his/her suicidal ideation was under control. Another patient had severe depression and was nearly inert. A college-age patient had been admitted after being found stuporous by his/her roommate. The staff was trying to determine whether s/he had taken some bad drugs (which s/he denied) or whether this was possibly the first psychotic break in schizophrenia (which manifests itself in teen/young adulthood).
This floor did not have padded rooms or beds with leather straps for holding patients down. It did have a couple of low-stimulation/isolation rooms (with no furniture other than a bed on the floor, and a set of locked double doors so the patient can be constantly observed from outside the room). I did not see any patients placed in these rooms, either--the goal is to prevent an escalation. All patients were checked at minimum every 30 minutes; patients who are checked every 15 minutes are also not allowed to have belts or shoelaces. There was one patient who was under constant observation but allowed freedom to move around. S/he was in such a delusional state (making phone calls claiming to be the President, etc...) that the one-on-one observation was clearly for the patient's protection.
I think my biggest issue with feeling like I could be really effective on this floor was the integration of 'therapeutic communication'--in which we're supposed to facilitate a stable patient identifying their concerns and then identifying some things they could do to address them; not making suggestions--with personality disorders. Personality disorders are ingrained patterns of behavior, and are classified differently from mental illnesses (perhaps in part because they really can't be treated except perhaps by long efforts of therapy after the patient recognizes the fact that their behavior is a problem). A frequent common theme in patients with personality disorders is an external locus of control--ie: the patient attributes almost every bad thing in their life to an external problem, and doesn't see any action that they could take themselves to change anything about their circumstances. Thus, it's pretty much impossible to assist them via therapeutic communication! About 20% of the population is believed to have a personality disorder--many are never diagnosed--and in the inpatient population, it's a much higher rate. Sometimes the patient's chart would list a diagnosed disorder, but usually it would just indicate that one was suspected. At any rate, several of the patients I spent a lot of time with were likely personality-disorder patients in addition to their mental health disorder(s). Thus, I kept feeling like I wasn't getting anywhere (especially since I often didn't realize this disorder until well into the conversation--I think this is an issue of experience, more than anything).
I think the tools learned on this floor will be useful--plenty of medical/surgical patients also have mental health issues after all--but I'm definitely more comfortable in the medical/surgical realm so far.