natural child birth

another thing i learned is whole childbirth often(?) involves popping babies out in water.


delivery under the water!!!

dolphins optional.

placenta

so i learned last friday that some people eat placenta.


Cooking Up Placenta

first bite @ 2:25. "livery but nice." nice.

i wanna see this on iron chef one day: "today's secret ingredient....PLACENTA!!!"

oh one more thing

take home tests where u have to cite the rationale out the textbook are the deal. for me, theyre more helpful than any other assignments, papers, quizzes, in-class exams, and studying for those things. if i had nothing but take home tests like this from this point out, i'd be in really good shape.

oh and one other more thing...i kinda put myself in the position again where i have to cram to learn basically the whole classs before the final again. the good news is kinda know the main points and at least i gave my self several weeks this time. :)

cool trick

if u iron ur scrubs right out the washer while theyre still wet, you can save so much time/effort on ironing them compared to when theyre dry...esp if they dry with wrinkles. ill pbly iron again before i wear them but seems that depending on how you store em to dry while theyre damp, u might not even have to iron them again.

this may only be worth mentioning if u normally hang dry em like i do. if u let em hang and they dry w wrinkles, it sometimes takes some effort to iron the wrinkles out. i dont remember what theyre like if u put em in dryer. the only times these scrubs went in the dryer was when somebody put them in the dryer wo me knowing way back in feb or something like that.

this what i'm up against

here's my med surg clinical instructor, peter pan

i just dont get this guy.



here's peter pan ignoring yet another one of my emails



here's how the talk we had last week should have gone

peter pan: you didnt bring your paperwork. that means you will pass meds late as a nurse.

*me: rly? thats a pretty fucking stupid analogy. those things are nothing alike. in one situation, i'm already on the floor doing what i'm getting paid to do, for real life sick patients that need their meds to get better. in the other i have to slave away for hours to write some time consuming steaming pile of garbage that is 1% useful, 99% busywork that i failed to grab on my way out the door.

peter pan: i'm concerned that you are concerned with passing the course. i question your motives for being a nurse. and i need to protect the nursing profession.

*me: u fucking kidding me? you know i need to pass to move the fuck on in the program dont u? n you realize u just pulled me aside to tell me that im not passing the course, rt? if passing is not a big deal, then why did u bring it up in the first place? the whole point is so i can make some changes so that i can pass...er i'd like to think it is. cuz if you pulled me aside to just let your inner dickhead rant about how youve got something personal against me...then fuck you. and my motives? excuse me but go fuck yourself. youre seriously overstepping your boundaries there buddy. i'm here to learn nursing and youre here to teach it. you need to evaluate and teach nursing. and just nursing. my motives and my life outside of clinicals is none of your fucking business got it?

peter pan: you're obviously knowledgeable about the medical stuff when i ask you about it. but that's not everything.

*me: doooooooood. i get it. you dont like me and youre trying to downplay everything and anything that actually matters and instead want to bitch and rage inappropriately about some stupid papers like its the most important thing in the world and im a failure with no redeeming qualities because of it. ZZZzzzzzz.

* = what i should have said but didnt

-------------
to be finished/edited later.
i'm supposed to work on some presentation thing for tmrrw. uggh.

i still can't believe it...

i'm still putting in more time/effort into OB than MedSurg.

why the fuck im doing this - i dont know. (i'm never gonna work in this area).

yet here i am doing it again.

and i do this wk after wk. (xcept when i slack off and dont put any time into either one).

weird.

vicodin

1: 2's going crazy with the drinking. did u notice?

me: 20 beers that one night. then again the next day. crazy.

1: and he's on that medicine...

me: yeah well at least the hospital's close by

1: ha but what if something happens and neither of us are here?

me: oh yeah huh. maybe i should talk to him...


with 2's super binge drinking combined with the fact that we just went over opioids at school, the timing is great to find out why he shouldnt drink while on vicodin.

ok so it's pretty simple...

Vicodin = hydrocodone + acetaminophen

1. etoh is hepatotoxic and a cns depressant
2. acetaminophen is hepatoxic. acetaminophen + etoh >> additive hepatoxoxicity
3. hydrocodone is a cns depressant. hydrocodone + etoh >> additive cns depression

the last time i asked him if he knew what might happen, he said his liver would bleed. that's a start. i suppose i could find out whether he understands how bad life would suck if he wrecks his liver.

clinical 7/6/10

change in c.i.
-just when i was warming up to the other, we get a new c.i. let's see how it goes...

aox2
-i think if you have any doubt, you should just go ahead and ask the questions. i was surprised at what year he thought it was.

a-fib
-rapid, irregularly irregular atrial rhythm; atria dont contract, av system bombarded with many electrical stimuli, causing insonsistent irregularly irregular ventricular rate, usu tachycardic; atrial thrombi often form >> risk of embolic stroke; one of most common arrhythmias; affects men and whites more; affects 10% of people 80+ yo; sometimes precipitates HF (bc CO decr w/o atrial contraction); the longer AF present, the less likely is spontaneous conversion, or cardioversion by any means
-most common causes: htn, cardiomyopathy, mitral valve DOs (left AV valve), hyperthyroidism, binge drinking
-sx: irregularly irregular pulse, often otherwise asymptomatic
-dx by ekg: wavy baseline, lacks discernible P waves (atria), irregular QRSs
tx: drugs to control hr, anticoagulation drugs, cardioversion

tamsulosin (Flomax)
-tx s/s bph
-moa: a1-blocker relaxes bladder sm >> urine flow improved >> decr s/s bph
-adv fx: hypotension

ezetimibe (Zetia)
-tx hypercholesterolemia
-reduces plasma cholesterol by blocking absorption of it in the small intestine

clinical 6/22

dextromethorphan
-otc antitussive
-dosage to tx cough = 20-30mg per dose
-been shown to alleviate pain at doses 60+mg
-no way i couldve known the pain thing unless ask provider...cuz not in drug book. cool the nurse already asked and told me. acutally she gave me full report since i missed the change of shift report. cool x2.

oxymizer (i think thats what they called it. classmate's pt)
-looks like nasal cannual xcept its high flow. 10 lpm. sounds hard on the nose?

pulse ox
-leave on for 30-45secs at least
-if low, ask pt to deep breathe. watch spo2 shoot right up.

Protonix (pantoprazole)
- tx gerd/hypersecretions
-proton pump inhibitor: inhibits gastric acid secretion.
-"prazoles" = proton pump inhibitors. eg, omeprazole, pantoprazole, etc.

hydromorphone (Dilaudid)
-was able to give, despite allergy to morphine. no x-sensitivity?
-1.5mg IV = 10mg IV morphine. >> more potent
-duration via IV = 2 hrs. pt needed it every 2 hrs.
-induces sedation. major sleepiness is sidefx everytime i've ever seen this.
-burns veins when given iv. trick learned: dilute it into 5mL NS. then administer slowly over a minute. easier to control rate of 5mL then 1mL. (used 1mg=1mL). oh yeah flush w ns b4 n after.

pancreatitis
-sx incl: epigastric pain (pt's complaint, along w diarrhea, which brought her to the er)
-acute & chronic forms
-both forms involve inappropriately activated enzymes
-will have elevated amylase and lipase
-in men: assoc w alcoholism, tauma, peptic ulcer, poor prognosis (pt was female, and not etoh abuser)
-tx includes going npo (pt was on liquid diet)
-care incl pain, n/v, etc. (pt said appetite lil bc pain, nausea, drowsy)

crohn's dz
-part of inflamm bowel dz (ibd), along with ulcerative colitis
-most common in caucasians and ashkenazi jews, appearing most frequently during teens-early30s or in the 50s (pt was mid30s...and said had some gi condition..forget which...for the last 2 yrs).
-aka regional enteritis aka granulomatous colitis
-chronic inflamm of any part of gi tract (usu terminal ileum) extending through all layers of the intestinal wall
-cause unknown
-s/s incl: steady pain RLQ, cramping, diarrhea (these r sx pt had. when i assx pain, it was sharp pain. but whoever assx the prev 2 days doc'd cramping pain. but then again pain i assx, was epigastric...prbly r/t pancreatitis).

blood transfusion, post-op knee (other pt)
-device drains blood, u empty blood from that container into iv bag, then hang that iv bag and infuse it back into pt (thru reg iv catheter, not back into the knee specifically) along with ns

compression stockings
-my pt had elastic stockings (supposedly not used much these days)...dvt prophylaxis bc recent colon resection
-blood transfusion guy had other kind that wrap around with velcro and are inflated with some sort of electric pump.

head to toe assx
-hand push/pull: if pt has iv in hand veins, gotta find another way bc it will be painful for them!!
-gotta remember to listen to apical after lung sounds! just keep steth on....listen lungs-heart-ab b4 taking it off...faster!
-make sure they know hob coming up. not just height of bed!


clinical instructors (all instructors, rly) here are so much better than at prev program. they actually use clinicals as teaching/learning opportunities...during clinicial, as well as pre- and post- conf. imagine that!!


p.s. coolest, most rebellious, punkish, stylish rn uniform ever: this dykish looking nurse wore a grayish top, grayish, nearly form-hugging, camo pants, black shoes that kinda looked like boots (but werent), black fanny pack that was nothing special but just lookd tuff w that outfit, bracelets n rubberbands on one hand, triple hoop rings in each ear, dark hair that kinda came up in a messy faux hawk type thing that was dyed blue at the top. it worked. maybe one day i will push the limits with my uniform...

clinical 6/15: 2.5 hour code

i'd like to write something great that captures the moment but meh i got too much shit to do. n if i put it off for later, ill never get around to writing about it. so a rambling, hurried, half-ass post will have to do...

so on the way back from the multidisciplinary meeting, er nurse c tells our clinical instructor that there is a code in the ER, send over a couple students. i was grazing behind at the back of the group, still behind the corner when he told us this. but i heard it. and quickly turned the corner rt in his line of view and practically started jumping up and down pointing at myself "pick me pick me pick me pick me pick me pick me pick me!" ok i wasnt literally jumping but i was changing levels at my knees. lol.

picked. yes!

so me and my classmate (who i wouldnt peg as the er "type") follow er nurse c down to the er.

upon getting there, there's talk at the nurses station (or whatever u call it in the er) that the pt might not make it in. i sorta felt like a jerk for being disappointed. i wasnt disappointed bc he died. or because i missed an opportunity to help save his lfie. theres nothing wrong with that. no, was disappointed bc i wouldnt get to do cpr and the code n stuff.

so we hang out for a while. saw how everyone gets ready for the code. how they position stuff in the big room to makee space. how RTs are on standby with their bags and machines and stuff. how the ekg tech and whoever else are on standy with their machines and stuff. how the nurses are on standyb with their different roles: how the one nurse is in communication with the medics, how the recorder nurse is ready with her papers and clipboard, how the med nurse and whatever other nurses are hanging out in the area where they would soon do most of there work.

how nurse c had these two cases of emergency meds ready on top of a....was it a bed it was on top of? i dont remember. (nurse c had me and the classmate open the plastic breakaway things keeping the cases shut by twisting them). one case was just like multiple compartments of epi, atropine, both prefilled in syringes built for emergency administration it seems. also there was bicarb, glucose, and some iv bags, the contents of which i didnt ever know. the other case had stuff that was in vials. the only comaprtment i rember for sure was amiodirone (sp?), because we used it.

nurse c's role was to prepare the meds that are called out and hand em to whoever. i think it was nurses actually doing the administering. nurse c was cool. she let me fumble with withdrawing the amiodarone into the syringe. she gave the classmate an opportunity to do prepare a quickdraw atropine or epi or whatevr. she took time to explain stuff and let us try stuff. she was even pretty proactive about getting me in there to do cpr. :)

in all, the drugs we used throughout the code:

*epi

*atropine
saw first hand (multiple times!!) how atropine and epi could take a pt from a 20 or 40 pulse to 120 within seconds! did similar things for bp. dont remember how low it got, but i 220/160 sounds about rt for the highs.

*bicarb (na bicarobate? i dont remember)
will have to read up why was used. but when doc called for it, it was usually around the time he wanted atropine. didnt always call for them together, but when he wanted bicarb, he wanted atropine. always insisted on bicarb b4 atropine.

*heparin.
"5000 bolus." we used it bc doc suspected ischemic MI.

*amiadrione.
used it once. im vaguely familiar with it. know its a heart med. wanna say its for arrhythmias.

-a rectal aspirin (or something). which was weird. the guy shit his pants. not sure if it was b4 or after.

finally i hear someone announce they're here outside. not long after 4 or 5 firefight paramedics come in with a fat guy covered with tubes on top of a stretcher. he kind of stays to the back rattling off the history. there was a lot of confusion and unknowns about this pt xcept this 60 yo male has a history of seizures, and prior to 911 he told his wife he had chest pain, clutched his chest, started seizing, then stopped breathing. (i think). meanwhile there was a lot of impressive teamwork going on, everyone playing out different roles, calling out this and that. everyone was playing independently, and it all worked out and had an organized feel to it. if i didnt know any better, i wouldve guessed it was all orchestrated and rehearsed. it was like an antfarm or something.

meh im getting tired of writing and spending too much time on this. so just bunch of unorganized, barebones bulletpoints now.

-nurse putting in foley set up sterile field n stuff. but didnt come close to maintaining sterility. classmate told me to watch. wonder if she knew nurse's field was contaminated in 2 places.

-i kick ass at chest compressions. sorry dude, didnt mean to break your ribs or sternum or watever. but compressions were most effective when i rotated in. doc says 2 per second. theres this monitor where you can see chest compression rate/depth/etc. i was pretty steady and had the right depth. broke the chest during my second rotation when the compressions werent as deep as they had been during my first set. see it was a big guy who had big lungs i guess, so the doc wanted the compressions deep. i think it was kinda my hand placement the second time. during my first set, i kinda didnt want to stop. i could see that i was more effective than everyone else doing compressions. but i was afraid i would get tired and lose effectiveness during future sets, so i agreed to let others rotate in after i felt kinda tired. i was winded, sweating, and started to feel my triceps burning. rt teacher dood handed me a towel. lol.

-there sure were a lot of ups/downs when it came to vitals. theyd give drugs to boost em up, then they'd drop back down.

-pts blood glucose was like almost 300 but doc said no insulin, wanted pt to keep blood glucose as high as possible. asked nurse c, she said it was to give the guy extra sugar for his brain n stuff.

-there was talk several times questioning the quality of life this guy would have if he made it. early on there was lots of pessimism about his chances. i'm glad they didnt give up. ironically, i am pessimistic about his chances travelling by ambulance to wherever it is they transferred him to. we had to do a lot of shit there in the er.

-but pt had to get transferred to a better equipped er. i'm at a pretty small hospital. when i got back to the floor, the sitter for my pt, who is a new grad nurse waiting for her new grad program to start this summer, was surprised anything like this happened in this er. she said she once had to float down there for a week and it was "pretty chill," which is fine for her since she doesnt like dramatic er stuff anywyay. on another side note, listening to her and the dialysis guy (a nurse?) talk, i got to hear their opinions for which local hospitals are good to work for.

-early on nurse c said she dint think it would end well. doc was ready to give up pretty early on. but 2nd doc didnt want to, said he'd feel bad about doing that. when family showed up, they decided to keep goin.

-classmate was amped up on adrenaline well after the scene was over and we were out of the er. surprised me for a couple reasons. one, she said she wants to do er now because of the focus she felt during all this. i can relate to the focus thing btw but i wouldnt of guessed she was like that. i wouldve guessed it would be overwhelming for her. but i was also surprised bc she didnt get the hands on that i did, right there rotating in doing cpr (she kinda just watched from afar, and in fact seemed kind of nervous when she was asked if she wanted to do it, in fact she insisted i go do it...not once but multiple times), yet for me, it was just something new and cool to be part of. not to say, i didnt care if the pt made it...bc i did want him to make it and was glad when his pulse came back after my compressions. i've spent good times in about 4 ers in my time, even been in various "situations," mosly involving 5150, psych, and drugged out pts, but this was my first cpr code and i like it. er wasnt nearly as exciting as i thought itd be except for those few "situations."

-true story: before i decided to return to nursing school, i was going to do rt school instead because i heard its exciting. and thats what i told the rt students there, who were bagging and rotating in with the chest compressions. the one guy offered to let me rotate in for bagging. pts pulse came back tho. wouldnt mind bagging rt student chick.

-the only emotionally arousing part for me was when the family showed up and i saw what mustve been the wife crying right outside the doorway after they shoo'd the nonessential peeps out of the room. actually it was more what i think mustve been the daughter that set me off. i had to look away everytime i saw her crying. (side note: the only time i came close to feeling that way was when i was in the other program following the home hospice nurse when we sat down with the early-20s-something yo daughter of a patient who the hospice nurse believed was on his way out. er daughter experience was much more intense tho).

-one of nurse c's responsibilities was to talk to the family. i asked if she did it bc was a responsibility or just thats the kind of thing that she gravitates to. she said both. but yes, is responsibility.

k, ill just wrap it up cuz im writing like crap now.

will just say my pt on the floor was pretty interesting too. 91 yo who looks 50. his secret is scotch and water almost daily. haha. dialysis. edema. pacemaker. defibrillator. cataracts returning after lasiks. interesting skins. low ass bp. like 70/50, but denies dizziness. hx crf, pna, hyperlipidemia, diverticulosis, and a bunch of stuff. if i had time to learn all his issues, tx, and meds, i'd learn alot. too bad i dont.

cool clinical day.

clinical 6/1/10

random observation. dont feel like elaborating. or writing clearly. ill just cross my fingers and hope i understand what it all means if i ever look over these notes again.

1. around here, u dont get xtra pay for being fluent in a 2nd language. in fact, it's almost expected. weird. must be a wage theory 101 oversupply thing. ie, enought potential applicants with this ability (or few enough positions available), that a premium doesn't have to be paid. im interested in learning a bunch of extra languages, but only at the most non-intesive, non-rushed pace. a financial incentve would prbly be just the thing to push me to take it from an on-off hobby into striving for fluency. oh well.

2. intermittent pain for medical pts. if its not getting progressively worse, sometimes all u can do is wait and see.

3. 2/3 of pts i worked with today were RNs orfamily members of pts here today.

4. observed the whole pre-op checklist thing. wonder why i never witnessed this after a whole semester of medsurg1 at the other program even though i was 1. at a much larger hospital and 2. got to watch actual procedures. we were even taught this checklist pre-procedure thing during the fundamentals class here....but never once at the other program even after a handful of clinicals class.

Teaching Incentive Spirometer & Turn, Cough, Deep Breathe

Deep breathing and coughing exercises
-improve (or maintain) ventilation and pulmonary gas exchange
(especially after prolonged immobility or general anesthesia)
-work by clearing mucus and allowing moisturized air to enter the bronchi/bronchioles/alveoli
-prevent or treat respiratory complications from immobility & illness
-inflates alveoli, removes secretion that may become reservoir for microbial growth, which may in turn interfere with gas exchange
-

Clinical 4/17/10

Just a few random things.

1. If O2 sat unexpectedly low: have pt deep breathe & recheck.

2. Crackles in elderly recovering from cold: deep breath & cough bc risk infx.

3. Macular degeneration: "I can only see outlines....it's dark in the center...it's especially difficult when eating....I can't recognize faces only voices....I don't want to go to exercise because I can't see the demonstration"

4. HIPPA. That is all. Pt's got a cool story tho. Cool enough to have been basis for a book, movie, tv shows, tv appearances, magazine articles....

piaget's stages of cognitive development

bc teach said is on test but dint lecture on it bec nurses dont teach u everything u need to know in nsg schl. something like that.

why nsg instructors, who are responsible for educating future nurses, hold this philosophy is beyond me. just thankful he doesnt take it to the xtreme my "instructors" (LOL) in the other program did. no comparison actually. that's a good thing. :)

notes from interwebs (not the text bc i dont have it w/me atm)...


*SENSORIMOTOR STAGE 0-2yrs
most in tune with sensorimotor stimuli; simple reflexes; circular reactions; beginning of mental/symbolic thought; understanding by coordinating sensory experience w/ motor action; knowledge of world via interacting with environment; problems with object permanence resolved by end of this stage

*PRE-OPERATIONAL STAGE 2-7yrs
begin grasping language, prone to fantasy, perspective is self-oriented, substitutes objects with symbols, able to think about things not happening now, thinks outside world, play pretend, think operantions through but only in one direction; difficulty seeing POV of others;
-SUBSTAGES
-----SYMBOLIC FUNCTION SUBSTAGE: egocentric thinking (only understands own POV), can formulate designs of objects not present, language, pretend play
-----INTUITIVE THOUGHT SUBSTAGE: primitive reasoning, knowledge but only know it intuitively, fails at conservation-of-liquid tasks*

*CONCRETE OPERATIONAL STAGE 7-12yrs
begins abstract reasoning; able to mentally manipulate info; begins solving hands-on prolems in logical manner; understands laws of conservation, working backwards; appropriate use of logic;
-IMPORTANT PROCESSES: seriation (pattern gradients), transitivity (if a>b, and b>c, then a>c), classification, decentering (multiple aspects taken into account..eg, not just height of container), reversibility, conservation, elimination of egocentrism (can take other's POV)

*FORMAL OPERATIONAL STAGE 12 to adult
full comprehension; can make decisions w/o concrete objects; can consider multiple POV, can solve abstract problems; more scientific thinking (devising solutions and systematically test them); finds identity; begins to deal with social issues; can transcend beyond concrete experiences into abstracts/hypotheticals to solve problems and draw conclusions; can think about the future

related

wikipedia




kinda creepy. but interesting illustration of the stages. sensorimotor was best. then it becomes less relevant with each stage thereafter imo.

Gordon's Functional Health Patterns

Why bother looking up Gordon?
CI said careplans based off Gordon. From what I've seen so far (not much), it's only loosely based on Gordon. But it's relevant so why not learn more.

Btw...
Ask an experienced nurse about care plan, and she can definitely help. Ask about nursing diagnosis...and maybe not. LOL.



Marjorie Gordon (1987)
11 categories, systematic approach to database

1. Health perception and Health management
2. Nutrition & Metabolism
3. Elimination
4. Activitiy & Exercise
5. Cognition & Perception
6. Sleep & Rest
7. Self-perception & Self-concept
8. Roles & Relationships
9. Sexuality & Reproduction
10. Coping & Stress Tolerance
11. Values & Beliefs