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Posted Jan 27 2009 7:13pm

This week our clinical focus was change. Change, in the sense of institutional change, change in the nature and standards of practice, perhaps changes in policies and procedures. Being mindful of how previous foci turned up during the day in unexpected ways, I breathed a sigh of relief when I saw this new topic. I've gotten through conflict, delegation, and the rest, how bad could change be? Surely some new change in policy or the nature of nursing practice in general wouldn't suddenly make an appearance in my assignment, the way the previous foci have. Right?

Well, although these kinds of Change didn't figure in to my day, plenty of other kinds of change did. This was a sort of make-or-break week for me, my last chance to turn around some of my issues with clumsiness and organization skills before the mid-term evaluation. Now that I've built up some comfort and confidence by having some smooth medication administrations, my goals have expanded to include:

*Taking charge of my assignments, showing that I can -manage- my patient's care instead of just accomplishing scheduled tasks.

*Improving my understanding of the "administrative" side of my tasks, the paper work that goes into this particular hospital's care-planning strategy, and the chain of information between Nursing, MDs and PharmDs.

I think I underestimated how difficult it would be to change hospital assignments during my last semester. Reflecting on the last two semesters spent in a large inner-city hospital, the aspects of the health care delivery system that I'm having trouble wrapping my head around now are the same ones that took me so long to figure out in the previous environment. I pride myself on being adaptable and thinking "on my feet", however, the challenges I've had are pointing out to me that there are some things that take me longer to figure out. What's been working well during the past couple of weeks is getting support from other members of the cohort. Some things that are common sense to them aren't obvious to me, and vice versa. Unfortunately, the things I'm lagging behind on (compared to them) are rather serious, deeply-rooted, and need to be addressed during my last 64 hours of providing bedside care as a student.

I had a short conversation with one of the other students that made me feel a bit better about the problems I had been having. This guy was with me at my last hospital assignment, where the med administration system required that we scan barcodes on the patient's bracelet. Transitioning to the system we're working with now resulted in him making the same mistake I had made (not checking the bracelet). Of course, he only made that mistake once. Hearing that made me feel a little better, because he's very "with it" and has tons of experience (in pediatric oncology, no less!), and what I took from that short conversation was a reiteration of the idea that learning from mistakes instead of feeling bad about them is crucial.

Change was the order of the day(s), I dropped back down to a 2-patient assignment on the first day (Patients X and Y), and was slightly dismayed to discover that the RN I had the conflict with last week was my co-assigned nurse once again. I was told that this had more to do with the assignment (it had more opportunities to practice med admin skills) than my previous experience with her, but I looked at it as an opportunity to get right some of the things I got wrong during the prior week. In a sense, being assigned to part of an RN's assignment who seems to actively dislike me has been beneficial, since I'm spending less time with the RN and more time at the bedside (which is good for building independence). I made sure to run by her the times I was planning on administering Insulin (since students can't do finger-sticks at this hospital). For purposes of this post, we'll call her RN1.

On the second day, I had my two patients from the first day, plus a post-op (Patient Z). I met RN3 who was assigned to the two patients I was already familiar with, and then she was floated upstairs immediately afterward. Change ahoy! The nurse who took that assignment was....the same RN1 from yesterday and last week. Meet the new nurse, same as the old nurse! Last week I dropped the ball on a post-op admission, so I made sure to write down the cellphone number of RN2 (who was assigned to the post-op patient), and coordinate with her to prepare for Patient Z's arrival. Working with RN2 is much different than RN1. She communicates with me much more openly, gives me some advice and direction here or there and helps me be more independent without ignoring me. Another student in the cohort told me they have had the exact opposite experiences with RNs 1 and 2, it seems like with some people it all comes down to their personal "feelings" about you, whether they have 2 years of experience or 20.

Patient X was brought in for cellulitis of the Left Lower Leg, history of a syncopal episode, diabetes, peripheral vascular disease, hypertension, weakness and dementia. Although I'm familiar with the pathophys. of cellulitis, this was the first time someone in my assignment had this as their medical diagnosis. The warmth radiating from the affected tissue was clearly palpable. Since the infection was evident circumferentially around the limb, I placed a high priority on neurovascular assessments of the lower extremities (my reasoning for this was that although cellulitis isn't the same as a burn, there may still be reason to worry about constriction of the blood supply or even compartment syndrome, especially given his co-morbidities). Pulses were auscultated by doppler, and I noted that the affected side was much quieter. Hello bilateral +3 pitting pedal edema (say that 3 times fast)! His orders included elevating the left-lower extremity with 3 pillows. A thorough assessment revealed a reassuring lack of capillary congestion over dependant bony prominences. His co-morbidities led me to make sure his heels were off the bed as much as possible. I had to readjust his pillows to make sure this was done (pedal edema+diabetes+PVD = protect those heels). His chief complaint during my time with him was neck pain, which I addressed with PRN tylanol and warm compresses.

His pharmacotherapy included a couple of novel items for me to look up. He received Namenda (Memantine) at bedtime. "Binds to CNS N-methyl-D-aspartate (NMDA) receptor sites, preventing binding of glutamate, an excitatory neurotransmitter". That's what I memorized in preparation for administration. What I SHOULD have memorized was "Decreased symptoms of dementia. Does not slow progression. Does not cure disease.". It has some hypertensive properties, which theoretically should peak about 3-7 hours after administration. He was also receiving Ketorolac (Toradol) eyedrops for a chronic inflammation of one of his retinas. I believe this is due to diabetic retinopathy, I wonder if the fact that it's happening to one retina and not the other suggests an asymmetry in his vasculature that could have some impact on stroke risk.

My care for Patient X included a lot of reorientation, a lot of time spent sitting down and giving him a chance to exercise his "cognition muscles" through verbal interaction. Although in some senses his memory was poor (couldn't recall his birthday, what day it was or where he was), he remembered making fun of my instructor's hair and felt bad about it the next day. I told him not to worry about it, and we both had a good laugh over it. Towards the end of the second day, I watched RN1 talk to Patient X's spouse about his living will, Patient X tried to enter the conversation but was ignored. I was sitting with him, and he turned to me, pointed to his wife and said to me "that's one hell of a woman. She'd have to be to put up with me. I'm not easy to live with, you know." I told him he's a lucky guy, didn't know what else to say, really. Something interesting I learned listening to RN1 (who also has experience as a visiting nurse) was that people are generally told to put their living wills in a safe deposit box, but not told to keep a copy of it handy. Living wills stored in safe deposit boxes are difficult to retrieve in the middle of the night on the weekend. Something about how the conversation transpired in front of Patient X as though he wasn't there bothered me, but I suppose time is limited and things have to get done with the time available.

Patient Y was Patient X's neighbor, he was in for a Left Total Knee Removal, due to a bacterial infection of his artificial knee. He had been a guest at our facility for 17 days by the time I met him, he was originally admitted for an incision and drainage, which was followed by a removal and insertion of a spacer four days later. He has been staying so long, RN1 explained to me, because he'll only be able to receive the treatments he needs (IV antibiotics) while he's hospitalized, his insurance wouldn't cover it on an outpatient basis. This is the second time RN1 pointed out to me a patient that has an economic, not medical, necessity for remaining in the hospital. "It's the game we play with the insurance", she said to me once again. His knee incision was open-to-air with no drainage. Something interesting about this fellow was a discoloration of his extremity below the level of the surgical incision. The skin was brown/black, a discoloration that began during a hip fusion, during which his left femoral nerve was severed. RN1 was skeptical about Patient Y's reports of pain distal to the severed nerve, which seemed odd to me considering pain can be subjectively experienced even from completely severed limbs. His pain was well controlled with controlled-release oxycontin, but a problem arose before my time with him, when the order for oxycontin expired and no order was entered to replace it. This gave me something to reflect on with my own confusion about how the orders work at this particular site, at the last site the med-loop (including orders) was 100% electronic, when changes occurred it triggered a print-out that was placed in my preceptors (and by extension, mine) wall-box reserved for this purpose. I got some valuable re-orientation to how the orders work here, I think I'll be able to be more independent in this in future weeks.

Patient Z was brought to the unit during my second day, freshly post-op from an incisional hernia repair with mesh. Mindful of past mistakes, I checked in with RN2 frequently to make sure I got report and had a good idea of when he would arrive. We prepared his room together and chatted with the PCT for that room so she would know what to expect. Patient Z was on contact precautions for MRSA, since a previous abdominal wound was infected with that agent. In the past he had a colon resection due to diverticular disease, and a temporary colostomy that was closed two years ago (had a nifty scar for me to check out). Post-op assessments are something I haven't gotten to do many of this semester compared to previous, so I was glad to do it in tandem with RN2. Noting a saturated dressing, we removed the abdominal pads and applied Montgomery Straps. He was medicated for pain with patient-controlled analgesia, the device was loaded with dilauded. While we were removing and reapplying the dressing, even light brushing stimulation of his right-upper abdominal quadrant caused intense pain. What stood out about this guy, to me, was that he was pretty alert and talkative for someone who just had major abdominal surgery. His blood-pressure was low enough for us to hold his prophylactic beta-blockers, but he walked two laps with me without any problems. He told me the reason he felt he was doing so well had a lot to do with his mental discipline from being an athlete during much of his young life. He said that he "felt like crap" physically, but mentally he was well-informed about his condition, experienced with hospital routine, and knew what he needed to do to get better. Most importantly, he didn't "feel bad about feeling bad", which we supposed causes a lot of post-operative patients to have a rougher time than they could potentially have. What was valuable to me about my time with Patient Z was that he modeled some behaviors and attitudes that are highly adaptive to the process of recovering from surgery, which I think will help me model that behavior more successfully for future patients.

I feel good about how things went this week, although every positive gain reveals new ground to cover. Repetition has been the key to building confidence and efficiency so far, and having the opportunity to pass medications on both of my shifts instead of just one has been extremely helpful. I think I'm "over the hump", in a sense, in building the familiarity I need to execute my duties efficiently. I still have a ways to go, but I think I'm moving in the right direction. Next week I'm going to focus on putting all of these pieces together, establishing strong lines of communication with the PCTs and RNs, and "taking control" of the documentation so I know what's going on without having to ask people.

The sort of tricky paradox I'm working with here is that, on the one hand, my major goal for this semester is to become an independent practitioner. On the other hand, I've been attempting to transition into an environment where all of the independence I've built up in a different hospital has been stripped away from me. It's uncontroversial to assert that people behave differently (sometimes radically differently) when they're being observed and actively critiqued, so despite the difficulties it's presented me so far, I think this has been a good way to prepare for being "on orientation" as a graduate nurse. I'm basically re-experiencing the "stage-fright" I had back in first semester -now- instead of when I enter into practice.

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