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Nursin' fo realz

Posted Jan 27 2009 7:12pm

I'm finally working full time as an RN! The nursing home job hasn't kicked in yet (still waiting to take my physical for them), but I have some shifts under my belt for the 1:1 pediatric homecare gig.

Since I'm new on this case, the parents are coming with me to school and helping me out after school's out for the last four hours of the shift. In about a month or so, the client's mother says, she can use those last four hours of my shift to sleep and get ready for work.

Being in the classroom for half-day preschool sessions is...interesting. It's difficult to say if any of the other students have special needs, maybe one or two of them do. My job is simply to stay by the client's side, watch 'em like a hawk, and manage the airway.

And manage it I do! For some reason, the mode of transportation that takes us to school causes the client to sneeze for most of the ride. This is a problem, because once they get up to three cough's/sneezes, they vomit, a potentially serious occurrence in the presence of a trach. This is most likely due to his Wrap, a surgical treatment for GERD. I got a chance to manage a couple of these episodes so far. The client needs to be suctioned very frequently to prevent this, since timely suctioning after the first cough will usually prevent the next one, thereby preventing the vomiting episode. The tricky bit is that suctioning TOO much is bad, too, since over-suctioning an airway can dry it out, increase ICP (and I'm not talking about the band), or make them gag. The client requires a LOT of suctioning, maybe 30-40 times in 8 hours, sometimes as often as every five minutes. Thankfully it's a cuffless trach and they can still breath through their mouth.

The classroom has a teacher's assistant and a paraprofessional in addition to the teacher, thankfully, so I have another pair of hands when it's time for diaper changes (the client can get a bit "wiggly"). The people at the school have been nice to me, so far. The physical therapist is absolutely wonderful with the client, and watching PT for special needs children has been interesting so far. The client also gets 15 minute visits from a woman who introduced herself as "Teacher of the Deaf". Not much seemed to get done, since she came during snacktime and there was a lot of distracting activity in the room, but she assured me that it was fine to do in that environment. I look forward to picking up some sign! I picked up a little bit back in the group-home, but everyone there used heavily personalized and modified dialects of ASL, and books on the subject were completely useless to me due to my spatial relationships deficits. Picking up some sign from an actual teacher should be interesting too.

Sometimes I feel a little bad about disrupting the class, the portable suction gear is LOUD and always distracts the class from their current activity. Still, when I gotta suction the airway, I gotta suction the airway, I can't wait for the teacher to finish the line of the story she started reading. It seems to me that it should be possible to implement a portable suction solution that doesn't drown out all the other noise in the room, don't you think?

The school nurse is wonderful, too. I'll be seeing her at least once a day, I think, since I think I'm the only RN following a patient the entire time they're at school. I got a tour of her office and she briefed me on emergency procedures and safety protocols, like making sure I have a radio whenever I'm outside the building with the client. Both of us have to be there for my client to be permitted at school.

I got to use a little of my critical thinking skills today, as well as having the opportunity to advocate for my client. The stroller the school provides was definately not safe, so I instructed the para to roll out the orthotic assistive chair (or whatever the hell it is) instead. The stroller they have has two plastic boxes on either side, far enough away from the head to -seem- safe, but close enough for the client to slice open a temporal artery during a sharp side-to-side movement. I caught one of these movements and reflexively caught the side of the head with my hand. The sharp edge of the ragged plastic cube dug into the back of my palm and that was the end of that. The assistive chair, although clumsy and complicated, is at least padded and made of rounded corners. I consulted with the physical therapist and the school nurse, and we agreed; the stroller was no good. We'll get a new one.

Everyone's been supportive of my presence there so far, but I was warned that this may not last, and that I should "watch what I say" around them. Heck, it's no different than nursing school; a coven of middle-aged white women who take their job very seriously. All I have to do is My Job, and if someone gets in the way of that they'll have to deal with the wrath of a very mature young mother who treats impediments to her child's care and education the same way you might imagine a bear would treat a dancing, shouting rag-doll full of sausages.

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