Confessions of a Registered Nurse: October 2006

October 25

Now what?

Starting an IV on a small child is extremely difficult. In the two months I have been an intern, I have successfully started several IV's on school-age children, but none on an infant. A few days ago I had the opportunity to try again. Nervously I gathered all of my supplies. My preceptor (a nurse I had never worked with before) was right there holding down the baby's opposite arm and ready to take over if/when I was unable to get blood. Holding the baby's hand tightly with my left hand, I poked her right hand with the needle. Nothing. I advanced it slowly and to my surprise, saw a flashback of blood. With my tongue sticking slightly out to the side (it somehow helps), I advanced the catheter into her vein. Success! I removed the needle and applied pressure to occlude the vein (to prevent blood from spilling out of the un-clamped IV port). Although I was holding her arm, the baby was still able to squirm, and the IV catheter started coming out. Quickly I held it in place with my right hand. I stood there confused, my left hand occluding and holding the arm in place, my right hand holding the catheter. I needed another hand! Embarrassed, I looked at my preceptor and had to say, "I've never made it this far, I don't know what to do now!"

Lesson of the day: Some skills are a lot like a choreographed dance. Memorize each step of the dance before the actual performance!

October 23

Blue is bad

During one of my internship classes, we were told, "At some point, you are going to have a patient who is not breathing, and you will have to do CPR." This statement definitely caught my attention, but I was comforted by the knowledge that all I would have to do is yell, "HELP!" and five nurses would come running to my aid. You are never alone as an ER nurse because all of your coworkers are right there to jump in when needed. Unless you are alone in the ambulance bay, that is.
Last night my patient's mother requested that I bring her daughter out to meet her in the ambulance bay with the car. We do not normally do this, but since I was not busy, I agreed. I wheeled the patient to the back door and waited inside. After a few minutes I heard car tires screeching and the car horn blaring, not letting up. Wow, she's in a hurry! I started wheeling my patient down the wheelchair ramp when I heard a woman scream, "He's dead!" Uh, excuse me? Who's dead? This is not where you are supposed to drop patients off. I looked up and saw the source of the scream, a woman standing by her car in the middle of the ambulance bay (pretty much resembles a dark alley). I looked at the car and didn't see any passengers, so I assumed that the "dead" person was a young child. My training kicked in and I knew what to do: run to the car, grab the patient and run him to the trauma room. I put my patient's wheelchair in park and ran up to the car (I know, probably not the safest move). I opened the door to save the child's life and was shocked to see an adult man slumped over in the front seat. He was blue and not breathing. This is when my entire body froze and all I could hear was my heart beating. I had no idea what to do. He was too big for me to move by myself, there was no one in screaming distance, and the driver of the car was too panicked to do anything. All she could say is that he had overdosed on heroin, and she had no idea how long he hadn't been breathing. Thankfully, my patient's mother showed up and I yelled to her to take her daughter away. She quickly obeyed. That's when I took off running inside for help. I didn't know what else to do- my first code and there was no "code blue" button to push. My gut told me to never abandon a patient but my brain told me I couldn't handle this on my own. Thankfully the trauma team responded to my plea and came running to the bay area where they pulled him out of the car and onto the street. Even though we are a pediatric ER they were able to bring him to the trauma room and save his life. My preceptor Susan, after lecturing me about never going to the ambulance bay alone, told me that I should be proud about how I handled the situation. To be honest, I'm most proud of the fact that I somehow avoided peeing my pants! Hopefully, my next code will take place in the comfort of a well-lit, warm, code-blue-button-nearby, ER room.

October 18

Isis, my little angel

One important lesson I have learned so far about children is that even the sweetest and cutest child can turn into a little monster when they don't want to do something. Whether they are scared and don't want an IV started or they don't want to take their medicine, I have been shocked by how quickly they can flip their switch and go from talking about Ariel to kicking, screaming and spitting. The parents are usually embarrassed and upset when their child starts behaving this way. I never understood what they were going through until I took my little angel Isis to the vet last week. I knew she had a UTI, so after a lot of drama collecting a urine sample from her, I called around to find a vet to do a urinary analysis on it. None of them would do the simple test without seeing Isis first. I made an appointment and brought her in. Trips to the vet are never fun, especially for the vet. I put Isis up on the table and the vet tech walked in the room. Isis immediately warmed up to her, rubbing up against her and purring like crazy. "I need to take her to the back to weigh her and take her temperature," the tech told me. I replied that I was ok with that, but that Isis was just putting on an act and that she has a quick left hook. The tech smiled and said, "No, she's a sweetheart, aren't you Isis?" She picked Isis up and the moment the door closed behind her, I heard that awful high-pitched ear-shattering cry that cats can only do when they are extremely ticked off. This screaming and crying went on for at least five minutes. I sat there in the room embarrassed and wanting to cry. My poor baby was being tortured by that mean tech who was trying to take her temperature, and everyone in that office could hear her screaming. When the tech finally returned with Isis, she said, "Well, I don't need her temperature that badly... "

I think I'll try that sometime at work- "Sorry doc, I didn't give Tommy his shot because he started crying and made a nasty face at me." I bet that will go over smoothly!

October 12

The joy of stubborn animals

The day after my NCLEX, when I was more stressed than I have been in years, Isis left me a wonderful surprise on the carpet right next to her litter box. She peed on it, twice. Some of you non-cat owners out there might not know this, but the smell of cat urine is extremely difficult to get out of carpet. I wanted to kill the little ball of fur. But I stayed calm and spent three hours cleaning it up. Five boxes of baking soda and two ruined towels later, the smell was gone. I had to accept the blame for the incident because I had been sick and stressed, and had not been giving her the attention she deserved. Plus, when I get stressed, so does she, so I can imagine what she was going through. I forgave her, Mike forgave her (he had no choice in the matter) and we moved on. I got home from work last night and there she was, "digging" on the carpet trying to bury her fresh new urine. "You can't bury your urine because you just peed on my carpet!!!" I screamed at her, knowing full well she probably only understood half of the words I was yelling. She ran and hid under the bed and knew to stay there for at least an hour. Things have been great here- I have been working a lot, but Mike has even been playing with her, so this is not a behavioral thing. That means that something is wrong with her, probably a UTI. When she had this a few years ago, the vet charged me a ridiculous amount of money to hold Isis in a cage all day waiting for her to pee on these expensive little beads in the litter box. I think we ended up paying $40 just for the vet to collect a urine sample, which of course Isis never provided (I don't know how she got so stubborn). I'm not throwing away $40 again, so I cleaned out a container of sour cream and dedicated my night to getting a urine sample from my cat. I get them from human infants, I can get one from my cat, right? Every half hour exactly, I would pick Isis up and place her in the litter box. She would sit there for a few seconds with her ears straight back and then make a run for it. Finally, on our sixth field trip, Isis started digging. I shouted to Mike, "She is finally giving in! Isis: 0, Katie: 1!" Once she squatted, I held the sour cream container under where the urine should be coming out. All of the sudden, she started making these funny movements with her stomach, and she stood up a little bit. Hmm... this is interesting... That's when she pooped. New score: Isis 1, Katie 0.

October 10

Would you like regular or decaf?

Some patients and their families think that nurses are waitresses in scrubs. They think that their request for a blanket should be their nurse's number one priority, because she couldn't possibly have any other patients with real problems, right? I had one of these patients the other day. The worst part was that she should not have even been in the ER, she should have gone to a walk-in clinic or her primary care doctor. But she showed up at the ER and was brought to my room, so I got to wait on her. Every few minutes the mother would signal me from the door. They needed a blanket, so I went and got a blanket. As I handed her the blanket, she said that they also needed towels. Why couldn't she have told me that before!? She wanted me to call the doctor at least every half hour to ask her questions. I can't bug the doctor while she is in with a trauma to ask how long until my stable patient is discharged! I don't know why I could not communicate this information to the patient's mother, but somewhere along the line we were not connecting. After the girl told me that she was in extreme pain, I got the doctor to write an order for IV pain meds. When I tried to flush the IV, the line was blown. I informed the girl that I would have to start a new IV or give the medicine as a shot, and she suddenly no longer had pain! She didn't have pain for at least two hours, until the doctor started talking about discharging her. While fetching yet another blanket for my patient, I noticed that another patient was being brought back to my other room, so I glanced at her chart. It said, "laceration to foot." The girl was wheeled into the room and she smiled and waved at me as she passed by. I relaxed a little bit, thinking that this would be an easy case. I went in the room and started my assessment of her. She had a make-shift bandage over her foot, so I put my gloves on and lifted it off. I could not believe what I saw- her foot was cut so badly that you could see the tendon to her toe. While I was examining her foot, her parents lifted the sheet up to block her view. I quickly understood why. These were some smart parents. I asked the girl to rate her pain for me. She said it was a two out of five. Had she had the chance to see how badly she was hurt, I'm sure it would have been a seven out of five! I just couldn't get over how different my two patients were- the one with nothing wrong with her was screaming "NURSE!!" every time I walked by the room, and even screamed at the top of her lungs when I took her temperature across her forehead. The patient with a cut down to the tendon was polite and never even complained. When going from the heavenly patient to the, uh, opposite of heavenly patient, I wanted to tell her how bad the girl next door was making her look. But I like where I work, and I don't want to lose my job yet, so I served her with a smile my entire shift. I was shocked and hurt when they stiffed me on the tip though..... Maybe that third cup of coffee was too cold?

October 05

Hi, I'll be your nurse today

At my sister's graduation ceremony, one of the speakers repeatedly instructed the graduates to "savor the first time you introduce yourself to your patient as a real nurse." I remembered this as I was walking into my patient's room my first day back in the ER after officially becoming an RN. I entered the room, proud, with my head held high. "Hi, I'm Katie, and I'll..." My proud moment was ruined by, "He threw up again and I think he might have had diarrhea." NOW I feel like a real nurse!

This patient was an adorable boy who was having some gastrointestinal issues. The doctor ordered a stool sample, so the boy and his dad went to collect one in a toilet hat. When I walked into the room a few minutes later, the smell hit me instantly. I can just dump the whole container into a big biohazard bag and ship it to the lab, right? Wrong. I had to get this tiny specimen cup and pour the diarrhea into it. I put on my gloves, opened the container over the trash and attempted to aim everything into the little cup. I managed to hold back the gagging for about two seconds, but then the reality of the situation hit me hard. I turned my head away from my work and looked back at the boy, his parents, and his two uncles as they all stared at me from across the room. The looks on their faces verified that what I was doing was, indeed, disgusting, and that maybe throwing up would not be so out of line. That's when those wonderful gagging sound-effects started. Please don't throw up in front of your patient, I kept telling myself. After a few interesting noises that I've only heard from my cat when she has a hairball, I had the majority of the specimen in the ridiculously small cup.
Lesson of the day: The RN behind your name does not make smells any easier to tolerate.

October 02

The NCLEX

I slept until 11:00 today. I know for my younger brothers this is considered "waking up early" but when you are used to getting up at 5:20 every morning, sleeping past 9 is really exciting (and a little guilt-producing). But you know what? I'm allowed to sleep in this late because I have nothing to study for!!! It is the weirdest feeling to sit here and not have anything hanging over my head. I absolutely love it!
The last week has been very intense. Going into the NCLEX without the two weeks of solid cramming I was planning on was intimidating. I got lost on the way to Fort Worth for my exam, but I left two hours early and still made it there with plenty of time. Once there, I felt like a criminal. I had my profile picture taken and I was repeatedly fingerprinted. While I understand that these things are necessary, they do not help with test-taking anxiety! I'm sure some of you already know this, but how well you are doing on the NCLEX determines how many questions you get. There is a complicated formula that explains all of this, but I'll give you a basic explanation. You can get anywhere from 75-265 questions on the exam. If you are acing the exam or failing miserably, the computer will shut the exam off at 75 questions because you have already proven your competence or lack thereof. If at 75 questions the computer hasn't determined where you stand, it keeps asking questions until it can decide whether you have passed or failed. (If you want to read about this, click here). While taking the exam, I quickly realized that I did not know anything. There were only two questions that allowed me to think, "I know this!" All of the others were guesses (although many were narrowed down to two options). Around question 40, I determined that I had failed the test. I kept on going, trying my best to focus on the questions and to stop thinking about how I was going to break the news to everyone that I had failed. When I got to question 74, I started shaking. I hit "next" and it brought up question 75. Now I was really shaking. I could barely concentrate on the question - all I wanted to do was hit "next" and have the test shut off. I've heard that the screen just goes black when the test is done, so I was praying for a black screen. Suddenly, my vision started going fuzzy black around the edges. This is not what I had in mind when I was praying to see black!! Maybe I shouldn't have taken all those meds before coming to the testing center!! Thankfully, I didn't faint, but when I hit "next", I didn't see a black screen. Nothing happened. The background was blue and a little box came up that said, "Loading next item." NOOO!!!! It's bringing me to the next portion of the test. I had not proven myself and I was close to failing, I just knew it. But then a survey popped up on the screen. I was done. For about two seconds I was relieved and I allowed myself to start breathing again. But then it hit me. I only knew two answers! It shut off at 75 questions because I FAILED MISERABLY!!! I began debating whether or not I should tell people I had the full 265 questions so that when I tell them that I failed, it would at least look like I gave it a good fight. I answered the stupid survey questions (which is an evil thing to make someone do after they have failed an exam), stood up on my wobbly legs, and left. The next two days of my life were miserable. I have been told by several people that the TX Board of Nursing updates their website every Wednesday night, so if I passed the boards on Tuesday, my license number should appear on the website by late Wednesday night. I obsessively searched for my name every fifteen minutes on Wednesday. I did not get much sleep- I’d wake up and run out to the computer, only to see “no results” when I would enter my name. When my name was still not up by Thursday morning, I knew for sure that I had failed. I went to work heartbroken, hoping that no one would ask me about the exam. Unfortunately, that did not happen. Everyone wanted to know how many questions I was given. I decided to tell the truth and just resign when I got the official results back. I went to one of my internship classes and checked my cell phone around 8am, and I had a message from my dad. “Congratulations, on passing!” was the first and only thing I heard before I almost dropped the phone. I ran to a computer lab and looked at the website- there was a license number next to my name. I actually passed. After all I have been through, I was finally done. I suddenly had confidence, which I have been lacking for way too long. Now all I have to do is learn some clinical skills, and I’ll truly feel like a Registered Nurse! But don’t worry, I have a great teacher and I know I’ll be there in no time.

If you found this posting while searching for: failed the NCLEX with ___ # of questions, please click here: NCLEX Survey

Confessions of a Registered Nurse

Sunday, June 13, 2010

October 2006