The rest of my lab stations went pretty much the same way. I passed friday night with no repeats.
I was taken up to the unit that same night. I was introduced to the floor by my CE. I was taken into an empty patient room. Now, this where have to tell you guys, St. Mary's is EXTREMELY nurse friendly. Everything you can possibly needfor your particular patient is right there.
So, I recieve my assignment:
PCS 1: 86yr female, admitting DX: Upper GI bleed
assigned areas of care: Resp Asses, Abd Asses, Medication
My CE hands me her chart so that I can review. I took 45mins doing that...I wanted to make sure I knew my patient.
I go to the hotel and first thing I do is...
jump in the jacuzzi! 15 mins later I was back in my room working on my careplan.
Do not write anything but your planning phase.
I chose: Impaired Comfort R/T upper GI bleed. AEB (I left blank)
Intervention #1 Assess Comfort Level
Intervention #2 Provide comfort measure: Mouth Care
Saturday morning we met in the hosp. cafe with our CA. She took us to the student area. She gave us a pep talk and off with our CE's we went.
As soon as I got to the floor I wrote my grid out on the back of my kardex and I handover my PCS kardex, Ce read it and told my I was now ready for my implementation phase.
I washed my hands, entered the room and indroduced myself and my CE, I id'd my patient, I assessed her IV site. I explained what I was gonna do. Did vitals, declared vitals and started on my resp assess. Then, out of nowhere...the breakfast tray arrived. "I wanna eat my breakfast before it gets cold."
I helped set her up and left. Did my as evidenced by which was patient laying in bed slumped to left side. Documented my mobility. Filled in my PCS Record Form, pulled out all my meds, (6 total)...and waited for my patient to finish up breakfast.
Finally...I go back in th room, measured intake and sat her upright position. assessed lung sounds, had her deep breath thr mouth...exhale slowly...done. Before I layed her down..."Miss Patient Name, would you like to use the restroom before I begin your abd assess?" She didnt. I closed the door for privacy, asked her if she was in any pain. I layed her in a supine position with knees slightly bent. Pulled up her gown, looked for distention and contour. Auscultated all quads, palpated all quads lightly, I didnt have to measure girth so I sat her back up. I Id'd and triple checked my MAR. Gave her her meds, provided mouth care, changed her gown(not part of my assignment but she was covered in jelly and eggs.) I asked if she was comfortable. Put her call bell and phone in reach. Bed was low, upperside rails up x2, thanked her for her time and I excusd myself. I had 10 mins to chart! I was scribbling everything! Thank goodness for my grid because everytime I did a critcal element I crossed it off my grid. I finished just as my CE stood next to me and said time is up. BAM! Here you go sir...He read me the dreaded statement, took my PCS form and my carpenito's and told me "Wait here"
I paced and paced and "Congratulations, you passed."
I was so happy I started to cry!