The CPNE
I brought my husband with me this time. We got to the Hilton across the street from the hospital at around 12:30 and settled in. I reviewed my flash cards and mnemonics and took a Xanax and shower. Went over to the hospital and waited in the lobby with 5 other supplicants – the seventh didn’t show.
If you test at Albany, if you get lost remember that the instructors will be in A-303. It’s in the medical school, where the halls are maroon. When you get off at the third floor there’s a sign that says “Hyperbaric” and doors right past that. Go through them and find them. It’s a little amoeba-like back there but you will eventually find them. Otherwise you'll always meet in the cafeteria - blue sign that says "The Cafe."
The Orientation
You need to show your driver’s license or another govt-issue photo ID. Don’t bring a purse or cell phone – you can’t carry them with you. I stuck my keys, ID, and some money in my pocket, along with a yellow highlighter, Sharpie, and BLACK pens. A little calculator is okay if you need it.
The Labs
SAY EVERYTHING OUT LOUD AS YOU'RE DOING IT.
IM or SQ Injection: You will be given either one. ID the dummy to the MAR. You will be getting insulins to mix for SQ or others to mix for IM. If you get IM use the thigh. SQ use the belly at least an inch away from the umbilicus. Pretend to pinch and inch. Remember to roll your non-clear insulin. Remember, inject air into the cloudy insulin first, which you roll, then inject air into and draw the clear, give to the instructor to check, then the cloudy. Again, the CE checks. Luckily, I had a great CA who didn’t flunk me because I forgot to write down the dose and total on the sheet. Don’t do that. PUT YOUR GLOVES ON THE DUMMY SO YOU DON”T FORGET TO GLOVE. Swab the dummy’s site with alcohol. Swab your vials as usual when drawing. DON”T FORGET TO SIGN. DISPOSE OF THE SYRINGES IN THE SHARPS CONTAINER. If you get IM don’t forget to aspirate. Choose the correct needle size.
IV PIGGYBACK TO GRAVITY: ID the dummy to the MAR. Again, put your gloves on the dummy’s arm so you don’t forget to assess the site before messing with the tubing. Select the correct med, figure the rate (vol to be infused in mL’s / total time in minutes x drip factor) and write down your work. Hang the med, remember to drop the saline bag, and set the rate AFTER ASSESSING THE SITE. Use the BOTTOM clamp that controls both bags. DON”T FORGET TO SIGN.
WET TO DRY STERILE DRESSING CHANGE: Again, gloves on the dummy so you don’t forget them. Set up your sterile field. I put the “most” sterile nearest the site – gauze, 4 x 4, ABD pad. I opened them in the reverse order – ABD, then 4 x 4, then gauze. Lip the saline, pour into the tub with the gauze without passing over our sterile field, re-cap and put away. Clean gloves, then remove the dressing. Roll your glove over it and then roll the other glove over it and throw it out where you’re supposed to – I asked, “Is this the appropriate container?” They can answer that. Then select sterile gloves, put them on properly, pick up and squeeze out some gauze, gently work it into the wound, making sure to get all of the jagged edges without covering good “flash.” Drop the 4 x 4 on top, drop the ABD pad on top, tape (I ripped mine before), and sign a piece of sape c your initials, date, and time. Apply that. Dispose of your trash. You don’t sign.
IV PUSH: I failed this the first time by putting a syringe into the regular trash. Didn’t even realize I had done that. ID the dummy to the MAR. GLOVES ON THE DUMMY. Select the correct med. Pull up the meds – swab the vials/bags c alcohol wipes, not the syringes. I pulled up extra and let the CE check AFTER I expelled the excess over the trash to MAKE SURE I HAD NO BUBBLES. Then tell the CE that you’re ready for them to check the first flush. SAY OUT LOUD that there is no air in your syringe. Then, if you aspirate and get air you can say, “Hey, this is from aspirating just now.” State that the the site, which you’re gently palpating, is free from edema, redness, and heat. Swab the IV c the alc pad, aspirate and flush not too quickly. Put the syringe in the sharps container. Swab again, prepare the med syringe, give it to the CE, while she has it put your watch on the table and tell her you’re going to begin at x time. DO NOT PUSH TOO QUICKLY. You can go slowly, never fast. STAY CALM. When you are done, put the syringe in the sharps container. Same thing for the last flush as the first flush minus the aspiration. DISPOSE OF EVERYTHING WHERE IT SHOULD GO, don’t forget to sign.
They then take you to the unit for your first PCS and orient you to it and give you the chart for your first patient.
Go back to the hotel, take another Xanax, and collapse. Write the care plan for the morning.
I combined them into one post.
My First PCS
Middle-aged woman with a cervical fusion. I was assigned I/O, comfort management, meds, I *think* pain management, PVA of the upper extremities.
She was a frequent flyer who wanted to extend her hospital stay. She complained about the food, I tried to get her something soft to eat, put a ticket into dietary, discovered that the nurses ate all the sherbert and ice cream in the freezer 
, and listened to her complain for the ret of the PCS that her meds were going to nauseate her. I then listened to her examine and question all of her meds. Quite the cocktail of pain and psych.
I was supposed to ambulate her but she was too woozy so I got her to her chair, gave her a bed bath, made up her bed, schmmozed with her, took her vitals (which included a manual BP – you will have to do one manual). In report I had gotten her vitals so I had a baseline. Did PMSTC – Please Make Sure to Chart. Pulse, Motion, Sensation, Temperature, Color/Cap refill.
My priority nursing diagnosis was “Acute pain related to tissue trauma as evidence by pain rated between 6 – 8 on a 0/10 scale” Goal: Have pt rate pain of less than 6 on a 0 – 10 sale by end of PCS. Intervention: Have RN medicate as ordered. Offer comfort measures such as back rub, distraction, repositioning.
When I wrote the evaluation, my reason for choosing this as the priority was “acute pain impairs tissue perfusion and impedes healing.” My goals were fully met, a/e/b patient stating “I guess my pain is a 5.”
The second was “Impaired mobility related to weakness as evidenced by need for 1 assist during ambulation.”
TAKE A YELLOW HIGHLIGHTER AND HIGHLIGHT EVERYTHING THAT NEEDS TO BE DONE. MARK N/A’s OR BIG X’s THROUGH THE THINGS THAT DON’T.
I made a grid, and on it wrote WIG – Wash, ID, Glove/Greet. PIGS – prepare, ID, glove/greet, sign. PMSTC. A list for vitals. A box for pain. A box for comfort. A box for I/O.
Although we didn’t ambulate her, that was okay as she was woozy and it would have been dangerous to walk her. We did, however, meet mobility requirements because she got out of bed to the chair.
Stay calm. Really. We used every minute of time for this one because she was such a whiny butt.
My Second PCS
Sad little infant with brain damage at birth and an ischemic bowel. Had spent most of his little life in the hospital. Foster parents, not present.
I got comfort mgmt, vitals including O2 sat and apical pulse, medications, abdominal assessment. The CE did the BP as she said they’re really tricky on infants. She was absolutely wonderful, BTW.
He was asleep in his jumper. Got his apical – did the tapping with my finger to get the rhythm – and took it again because it was under 100 and that seemed wrong. 105 the second time. Bowel sounds, avoiding the g-tube site, which made it hard. Assessed the fontanelle for turgor. Poor little guy had the instinct to suck but wasn’t coordinated enough to take a nipple.
Changed his diaper while gloved, and weighed it on the diaper scale. That was “dirty” and didn’t require cleaning. I zeroed it with a diaper on it. Grams = mL’s. Discarded the diaper. Washed my hands again.
The CE did the baby syringe pump for me after I id’ed and verified. Be anal about IDing. It won’t hurt you and I’ve seen laxity with it hurt people. I flushed his PICC – she helped me with which tube was which, because his tiny little body was all tubes and dressing – and attached the tubing after swabbing c alc.
I was going to rock him because he was so alone but he was sleeping, and a sleeping baby is a happy or, at least, comfortable baby. She said that changing the diaper and cleaning his linens were sufficient for comfort.
My priority diagnosis was “Acute pain r/t tissue trauma as evidenced by pain of 6 on scale of 0 – 10.” Usual reason for choosing it. Reassessed as “not necessary” to meet as infant showed pain of 0 on 0 – 10 scale – his meds had been changed from opioids to benzodiazepines, and that worked. Poor little guy was lonely and scared.
My second was “Risk for injury related to maturational age” and the interventions were the usual safety precautions you take with kids – rails up, not left unattended, etc. Goal was “infant will sustain no injury or harm during PCS.” Or ever, but that isn’t up to me.
Wash your hands. A lot.
He broke my heart.
My Third PCS
This was my favorite. Older gentleman, abd surgery r/t return of cx, tremors, nice, funny, A&O x3.
I got comfort mgmt, ABD assessment, meds, I/O, and resp mgmt.
Walked into the room and he was in the bathroom, so I knew I wouldn’t have to get him out of bed. Had a walker. I washed my hands and said the the CE that I needed a sheet for the recliner as I didn’t want his skin against the plastic. We trotted to the clean utility room AFTER USING HAND SANITIZER and got that, as well as some clean chucks. I came back, set down the linens, and washed my hands. Introduced myself, checked his bracelet against the Kardex (always do that), told him I was going to check his IV site, gloved and did that. Noted it on my grid. He told me to call him “Hank.” He joked a lot.
We talked a bit, about his dx and life, and then assessed his lungs. I was told I could asses from the front as leaning over hurt him. Clear R upper and lower lobes, had crackles left upper and lower. Noted it on my grid. Had him do the 10 deep breaths. Asked him if anyone had done coughing and deep breathing with him and he responded, “Yes. And it hurts.” “Have you tried splinting with a pillow? Has anyone shown you that” “Yes.” Tight-lipped. “And it still hurts?” “Yes.” “Well, then we won’t do that.” He used the incentive spirometer 10x, and I was encouraging and praised him throughout, without being condescending. Re-assessed his lung, clear upper and lower lobes bilaterally.
I then assessed his bowel sounds and his incision – part of ABD assessment. Bowel sounds present all 4 quadrants, incision approximated, redness noted along incision and around staples. He complained of a sharp twinge that periodically occurred in his lower left quadrant and I explained that when his bowels finally moved he’d feel better. Noted that he had passed flatus.
Gave him his 0900 meds after identifying him by everything again – asked his name and DOB, AND checked the MR#. Sips of water was the only intake during PCS, urinated into bowl instead of hat so couldn’t be measured. Documented as void x 1, couldn’t be measured.
Kept washing my hands. At one point I moved my wedding band up to wash underneath and I saw my CE scribbling furiously.
I also remembered to pull the curtain when doing anything.
I made up his bed – his linens had been changed the day before so we just straightened it, and I put it back the way it had been, low.
He had also had a fall, and I asked at the beginning if he had a bed alarm. CE explained that he wasn’t that confused, just forgot his DVT cuffs. But I kept reinforcing that he should use his call bell and he said, “Well, I don’t like not getting up myself but I promised enough people I wouldn’t.” Documented what he said.
I then did “comfort measures” but basically gave him a pretty complete bed bath. The CE was actually beaming when I just got his member, matter-of-factly, and included it in my care. Well, they do get funky, and it is attached to him. And he didn’t even notice. I changed his gown, combed his hair, and took his glasses because no one ever washes an old fart’s glasses, and then asked, “Hank, got a question for you. Are those your own teeth?” The CE cracked up, and he spit them into the emesis basin for me. I got that stuff all cleaned up – I was gloved for all of this – and also handed him a swab with a little toothpaste on it to refresh his mouth, with the basin and his water nearby to rinse. I handed him back his teeth and he chomped them at me.
My care plan was “impaired mobility r/t weakness a/e/b need for walker and 1 assist.” Goal: patient will transfer from bed to chair s injury during the PCS. Interventions: Assist pt to chair. ? I don’t remember the second. Priority because immobility leads to further weakening, impaired tissue perfusion, constipation, and slower healing.
The second was risk for injury r/t weakness. Goal: sustain no injury during PCS. Interventions: reinforce need for call bell, keep it in reach, non-skid slippers on feet. REMEMBER THE SLIPPERS. You’ll fail if you get someone up and they could slip.
I said my good byes and the CE told me I did a good job.
:)
