Meagan

Wow! I loved reading this and really felt your passion and true love for your career as a nurse through your stories. Good luck to you in your future endeavors. We need more nurses like you today :)

To the Patient I’ll Never ForgetWhen we first met, it was my third year of nursing. I was young and excited to start my new job in the clinic. You were in your 80's, and had been through a lot - Heart Disease, Chronic Kidney Disease, Dialysis, and now CHF. By the time we met, you had been coming to the clinic for several years. I heard nothing but wonderful sentiments about your kindness and resilience from my coworkers. I had only known you for 6 months before you surprised me – you wanted to transition to hospice. I remember that day very clearly. We had been working very hard to keep your CHF under control, but we knew it wasn’t enough. You were more short of breath with minimal activity, had more swelling to your legs, and developed reoccurring ascites for which you required numerous abdominal paracentesis. You went to see the renal specialist and cardiologist – and hadn’t received good news – there was nothing else they could do. You see, at that time, I had been a nurse for about three years and my experience came from a busy Telemetry unit. I had taken care of and helped to transition many hospice patients, but they hadn’t walked out of the hospital to go home. They were usually very ill, and after lengthy conversations with family and physicians, they were transitioned down to the inpatient hospice unit. As a nurse, my experience was actually caring for the hospice patient. What I didn’t have experience doing was initiating the hospice transition. You were my first. And, after you passed away, I realized I had learned some of the most valuable lessons in my nursing career. I learned to slow down. When you work in the hospital, you’re always in “save” mode. You’re on high alert for the slightest change, because if you don’t catch it, it could spell disaster or even death for your patient. You’re ready at the slightest change to race down the hall and put to work those ACLS skills you worked so hard to learn. You’re ready to be the best patient advocate you can be to save their life. But I didn’t work on the unit any more. I worked in a clinic with a patient population consisting of the chronically ill. It dawned on me when you chose hospice that it was okay to slow down. I learned it was okay to use my clinical judgement as a nurse to initiate those difficult conversations with my patients and take a more holistic approach. I learned that hospice does not mean “giving up.” When we talked about hospice and your thoughts on starting the process, you told me with such conviction that you were ready. You had been through “save” mode many times. You had been stuck countless times for IV’s or labs, had numerous abdominal paracentesis’, and had already been through dialysis. By this time, you didn’t want any more doctors office visits, trips to the hospital or any invasive procedures. I remember you telling me that you felt so blessed to have made it this far, and that resonated with me. I learned what dignity truly means. By definition dignity is, “the state or quality of being worthy of honor or respect.” After you passed away, it was hard for me to see that empty chair every week. But, what I realized was that you had given yourself and your family a gift. There are times in our nursing careers when we see patients who can’t make these decisions for themselves. Sometimes they don’t have advanced directives in place, or they have family members that just can’t agree. I respected your family’s commitment to your wishes, as this is something I don’t think we get to experience often enough. Although many years have passed, I will never forget the conversations we had, and the lessons I learned as a new nurse. I think about that day often and I thank you for helping to shape my nursing career. Fellow Nurses, have you had similar experiences that changed your nursing practice? What was your greatest take-away?

I work in a CHF clinic, so the focus with low sodium diet is specific to fluid retention and symptom management. For us, it's about the overnight weight gain that can accompany those high sodium foods. A Liter of fluid weighs around 2 lb, so in a patient with CHF that could lead to worsening symptoms and possibly an admission for diuresis if it's left unmanaged.

Thank you for your response. I can certainly appreciate the need to better study the effects of an increased or reduced sodium diet on patients patient as it pertains to patient outcomes. I also like to look at lower sodium diets as a more health conscious diet in general. It doesn't hurt to limit intake of processed "junk" foods for any patient population.

Thank you so much for your response. In my area we also struggle with transportation and lack of grocery store choices. We have several patients that are limited to food that is given from food pantries. I will often times try to help them maximize on quantity of food by seeing if there are any lower sodium options that they can pair with those higher sodium foods. Have you been able to reach them by showing them real time sodium content in fast food? This is always eye opening for my patients.

What do your patients typically say when you tell them they need to reduce their dietary sodium? I hear, "What is sodium anyways?” Guess what? - Its salt! And in my clinic, most patients have never heard this before. As a heart failure nurse, teaching about sodium is something I practice daily. I've put together 5 ways to help teach your patients how to reduce their sodium intake. Put away the salt shaker I know – it seems obvious right? But in fact, it isn't. Most patients have not been educated on nutrition and have never been on any dietary restrictions before. Teaching them that sodium = salt should be your first step. Did you know that a single teaspoon of salt contains approximately 2,300mg of sodium? Chances are, neither does your patient. Putting down the salt shaker could mean the difference in thousands of milligrams of sodium taken in per day. Another important consideration is to teach your patient that salt = salt. Don't get confused by other types of salt such as Pink Himalayan or Sea Salt. These still contain sodium and count toward the total daily limit. Read the nutrition labels Would you be surprised if I told you that most patients don't know how to read a nutrition facts label? This is an essential step in making sure your patient knows how to reduce their daily sodium intake. Start with the basics. What is a serving size? How many servings are in this container? Then move on to the good stuff – milligrams of sodium. A lot of my patients gravitate toward the daily percent – but what we really want is the milligrams (mg) per serving. The Heart Failure Society of America recommends that a heart failure patient should limit their sodium to between 2,000 – 3,000mg sodium per day. If your patient doesn't understand how to read a food label, this recommendation becomes difficult to visualize. Ensure you know what their restrictions are, and help them understand how to stay within that range. Prepare your food at home One of my favorite memories as a new nurse in CHF was an elderly patient telling me, "Honey, I'm not going to learn how to cook now!” Cooking at home is a struggle for many patients as they belong to all backgrounds and all walks of life, but it is essential for being successful with a low sodium diet. Teaching patients that they can still have proteins that they season and prepare along with fresh fruits and vegetables is a good place to start. I always say- the fresher the better! Providing patients with a visual of options to choose and options to avoid has been really helpful in my practice because patients usually start out by saying "what can I eat?” I also like to add that seasonings are NOT off limits, they just need to be sure the seasonings they buy don't contain sodium. Choosing seasonings like black pepper, garlic powder, onion powder, cumin or chili powder are all perfectly good alternatives to pre-made seasonings. Limit intake of processed foods As you can probably tell, I've created my own personal script after teaching low sodium for 5 years. My favorite line is, "if it comes in a box, a bag or a jar, you probably shouldn't eat it!” Explain to your patient that processed foods (food that is not fresh and comes in packaging) generally contain much more sodium than foods that are fresh. Educate them that nutrition labels live on these food items and that it's important to read them before purchasing. Also, inform your patient that labels are often tricky and can say things like "reduced sodium.” In reality, this could mean the difference of only a few milligrams versus several hundred. Check restaurant menus before you go Thankfully, most restaurants these days are sympathetic to the nutritional needs of their customers. It's now relatively easy for a patient to Google the nutritional facts for their favorite restaurants before they leave the house. This way, they can have a plan before they go, and are aware of what foods with easily work within their sodium restrictions. Often times in the clinic I will ask my patient, where do you go out to eat? If they give me an answer, I will look it up right there and show them the sodium amounts for that particular item. It can be quite shocking to discover the chicken nuggets from your favorite place are suddenly off-limits, but this is a really great way to help your patient visualize actual amounts of sodium in processed or prepared foods. Every opportunity we have to teach a patient can help them to be more successful. What techniques have you developed in your practice to teach patients about sodium restriction? Resources HFSA Module 2: How to Follow a Low Sodium Diet

In our hospital we have the color coated scrub system, but we also have badges with large lettering to indicate our positions. We have to wear two so that if our badge is turned around anyone can still see it.

If your personal goal is to become a nurse, don't let what your instructor says get you down! Dust yourself off and keep trying. If this school doesn't work out, do what you have to do to get into another one. Retake some of your undergrad classes to get your GPA back up or look into those schools that are further away. If this is your dream, only you can make it happen. Good luck!

The only reason I left the bedside was because I knew that CHF was a passion of mine, and I had to follow it. I will tell you, it took me a long time to adjust to working Monday-Friday and depending on where you work, it may not be any less stressful.. I actually think I spend less time at home than I did when I worked on the unit. You just have to weigh out the good and the bad. If you love the unit you work on, stay and enjoy your weekdays off while the Monday-Fridayers are at work! Good luck on your journey, I am sure you will make the right decision for you ?

There are some certifications out there that she could obtain in order to be certified to provide dietetic education, like a CNS or a wellness coach. As an RN she will always have to work under a physician's orders. I don't know if RD's really prescribe anything themselves, in the hospital it would just be dietary recommendations (tube feeds or supplements) but I think these still have to be signed off by a physician.

The hospitals in my area just recently changed the pay scale for ADN vs BSN and it wasn't by much.. Is there any reason you aren't reaching for an upper level position now that you have you MSN?

Does your hospital do a graduate-nurse residency? The fact that you are a new grad could be used to your advantage and you could start working on the unit you really want to without having to build up the experience first.

You made some really good points here, and I can tell you from my personal experience with anxiety and my first nursing job felt the same in many ways. Try to find a little bit of light if you can. Maybe you needed a different preceptor, or a different unit, but most of all, you need to give yourself time. I had many sleepless nights, and even considered getting out of nursing myself. Your path will show itself to you ?

When I was a new grad, I had a preceptor that just didn't click with me. She was a great nurse and a wonderful person, but I knew I wasn't getting what I needed to succeed. I wound up going to my manager and telling her I didn't feel that I would be prepared to go off of orientation if I stayed with her. You don't have to tell them every last detail of what you think she did wrong, but it's clear that you are not comfortable with the way she instructs you. In my opinion, it's your career.. you only get one orientation and they should want you to succeed.

The hardest thing for me to adjust to was working 5 days per week. It's still hard to find the time to schedule appointments or get errands done. You will find your balance and what works for you though. The nice thing is not having to worry about holidays, nights or call. That is a huge relief!