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For those of you who have gone through the program, can you please share your experience securing clinicals during a program. The program is tempting due to its affordability and high pass rate, however none of it will matter without ability to be certain in clinical placement. Thank you . Your input is much appreciated!

Thank you so much for all of you who replied and gave your opinions on the matter. Incurring debt so close to retiring is definitely very concerning and it is something I would like to avoid. However, wound care field is not easy on the body and I am wondering if I can afford not to get out of it in the long run. But, again thank you for your food for thoughts and I would definitely be looking into transitioning into other fields of nursing without accumulating debt on the way.

Hello everybody! I am 46 year old WOCN with tons of experience in wound care which I truly love. However, the work is taking a tall on my body and I am beginning to wander if its time for me again to return to school to become an NP. My concern is that by the time I am going to be done with the program and licensing, my age (49 -50, if all goes as planed) would be an interfering factor to getting hired. Would love to hear your opinion and your experience on the topic. (I am open to all fields of medicine practice, not just wound care, but probably would be a better fit for low stress area). Thank you

Hi there, No, I do not include the epithelial tissue in the measurement. However, in my nursing documentation of the wound description I might add something like " epithelial cell migration is noted at the right wound margin" or if there is an epithelial tissue formed right in the middle of the wound that caused one big open area to separate into two smaller areas, i will write: " wound noted with epithelial island formation in the middle resulting in one big area separating into two smaller areas. area #1(distal/proximal/lateral/medial) measures xxxx, Area #2 (distal/proximal/lateral/medial) measures xxxx" . You will need to clarify with your facilities policies if you need to create separate record for each of those areas. In my facility, I do not create a new record but continue to record that previously one bigger area now presents as two distinct smaller areas. I see that a lot with the wounds that just about to heal. Hope i did not make it confusing. The more important question is why is there a more favorable condition at the right wound margin and not on the other areas? It is possible that initially, the wound presented in the form of the shape that is narrower at the right wound side, and of cause in that case epithelial cells need to travel less distance to cover the surface. But if the wound is round, the epithalization should have happen around all wound margins. If there is any necrotic tissue or may be epiboly (curled, rolled edges) that is present, the epithelial cells would not be able to progress and the wound would stall and the healing will be delayed. Again, I hope that I did not make it confusing as I normally tend to do!. Please let me know if you need any clarification. Inna

Thank you both for your much needed advice. I will definitely look into eakin rings and coloplast as you both suggested. Since my initial post, the MD did stop NPWT temporarily to let the periwound to heal better. We are resuming NPWT on Saturday and i will be using your tips. Thank you again so much!

I am a nurse at LTC facility where we have a patient with NPWT at a sacrococcygeal site. The wound extends far down close to the orifice and makes it really hard to seal the dressing so it is impermeable to BM. The patient is incontinent and has frequent very soft, almost runny stool that has a tendency to get under the drape. We have to redo the dressing every day and sometimes twice a day. My questions are: 1.Please offer any advise about making the dressing last. 2. Also, are we loosing the benefits of the wound vac therapy because we are not achieving continuous uninterrupted suctioning? Thank you so much Inna

Thank you for validating my thoughts. My supervisor and 911 both said remove old one,apply new. I decided against doing that. Not and easy thing to trust yourself when you are new grad and your more experienced supervisor tells you the otherwise. thanks again.

Ah yes, should be more specific. :) It is groin area vein which was accessed for IVC filter placement.

When a wound site is bleeding and applying pressure does not help, would you remove old saturated with blood dressing and put a clean one (and then of course continue to apply pressure until help arrives) or would you just pile up gauze on top of a old one and keep the pressure on? We kind of divided on this one at work. Please share your thoughts.

Thank you everyone who replied to my post. I definitely learned my lesson here. When I meet with the DON I will accept the responsibility for my part in what happened. I will also ask for full clarification from DON of my responsibility as an only RN in the facility during NOC shift concerning assessments and monitoring of residents with IV therapies assigned to LVN. I wish I thought about this in the beginning. The orienting me nurse explained that we only hang the medication for LVNs. But I should have known better to clarify. Lesson learnt. Anyway, thank you again for everybody. This board provided me with a lot of support during my nursing school and now as a new nurse. I am greatfull for that.

Ok, here is my story: On July 25 NOC shift we had a bad case of infiltrated IV case that is now being investigated by the management. The resident was on continuous D5 ½ NS +10 KCL for dehydration, was assigned for another nurse, LVN. At the report time the out coming RN told me that I have a new IV bag to hang (me being only RN at night). After midnight on the way to another station I stopped in the room to check when I need to come back to hang another bag. There was more then 250 cc left in the bag, so knowing it is running at 50ml/hr I wrote myself note to come back in about 4 hours. I did not assess this resident at that time since it was not my resident. I did look at the arm with IV site, it did not look swollen or red, and the IV was running without problem. But then again, it wasn't really thorough assessment. Shortly after 1, the LVN assigned to that resident told me, you have an IV bag that you would have to hang later. She asked me to take a look at the site. I said that I already did and it looked fine. AT around 4 am my coworker called me to the resident room. The IV had infiltrated and the arm now was swollen to the shoulder and was oozing with fluids. We stopped the infusion, elevated the arm and applied warm compress to the arm. The resident had no signs of any distress. I did assessment for the integrity of circulation in the arm. All fine. I did not start new iv at that time. TO tell the truth, me being a new grad and never until that point started IV at the facility (The residents usually get to us with PICC lines or the rare PIV that I came across during my 5 month of work started during day shifts) I was really sure that I would not be successful to start IV on my own and did not want to subject the resident to being guinea pig for my practice (Last time I started IV s was in nursing school more then a year and a half ago). The LVN who was assigned to that resident did not think to restart IV either exactly for the same reason (she is IV certified). There was only one more nurse in the building and he was really busy and said it would be bad time now. So we made sure the resident is stable and continued with our med pass. I have a very nice ADON, I have asked her many questions in the past and she was always great resource to me new nurse. She always said, if you have any questions don't hesitate to call me at any time of the night. So I insisted my college call her, just in case I missed something. She did and ADON said to try to reinsert IV any way. I did, and got in first try! That IV hydration that she got before must really have helped. I checked with new bag against the MAR (which did not have stop day. Should have alarmed me) and hanged it. Next day my DON called me to the office. (july 26th). She said that IV infiltration probably had started long ago before 4 am and that would I assess the arm, I would catch it earlier. Truth. I felt the same way. I looked briefly, I did not properly assessed. And then the order was only for one bag. Truth again. I did not check the physician order, I only looked in MAR. I learned a lot during that meeting, but I definitely did not feel that I might be in a real trouble. The DON said that she would like to follow up with me and we set up to meet on Monday after I finish report. She called on Monday to say that she cant make it on time and that I should go home to rest after the night. We rescheduled for next day, again after I finish report. Tuesday, she called again and rescheduled for Friday. Today, I saw her coming early and going straight to the business office. That scared me so much. I heard stories of nurses getting checks at the time they are fired.( When I got to DON office, she said again she did not have time for me, and would like to set up a proper meeting. She said she will call. All this anticipation is making me very scared. I am afraid they are building a case against me and would fire me. It gets even more complicated than that. It was not the first time I got written up. I got written up the very first night on my own after orientation. I made a med error. (no harm done ) it is a very busy sub acute center and I was having hard time. But don't get me wrong, I accept whole responsibility and really did learn from it and really check against the MAR my meds. So do you think it is still possible that they would let me work more than a week after the incident and still fire? Any advice how to handle my self during the meeting (whenever that will be) Thank you for sticking with this long story. Sleepy, scared head

Sorry for the confusion. The exact wording is "Application forwarded to manager".

I applied too. My status is "Forwarded to the hiring manager" . No call received yet Good luck everyone.

Yes, I agree with you about making death as comfortable and as painful as possible. I said yesterday, I did not understand being hospice and full code, but after thinking about it I know why he didn't want to be DNR. He did not accept his cancer. He defied it and wanted to live for as long as possible. Even if it meant to undergo painful interventions. I have a very dear friend who has ovarian cancer for 7 years now. It is an end stage. But drive to live in her is incredible, she is moving rivers and mountains to get herself newer, more experimental treatments and often has to overcome MDs attitude of just accept your cancer and make the most of what time you have left. And yes, she is suffering a great deal of pain and side effects of treatments, but she wants to be around long enough to see her grand kids graduate from college and see them married. She wants everything done to make it as long as possible. Anyways, I want to thank you for your reply I learnt from it. A lot. I learnt that I need to change the way I am thinking. Especially in the environment I am working, where there are a lot of people who close to final stage of their life. My thinking was of saving the life, of not causing problems by overlooking something. Instead I should have may be concentrated more on comfort measures. And then also calling a code ....

Thank you for your kind words. Yes, I am feeling a little more comfortable with English compared to 12 years ago when I came to US from Israel and knew only 5 words. And then thank goodness for the spell check in the Microsoft Word! I hope that this experience will help you in the future when you will become nurse. It is long and hard journey before you get there. But it is very meaningful and worth full of a effort. Good luck to you in your journey.

Thank you so much! You got it exactly right. Everyone at work and 911 people and here on board are so nice and keep saying I did everything I could and nothing wrong. I am not young, but I feel very very green in this profession. Deep inside the feeling is that I screwed up and not only let that pure person die, but die in pain. Till recently this person was very much alive. He was OOB all the time, happy and nice to us nurses. He talked to us. He knew and would ask about my girls at home and I knew about all his grand kids. He would come out in the hall to ask for something and we would talk while I am signing and getting it out of a med cart. Those little 2 minutes that I had before I had to run do something else where always pleasant and I was always looking forward to seeing him. He made me feel good when I was coming to shift and doing my rounds he would wave at me and say "Oh, good it is you tonight. How was your day?" It is because of my residents who are often like him I really love my job despite of the fact that I am underpaid and overworked in the unsafe conditions. I am really sorry he had to die this way. Even if, as people say, it was not my fault.

Thank you for your kind words of encouragement and wisdom. I am taking it all in and learning from it. Let me clarify. This was a hospice resident who is a FULL CODE. I don't understand it and don't agree with it, but those are wishes of the resident and the family. He did have pain control ATC and prn. He received scheduled morphine on time earlier that night. I was monitoring him thought night. Until 6 o'clock he was comfortable. AT 6, when he started to c/o pain, I was uncomfortable because of my gut feeling that something is going on, but I did give him his morphine, because wanted him as comfortable as possible. Until yesterday, when he started to bleed excessively, the pain was fairly controlled. Thank you again for reaching out to me. I am still pretty shaken up from yesterdays events. I guess I learned a lesson that I did not get in nursing school. I learned my role as a nurse is not only to save lives, but also to help let go of live pain free as possible and in dignity. I think I get it now

I am a new grad (4 month) working at a very busy long term nursing sub acute center. Yesterday morning I lost one of my residents. It is not the first time I lost someone, but this one got to me a lot more then others. This person who has end stage of cancer in pelvic cavity was found in the previous evening with a profuse bleeding from wound at the groin area (old deep wound). Nurses gave accounts of big clots passing through the wound. My colleges called 911 and resident was transferred to the hospital. Only came back a couple of hours later. No blood transfusion, No IV fluids were given. Only orders were to monitor the wound and to follow up with PCP. When I assumed my shift, the resident was stable, no bleeding, vitals stable, no pain. I checked on him thought the night, checked vitals and a wound site for bleeding. All was good. Around 6 a'clock in the morning the resident started to complain of pain in a lower abdomen area. He often did in the last months. He had narc's to cover for pain and they were helpful. I checked wound dressing = dry and intact, no signs of bleeding. Checked vitals = WNL, BP on the lower side (92/50), but I expected that from the recent bleed. Yet something was different, I had this knot gut feeling. I was hesitating to give usual pain relief. I was concerned that there might be bleeding inside ( abd was on the hard side, but not rigid board like as I learned from textbooks in case of internal bleed ) and that pain relief would mask more serious problem. In addition BP was on a lower side and there is this side effect of lowering it even more. I wanted to call MD, only I didn't. I talked myself out of it. I said to myself there is no signs of bleeding, his dressing is dry and intact, vitals are as expected given recent bleed that day and no remediation for it in the hospital. The pain is expected for someone with the cancer in the pelvic cavity. I told to myself he's been on that med for long enough and will not be affected and he is in pain and needs pain relief. I gave him pain med and went to tend to the rest of my 47 residents who needed their morning meds too, 14 BS checks, 3 GTs and 4 IVPBs. About an hour later I went to check on him again, found him screaming in pain and bleeding profusely from his wound. I yelled for help, we grabbed gauze still left by his bedside from previous evening, applied pressure to the wound , put him in the trendelenburg and initiated all the steps of the code. There was so much blood gashing from the wound, it would not stop. The BP at this point gone down to 50/20. As we were applying pressure on the wound, we saw the color disappear from his face , he was no longer responsive to us. 911 crew arrived and we worked more on him together. When they were taking him to the hospital he came back to us and was responding. I taught we got him back When I came back to work, I learned that he didn't make it and died in the hospital an hour later. Since then I have been replaying what happened in my head and feel responsible for his death. I should have listened to my gut feeling and sent him back to hospital. All my coworkers ( who are absolutely wonderful, ) kept saying they would do the same thing I did. What do you think? I want to learn from this experience so I can be better nurse and so at least I cna attempt to make sense of my resident's death. Thank you and sorry it is so long PS. Please be gentle to my English . It is not my native language and I haven't slept yet. Just been replaying what happened in my head.

Thanks 300g so much, that makes much more sense now.

Hi there, I'm a second semester nursing student finishing up a care plan for a preemie. I have to write patophysiology of RDS, but not sure if i understand the process right. Please correct me if I'm wrong. Here it's goes: The primary cause of RDS is inadequate amount of surfactant produced by the lungs that helps to reduce surface tension in the alveoli, reducing amount of effort infant has to make to get air in. When there is not enough of surfactant, alveoli collapse, atelectasis follows causing hypoximia and hypercarbia --> respiratory and metabolic acidosis,--> pulmonary vasoconstriction, --> endothelial and epithilial cell damage --> pulmonary inflammation and edema. What i'm not sure is that i interpret the symptoms right: In the beginning symptoms are tachycardia and tachypnea as a compensatory mechanism to get more oxygen in and carbon dioxide out. At this point things are not that bad still? Is that right? But as respiratory muscles fatigue, the respiratory rate slows down THAT is when things are going down hill leading to hypoximia, hypercarbia and everything else. I guess the question is would maintaining a tachycardic rate be a reassuring sign that infant is coping. At least for some degree? And would bradycardic rate be more reason for concern? I'm not sure if I'm making sense here. I'm totaly confused. PLease help! Thanks

I have to do presentation to my clinical group about sucrose usage for pain relief for newborn babies. I have found a lot of information about how it works and its beneficial effects, but have difficulty finding articles about why administration of sucrose to newborns falls under RN responsibilities (not say phlebotomists), sucrose adverse reactions and contraindications for babies that are not preterm (such as newborns of mothers with diabetes). I would really appreciate if someone could explain this or post a link to articles that are discussing this topic. Thank you very much for your help.

thank you for helping me out here. this is what i got: hr 140; bp 118/58; skin warm and dry; (3) peripheral edema +1; (5) peripheral pulse weak; rr 28, oxygen sat 88 % wheezes in both sides of lungs ;(6) no sputum produced; bnp 276 troponin 0.69 admitting diagnosis: pneumonia, atrial fibrillation with rapid ventricular response and chf class iii this is my only second week on the clinicals so i hope i look at the right data. is there any other specific information that i'm not looking at but should? if so could you please guide me? thank you so much for your time and help.

For our care plans we need to write up assessment data and for each abnormal assessment we have to come up with the influencing stimuli for that ( that would be the R/T or the etiology of the abnormal finding as how I understand it). My patient has a long history of COPD and recent diagnosis of CHF. The admitting diagnosis is pneumonia.. When presenting in the ER was complaining of chest pain. I'm having trouble to decide what would be influencing stimuli for the symptom (chest pain). I have trouble choosing between hypoxia, infection in the lungs, COPD and CHF. There is a lot going on in this patient. Can you please help.

I’m a SAHM of two kids. I started the first prerequisite class in 2005 on the very part time basis to accommodate schedule of my then preschooler and now kindergartener. Doing one science class and one GE class took me 3 years to complete all of them. I start nursing school in August. Good luck to everyone.

I wish I could be there to give you a big hug. :redbeatheI'm not a real nursing student yet and can't offer any advise, but even I can tell from your post what a wonderful person you are. Everybody makes mistakes and it sounds that you are not one of those people who makes mistakes and not learns from them. I can tell that one day you can make a great nurse and I hope that somebody like you will take care of my family or me . I'm pretty confident your list of positive qualities is much more significant then the one you listed. Just look and you will see:luvnltr: