datalore

"Am I going to have to chart this as patient elopement...?"

I've had an anxiety disorder basically from the moment I popped out the womb! I had to wait til I got mine under control enough to finally follow my passion. Sounds like you're working hard. My only additional advice would be that different care settings offer very different pace and frequency of emergencies. Even different med-surg units within one hospital! Shadow in different settings if you can; see the pace, see how often staff find themselves in Codes and emergencies; etc. Also, not that night shift is great for anxiety (I.e. Sleep deprivation!) but there's very little family conflict at night vs at day shift. As you continue down your path, keep working hard like you are, keep your needs in mind and see as many settings as you can til you find ones that will help you keep your anti-anxiety gains as you follow your passion. Good luck, and know you're not alone

I think it's appropriate on a group-by-group basis; my current work team does it well, but I've seen it crash and burn with other worksites. I go out for dinners when it's a large, all-people-were-invited work gathering and no problems in 2 years (yet? haha).

Among other things, we've all joked before about how doctors only ambulate patients on Grey's Anatomy. We have a surly, nurse-frightening, House-esque doc that not only regularly ambulates our elderly patients, but I also caught this doc helping my pt shave their face despite a full caseload and an aide in the wings able to help instead. It was amusing in an endearing way, because it was completely unexpected and sweet. So, I must ask, what other funny, cute, ridiculous, hilarious, unbelievable, incredible, etc, things have YOU seen at work that you once thought, "I thought that only happened on TV!"?

Most of the questions I got asked (I work tele) were about patient safety, willingness to accept feedback, how you'd handle an emergency, handling difficult patient situations etc, and way less about tele-related stuff. Basically "are you going to be a good, safe, teachable nurse" type questions. Your mileage may vary! Good luck!! Sleep well and eat a good breakfast :)

You're going to see many a coworker do things in a way that you don't prefer and/or that gets bodily stuff on you. It's not always carelessness or being incorrect. I've seen everything on that spectrum, like someone focused so much on the patient that they didn't realize they whipped the pee-soaked gown into their coworker's face instead of the hamper. Accident. Usually it's as simple as saying, "Oops, careful, that's going in my mouth," and that's enough to fix it.

I work in cardiac intermediate care (stepdown) and I'm only "ordered" to do q2-4 vitals and assessments - sick enough that they are moderately septic, bipap-requiring, titrating cardiac drips, unstable angina... etc. (Of course I do as often as clinically appropriate in addition.) At a nursing facility, these folks are definitely more higher-need than independently-living individuals but they are stable enough that they're "at home with help", so I would feel very comfortable with less frequent vitals if I walked by and they were breathing normally. :)

For me it was undeniable interest in an area long before nursing school. Significant family history of strokes and heart failure makes me think that hearts, lungs, and kidneys are cool... so for me the cardiopulmonary unit in my hospital was my only goal. And then once I worked there, my interest continued to deepen -- that's how I knew I chose wisely. Now that I've floated to a few other units, I see other areas I would love to learn in the future. But for now I want to become an expert in my area before I move on. The beauty of nursing is you can move about if different types of nursing interest and excite you. The other side of that coin is that I learned quickly what I can't stand. I don't like post-surgical care, so that eliminated quite a few units! I am severely uninterested in orthopedics. I floated to my ED, which I thought I would end up doing, and hated it. I love kids, but don't like peds/NICU after shadowing there. I did a few shifts shadowing a scrub nurse in the OR; hated it. I still learn a lot when I float to those areas, and I love that, but I'll never apply to work in those specialties. So that helped too! :) Edited to add: If you're not sure what area you'd like, use nursing school to get as many types of experience as you can!! It's ok to not know. It's ok to never find one area to stick to, too! Nursing school is such a unique and wonderful place to get as broad and varied an experience as you can. When I send my nursing students to go see cool procedures and the like, I am always a little jealous! Do as much as you can, in as many areas as you can! And if you think you know your specialty, STILL go see other areas, because you might be surprised (and at worst, it reinforces your decision to specialize elsewhere).

In the grand scheme of things, a NICU preceptorship is not likely to be the resume line-item that gets you directly into a NICU after graduation. So, although it's a serious disappointment as you likely would've loved the hands-on experience NOW, it's not a death-blow to your career path. At all. I promise. It's going to be just as hard to get that job, but if you're willing to put in the time and wait it out, you can get there. I had a similar disappointment in school; desperately wanted a cardiac placement, ended up in PEDIATRICS, to my distinct horror...... ended up learning a ton that I use in my cardiac job anyway. (I'm your opposite: I only want the oldest, most elderly patients! Hehe.)

Good on you for quitting! Watching my hubs do the same and you about-to-be-former-smokers are warriors I swear. Kudos. Hang in there.

I keep a ziplock baggie in one pocket of my scrub pants, one that is covered by my top anyway, but I hide a granola bar or something in there for when I'm on hold on the phone for a minute or charting furiously and I don't want to run all the way to grab something... anyway, I hide snacks on my person like a squirrel. It helps.

For the heart muscle portion of this... Hypokalemia (and/or hypomagnesemia) prolongs the QTc -- in less wonky terms, it increases the absolute rest period of the heart muscles; the time during which they cannot contract again. In hypokalemia and/or hypomagnesemia, it takes longer for the ventricles to get ready for the next beat; by the time they are ready to beat again in a patient with low K+/Mg+, the next ventricular contraction may already have fired, and then you are in danger of going into a rhythm like vtach or Torsades de pointes. It's called an R-on-T phenomenon, and can quickly degrade into a life threatening situation. If someone has low potassium and I need to give them an unrelated drug that also prolongs the QTc, like zofran or haldol or many others, I need to get an EKG and replace potassium or risk having to use my CPR skills on them. Taking it back a step, if I'm giving a patient something that lowers their K+ or Mg+, like some diuretics or some laxatives (or they have diarrhea), and I'm giving them other meds that lengthen QTc I definitely want to know their K/Mg levels first. I deal with this almost daily -- I'm giving lasix and not replacing it, and a potassium level hasn't been drawn in three days and the last one was borderline low, AND you want me to give more lasix? I call the doc and ask for another lab draw, which they are generally happy to have the nurse questioning! We all love patient safety

Wage/salary-wise, I can't give a number because the cost of living is so vastly different all over the US. I make peanuts compared to what other states pay their RNs, but I feel like I have a ton of monetary cushion because I live in a cheap area and I budget around my relatively manageable debts. What I think I'm worth as an RN, though... I think I'm worth adequate staffing ratios, I think I'm worth listening to when administrators want to make changes that make my job harder, I think I'm worth acknowledging when patient outcomes are improving... I think I'm worth at least that.

You're going to age anyway, might as well be a nurse when you get there.

As long as HCAHPS is GONE!... I'm open to options. But not "no" option.

Furosemide, ototoxicity means you can cause hearing damage if pushed too fast.

That's exactly what I mean! A warranted heads up is great so I don't walk in and create problems. But I don't need to know that grandson Billy's cousin's sister is a park ranger in Timbuktu.

I had one nurse tell me 10 minutes worth of stories about the patient's family dynamics (which weren't anything out of the ordinary, just who does what for work and life stories), and get annoyed with me for asking pesky questions like, well, do they have any edema? (I work on a heart failure floor.) She didn't last long.

Because he was taking more diuretic than recommended, the patient (a) was probably (vascularly) very dry, which can (b) cause mild kidney dysfunction and/or acute kidney injury. Both things increase creatinine. Creatinine is cleared by the kidneys, and is a product of muscle metabolism. If your kidneys disappeared *POOF* right now, your creatinine would go up by about 1.2 per day, just because you have muscles and that's how much creatinine you make a day. If the kidney is not working properly because of dehydration, acute kidney injury, etc, it is not clearing creatinine appropriately, hence creatinine increases. So, CHF is treated by diuretics, then what happens if the patient isn't taking enough diuretic? More fluid stays in the intravascular space. This increases the stretch of the heart. Frank-Starling law is a fancy way of saying the heart pumps more blood as it stretches out, until it stretches too much then it stops working effeciently. THAT is CHF. There is too much fluid in the vascular space, the heart stretches too much, and blood starts backing up into the lungs and body. When it backs up into the body, you get edema. When it backs up into the lungs, you get SOB and pulmonary edema, crackles, a nagging cough, low O2 sats, etc. So if this patient had not been taking their diuretics at all... what would happen to them? How would they present and what symptoms/signs would they have that would be different than what really happened? Creatinine would likely not be effected, because they're not dehydrated and there's not enough diuretic to injure the kidney. But another lab, one that is an indicator of CHF, may elevate -- which one would that be? There's a delicate interplay between CHF and kidney function. The kidney is the way the body rids itself of fluids. The heart needs a certain amount of fluid -- but not too much -- in order to perfuse and oxygenate the body tissues. If a person is dehydrated, has kidney disease, etc etc, you see overlapping effects of CHF on top of kidney injury/failure. You're doing great thinking through it and piecing this together, what else are you thinking about this patient now? Keep going! :)

Yes! Definitely practice and exposure -- the repeated exposure reinforces the concepts. And, if you have good physicians around you they'll teach you more nuances as they prescribe certain things for certain patients. I'm finishing up my first year as an RN after graduating from an ASN program, and it was after graduation that it all *really* clicked. And even then it took a few months of working! You will get there.

Think of the fluid compartments your body has: 1. inside the cells, 2. between the cells, 3. inside the vascular system. You can be dry in one and overloaded in another at the same time. You can be dehydrated (low intravascular volume) while still third-spacing (the the extracellular space). Someone with low serum albumin can't hold the fluid in the vessels, and it leaks everywhere, so you end up with a dry, hypovolemic, extremely edematous patients. A ton of lasix will pull fluid out of the intravascular space (and hopefully take the third spacing with it, though it doesn't always get enough of it). So, dehydrated with edema. Also, don't forget lasix is harsh on kidneys, not surprised their creatinine went up if they were taking more than they were supposed to.

Same for me as kejRN- the night charge nurse runs it, and all day staff and most night staff attend, but nights are expected to be finishing tasks and answering bells. (And then vice versa at night shift.) We quickly cover patient safety issues, risk related items, equipment/education/policy items (if applicable). It's usually 5 minutes long, occurring 10 minutes after we punch in and immediately before getting report from offgoing RNs. I find it helpful at promoting safety because then everyone knows the high risk situations they may walk into/need to help with on the unit, and any major unit- or hospital-wide changes are known by all.

1. I'm 8 months into my first year -- I'm JUST starting to feel like I know what I'm doing, even though I've been doing "great" all along. Don't feel like you're not meant to be a nurse because you feel like you have no idea what you're doing -- that is normal! It goes away eventually, because.... 2. ....Lots of people will have to tell you things you've done incorrectly or things you can do better. This goes along with the point I made above -- it's because there's SO MUCH to learn in the first year. It's not because you suck, it's not because they don't like you. It's how you get over the "I have no idea what I'm doing" feeling: listening to and acting on that feedback from others. 3. You will make a med error. You will. Any instructor that ever told you, "I never made a med error" is either lying or hasn't worked at the bedside.... OR, doesn't realize they made errors. WHEN (not IF) you make an error, own it, learn from it, cry about it, feel terrible, but know you'll always be vigilant to never make that same mistake again. Good coworkers will share their own stories with you when you're feeling terrible about your own mistake. Everyone has stories. 4. Be a sponge for feedback and information. Be curious. Be open to criticism. Be willing to advocate for yourself if you're given a task that is inappropriate (e.g., you haven't seen it done, been signed off on it, no necessary supervision) while in orientation and when you're first off orientation. 5. My best advice: KEEP A JOURNAL! :) I've never been a diary/journal type person, but an instructor told me to jot things down occasionally, so I have and it's so fun to go back and re-read the nice/sad/scary/proud memories. In 20 or 50 years I'm sure it'll be even more fun to remember things about the journey. It's worth the occasional writing!

The flowers look more alert and oriented than I feel.

They will (hopefully, eventually) learn enough to make their own decisions... humility can never be taught! Unless they're creating unsafe situations by simultaneously not knowing AND not acting on solid advice, I'm happy when they know what they don't know and defer to more experienced team members.