David's Harp

On a related note, is there anywhere where I can learn the shorthand being used, eg a "T" with two dots on top of it to indicate "two tablets"? I don't even know what this system is called, and it's pretty frighteningly easy to misread/misinterpret... -Kevin

I forget things, too. My managers seem tolerant, even positive towards me, but some of our other staff seem to think I should have it all down-pat from day one. Friday was particularly bad, and after having the weekend off I'm not too keen on going back in tomorrow. I've had off all weekend, but I might as well have been at work as I've been dwelling on it ever since whenever I'm idle. I also wonder if this stuff will ever come together. Our clinical nurse specialist tells me that I'm not expected to have a seasoned RNs level of expertise, but again I'm not sure everyone I work with would agree, and in any event I feel like my patients need me to have that expertise, immediately! I'm sorry this isn't the most reassuring message, just letting you know that there are others who feel "under the gun". It's bound to get better, and that's something I hear from everone, so trust in that!

Honestly, one newbee to another, it sounds like you need to be either on a different floor or in another hospital entirely. Tenacity is one thing, but this sounds like an environment that can either chew one up & spit one out or otherwise assimilate one, and neither option is all that desireable. I always want to know, when I hear of horror stories like yours, how do patients/families get treated there, considering the way vulnerable staff is treated? Is there a "caring/cut-throat" toggle switch somewhere? Are there other institutions in your area that you'd consider?

Youngest of 6 and male, no ETOH but plenty of dysfunction nonetheless. Also, no other nurses in the family. Never the most outgoing one, but always the one who would find alternative paths and notice details that the others hadn't, which I think must account for both the music and nursing careers. As much as I love smashing stereotypes/preconceptions, birthrank-related theories have always interested me. For instance, very little in my upbringing (as far as I can see) points to me being a caregiver, but somehow people saw it in me before I did and suggested nursing back when I thought it was out of the question. Co-workers see it in me now, too. These things all have roots somewhere, but they're not always as plainly obvious as we'd like them to be, which keeps things interesting! On a related note, a neat read is Born to Rebel (I forget the author's name), though the guy paints with pretty broad strokes, and had clearly never met many in the nursing profession. He suggests that firstborns are the more authoritative type, due to their having only parents to look up to from Day One, while lastborns are more freethinking, due to their having to scramble to find a niche-role to fill in the family ranks. I've known too many people who have gone against those generalizations to take them too seriously, but he does raise some thought-provoking points. -Kevin (I guess I did end up the "wordy one"!)

Likewise on our floor. It goes into report, and as long as the communication is good and the order isn't life-or-death-stat, it'll get done. If it was life-or-death, you'd have already been at bedside anyway. Nursing is a 24-hour job, though it's taking me time to realize that that doesn't mean I do it for 24 hours!

I didn't say it was an entirely reasonable concern, just that it was a concern! Who knows, it might not be an issue - I'd just rather have it off and not think about it. If I could, I'd go without a watch, too, for the same reason, but that's a tougher workaround. -Kevin

I keep mine tied on the drawstrings of my scrubs. I don't wear it because I figure it's better to have all surfaces of the hands clear for washing, and I figure should be no need to show proof of marriage in the workplace. That said, I have gotten questions about it (naturally, in a mostly female workplace), but my reasoning is pretty straightforward and, since I'm never trying to be a player or anything anyway, folks put 2 and 2 together and it's not an issue. The drawstrings idea works, though, as a way to keep from losing the darned thing altogether. -Kevin

Great to hear this, LadyPhantom. This must be the "magic moment" I've heard about, and it gives the rest of us hope.

I guess it depends who you're asking. In June I was told by an HR person at Presby, after being referred there by a Presby RN who'd graduated CCP a few years ago, that they weren't accepting newly graduated ASNs. At Penn, the last I heard (this was in August) was that the Spring '07 group was the last they were taking of ASNs, though this is word-of-mouth from someone in that group. My last clinical rotation was at Jeff, and a few people I spoke with there (one was the person who did the Lastword training class) said that they were "going in the same direction", as far as BSN-only. So in that instance it was merely strongly implied, not stated outright. I pursued all of these options nonetheless and nothing turned up, though obviously in April-through-July I was part of a wave of hopeful candidates. Einstein (now my employer) and Hahnemann (where many of my classmates work) are fair game, as well as other, smaller institutions in and around the city. I wanted to post this because my initial post was in frustration, and while it was not intended to cause a scare, I obviously should have been clearer as to what the source of that frustration was, and for that I apologize. RNKaren and others in the thread are better sources of info about the various viable options than I am, and you can see that there are plenty of them. Basically the moral of the story is that you keep plugging at it and you'll get something, but that there are no guarantees. Not unlike all other professions, come to think of it! -Kevin

Here goes. Hope some of it's useful! Nursing_Worksheet.pdf

Hytrin and Ranexa are two I've come across that I didn't see in school. Bumex comes up alot when Lasix isn't enough. Labetalol, too, for when Lopressor doesn't cut it. Lot of Diovan on the floor, too. Then there's all the stuff your dialysis & renal transplant patients will get, like Phos-lo, Renagel, & CellCept. That's what's coming to mind for this newbie.

By which route? When they are depressive, are they completely sedentary? Again, more info, please!

Cardiac Nursing is pretty intense & in-depth. We have a copy of it on the floor - it's a little pricey! -Kevin

You know, I am 100% with you. I also started in August, also on an (overall) very supportive floor, but I have had some shifts like today and yesterday that have made me want to hang up the cleets and try paying my loans back a different way. I feel not only as though I'm asking dumb questions about some things, but that some of what I can't seem to get are insanely difficult and I can't fathom _ever_ getting a handle on them. Some of these nights after work I kick into self-criticism mode and it's all downhill from there. I'm told by everyone that i'm not expected to be as competent as the more seasoned nurses are, which makes sense, but I can't help but feel that my patients need me to be that competent. And at times I feel like fellow staff are leaning on me as though I'm that competent and getting disappointed when I can't deliver. When a manager or clinical specialist stops me and asks how I'm doing, and I say "Not good", their response is "how can I help?" or "what do you need done?", and most of the time I either have something stupid that needs doing, something needs to be assessed (only I can do that for my pt's), or otherwise I just can't think of anything in particular and am just feeling swamped in a generalized way and have no intelligent response. I'm sorry there's not much reassurance in what I wrote, but for now comiseration will have to do! I hear it does get better, honestly, and this is from reliable, peer-reviewed sources, so maybe we just need to stay in the game and not let ourselves get psyched out. That's the best I've got right now. All the best, Kevin

I don't find SBAR to be as useful in giving report as it is in communicating w/ physicians & other nurses regarding present issues needing immediate action. For change-of-shift report, which has really been a struggle for me, I have a little section at the bottom of my "brain sheet" with the following rough outline of what will be needed: -Demographics (name, age, gender) -Allergies, risks (falls, aspiration, etc.) -PMHx -Chief complaint -Story of present visit (salient points, not minute-by-minute - some pts are there for a month or more!) -Plan (if known) -Systems, including skin (& any interventions being done) -Pain mgmt -IV access, IVF if there are any -Issues during last shift -Unusual Labs, interventions being done -Labs needed -Rx that need mentioning (Heparin, any drips, anything needing special mention) -Any heads-up (family, behavioral if not already covered in "Systems", restraint orders that will need renewing, etc.) I try and fill these in throughout the shift if I can, but if not at least i have the blank outline to guide my thought process. Some of these bullet points lead to others out-of-order, but at least I have it all in front of me. Hope this helps a little bit! -Kevin

Umm...I was told there'd be no math... Seriously, as a new grad I do days with rotation to nights, and each has its pros and cons. Nights are easier for more reasons than days, though. Not nearly as many conflicting agendas on the floor, no family, no juggling trays-versus-NPOs, fewer BG checks, fewer med passes, fewer people to fight for the chart, almost no discharges, fewer admissions. On the other hand, during the day you always know who's covering which patient. At night it can be a little tricky to work that out, and sometimes it's someone who's on-call for a seriously huge number of patients. Sometimes the last progress note and set of orders were written at 13:00, and that tells you exactly nothing about who to call at 01:00. Our main pharmacy closes at around 11PM, so there's ambiguity around that time as to which one to call for things you're missing. Fewer resources are available, personnel-wise; our Clinical Nurse Specialist is almost never there for nights, and that's a good person to have around when you're new to the profession. Otherwise it's easy to fall into everyone else's bad habits from the git-go. During the day, too, you can always go back in to a patient's room and re-check something you weren't sure about, whereas at night they're trying to get some sleep, thank you very much. And then you realize you need to draw for this or that lab an hour later...:trout: Remember, too, that most day-nurses think you have all the time in the world to do whatever at night, and that that's not necessarily the reality. We have to enter the tele summaries in the chart twice at night: at 23:00 for the monitor techs who work 3-11 and at 07:00 for the ones working 11p-7a. The shift in general just flows differently, is the main thing. My vote would be for the rotation-thing I do, so you see both sides. I was on nights for a week during rotation and then again for the first week I was off orientation, which worked out well for me, even though the latter ended up being a few of the craziest nights I've seen yet! Hope some of this helps, Kevin

Didn't much like it then, and in retrospect I dislike it even more because it didn't really give me any kind of taste of what floor nursing entails. There was _no_ practice in taking off orders (and variously questioning/recommending them), working with the greater healthcare team (including residents, social workers, etc.), or really giving change-of-shift report and the responsibilites that that carries with it. I don't know if it's even possible to incorporate these things into clinicals, but these are a few of the things that have smacked me in the face coming out of school. A lot of rotations teach you more about that instructor's pet peeves than about anything useful. I can tell you that my last clinical instructor got headaches a lot, was fanatical about us cleaning up our patients' rooms to her satisfaction, which involved putting all of their belongings away (on an ortho floor, where patients generally preferred to have everything out where they could reach it). She also had a traumatic run-in with her clinical teacher when she was in nursing school that left her pretty OCD about starched collars, perfectly white shoes, etc. Fascinating stuff, though what that all tells us about nursing, and how that all allegedly benefits the patient, is anybody's guess. -Kevin

This. :yeahthat:

Wow - good on you for your grace under pressure! I can't picture any of the flock of residents on my floor wanting to be bothered with someone who wants this badly to bolt. There's usually someone who can get that person's bed within the next couple of hours anyway, so if the person is with it it's a matter of treat-OR-street. This is a good example for me in the likely event that it comes up, because by my understanding had you forced the IM Ativan it would've been your orifice on the line, legally speaking. -Kevin

Nope. We still do it, too. Sometimes, as a nurse, your best interest is to be in there doing it yourself, as you learn a lot about a patient's mental state, level of concsiousness, muscle tone, respiratory state, functionality (can they use their limbs to turn), concerns (talking them through a cleanup, if appropriate, can help them a lot!), etc. But, sometimes it's just the nature of those busy times when you have only one aide available or they're otherwise running around doing other things. It's really no biggie when it's your standard "oopsie-daisy" BM, and a little more involved when it's a kayexalate-related situation. Another point regarding the "grin" is that a good CNA is one of your strongest allies, and don't kid yourself otherwise. You'll feel it pretty keenly when he/she isn't there to be your third and fourth hand. -Kevin

Sorry to threadjack, but as a followup question: How often are Dig levels drawn at your institutions? Ours are done weekly, which seems to be not often enough to me. I caught one case a couple weeks ago where a pt had been on it for three weeks with no levels ever drawn! We drew it, and she was about 0.13 above therapeutic (invisible self-pat-on-back goes here...). Seems to me it ought to be done daily, or is it generally done weekly? Thanks, Kevin

How long have you been on orientation? Is your preceptor approachable re. what you need to do to improve? Is a lot of this criticism internal, from your own perceptions? There is a lot of "I'm dumb" in orienting to your first nursing job - it comes with the territory. You just have to try to put some faith in the idea that you'll get up that learning curve and that today's goof-up and subsequent correction will become tomorrow's learned concept. From what I hear (I'm one week off orientation), we should get used to this feeling, because it lasts ~ 1 yr, give or take. If it's true that it takes 1,000 repetitions for any action to become second nature, and you figure you're learning....how many actions and pieces of data not only about nursing but about how your institution works, as well as how the different personalities on your floor work?, then you see what we're all up against here. Sad to say, but nursing school prepares us for none of this, because it really can't. They do all they can to teach us the equivalent of basic, "English 101"-level vocabulary, and now we're expected to hold a conversation in English, and it's a whole other ballgame. How many English 101 classes taught us what "whole other ballgame" means, anyway? The "man in a woman's world" is just another element among many. It's significant, sure, but it's not the whole thing, and it shouldn't be a barrier to you doing well in this capacity. If it proves to be a barrier, I'd say the problem rests more with that institution than with you, because it's not like that everywhere. I say this because women who are starting out are going through a lot of the same feelings of being overwhelmed, out of one's depth, etc. So try to stick it out. Hopefully you'll get some better-informed answers from others who have been at it longer than I have! -Kevin

Or, someone who feels it's someone else's fault, and nothing will remedy the situation quite like a cash settlement. Either way, it's certainly not inevitable.

Ditto what Bubbly said, though I did post something in the "Brain Sheet" thread a little down the page. The one side has my to-do tables and the other has a blank hourly flowsheet. But it's true, you'll probably just need to do a custom one based on the needs of your particular floor and your own style. Heck, mine's a work-in-progress, as I'm only a week off orientation myself...

I do multiple double-sided copies of these, for each patient. The worksheet is, roughly, the following: on the right side, what I see & read; on the left side, what I do and report. The flowsheet is just in case I end up with a patient for a while doing interventions and can't get out to write their note; just gives me a place to jot down the rough chronology of events for doing a "late entry" note later. It's formatted for my day-night rotations: Nursing_Worksheet.pdf Nursing_AM_PM_Flowsheet.pdf