chemshark

Hi welcome to the ICU! Here are some things I wish I had known right away: - Understand what makes the ventilator alarm and what steps I should do to 1. Prevent it, 2. Do immediately before calling the doctor or RT, 3. Set the RT up for success, 4. What to know to say before calling the doctor and what I recommend he or she does (especially if you’re in the COVID unit during night shift and doctors can’t come down to assess your alarming patient right away. - How to chart fast and accurately - Which drips and drip combos are preferred in your unit for different types of shock, paralytics, pain, and sedation (and how/when to wean them off) - How to prevent self-extubation and/or falls - What steps, equipment, and personnel are needed for rapid intubation or if a patient self-extubates LATER ON when you get experience : - what are acceptable methods of titrating drips in an emergency (I.e., not necessarily based on the order directions) and how to justify that in the charting after the mess is over (retro-charting) - how to catch shock/sepsis if the ED misses it and get fluids then pressors/antibiotics on board - how to balance sedation and pressors just enough that you don’t snow the patient (and when you have no choice but to keep the pt snowed but just enough not to piss off the intensivists) - catching DVTs (in ANY limb) - basically understanding everything in the AACN Critical Care Essentials book, and the Marino ICU Book - how to time your drips so that you know your units acceptable way to replace them so they never dry. Ever. (And not waste a single drop of you can help it). - how to fend off burnout and the constant creeping sense of mortality that hovers over you in this unit and how not to take that home (or how to deal with it if it does) - dealing with usual nurse drama and ICU ego THATS IT FOR NOW...I’m sure more seasoned nurses can chime in better tips but this is what I wished I knew starting off! Good luck, fellow nurse! -ChemShark (Qualifications: ICU 3 years. I have a BSN, CCRN and biochemistry degree)

This is not med/surg. This, of course, means that most of our patients are on vents. They usually assign us only 1-2 patients here, but they are quite acute. But, I also think that my med/surg experience helped me out a lot. For example, most of our sickest patients are on a minimum of six(!) drips. I usually keep two TKOs and draw blood from an A-line. Since this is a neuro specialty, many of our patients are on ICP precautions and use drains to allow the CSF to seep out. The monitors are connected to every part of the patient and they are usually on a Foley or dignity tube (which collects feces). Depending on the situation, each patient is hooked up to a vent, an exterior ventricular drain (EVD) for CSF, an A-line which also has a transducer, and an EEG to read brain waves, lumbar drains, and multiple drips. Since I work during the day, I send many of our patients down to CT scan for an angiogram or a surgical coil to plug up their aneurysm, and to surgery so they can get the catheters inserted into the ventricles of their brain. My basic responsibilities include hanging lines and drips, maintaining the monitors (except for the vent) & ensuring all waveforms are accurate, supplying emergency airway equipment & maintaining the airway until the RT arrives, administering medications via OG tubes, inserting NG tubes, and drawing labs. Nurses here are more apt to chart by exception so it's not as hard to chart as it was in med/surg. But med/surg helped me to become more comfortable with hanging piggy back lines and mixing antibiotics and other high-risk IV meds. What's different about ICU, other than equipment, is that patients look serene because they don't talk to you. But right when you start to go on break, they usually crash and all kinds of monitors are beeping: the Spo2 has gone down to 87% because a patient is desatting, and their b/p is high because they are in pain or are agitated because the family members keep trying to wake them up from their coma, or their labs are off whack simply because they are decompensating. When it comes to physical problems, something is always related to another. MY FIRST DAY AS A NEURO ICU NURSEAnother thing that I've noticed is that ICU nurses must be more keen to criticize medical interventions. I have a story of my first day here. Since many patients would be in too much pain due to their medical condition, they must be sedated and thus are unable to communicate. Every hour, I do my nursing checks to make sure everything is on the up and up. This includes neuro checks. The difficulty of neuro brain injuries is that there are few physical tell-tale signs of distress. The brain does not always make profuse amounts of CSF and propofol keeps them from waking so you cannot ask the patient to respond to your commands or inspect the sheets to see if they're bleeding out. You can, however, inflict pain. LOTS of pain. You can either pinch them in their traps, or hands or thighs or sternum. It is in the hopes of gaining insight into their basic brainstem functions. I had to do this to a poor man who came in due to a spontaneous ruptured aneurysm. His whole family was there. They were quite supportive and talkative, but every time I went into the room to do my checks, I had to inflict pain into him somehow. This caused a rush to come into the room and I would feel ten pairs of eyes watching me pinch, harass, and yell at their loved one. Nevertheless, they showed that they had complete confidence in me even though I had introduced myself as a student nurse earlier. The nurses warned me that families have little to no neuro experience so they perceive that every little twitch made by the patient is a sign that he/she is going to fully recover. Unfortunately, this is rarely true. At the tenth hour, I still had no reaction-and things were looking grim. I yelled and screamed and pinched the patient as hard as I could but...nothing. I looked intently to see if he reacted to any of my stimulation. After a minute or so, I retreated to the computer inside the room to document my findings. The EEG readings hadn't changed. I could hear the family shuffle slowly past me as an entire group and when I walked back up to the nursing station, they were in a forceful huddle. A few looked intently at me, but went back to consoling their mother (the patient's wife). After the shift, I went home. I plopped onto bed, eager to get some sleep. Right then, I sprung up in bed. "Should I have turned off the Propofol before doing my painful neuro checks???" When I returned to shift the next day, I walked in and saw that the bed my first patient was in was empty. "Hey, what happened to the patient that was in this room?" I asked the charge RN. "The family decided to withdraw care." At this point, I panicked. Did they make the decision to let their dad go because of me? How did that make his poor wife feel? Could I have changed the outcome of this decision? I felt like my heart fell all the way down to my feet. I confessed my worry to my preceptor and the other nurses. But they all swarmed around me and reassured me that it was not my fault. There was no way I should have taken the patient off sedation to do an accurate neuro check because the patient was in too much pain and ventilated with an ET tube that it would be nearly impossible to stabilize him if he decided to buck the vent and crash. This made feel a whole lot better about myself, but not so much about the family's situation. Weeks later, I find that this is the norm in the ICU. Most days when I return, the patient I had cared for is gone.

[TABLE=class: listHier messagesThreaded specialLink, width: 100%] [TR=class: hierItemBlock] [TD=class: bogus] I created an ICU cheat sheet. Though not exhaustive, it helped me when I felt overwhelmed. Most days when I get up in the morning, I have a routine: I wake up, take a shower, iron my clothes, eat breakfast, brush my teeth, comb my hair, get my things and go. But when you're in the ICU, things are different. You have your IV drips and they are running nice and smoothly, but then something happens. Your patient starts to crash and the resource nurse is busy helping someone else. So hopefully you memorized the orders and parameters and are able to titrate your various drips according to protocol. If you have time to document each and every single dose adjustments, when they were given, what the dose, rate & volume was, and what time, then great. But that's not likely going to happen. After a few days of the ICU, I felt that it was quite slow. Most of the nursing skills I practice were quite rote. For example, I hung IV bags, gave meds through the OG tube, or turned the patient every two hours. On days when I came in early, I already the patient's H&P down, noted the plan for the day, active orders, lab draws, and MARS. All I had to do was keep up with it and it would be fine. Maybe a family member would come in and fall into tears, but I had learned to expect it. It was better than the alternative, which is when patients' families would scream and yell in the medsurg because they thought it was a restaurant and nurses were the waiters. In the ICU, the nurses were the main source of communication & comfort for the family because they are able to translate what was going on. The family also sees--and are usually thankful for--the hard work that you do because they are in the room right there with you. Another advantage of being by the bedside constantly is that when patients' status changes often, the nurses are the first person to notify the medical team. One time I had a patient who had her tube feedings turned off and when I received her from the night nurse, her intracranial catheter dressing was undone, she had bitten through her tongue, and there were orders for her to still be on hypothermic precautions even though she was taken off the Arctic Sun machine. I had to discuss these issues with the team during rounds so that they could update the orders for me. But what was really important was that the parameters for the IV drips were updated as well. Sometimes the doctors preferred to monitor the patient using MAP instead of the SBP, or they would change the parameters if the patient was too sedated or not enough. This would then change my orders for giving 3% hypertonic solution, or Mannitol, or Fentanyl depending on how the patient reacted to those numbers. I had to remember what dosage strength was ordered initially and what the maximum dose was allowed. And since my access was usually limited, I had to choose which lines were compatible, which lines I could temporarily suspend in case I had to draw ABGs or suspend heparin if I was drawing from the PICC for a blue top. It took too long for me to access Micromedex so I relied on my preceptor's experience to know which medications mixed with what. Mainly, nothing mixes with anything filtered, viscous, or high-risk, e.g. propofol or 3% NS, or heparin, FFP, or even diabetisource. More than once, a seasoned ICU nurse would tell me, "If you no longer have the fear [of making a mistake & killing someone], then you have no business being in the ICU anymore." I hope I never lose that fear. But then I take a look at my "tree of life" and I find that that's not going to be the case for a long, long time. [/TD] [/TR] [/TABLE]

I've challenged the board. The LVN board. And I was in the military as a Hospital Corpsman. I think that's the main reason why people challenge the boards: so that Veterans can have a meaningful job when they return from war. However, I don't think there is a way to challenge the RN board without a BSN from another state let alone a bachelor's degree in anything nurse related. I'm sorry you had to go through many things. Your willingness to get through the LVN program shows that you are still passionate, though. I don't know how many more obstacles are still in your path to get good grades but I suggest going through that first. Are you still too injured or do you plan to have any more surgery or recovery that may hamper your studies? Maybe think about what are your physical and mental handicaps then have a plan about how you would go about it. I never proceeded without a backup plan, and now I received my BSN and will start my NP program in two weeks. My first degree was in biochemistry, and although I passed, it was a very difficult subject for me. I also found that I didn't like working in a lab anymore. So although my GPA wasn't amazing, it wasn't competitive enough. I had to go through community college to take classes related to nursing that raised my GPA. Then I applied. Good luck with your endeavors.

What can I say? This has been an eye-opening experience. Everything that I didn't learn in class, I learned here. My 3 biggest takeaways are: 1. Time is EVERYTHING 2. If you have a problem with someone, TALK TO THEM 3. Stay positive "Nursing is a people profession, so don't do it alone." (My new mantra). --- FINAL THOUGHTS It's mundane, but to me this place marks my official transition from Marine Corpsman to Registered Nurse. It took me 13 years to get here. And always with the help of others, both military & civilian. And I will keep going until I reach my goals. DISCUSSION "One of the known reasons that newly registered nurses are more vulnerable is because they have known areas of knowledge need and no past experience as registered nurses, making their work more subject to micro-managing or scrutiny" (Griffin, 2004). No truer words have been said. When I had a problem with how hard my preceptor was pushing me, and how she was criticizing me in front of others, I talked to Professor. She encouraged me to discuss my feelings with my preceptor and I did. She didn't realize that she was being so harsh but said she wouldn't back down & would keep her expectations high (especially w/ charting!). But she would at least try to criticize me away from the nursing station & be more patient with me. That was all I needed to regain my confidence. It wasn't until Week 05, but I think I truly started to progress at that point. When the wife (an actual nurse educator) of a patient screamed at me for putting in a Foley on her husband differently from how she teaches, my preceptor & the other nurses gave me reassurance. And when a mother (also a nurse) of a patient I was drawing blood on snatched my tubes from me while I still had the needle & tourniquet on her son because she wanted to label it herself, my preceptor stood up for me and made me redraw it on my own again but this time with support. When I interviewed my preceptor, to talk about the nursing profession/lateral violence/patient violence, at first she said "Don't let anything get to you and just move on." But after a while, she came back and said, "No, you should ask for help. Know when you need it." Nursing is a people profession, so don't do it alone. Now, on to the next thing!

[TABLE=class: listHier messagesThreaded specialLink, width: 100%] [TR=class: hierItemBlock] [TD=class: bogus] This week, I assumed full care for 2 patients. The only time that my preceptor would come inside the rooms were to introduce herself to the patients, watch me give meds, and hang antibiotic infusions or give blood and other procedures. "It's about time that you started picking up your own patients," she said. This took me aback because I was waiting for her to tell me that I could do so. It feels different to fly solo. I explain to my patients that I am a student nurse and the preceptor will step in to help but that I would be their main contact. Even when patients are sick, I see that they only believe me if I believe in what I'm saying myself. I'm patient, though. I assume this will come in time. 0630-0730: Every morning, I try to have a plan. It's more like a timeline, really. I come in, change into scrubs, say hi, then grab the patient assignment list and a blank kardex. If I have been gone longer than two days, I tend to not have any repeat patients so I go straight into the chart and read up on their H&P. Unfortunately, I can't access new orders (very frustrating) but I am notified that there are new ones. My preceptor clears them all for me and lets me know if there are any pertaining procedures for today that involves a road trip. If so, I make space on my kardex for tasks to be done. I get the report from the offgoing nurse--I don't want them to wait longer so I try to be ready when they call my name. I try not to interrupt, but if there's something pertinent that I didn't read on the chart such as a change in diet or a consult from surgery or wherever I ask questions. I try to have the handoff at the patients bedside and I inspect my lines while the nurse is talking to make sure they are secure and patent and that they are the right gauge as on the flowsheet. I don't do my general exam just yet but I inspect the particular site that the patient's chief complaint is about. I.e. most of our transfers are from surgery, ICU, or the ED. Therefore, if someone is here with laparoscopic incisions or I saw that they had >900 BNP then I quickly do a focused exam with the nurse there so she can tell me if something is different or new. Once they leave, then I go back into the chart and list the medications for the day. I try to give the meds within an hour pre and post of the given timeline. If it says, 'daily' then I am allowed to reschedule the med to when it is convenient for me. I can't do that with qhourly meds but it is good to be able to aggregate them together so I don't have to keep going back and forth. It is these little tricks that save me time during the morning rush. After writing the meds, then I look them up quickly so I know what I'm giving and why. The computer system in the Navy isn't as fast as EPIC so I can't bring up LEXICON at the patient's bedside. I have to prepare ahead of time so I don't look like a fool. Next I talk to my Corpsman and we work out an agenda for the day so that we don't waste time doing things redundantly. He or she knows that I will let her do the vitals and strict I&Os for me but if something is abnormal then he must notify me so that I can get the vitals for myself. They can clear my infusion pumps but I need to know how much fluid my cardiac patients are getting because we have to observe how closely they diurese lest they cancel their discharge plan because I'm not charting accurately. I also let them know if I am expecting my patients to make a trip to imaging, the OR, CATH LAB, or if the PT is going to visit today. This way, I can ensure that my patients have been NPO, have had their vitals and samples taken prior to the road trip. 0800-0900: Okay, so now I go back to each of my patients and systematically do a general exam. This is quick, usually takes 5-10 minutes. If they are a concern for something else, then I add an extra few minutes listening to murmurs, ascites, or evaluating their strength and neurological status. Those who are immobile or have respiratory conditions I have to ask my Corpsman to help me turn so I can listen to their lungs while I look at the Mepilex on their butt so I can stage the wound. My preceptor expects this to be done because she just wants to walk in and concur or disagree with my findings. She will let me chart what I see but she will add a new note if it differs from what I wrote. I like that she lets me record my own opinions and assessments (for the most part). Next I inspect and palpate the PIVs and flush them to make sure that they are still viable. Then if there are continuous infusions I verify the bag and orders and check the Alaris. There should be tags on the bags and labels on the lines so that we know when to change them since lines are only allowed to be used for one day if they are intermittent and four days if they are continuous. Then I go over the plan of care with the patient and chat a little bit. This is when I evaluate their pain levels and I discuss pain management and other education with them. I am also charting my full assessment at this time. I do this for all my patients then I run back to the Pixies. 0900-1200: I pull meds for only one patient at a time. If they are on antibiotics or any other intermittent infusions, I check online to make sure that the meds I'm giving are compatible. If I have a question, I call the pharmacy--though they're not always helpful. Sometimes I have to be resourceful: if the order calls for 1500 mL D5NS and I only have 1000 then I label the bags with my date, time, initials, rate, type of fluid, then I write "bag 1/2, where bag 2 to infuse 500 mL only" so that if it is still running at the end of the shift, the other nurse knows exactly what I'm doing. Otherwise, sending the Corpsman to pick up a bag of 500 mL would take too long and I'd miss my deadlines. If the medication is Novolog or Enoxeparin I make sure that the Corpsman has done the BS and that the food tray is on the ward. Then I give the med or watch the patient do it so I can annotate that I educated the patient. If it is a controlled med such as Morphine or any other Norco, then I make sure there are stool softeners in the morning meds. My preceptor makes sure that I also input the exact time of when I administered the Morphine so that they don't overlap. And if I am giving meds with parameters, I take the vitals before giving it to the patients such as pulse for Lovenox, PT/INR for Warfarin, as well as B/Ps for -sartans, -pines, -lols, and -arbs. An additional complication is when a patient is on lidocaine patches. Since these are only to be given q12, if the patient decides to restart taking it, then I have to readjust the orders in the chart so that the q12 countdown begins again. Then I have to remember to write "remove" 12 hours from when I placed it on the patient so that the night nurse will know to take it off otherwise the patient will forget. Then I have to place it in a special bio container. Antibiotics are complicated to, because when I was preparing them for my nurse, the pharmacy or the docs made a mistake on the order and it was actually supposed to infuse for 4 hours, not 30 minutes. So we had to write an annotation on that and an incident report but luckily the patient didn't get that infusion and we were able to backtrack everything and start over. Thank goodness that there is a policy where if the doctor or pharmacist wants to talk to me and my Corpsman answers the phone, they must refuse to take a message and insist that they speak directly to me so that nothing gets lost in translation. 1300-1330: I take lunch. I have to bring my own salad because the food sucks here and we don't have time to leave the floor anyway. : 1330-1700: I start prepping my patients for their surgeries. I coordinate with the OR and we discuss the best time to transport. Then I let my Corpsman know so that he can get all his vitals and I/Os done on the other patients before he wheels my surgery patients out. I continue to take care of my remaining patients and help out with my preceptor's patients while keeping an eye out on the surgical patient's location and status. At this time, the charge usually flags me down and notifies us which patients we are expecting to recieve. I read on their history, and get the telephone handoff report from the nurse. I can't do this on my own so my preceptor takes the report and I listen on the other line. She asks all the relevant questions needed especially on what brought the patient here and what medications need to be continued during their stay on med/surg. If they are on trachs, or PICC lines, and what interventions still need to be done. Finally, if there are bed sores or fall/seizure precautions that we should be aware of. If there are medical interventions that my preceptor isn't familiar with, she drills the nurse and asks for the rationale. She does not accept when the ICU or ED nurse does not understand why the patient is getting certain treatments. She wants to hear it from their mouths or at least have the contact information of the specialist that she can talk to. There are five notes that must be completed before I am allowed to accept patients and they are: 24 Hour Nursing Note; a completed Admissions History Note; Medical Requisition Note; Admissions Assessment; and ED/ICU Transfer Note. They must be signed by the nurse, intern/resident (both), or the attending otherwise they are not legally viable and we will refuse transfer. Badgering the nurse/intern to get it done works. Since I care for the somewhat stable patients, they are usually on their way to be discharged. Before my admit comes in and while my other patients are in surgery, I prepare the other patients for discharge: I take their last vitals and have the Corpsman d/c their PIV lines. I will d/c the PICC line on my own but if the patient has a thrombus, we insist that the physician is at bedside just in case anything happens. Then I check that the interns signed the Patient Discharge paperwork and I annotate my 24 Hour Nursing Note with the Assumed Care entry and start to populate the Multi Discharge Summary Note. I annotate the patient's status and that I have removed all lines, bands, and anything else invasive. Then my preceptor clears all orders and I wait until the D/C orders come through. Then I print two copies of the discharge teaching plan and highlight what is different, such as new or d/c'd home meds, upcoming appointments, and I take it to the patient's bedside after finding out when their ride will arrive. Once they are cleared and ready to go, I send the Corpsman to pick up the discharge meds from the pharmacy. Then I get it and go to the patient's bedside. My preceptor says nothing as I go through the paperwork with the patient one by one. I do my medication teaching and I provide the medication rationale and make sure that the patient can tell me when the next dose of their new medications are. If they have to d/c their home meds or continue it but with a different dose then I discuss that as well. If they have to give their own injections then I make sure I watch them do it. I go over their hospital summary and instruct them to show it to their PCP. Then I talk about their upcoming appointments and who to call if they don't hear from anybody in x amount of days. Finally, I address any questions they have and have them sign my copy while they keep their copy. I send them out with the Corpsman who wheels them to the quarterdeck. I notify the housekeeper to let her know that the room is ready to be cleaned and sanitized. Next I go back to my computer and continue to populate the flowsheets making sure that my I/Os, PIVs, and TXs are backdated. Then I open up the discharge note and make sure that my note times are in line so that there is no confusion. Finally I go back to the flowsheets and annotate that I discharged the patient on all the entries and that medications are all d/c'd so that no one else can come and make an entry later. CONCLUSION: ...I still get overwhelmed. After the 12 hours I am physically tired but I no longer leave the hospital exhausted. I sleep a little better but I am still haven't gained the endurance for three 12 shifts in a row. It is just too much right now still. I talk to Commander Jack when I am feeling overwhelmed. He always has an open door policy and stops everything that he's doing to talk to me. We discuss the difficulties of working with preceptors with very high expectations as well as the challenge of working in an institution that have unnecessary policies that slow things down and makes the work harder. He listens and empathizes with me. I always feel energized after talking with him. Sometimes when Commander Jack isn't in his office, I draw on his whiteboard on his door. On this particular day, the Rear Admiral was going through the spaces for an inspection, haha. I hope he didn't get in trouble. She was actually very nice, though, and was impressed that I told her that my preceptor has an eye for detail and refuses adjust her high expectations of me. [TABLE=class: listHier messagesThreaded specialLink, width: 100%] [TR] [TD=class: bogus][/TD] [/TR] [TR] [TD=class: bogus]WHAT I LEARNED THIS WEEK: Have a plan. Stick to it, so that when things go south, you will have time to figure out what to do. [/TD] [/TR] [TR] [TD=class: bogus][/TD] [/TR] [/TABLE] [/TD] [/TR] [/TABLE]

# NMCSD RESIDENCY EXPERIENCE SEPTEMBER 2017 ## WEEK 2 As I get more familiar with the staff and learn to pace myself for the daytime 12 hour shifts, I begin to find myself getting comfortable. This has its pros and cons. Pro: I'm feeling more "at home" in my med/surg unit. I can now tell the difference between an Alaris pump running dry, a call bell, or a bed alarm going off. A week ago, whenever the bed alarm screeched, I would jump up from the nursing station and rush to the room in a panic--worried that my patient had fallen off. Now I don't think twice about it because my Corpsman will do it for me! Why? Because they are young and between the ages of 18 and 22 so 1) they can react faster than me and 2) are willing to drop *everything* at a drop of a hat if a patient leaves the bed. You see, the Corpsmen allow me to stay at my computer while I chart feverishly my nursing assessments, 24 hour nursing notes, strict I/Os, VS, TX, and invasive lines before my next ICU TOW (transfer onto ward) patient gets wheeled in. It's great to have a dedicated Corpsman assigned to help me every single day! Con: I'm still feeling out my role in the unit. I think the reason why the Corpsmen are so keen to help me is because I have been so willing to help them during the first week. When I do something for them, like help clean or turn a patient, they thank me *loudly* in front of their peers. "THANKS FOR GETTING THOSE BABY WIPES FOR ME, HOWIE," is what they say, usually in the direction of the nursing station. I think they want to feel like they're no longer the lowest ranked personnel on the unit. But I'm no fool. Military rank is not a form of currency to be used as leverage in a hospital ward. A Corpsman who feels disrespected will neither tell me when a patient needs a stick or an IV, nor setup the butterfly needle, vacutainer, and syringe so that I can grab the sample and send it to lab stat (withdrawing from PIV lines is not allowed). He or she will not pass on relevant patient information to me when I'm swamped pushing meds with my preceptor or running out to different floors chasing down End Tidal CO2 equipment or begging for Yankaur tips from other units. He or she will not *ahem* cough at me when I am in a room with an obese PVS trach patient that we have to turn and clean which means that I have to not never ever forget to re-run the TPN to prevent her from aspirating and then remember to clear & chart the TPN flush q2h while the entire family glares at me in the tiny room blocking my way out until everything is in order. Or worse, the Corpsman will not help me find extra pillows! (It's impossible). The interns are funny, too. My preceptor, at 22 years old and one year as an RN, is so competent that she dances around interns like Muhammad Ali. She demands orders to be written *right now* and calls them back if parameters are not to her satisfaction. "As long as [the interns] don't [bleep] with me, I won't [bleep] with them," she said to me.[^does not apply to attendings] I'm glad I finally have access to Essentris to chart because I have about five minutes to annotate my comprehensive assessments based on two minute mini-assessments of each of my patients before we start pulling 9 o'clock meds. And let me tell you that Essentris is a disaster compared to EPIC because I have to type in a number to input an intervention but it wasn't designed with usability in mind. I.e. if I want to chart a numeric pain scale of 0/10 I have to type '1' in the cell! How inept is that? (I'm really thinking about getting into nursing informatics now because whoever designed this software was not a nurse). It slows me down and my preceptor gets irritated when she proofreads my note and finds my neurologic assessment saying that the pupil is 6mm when I clearly meant to type the number '6' so that it would chart that the pupil was 3mm. Yet somehow I still find pockets of self-arrogance like when I watch the residents do assessments on my patients while they teach their med students. One time, I saw a fellow show a wide-eyed med student a comprehensive neurologic test on a patient with AMS. I became very concerned when I saw what he did and said, "Whoa. Did he just have a positive bilateral Babinski's?" "Yes, that's right!" "Well, sir, I don't have much experience with neurologic degeneration, but...what's his prognosis?" I can't believe I said that. The patient was AxOx1 but at that second I knew it wasn't the most appropriate question to ask. I was clearly too attached to my patient or was tired at the end of the shift because c'mon, what kind of answer was I hoping to get from that question? "Uh, it depends." was what the doctor said. Saving me the embarrassment of putting him in an awkward position. They quickly made their exit but at least when I looked down at my patient he had a smirk. He didn't know what year it was or where he was at but even he knew that I asked a dumb question. WHAT I LEARNED THIS WEEK: Time is the best medicine. And management of time (whether cutting it or extending it) is the nurses' best intervention. This week I realized that if I listen and take time to understand the unit's high rushes and low lulls, I can prioritize nursing interventions that take longer but can be forgotten such as hanging continuous infusions. Then I can focus on fast & easy tasks such as prepping discharge paperwork while waiting for the order to come through. This, then, allows me time to focus on giving high risk meds w/ my preceptor such as novolog or morphine or when I'm helping my preceptor setup IVPBs so she can give them without incident or helping her manage her other patients while she stays in one room to administer blood.

Hey phenoma21! Congrats on making it to the family! Uniforms are expensive, but luckily the program coordinator, Renee Dierking, collects used scrubs from the advanced cohorts to donate or sell to the newbies. I made it through the program fine with two pairs (although I had to stitch one of the pants). I'm just about to finish my externship this month so I'll donate them back in December. But for now, you can just ask Renee for it when you check in. She will have scrubs from other cohorts, as well. Roughly 10% of each cohort class of 20 are men. So if finding male scrub tops (bottoms are unisex) doesn't pan out, I would just buy one or two scrub tops from Dove Apparel and then purchase old versions of the scrub pants from the same company, but through Amazon. Good luck with the program and feel free to contact me or the guys anytime! -Howie Cohort 65 Amazon link: Amazon.com: Dove Professional Apparel Unisex Scrub Pant: Clothing [ATTACH=CONFIG]25145[/ATTACH]

[ATTACH=CONFIG]24560[/ATTACH] What was missing was that the drop factor units are gtt/mL. That's what you use to setup the multidimensional analysis. Next you just convert the minutes to 6.25 hours.

Bwahaha, windsurfer8 was a little harsh in response to your post. I can just imagine him giving out meds in the unit: "Take this enema or you'll die!" LOL but he had a point. Anyway, Gen Chem is hard; It's a lot to take in because it involves multiple theories that are difficult to swallow for someone who has had no prior experience. It entails everything from molecular structures, basic nomenclature, stoichiometry, electrolytes, and a basic introduction to atomic orbitals. I failed my gen chem class too because I was too hung up on someone and I was working full time as an LVN. But my thought process was different because I realized that I was the one that had to change, not those external circumstances. But you know what? I pulled myself up by my bootstraps, said goodbye to that person who didn't love me back, and started making a tight schedule. I made sure my friends knew I was serious about my school and eventually earned my degree in biochemistry at a top University of California school (I was thinking about going to med school at the time). I ended up choosing to be a nurse practitioner instead and got into an entry level Master's degree program and then moving on to be a CRNA. All this wouldn't have happened if I blamed outside sources as my reason for failing. I didn't fail because I was heartbroken or too poor to pay for school. I failed because I didn't take responsibility for my shortcomings. One more thing: there are too many students for counselors and they are overwhelmed. Most counselors know nothing about you. They will just tell you what to take because you asked for a chem class. They didn't know you would be too fragile to handle an intense class and neither did you. But now you know understand your limits and I hope you will learn from it. Exercise your critical thinking skills to think for yourself. WHAT TO DO NOW: Retaking classes can be psychologically defeating. I hope you saved your notes and either take the same teacher or find an easier one. I also started making friends and we would write notes for each other if one of us got sick. We would even assign each other questions to ask our professor during office hours and then pool the answers together so the professor wouldn't have to keep explaining the same things over and over. I'd study with them but afterwards I would study alone as well. I also planned my leisure time so I don't feel so overwhelmed. Finally, research shows that lessons are learned when you study for something in intervals. Then you take a break and restudy again and test yourself. Pretend like you're actually taking the test under time constraints and without the book in front of you. Do this with similar problems that have slight deviances from your homework and you'll be prepared for a chemistry test. It can only be done when you take the time to practice and not cram. This is what enabled me to succeed in general, organic, inorganic, quantum, and bio chemistry classes through the years. It should work for nursing school, too. I hope this helps. Good luck.

@July26, the National University programs for California link are all here. But the deadlines for applying differ. Still, they offer programs in Fresno, Los Angeles as well as San Diego (Rancho Bernardo).

Congrats @ienurse! What a long wait. Glad you made it through. I think I'm going to send my check tomorrow. Can't wait to meet you all at the Orientation. On a different note...does anyone know the percentage of people who start this program and continue all the way through to the MSN after the BSN?

Thanks for starting an all-campus Facebook group, @Malec001. I sent you a friend request.

@Malec001, would you like to start a Facebook group for ELM Summer 2016 but with all campuses involved? Maybe we can help each other out and find out more resources if we band together. For example, we could expand our choices for study groups if we are traveling up in L.A. or you're vacationing down in S.D., or compare notes with professors that have different ways of teaching. At the very least, we could share/sell textbooks and other stuff to save money. A member of our group is already saving to put down the $1000 deposit required of us to reserve our seats. I think it's important to keep our debts down while we keep our grades up, wouldn't you say?

So the administrators at APU mistook me for another person and thought I was in the Spring Cohort. But I'm not, haha. Still, I learned that the Spring cohort will begin their orientation on January 11. It consists of two days: the first day will have to be at the Azusa campus. For those still waiting, it seems like the administrators are still doing a lot busy back-and-forth, planning the acceptance invites and orientation events. Hopefully the decisions for acceptances come out soon. Can't wait to meet everyone from all campuses.