Pseudonym

Thank you!!

How does a person correctly pronounce "citrate" like when I tell people to take magnesium citrate or I'm watching for a citrate reaction? Is that first syllable the same sound as the first syllable in "sick" or "cyan"? I

Thanks for the thumbs up & your encouraging words. This was nice to wake up to. I will take your advice to "Move on" believing I WILL "be an asset to any facility" :-)

I really appreciate your suggestion to "ask nurses have a good rapport with to be [my] references." I can use that going forward. Thank you!

I'm not really sure what went wrong; although I have my suspicions. I had heard that if I go a job as a Nurse Tech while still in nursing school, it would increase my chances of getting into a Residency when I finished nursing school. So I applied and got a job in a Med-Surg dept. I've worked there for 9 months while in a full-time nursing program. It was really a lot to juggle in addition to my family obligations as well but I never came late or called out sick and I covered shifts for other people nearly every time it was requested of me. Before nursing school, I had worked as a home care aide (taking care of just one patient at a time), but I had never worked as a nursing assistant prior to securing this job (where I took care of 11 patients each shift). I feel like I grew quite a bit in my ability to manage the care of multiple patients simultaneously, completing my tasks despite interruptions and making connections between what I was learning in school and what I was seeing manifesting in my patients. I am comfortable charting in the electronic medical record system now, can find most equipment, supplies and departments in the hospital and even moved to live closer to the hospital where I work. I clearly recall that my performance review was unremarkable and I felt butterflies in my stomach each time my boss would verify, "You're graduating in March, right?" I was called off my duties last month, handed a slip of paper and told my boss wanted me to apply for 2 available RN positions just listed. Then my boss texted me to ask if I'd had a chance to submit my application(s) yet. She asked me when I would be at the hospital next so she could have me come into her office for an interview over my lunch break. At the beginning of the interview, she instructed me to answer the questions for the RN position for which I was applying, not in the capacity of a nursing assistant/tech. She asked me what I felt my strengths and weaknesses were. I should have prepared an answer in advance. I answered honestly that I would probably feel Confidence-in-myself as an area of weakness, just entering into the RN profession and all. My boss enthusiastically jumped on the bandwagon and told me, "Oh yes, that's what I hear everyone say about you: that you don't seem very confident. In fact, I've had some nurses come and tell me they don't feel comfortable delegating tasks out to you because you don't seem confident." That hit me like a sucker punch to the gut. I was speechless. I couldn't imagine having exhibited such a lack of confidence working in the capacity of AN AIDE that nurses felt uncomfortable DELEGATING tasks to me! Aides deliver & collect trays, feed patients, reposition patients, change linens, incontinence pads and briefs and assist with toileting, bathe patients, provide peri & foley catheter care, ambulate patients, transport patients, take vital signs and answer call lights in general. Was I really so incompetent that nurses didn't feel comfortable delegating such menial tasks out to me as an aide?!? Such a revelation certainly did nothing to bolster my confidence in my ability to perform in an advanced capacity as an RN! I know I was unfamiliar with the bladder scanner when I first started, and a kind nurse took the time to show me step-by-step how to care for a colostomy stoma and change the bag the first time I encountered one of those, but did that really make me incompetent? As a tech, I've sought out opportunities to complete "advanced tasks" such as bedside blood sugar/glucose checks, IV removal, inserting & removing foley catheters in both male & female patients, straight cath'ing and I've provided patient education when I can, re-teaching a dementia patient how to use his incentive spirometer and explaining to patients the pathophysiology when O2sats drop D/T their not wanting to wear the "uncomfortable" nasal cannula or they don't understand how not taking their antiHTN med or "water pill" is affecting their bodies. I jumped right in when we lost patients last month and did all the postmortem care. In the past couple months, I've had several nurse sincerely complement me and thank me for my above-and-beyond nursing assistance and patient care. The interview with my boss was followed by an interview with the charge nurse and a floor nurse, which I felt went well. They praised me on my excellent answers and talked to me as if my being offered a job was expected. The charge nurse told me she would recommend a night shift position for me "because I know you" she had said. But I walked away feeling bad. It seemed like the wrong venue for my boss to have brought up that a nurse (or nurses) had told her they didn't feel comfortable delegating tasks to me. That's a serious thing to say. Why didn't she immediately pull me aside and talk to me about the issue when it was brought to her attention? Why didn't she have a performance review with me so I could be made aware there was a problem and have the chance to improve? She just let me go about my work not saying anything to me until I applied for a promotion; a promotion that she had told me to apply for?!? Now I'm embarrassed and feel like people saying negative things about me behind my back that they wouldn't say to my face for me to grow from. I can receive constructive criticism, but it just caught me off guard to receive it in that manner, during a job interview. Today I got an email that I didn't get the full time days RN residency position for which I'd applied. I don't feel confident applying for the night position in the same department until I talk with someone about what happened; what went wrong. I have applications still pending in other departments within the same hospital, but I can only imagine any hiring manager would ask my current supervisor how she feels about me, and if she wouldn't even hire me to keep working in her department, what good could she have to say about me? I wonder if she weighed my performance against the fact that I'm still a full-time student and juggling a lot of responsibilities right now. I wonder if my kid was rude to her kid at school or something. I'm just up tonight, licking my wounds and wondering what just happened. Any advice going forward? Should I apply for the night position or just move on? What do I say to my boss when I see her next? Is it appropriate to ask her what went wrong so I can improve? I want to be an employable nurse. I've been looking up articles how to boost my confidence in myself and plan on answering strength/weakness questions in the future with something more task-oriented than characteristic, such as, "My weakness has been jumping into tasks without remembering to have all of the supplies laid out on the counter, then I'll recall I need that last flush and will have to stretch back to the drawer to grab it." I don't know what's worse: maybe I should confess I work through my breaks to stay on top of my work

I read all your comments a couple nights ago and was going to respond then but lost access to the internet due to storm conditions where I live. Lev Horseshoe & NeedlesMcGee, yes this is the same patient scenario I posted on previously. I'm still learning from this scenario. Yesterday, when my instructor opened discussion for this scenario, we spent less than 2 minutes discussing it and not even everyone in my group participated in the conversation! I was so disappointed after I'd spent so much time really analyzing this case, but in the end, my goal in school is to really build up my knowledge base so I can become a competent nurse. Thanks for your patience with me while I maximize my learning! Keith, I appreciate your reminder not to view clinical data as separate silos but to identify the WHY behind it all. What I hear you saying is if I focus on the PE [the why] the treatment priorities become clear. Thank you for the encouragement re: giving myself time to gain clinical experience and to make these connections. Larry, thank you for sharing that intubation might be warranted should the patient become disoriented. The only intubation we've covered so far in school has been of the digestive tract so I genuinely hadn't been thinking down that line at all until you brought it up. I had hoped to look more into it before my teacher opened this scenario for discussion, but I will follow up by researching this more independently as soon as I get a chance.

LOL Yes I am a real student. I have my associates degree in pre-nursing and am nearly halfway through my ADN program.

Levhttps://labtestsonline.org, I learned my patient exhibiting Rapid breathing & rapid heartbeat are both indicative of an infection and I can see the value in running these labs. Did you have something different in mind when recommending these tests?I don't want to suggest things prematurely. I've read a couple threads where nurses expressed that its our job to advocate for our patients by suggesting things we feel our patient would benefit from (as residents may not always know and are often open to our suggestions). I thought an ABG would be necessary to determine if the patient was experiencing resp alkalosis. Am I overcomplicating things? Should I just focus on the textbook PE s/sx & not worry about tests to diagnose resp alkalosis R/T PE? Thanks again!

*I am working on a minor school assignment. It is not due tonight and I have put a lot of thought into it myself, researching concepts and whatnot, before asking for assistance. This is the scenario: I'm caring for a 75 year old patient after hip replacement surgery At the beginning of my shift, he rated his pain 2/10 and his vitals were BP 124/84, HR 76, RR 18, O2 98% on RA On my next rotation, his BP 112/72, HR 98, RR 30, O2 88% He seems anxious and is sweating, experiencing SOB, coughing up blood-tinged sputum & c/o chest pain when he breathes I suspect my patient has pulmonary embolism induced respiratory alkalosis. To address his resp distress, I plan to raise the head of his bed & initiate supplemental O2 therapy, probably via NRB mask@15L/min. I probably need to call a rapid response team, or at least the doctor. I would inform the provider of my assessment findings and I could suggest the provider order testing of my patient's arterial blood gases to evaluate PaCO2 & HCO3 levels (to evaluate for resp alkalosis & to establish baseline for comparison to evaluate effectiveness of O2 therapy). A D-dimer test could rule out a PE; this might be worth suggesting so we don't end up wasting our time trying to treat something if that isn't really the problem. I could suggest a chest x-ray/CTPA to locate the suspected PE. (An ECG could be helpful in finding the clot if it were in the heart, but I think its in the lungs.) Clearly, antithrombolitic pharmacological intervention(s) would benefit a patient with a PE and I would suggest this if not already addressed by the doctor. Part of monitoring antithrombolitics for effectiveness would be testing the PT-INR prior to and after initiating treatment with Warfarin (or PTT for administration of heparin). To address the patient's ongoing risk for DVT development, I could educate my patient how to perform exercises appropriate to whatever stage of healing he is in after his hip replacement surgery. According to Hip replacement surgery What you can expect - Mayo Clinic, it is likely it would be appropriate to encourage ambulation with a walker as soon as the same day as the hip replacement surgery or the day following; I could suggest we walk the halls together after my patient completes his meal. If not already ordered, I could suggest to the provider she order sequential compression devices, or prescribe compression stockings. My question is this: Do I need to address the patient's diaphoresis? To address the patient's risk for fluid imbalance/dehydration R/T diaphoresis, I want to suggest IV fluid replacement to the provider and/or encourage the patient to push fluids (avoiding coffee & alcohol) but I hesitate because I'm trying to figure out if you have impaired respiratory functioning R/T PE is there any risk pushing fluids could lead to pulmonary edema? Sorry if that's a stupid question, but I'm thinking about how my patient's at risk for pneumonia after anesthesia and he's already coughing up blood-tinged sputum. Do I even need to address the diaphoresis? How much fluid can a person really lose before I can get them stabilized? Do I need to address the patient's anxiety with anything special? I imagine resp distress is scary and providing my presence in addition to resolving the issue while explaining to the pt what is going on, how my interventions should be addressing things and providing education about how we can prevent reoccurance/complications is probably enough. Should I suggest the doctor order Nitro for the angina or something for the altered B/P? I imagine these symptoms would resolve themselves by treating the PE. Is anything more needed for resp alk? Thank you so much for your insight. Please let me know if any of my interventions sound off or if I've missed anything major. Thank you again for your time!

Thank you all so much for all of these really great responses directing me to consult multiple different sources to expand my knowledge base! SheDevilPrincess, I looked up PE but am not sure what you meant by "side effects." My understanding is that some people can develop LT heart and/or lung problems after PE. Obviously death is a possible effects from a severe PE. Pharmacological interventions could result in an increased risk for bleeding. Is there anything I missed you were specifically hoping I would find? AceOfHeartHip replacement surgery What you can expect - Mayo Clinic, it is likely it would be appropriate to encourage ambulation with a walker as soon as the same day as the hip replacement surgery or the day following; I could suggest we walk the halls together after my patient completes his meal. If not already ordered, I could suggest to the provider she order sequential compression devices, or prescribe compression stockings; and antithrombolitics, like Warfarin. I also reviewed the other thread you posted. One nurse suggested those symptoms sounded more like acute coronary syndrome than PE (given the fact that patient was already receiving antithrombolitics) so I researched ACS. My patient has ACS s/sx (chest pain & diaphoresis), but I feel my patient's s/sx are more indicative of PE. From that post, and additional research, I learned I could suggest the provider order testing of my patient's arterial blood gases to evaluate PaCO2 & HCO3 levels (to evaluate for resp alkalosis & to establish baseline for comparison to evaluate effectiveness of O2 therapy). A D-dimer test could rule out a PE; this might be worth suggesting so we don't end up wasting our time trying to treat something if that isn't really the problem. I could suggest a chest x-ray/CTPA to locate the suspected PE. (An ECG could be helpful in finding the clot if it were in the heart, but I think its in the lungs.) Part of monitoring antithrombolitics for effectiveness would be testing the PT-INR prior to and after initiating treatment with Warfarin (or PTT for administration of heparin). To address the patient's risk for fluid imbalance/dehydration R/T diaphoresis, I want to suggest IV fluid replacement to the provider and/or encourage the patient to push fluids (avoiding coffee & alcohol) but I hesitate because I'm trying to figure out if you have impaired respiratory functioning R/T PE is there any risk pushing fluids could lead to pulmonary edema? Sorry if that's a stupid question, but I'm thinking about how my patient's at risk for pneumonia after anesthesia and he's already coughing up blood-tinged sputum. Do I even need to address the diaphoresis? How much fluid can a person really lose before I can get them stabilized? Also, if I think there's a risk my patient might begin seizing, I know I would want to make sure they didn't have anything in their mouth. Can I put up at least one rail on each side of the bed, or will I now be in trouble for restraining the patient without doctor orders to do so? I imagine this patient is already in a hospital bed. Is there anything else I should do? I'm sure I'm totally overthinking this scenario, but I would hate to encounter such a situation in practice and freeze up, not sure what to do. I'm also struggling determining which O2 delivery method is most appropriate? I'm expecting ABGs to reveal resp alk; would I want to use an NRB mask with O2 or is that exactly the opposite of what I'm trying to do? I keep getting mixed up while trying to think it all the way out.

Thank you for the complement

Thank you for the feedback

Thank you for the affirmations I'm on the right track! Would suction be necessary for blood-tinged sputum or would such an intervention be overdoing it?

Thank you for noticing that this is my first and only post. I'm clearly new to this forum and didn't know what was expected. I didn't wait until the last minute to do my homework” and I don't expect people to spoon feed me my answers,” but, being a student, I am not finding this to be an easy one” and thought it was a good idea to ask for help so I could learn, because I also believe This is important stuff” and I want to not turn in half-thought out homework, get my point and move on, but I actually want get a good understanding of what's going on so I will know what is happening and what needs to be done when I see the same symptoms in a real live patient.” Snarky comments aren't necessary and nursing school is hard enough already without being made fun of. I appreciate the offer to be guided along.” That's all I was hoping for by posting this well before the due date as evidenced by my continued correspondence; why would I bother if the assignment due date had passed and I didn't care to learn? I thought I would be able to work through this” with the help of like-minded people so I could build my critical thinking skills. My thoughts on the matter are: His initial vital signs indicate a slightly elevated B/P (which could be a prehypertensive baseline), HR within normal limits, RR within normal limits and acceptable O2 saturation on room air. He reported 2/10 pain, but the elevated B/P could indicate unmanaged pain he's just trying to tough through. If this were the case, it would explain is altered vital signs on my next rotation, but not the coughing up blood-tinged sputum & chest pain while breathing. I'm thinking I need to look for something else. I'm really concerned that his O2 has dropped so low, he's panting, SOB, coughing & in pain while breathing. I'm struggling to understand why he's coughing up blood-tinged sputum after a hip replacement surgery. I really don't know what would cause that. Post op I wanna watch for immobility leading to DVT; did he throw a clot and it's causing him to have breathing problems (pulmonary embolism)? I can see his B/P dropped. Dropping pressure could indicate an internal bleed. Are his lungs running out of room to properly function because he's got internal bleeding? I would look for pallor. O2 this low requires supplemental O2 (unless COPD, but he was demonstrating 98% O2 before, so this is not his norm) SOB & coughing: elevate head of bed profuse sweating can eventually lead to fluid volume deficit pain or fear could be causing the anxiety. If I was having trouble breathing, I'd feel anxious too A pulmonary embolism could produce respiratory alkalosis, which is what the hyperventilation, tachycardia, decreased B/P, and anxiety sound like to me, but the SOB is contrary to the increased depth of respirations I was taught to associate with respiratory alkalosis. Respiratory Acidosis could result from anesthesia or pneumonia and presents with rapid, shallow breathing, decreased B/P and dyspnea, but my patient is demonstrating hyperventilation, not hypoventilation & the patient has tachycardia, not dysrhythmia. Is the development of blood-tinged sputum in just a matter of hours associated with pneumonia? I'm really thrown by the blood-tinged sputum and don't know to what to attribute that. I'm sure there is something I should be able to do before "doing some notifying." It does not seem that easy to me and it would be nice if someone would be nice enough to respond with something constructive. Thank you

I'm caring for a 75 year old patient after hip replacement surgery At the beginning of my shift, he rated his pain 2/10 and his vitals were BP 124/84, HR 76, RR 18, O2 98% on RA On my next rotation, his BP 112/72, HR 98, RR 30, O2 88% He seems anxious and is sweating, experiencing SOB, coughing up blood-tinged sputum & c/o chest pain when he breathes What's wrong with him? What do I need to do?