The Dog Ate My Care Plan…

Just a mom/wife/nursing student extraordinaire trying to make it in the big bad city…

Posts Tagged ‘maternity’

Silence Is Not Always Golden

Posted by isntshelovlei on May 3, 2010

Our last OB clinical was yesterday—there really was a light at the end of that long, dark tunnel. I really didn’t think I could take another day on the postpartum floor so I was glad when my instructor said I could go to the NICU. But it’s never a good sign when you get there and the charge nurse presents you to the nurse she’s assigning you to and tells her, “I’m sorry, I have to give you a student today.” WTF?!? And like I wasn’t even standing right there! The nurse kept a straight face but you could tell she was less than pleased. So there I was, only there for about 60 seconds, and I was already turned off to the whole situation and ready to leave. You have TWO whole patients who sleep 98% of the day anyway, what is the big damn deal? Lord forbid I keep you from your sticky buns and trash mags…  

But I took a deep breath and kept it moving. It was the last day, and I was determined not to feed the trolls. I did the eternal scrub up to my elbows just to be able to enter the unit but was not allowed to touch anything—not  a chart, not an isolette, and certainly not a baby—for five-and-a-half painful hours. I should have brought a crossword puzzle or something. I’m really starting to rethink my desire to be a NICU nurse. Not because of the less than stellar experience I had (because the nurses in the NICU where I volunteer are great), but because I’m starting to think it’s just not enough excitement (patient care/interaction) for me. I know that some people like relaxed jobs where they sit around and don’t do much, but if that’s all I wanted to do I could have went to school for envelope stuffing or something. The most interesting thing that happened all day was two incidents where fentanyl (big time pain med—100 times more potent than morphine) syringes came up to the unit completely empty. But they weren’t just empty syringes. They were actually drawn up to the dose that was supposed to be in them but there was nothing in those chumpies but air. Gone unnoticed, that would have been one hell of an air bubble… Freak pharmacy thing or…you fill in the blank…

Though it’s no secret that maternity wasn’t my favorite rotation, our last moments in OB will forever leave a footprint on my heart. As we walked through L&D we could hear a woman in the actual pushing stage of labor. And she was a-hollering—totally to be expected when you’re pushing something the size of a watermelon out of a hole the size of a lemon. She had the nulliparous students in the hallway cringing at how much pain she apparently was in. So she’s in there screaming and you can hear the nurses encouraging her to push. There was a climax of activity/noise and then all of a sudden it was quiet. Since we were not actually in the room and able to see what was going on, at first when you hear the woman stop screaming you figure okay—the baby is out. But then you slowly start to realize that it’s too quiet. The critical thinking wheels start to turn and you ask yourself why isn’t the baby crying? Next thing I know they were calling for a neonatal crash cart… 

…dystocia…nuchal cord x 2…baby completely blue…umbilical cord separated from the placenta…blood everywhere…

When you work in health care you will sometimes see how even in a beautiful situation such as a new life being brought into the world, things do not always go as planned. Always count your blessings.

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No Crystal Stair

Posted by isntshelovlei on April 28, 2010

We had an exam last night in Maternity/OB (final next Tuesday!). Usually there are not a lot of meds to remember for maternity since technically the patients aren’t “sick.” Other than epidurals and such during labor most of what you’ll see is postpartum—percocet and motrin for pain, maybe a stool softener if mom had a episiotomy. But when something goes amiss—antepartum, intrapartum, or postpartum—that’s when you get hit over the head with all kinds of stuff—pitocin to start or augment labor, tocolytics to stop labor, hydralazine  for hypertension, magnesium sulfate to prevent seizures (in eclampsia), methergine for hemorrhage, and injection-only insulin for diabetics since oral agents are teratogens. It’s enough to make your head spin and this is only scratching the surface of all the meds I need to know!

So needless to say I can already tell that pharm is going to be a beast. Everyone makes it sound like such a “bird course,” and that “it’s just straight memorization”…OK, if you say so. You not only have to learn the names (trade and generic) of about a gillion drugs, but also the actions, interactions, indications, contraindications, side effects, rationale for why you are or aren’t giving it…the list goes on. You have to know all of these things to be able to challenge that brand new resident’s order for your pregnant patient to receive coumadin (which crosses the placenta), or to be able to question why he wrote an order for methergine when your patient’s blood pressure is already 160/100. You have to know all of these things because in the end YOU are giving the patient their medications—YOU are their last line of defense before a potential medication error occurs. Yes, Mr. Resident that wrote the order should have some accountability as well, but everyone will be looking at YOU because YOU should have caught it. 

So although the wonderful world of maternity is coming to a close, I now have to prepare myself for a whole new kind of headache. One of my favorite poems, “Mother to Son” by Langston Hughes, sounds just like the plight of a student nurse. Nursing school for me ain’t been no crystal stair…

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HESI Smesi

Posted by isntshelovlei on April 22, 2010

It’s that time again—maternity HESI in T-minus 9 hours. For those unfamiliar with this particular form of headache, HESI is yet another test we take in addition to our regular exams/quizzes. I like to think of it as nursing SAT’s. It’s not quite the NCLEX but it’s supposedly a pretty good indicator of how well you’ll do on the real thing. In our program it doesn’t figure directly into your actual class grade (so depending on if you do well or poor on it, it may feel like a waste or a relief) but they’re currently giving us a few points (on a sliding scale) towards our final exam depending on how well we do.

So I’ve been up to my eyeballs in case studies, practice questions, and reviews/rationales most of this week in preparation (I don’t throw away any free points!). And for some reason, one concept that really gets my panties all in a twist is GTPAL, which basically gives you a summary of a woman’s obstetrical history. I wish they would just do away with that mess and write it the hell out. Damn, you don’t have to abbreviate everything!

Here’s a little scenario from one of my case studies I did last night: Jane Doe, who is currently pregnant, has previously given birth twice, twins born at 35 weeks and a singleton born at 39 weeks. All of these children are alive. She also has a history of having had one miscarriage (the more medicalese term would be “spontaneous abortion”) at 9 weeks into the pregnancy. What is her GTPAL?

Well first a refresher on the acronym/abbreviation itself. Gravidity is the number of times pregnant, including the current pregnancy (which is what I always forget to count). Term is any birth after the end of the 37th week, and Preterm is any birth between 20 and 37 weeks. Both term and preterm include live and stillborn babies. Abortion is any fetal loss, whether spontaneous or elective, up to 20 weeks gestation. Living refers to all children who are living (duh). Multiple fetuses (twins, triplets, etc.) are treated as one pregnancy and one birth. It’s just too many variables and parameters and whatnot…it makes me cross-eyed. So…Jane’s GTPAL is 4-1-1-1-3—four pregnancies including the current one; one baby born at 39 weeks; one set of twins born at 35 weeks; one miscarriage/spontaneous abortion at 9-weeks; three living children.

Well I don’t know about you, but I’m spent…

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Touchdown!

Posted by isntshelovlei on April 18, 2010

At first I thought it was going to be like our last few clinicals where I was bored to tears. For the first two hours or so, we watched the nurses eat their full-course breakfasts complete with omelettes, bacon, home fries (which everyone complained were too salty), bagels smushed with avocado (WTF?), and toast—with Smart Balance spread of course. We did not partake in their feast though one nurse offered me a Starburst. When they were done eating they proceeded to cackle about the Kardashians, the Gosselins, and just about every other celebrity as they perused their mile-high stack of trash mags. The conversation then shifted to Martha Stewart, how they liked their Bloody Mary’s spicy, and so on. One even remarked, “Oh, I remembered to bring my iPod today.” None of them wore stethoscopes (not much patient care going on anyway) and honestly you couldn’t tell the nurses from housekeeping as both wore varicolored scrubs.

But it got better.

When it was all said and done I got to see a vaginal birth, a C-section, an epidural placed, and a D&E (dilation and evacuation). Just for that stroke of luck, you can bet your sweet ass that I won’t see anything else the rest of this rotation. The vaginal birth was great—as the mother of three I had been wanting to be on “the other end” for once. The baby was big (8+ pounder) and mom was small which unfortunately landed her with a third-degree laceration (tear) in the end. The C-section was a lot faster than I’d thought it would be—if I had blinked I would have missed it. The patient came in actually wanting to try a VBAC, but the doc wasn’t having it. I think they did entertain the idea at first until her blood pressure went up and the baby starting having decels. Third patient had a history of a LEEP and was dilating slow as molasses (which I’m told often occurs with LEEP patients). She was only 2 cm dilated when they gave her the epidural (I thought you had to be at least 4 cm), but she just couldn’t take the pain anymore—the Nubain just wasn’t cutting it. They were also augmenting her labor with Pitocin (which in my experience creates the worse contractions), and she was now having contractions every 2-3 minutes. Hell I’d want my epidural too. It was the D&E that kinda bothered me. A D&E is a surgical/therapeutic abortion done in the second trimester. Basically the cervix is dilated and the contents of the uterus are removed by vacuum. They use an ultrasound to make sure they got all the tissue out. But it just seemed like there was blood everywhere—they were slinging it and tossing bloody gloves and instruments and whatnot. And right after that—we got to eat lunch! Sheesh…

That’s all for now folks—a nap is definitely in order!

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Some Boo-boos You Can’t Kiss Away…

Posted by isntshelovlei on April 11, 2010

A lot of boo-boos and ouchies in clinical today. First, I had a postpartum mom with a fourth-degree episiotomy. She was postterm so of course the baby was big, and they “had to” use the vacuum to assist with the delivery (I’m not a big fan of vacuums and forceps and such). To me, the situation just screamed C-section, but hey what do I know? So for those not fluent in the language of OB, a fourth-degree is the most garbungular type of episiotomy you ever want to have. This cut goes not only through the skin (first degree), muscle (second degree), and rectal sphincter (third degree), but through the rectum as well. “Ouch” really does not even graze the surface. I’ve had a second-degree episiotomy myself and while I hardly noticed it compared to the “ring of fire” during birth, afterward it felt like I slid down a razor-blade-lined water slide and landed in a pool of lemon juice. So I could only imagine what my patient was going through. And those puppies take time to heal. Cold packs help reduce the swelling and pain; and sitz baths circulate (warm) water to the area increasing circulation which promotes healing. You have to be careful with sitz baths though; if you sit in that water too long (which is a breeding ground for bacteria) it increases the risk of infection–15 minutes per sitting is fine. Some women also find witch hazel pads (better known as Tucks) to be soothing.

Second, I got to see a circumcision performed. Let’s just say it made me want to go home and profusely apologize to my 10-year-old son. It just seemed like so much trauma for that little piece of skin they removed. However, the doc that performed it informed me that it “really wasn’t that traumatic for the baby.” Yeah, okay–if that helps you sleep better at night… She used the Mogen Clamp method, which I wasn’t familiar with though all of the methods look pretty unpleasant to say the least. For those of you that have the curiosity and the stomach, you can find a video of the procedure here. I will say I’m glad that the myth (or maybe it was just denial) that babies do not feel pain was finally debunked–it is obviously so not true.

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I Just Didn’t…

Posted by isntshelovlei on March 29, 2010

Clinical this past Sunday was a little more interesting than last week—but not much. I did a newborn assessment, and charted a little in the paper and computer charts. Oh, and I got to help make a couple of beds—exciting stuff for a student nurse thirsty for hands-on patient care right? I did not get to do a postpartum assessment on mom (her regular nurse completed it when I whisked the baby off to the nursery). I did not get to see a birth (vaginal nor c-section). I did not get to pass meds. I did not pass go and I did not collect $200.

It was a little strange at first handling “normal” newborns. I’m used to my NICU babies who have various catheters and such attached to them; these babies were so….free—bundled up like little burritos. Mom was still kind of out of it and preferred that I fed her daughter so I did. It just felt weird being able to scoop up the little peanut from her bassinet and stroll over to the rocking chair with no IV poles or monitors to navigate around. Sitting there with that 7lb bundle of joy made me think back to when my own children were that small (and before they learned to say words such as “no” and “mine”). My lecture instructor said in class that someone always gets pregnant during this rotation—uh, no thanks, I’m retired from that line of work. I already have three strikes, so I’m out of that game.

Sadly, most of the nurses weren’t any better (read: nicer) than the ones we had last semester. I thought (or hoped) that since these nurses cared for hormonal women and babies their demeanor would be a little more accommodating—guess not. No one was outright hostile like my dear Nurse Nasty from last semester, but they did tend to make you feel like some colossal inconvenience. I still don’t quite get that whole “nurses eat their young” thing…

No clinical next weekend since it falls on Easter. Good thing too since I could really use a solid weekend to catch up on some much-needed reading.

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Zzzz…

Posted by isntshelovlei on March 22, 2010

Our first day in Maternity/OB clinical was pretty uneventful–almost downright boring. Part of the problem is that we have clinicals on the weekend. C-sections and inductions are not typically scheduled for weekends. So we are basically just sitting around waiting for someone to spontaneously go into labor (and with all the planned C-sections these days I’m not sure if people still do that…). There was a single postpartum mom on the entire unit. The clinical instructors had to go “find” a baby so that they could show us how to do a newborn assessment. I will admit technically it was just our hospital orientation day (which translates into boring computer training on yet another EHR system), but I was all ready to palpate some funduses (fundi?) or something. I also heard that we’re not even going to be giving meds which leaves not much else to do than a lot of patient teaching–if there’s anyone there to teach…

So although many of my fellow students are still excited about this rotation since some would like to work in maternity, I can already see it’s not my cup of tea. I need more “action”–like in an intensive care or ED environment (but real emergencies–not “my baby has hiccups”). Not that I thrive off of dire emergencies or people being critically ill/injured but when you’ll be working 12-hour shifts I’d like to be doing a little more than reading the tabloids at the nurse’s station (don’t act like you haven’t seen it). Who really cares how Kendra Wilkinson lost 10 lbs in 10 days?–she probably ran 5 miles a day on a strict diet of romaine lettuce…

Of course now I’ve totally jinxed myself and this weekend it will be on and popping (hopefully)…

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VEAL CHOP

Posted by isntshelovlei on March 16, 2010

Let me tell you a little secret–nursing students LOVE mnemonics. There would be absolutely no way to store all of the information we need to know without them. You’ve got the basics like “ADPIE” (which is the nursing process: assessment, diagnosis, planning, intervention, and evaluation) and “OLDCARTS”  (the attributes of a symptom: onset, location, duration, characteristics, aggravating factors, relieving factors, timing, and severity). Some others I’ve picked up so far are “Nancy Reagan, RN” (how to draw up a mixed insulin dose–air into NPH, air into Regular, draw up Regular, then draw up NPH); “LAB RAT” (left atrium: biscuspid; right atrium: tricuspid–which I always used to mix up!); and there are about gillion different ones for cranial nerves. I like “Olympic Opium Occupies Troubled Triathletes After Finishing Vegas Gambling Vacations Still High”–olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear/acoustic, glossopharyngeal, vagus, spinal accessory, and hypoglossal. Tonight, I learned a new one to add to the list–VEAL CHOP–which relates to fetal heart rate.

Variable decels => Cord compression (usually a change in mother’s position helps)

Early decels => Head compression (decels mirror the contractions; this is not a sign of fetal problems)

Accelerations => O2 (baby is well oxygenated–this is good)

Late decels => Placental utero insufficiency (this is bad and means there is decreased perfusion of blood/oxygen/nutrients to the baby). You’ll also hear/see this called “uteroplacental insufficiency,” but VEAL CHOU just doesn’t have the same ring to it does it?

And that’s our lesson for today folks. It’s only the first lecture but so far I think I’m really going to like this class. My professor is really on the ball and I actually didn’t mind that she kept us until the last minute of class because the material was interesting and I felt like I was actually learning something–like the stages of labor (not to be confused with the phases which all occur during the 1st stage) and the 5 P’s (powers, passage, passenger, psyche, and position). I think I’m almost ready to catch a baby–clinical starts on Saturday! :)

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Coming Soon to a Delivery Room Near You

Posted by isntshelovlei on March 12, 2010

Like most of my classmates, I cannot wait to start Maternity/OB–or is it more that we’re eager to escape the clutches of Health Assessment? ;) Now I’ve had three children of my own–one I was so completely epiduralized (I’m sure that’s not really a word) that I could not feel my legs; one natural, but not by choice; and one using Hypnobabies (that’s a story for another day but check it out, it really works!). So although I’m sure my husband would disagree, I personally think it’ll be quite interesting to be on the “other end” for a change.  Guess I’ll need to drag my clinical uniform and lab coat out of retirement…

In other news, I purchased my own individual malpractice insurance policy from Nurses Service Organization (NSO). It’s only $29/year for nursing students and I think it’s a pretty worthwhile investment. Sure we have malpractice coverage through the school (maybe that’s where all my tuition goes…), but I am positive that their policy covers their asses more than mine. It’s also shared between a lot of nursing students so I’m sure there’s some sort of cap per individual. And contrary to popular belief–shit happens–and yes, you can be sued as a nursing student. So don’t be sorry, be prepared.

~ Peace, love, pickles and ice cream

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Now Back To Your Regularly Scheduled Program…

Posted by isntshelovlei on January 31, 2010

That’s right. Winter Break (and nights that involve a solid eight hours of sleep), is officially over. Back to the grind.

This semester they’re shaking things up a bit (BIG shocker there). So instead of taking two classes simultaneously for 14 weeks, we’re taking Health Assessment for seven weeks and then Maternity/OB for 7 weeks. At first I thought it would be better to only have to concentrate on one subject of books, BUT now you have to learn everything twice as fast! So even though we’ve only had four classes so far, we’ve already had to read about 20 chapters! My brain, is so overstuffed with information, that I am starting to have dreams about Kaposi’s Sarcoma, black hairy tongues, furuncles and frickin’ cranial nerves! We had an exam last Tuesday; we have an exam this Tuesday. I have to do a genogram and health teaching project in the next two weeks. And check-offs are fast approaching at the end of February. Sheesh. Things are moving so fast I feel like a walking case of vertigo!

Clinicals are good so far. Again, it’s a lot of information being crammed into a few short weeks, but my instructor is good. She’s thorough and always willing to answer any questions you may have. My lecture instructor, on the other hand, replies to 90% of our questions with “It’s in the book.” Gee thanks. Well instead of me coming and sitting in this classroom for three hours listening to you read off the powerpoint, maybe I should just stay home and read the book. She’s nice and all, but it just feels like yet another course where I basically have to teach myself. What exactly does my $480/credit get me around here?…

Well this is going to have to be one of my shorter posts–duty (aka studying) calls!

~Peace, love, and coffee :)

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