Category Archives: Words-o-Wisdom

Staying Organized During Football Season and Your Average Hospital Shift

Staying Organized During Football Season and Your Average Hospital Shift

Really, there aren’t two topics of more importance, so why not lump them together. Since I’m sort of between teams right now (oh, the heck with it, Go Raiders!!!) it will be fun to work through this flowchart, since I hate thinking for myself!

On another note, I’m attaching the shift routine worksheet I’ve made to keep on track at work, and prevent charting deficiencies. It really helps me remember to order labs when I’ve got patients on protocols (e.g.; K+ replacement, etc.), to identify Core Measures (thanks, Jay-Co and CMS!) and mind my p’s and q’s. I’m attaching it should it be useful to others on the internets.  Here you go:  Shift Routine for Med-Surg

 

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Nursing Students – Alternate Item Format Got You Down? I Recommend. . .

Strategies for Alternate Item Formats on the NCLEX-RN Exam, by Silvestri and Mojica (ISBN-13: 9781416038412) is the best resource I have found for tackling the dreaded SATA (select all that apply).  You know’em, and you hate’em.  I have never encountered one nursing student (or a nurse, for that matter) who LIKES these types of questions.

And, guess what?  They don’t end with nursing school and the NCLEX.  No siree. . .turns out RN-BSN programs love’em too.  Yay.

So, I present to you a link for purchasing this resource, dirt-cheap at Bookbyte.  Unfortunately pour moi, I am paid nothing for selling their stuff, but frankly, the warm, fuzzy feeling in my heart that will come from knowing that someone listened to me, took my advice, and had a less hellish time in school/NCLEX/RN-BSN program will be enough.  (Yes, I am being unduly dramatic.  And, guess what?  I don’t care.)  Because I bought this book as an impulse buy (much healthier than my usual gazillion-calorie latte as an I-love-me indulgence).  I loved it.

My hilarious classmate (loved the way he would say, during study sessions in the library – “Damn you, (insert nursing instructor’s name here) I hate your questions!  This is shit!” (imagine Russian accent) at the top of his lungs – well, he loved this book too.  Another classmate who failed NCLEX the first time around and then slayed it – partially, she said, due to this book – loved it.  Now the book lives on, humbly serving this year’s second-year nursing students who suffer after us.  I’m sure it will continue to be passed on.  You need this book, nursling.

If you don’t heed my advice?  I’d better not catch you complaining about SATA questions (except to say that, darnit, there were not NEARLY enough SATA questions for me when I took the NCLEX).  Said no nursing student, ever.

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A Few Lessons Learned this Week

A Few Lessons Learned this Week

It was an interesting week for this newbie float pool nurse. Here are the primary lessons learned this week:

1. Saving hundreds of dollars by replacing cable with Netflix will be partially cancelled out by Mr. DisorderlyCNA watching the show My Cat From Hell and deciding that our well-behaved Russian Blue needed an 8′ cat tree (costing more than I used to gross in a week as a CNA). Oh well, the cat’s happy.

2. If you run piperacillin-tazobactam (running at 12.5 mL/hr) as a primary line and “Y” the patient’s maintenance fluids into said ABX line, you are a bad, bad person. No, I didn’t do this, but I was the lucky nurse who got to completely re-route this disaster someone left for me. I guess my infusion skills can always benefit from practice, but , seriously!!! Zosyn run at a very slow rate and NOT piggybacked into some NS set to run at 21 mL/hr leaves you with air in your line, which is miserably difficult to clear (and will definitely wake up your poor, sleeping patient).

3.  Not used to working with psych patients?  Well, reflective communication and therapeutic silence are your best bets!  Otherwise known as stall, stall, stall until someone who usually works with the patient shows up and saves your bacon!

4. People with health conditions should/must wear medic alert tags or bracelets. There really is no excuse, and, in an emergency, even the most composed person can miss an important detail when giving a history to the medics.  Don’t settle for the cheapie kind that let you put a label or labels with the person’s condition on the tag, go ahead and get an engraved one like this.

5. When making a new muffin recipe for the first time, bake just five (one in each corner of your muffin pan and one in the center) to gauge the success of the recipe and/or make adjustments before using the vast majority of your batter and having to to start over.  Waste not, want not!

So, with that, here is a lovely recipe for Orange (ahem, Grapefruit) Glazed Poppyseed Muffins!  (Adapted from this recipe.)

Cook’s notes:

1. This recipe could be lightened substantially by going halvesies with the oil and some applesauce. These are not for the faint of heart, and one muffin goes a long way.  Probably could reduce the sugar to 1.75 cups and be just fine, as well.

2. Do not, do not, do not underbake these babies! Or you will wind up with your muffins doing a Jim Breuer imitation (early career).

3.  No orange juice?  Raid Mr. DisorderlyCNA’s secret stash of ruby-red grapefruit juice!  Or apple juice would work, I suppose.

4. A colored dishtowel makes a lovely backdrop for a photo of your baked goodies. Thank you, Costco!

INGREDIENTS:

Muffins:
3 eggs
2 1/2 cups white sugar
1 1/8 cups vegetable oil (or half oil, half applesauce for a lighter muffin)
1 1/2 cups milk (you can actually skip this if you don’t want it – I forgot to add this and the muffins were still bomb!)
1 1/2 teaspoons salt
1 1/2 teaspoons baking powder
1 1/2 tablespoons poppy seeds
1 1/2 teaspoons vanilla extract
1 1/2 teaspoons almond extract
3 cups all-purpose flour
Glaze:
3/4 cup white sugar
1/4 cup orange juice
1/2 teaspoon vanilla extract
1/2 teaspoon almond extract
2 teaspoons butter, melted
DIRECTIONS:
1. Beat together the eggs, 2 1/2 cups white sugar and vegetable oil (and/or applesauce if using). Add in milk (or not!), salt, baking powder, poppy seeds, vanilla, almond flavoring, and flour. Mix well.
2. Bake in paper lined muffin cups filled 3/4 full at 350 degrees F (175 degrees C) do not adjust temperature if using a convection oven for 20-25 minutes. The tops should be browned and a toothpick inserted in the center should come out clean.
3. Remove muffins as soon as you can while still warm/hot and cool to just warm before dunking tops into glaze. Turn right side up and cool on a cookie rack (with a cookie sheet under it or you’ll have a hella fun mess to clean up).
4. To Make Glaze: In a saucepan over low heat, combine 3/4 cup sugar, orange juice, 1/2 teaspoon vanilla, 1/2 teaspoon almond flavoring and 2 teaspoons melted butter. Warm in pan until the sugar is dissolved. Dunk muffin tops into glaze when cooled to room temperature. (Omit the glaze altogether if you don’t like the mess, but you’ll have to live with yourself for being such a chicken!)

Enchiladas, ACLS and CIWA

Verde Chicken Enchiladas Tillamook

enchiladas

In tonight’s episode of “disorderlyCNA is too lazy to go out,” I submit for your consideration an enchilada recipe that takes 10 minutes to assemble and 30 minutes to bake. . .serves 3-4 comfortably. I make this when I am totally uninspired and need to clean out the pantry. Plus, it’s quite good left over.

28-oz can verde enchilada sauce (I like Las Palmas, although La Victoria would get the job done also)
7-oz can fire roasted diced green chiles
two 12.5-oz cans Kirkland canned chicken (although you could probably also use a rotisserie chicken – unfortunately for me that would involve leaving the house. Fail.)
*Oregano
*Cilantro
*Ground cumin
*Tillamook extra-sharp cheddar
*Tillamook extra sharp vintage white cheddar
6 tortillas (burrito size, please)

Preheat oven to 375 (350 convection)

In large saucepan, combine all the canned stuff (drain the chicken before adding) and spices to taste. Mash the chicken into the sauce with the back of a slotted spoon. Subject mixture to medium heat until bubbling. Remove from heat.

Next, shred generous amounts of the cheeses, then mix together (I suggest an amount that yields at least 3/4 cup when in its final shredded form).

Microwave the tortillas on a plate for 1 minute on high (10 seconds per tortilla). To assemble enchiladas – lay one tortilla on another plate, and, using slotted spoon, remove 1/6 chicken/chile/spice mixture, place in a line along the center of the enchilada. Add some of the shredded cheese, then roll tightly and place in 13 x 9 pan (I suggest a heavy pan, such as a Corning ware). Repeat until you are out of tortillas, chicken filling and all but 1 cup of the cheese. Pour the green sauce over the tortillas, being sure to “paint” all of the top surfaces. There will be a lot of sauce in the pan. This is not a reason to panic, but rather to rejoice. Add the remaining cheese to the top, then bake for 30 minutes. Cheese adequacy is important here – don’t skimp!

I have to take ACLS this month.  I’m looking forward to yet another opportunity to freeze up in a mock code situation.  Real codes, no problem. . .but there’s something about skills lab that makes me freeze!  It’s all good, though, if I can just memorize those pesky algorithms and the meds, I should be OK.  At least the CPR part is familiar!

One last pro tip and I’m out for the night.  Nurslings, when you care for your first patient who is withdrawing from alcohol, you may well follow the CIWA protocol for monitoring and medicating your patient so’s they don’t climb out of bed/seize/wind up in the ICU/die on you.  Key tip – it’s great to assess the patient while you’re in the room. . .but don’t forget to step out for a few moments, then sneak back in to see if they are pulling at their covers, gown, or otherwise acting withdraw-y.  Could mean the difference between an appropriate Ativan dose or one that is inadequate and results in your patient hitting a score in the 20’s and scaring you.  **Whew!**

Well, that’s all my cooking/medicating hints for today!  To your health!

C-SPAN…when boring is beautiful

I can’t believe it took me so long to figure this one out. Was a sitter for an unhappy, withdrawing ETOH-er and things weren’t exactly therapeutic.

Patient: I wanna go home.

Me: Everyone here wants to go home, including all the staff.

Patient: I’m gonna hit you!

Me: No you’re not, that’s not OK.

Patient: I can kick your girlie ass!

Me: Uh-uh…I wouldn’t try. I outweigh most NFL linebackers. I got moves.

Patient: F— you!

Me: No one gets to say the f— word here, except for me, silently, in my head.

Patient: (Sulks silently.)

Me: You want to watch TV?

Patient: F— you.

I turn on the TV, with the objective of distracting the patient. Network news? Ugh, that crap makes me feel agitated…and it isn’t helping the patient. Infomercials? Ugh. (Patient continues to squirm and attempt bed exit maneuvers.)

…What’s this?? C-SPAN! Worth a try…sure enough the melodic, droning sound of the political voices draws Mr. Twitchy’s attention…hey, looks like he’s falling asleep! Whaddya know?

Yet another reason to love this great country! Our unfettered access to the political machinations in our Capitol not only enlightens, but calms.

Remember C-SPAN the next time someone squirmy is trying to clock you…it’s the cat’s pajamas for inducing sleepytime! (Maybe Ativan should be renamed C-SPAN!)

And. . .that’s a wrap. . .

As I cruise toward my final examination of the term, I’m reflecting on all the good times.  Like the staggering 42.3 hours of lectures I’ve recorded for this term (doesn’t count the first day when I forgot. . .there’s another 3 hours or so in there).

It’s helped some to have a second chance at listening to the content again. . .and I’ve been able to share these golden hours with my classmates by uploading lecture recordings to our online class website.  Sometimes, life happens:  a kid gets sick, work mandates you to stay over, or something else, and it’s not possible to make it to lecture.  Nursing school is hard enough without missing school (physically or mentally).

I feel like such a media bigshot, using my nifty digital recorder.  No, it’s not for my American Idol tryout (too old, and no one’s pants are anywhere near the ground). . .but there’s no better cure for insomnia than a nursing school lecture recording (almost as good as sleeping in class).

I do love the recorder – a Sony ICD-SX712. . .the software that comes with it allows me to edit, name and export lecture recordings like someone who knows what they’re doing.  Plunk the recording into iTunes, and there they are, hours of jaw-wrenching yawndom, ready to insert knowledge into my brain (which resists information like cellular receptors in a person with DM2 resist insulin).

You can probably find this one cheaper, but as Ferris Bueller would say, “If you have the means, I highly picking one up.”  Link to Sony: ICD-SX712

 

Kitty Code

So, we’ve all been through codes at work. Or at least hopefully if you have worked worked in intensive care, you haven’t run from too many. (Famous quotes from disorderlycna – “Oh look, someone should cover the front desk – you all look busy – I’ll go!”)

Well we don’t expect people to code at home. In particular, we don’t expect the cat to code at home.

Trust me, it can happen. Despite being relatively smart animals, cats can be in over their head, if they swallow something that blocks the airway.

You’ll notice that this is occurred, because your cat races crazily around the room, in a panicked fashion. The cat will try to rub itself long the floor in an effort to clear their airway. The behavior has a seizure-like quality.

My cat did this yesterday. Out of the blue, she ran madly around the house and frantically rubbed her face along the floor, then stood, legs splayed out to the side. It reminded me, in retrospect, of tripod breathing demonstrated by a human. Anyway, I decided to panic first, then focus on the ABC’s.

Focusing on the ABCs is a way of prioritizing the rescuer’s response to an emergency medical situation. It is designed to help the rescuer remember to check what’s important. Obviously, breathing is pretty darned important, but we forget that the airway may be blocked. So A first for airway, then B second for breathing, and lastly C, for circulation. That is the focus for a rescuer in an emergency situation.

I noticed that C for circulation must be okay, because her I could feel her heart pounding through her ribs as I held her.
Then, I attempted the Heimlich maneuver in order to dislodge whatever object was blocking her airway. No luck, cat still in distress. Damn. Now what to do?

By this time, the husband suggests putting the cat up on something, because bending over for too long dealing with her on the floor is just plain uncomfortable. Ergonomics are important!

We put the cat on the breadboard in the kitchen (because of course my study materials completely cover the table). He suggests we look at the airway – I concur. However, I’m not fond of the idea of being bitten, so I suggest we block her mouth open with something. He shrugs and looks at me. I get a wooden spoon out of drawer underneath the breadboard and put it lengthways in her mouth, and then hold the cat from behind, opening her mouth, while my husband takes look at the airway. He’s a brave guy.

He sees and points out to me some gristly gooey substance that appears to be stuck in her mouth and is extending down the airway.

He says we should remove it, and I agree. Into the living room he blitzes, and returns with needle nose pliers. Why do we have tools in the living room? I don’t know, but they sure look handy at this moment.

Using the pliers, he grasps the icky substance that is firmly adhered to one of the cat’s back teeth, aaaaannnnd -nothing! He then pulled again and the icky thing comes out and plops onto the breadboard. El gato stops panicking, and her respirations return to normal, although she looks little stressed out.

Things returned to normal, and the cat starts to purr. “Thank goodness that’s over!”, I said. DH returned to watching football, and, after my heart rate returned to normal, I returned to studying.

It’s nice to have a happy ending emergent situation. Sadly, this is not always possible. However, we’re home, and the cat wasn’t grifting around the neighborhood begging for tunafish.

The lab (I’m kidding, we don’t have a dog) determined the substance stuck on her tooth was sinew from some beef jerky that she had found (where, I have no idea). So, add jerky to the list of hazards to keep out of kitty’s reach.

So, let’s all remember the ABC’s!

No More Cable Bill. . .Also Known As Saving Over $100 a Month

Guess what?  When you work as a CNA and are a full-time nursing student, you don’t have very much time to watch TV. 

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So unless you absolutely must have ESPN, switching to free, over-the-air broadcast television, supplemented by a couple of other goodies, will help you save a bundle while still getting your Grimm on.  (Yay for a nationally broadcast series that not only gets the whole “Keep Portland Weird” vibe but also features a leading lady who is the niece of my CNA course teacher.)

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How do you still watch football, OPB (yay for muppets and McNeil-Lehrer) and other stuff without cable?  Here is my personal collection (thank you husband for the research and installation) of components you can easily install to get back some of the features you’re giving up:

1.  The Mohu Leaf antenna:  this flat little insanely amazing piece of engineering goodness installs in seconds and has amazing range.  I use the amplified version of this indoor antenna (can be powered by USB or electrical outlet), but if you live in a major metropolitan area, you can probably get away with the original or the non-amplified HD antenna.  Price tag?  $38-74 plus shipping (about $10).  Look, just buy it, OK?  This company also sells a digital-to-analog converter box if your TV is not able to receive a digital signal. 

2.  Orca Antenna:  $70 plus shipping as charged (varies).  Advantages?  Looks like it came out of Star Trek, signal strength reception independent of whether it is mounted on/adjacent to exterior wall.  Disadvantages? Some assembly required, requires electrical outlet, makes husband feel silly for buying it.  You could mount it outdoors (have fun finding the needed pole/adaptor) or in your attic.  Or, you can be like lazee me and stick it on top of a bookcase and have done with it. 

3.  Channel Master CM-7000PAL Tuner/Dual DVR:  The other half bought this one through eBay. Someday, there will be no more from this source, as this particular model is no longer manufactured.  Features an easy-to-use channel guide and DVR recording setup.  This product was manufactured for DISH network; DISH has since switched to another product, but this one works extremely well!

4.  Subscription TV service of your choice.  Netflix (about $8/month) has been around the longest.  If you’re a procrastinator, don’t bother to add DVD delivery service to your account.  You’d be better off with a quick trip to the store or McDonalds to visit Redbox or Blockbuster’s vending machines.  Hulu Plus (about $10/month) is favored by others (different offerings).  Amazon Prime ($79/year) allows pay-per-view viewing. Beyond that?  Waaaaay more expensive!

Yeah, I’m spending my savings on movies at the theater (with beer, thankyouverymuch), more beer, textbooks, and support socks. 

Happy Idiot Box watching!

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Keeping That IV In – How to be a Pro With Mitts

Sometimes, patients are unable to control the impulse to pull at their various lines, ET tubes, telemetry leads, or (gasp!) Foley catheters.

Restraints may not be in the best interest of the patient’s safety, and sometimes serve to agitate the patient further. Using a CNA as a sitter is a great restraint alternative choice, but let’s face it, sometimes keeping a patient from pulling at their lines is like trying to put a cat in a box to go to the vet!

So, here’s where mitts can be the BFF you’ve been waiting for! Several manufacturers produce washable “hand protectors” (yeah right, more like dressing/Foley/IV/nurse sanity protectors). In general, these protectors feature a generously pillowed palm, and lace-up or Velcro closures. The patient can move his/her arms freely, but cannot grasp lines to remove them.

So, you ask, how do I keep the patient from removing the mitts by using their teeth/other hand/legs? The hidden secret (when using lace-up mitts) is to cut a small hole in the top of the tongue (of the mitts, NOT the patient! This is important!). Lace up the mitts, and thread the top laces (furthest from the fingers) through this hole, then tie the laces in a bow to secure the mitt. This one small modification makes a world of difference when it comes to keeping the mitts ON your patient!

So, happy sitting, and enjoy that patent IV line!

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Slacker CNA Jobs to Grab For. . .

So, it’s a busy night in the ICU. . .what tasks should you jump at to give your barking dogs a break?

  1. unit/monitor clerk – on the plus side, you’re definitely off your feet.  On the minus side, that phone just keeps ringing with the lab tech whose accent makes him/her impossible to understand!  Don’t miss the chance to remind your peers when one of their patients has a telemetry lead off, but don’t bother to tell them which one.  Who doesn’t love a game of bug the sleeping patient??  Be the most popular person in your unit!
  2. 1:1 safety companion – pros:  possibility of patient falling asleep, leaving you with time to read, study, Facebook or finally solve that tough Angry Birds level.  cons:  being hit, scratched, kicked, punched, spat upon or sworn at (my fave comeback:  “Hey, only family gets to talk to me that way!”)  LOLs aplenty for all! 

  1. bed driver for MRI/CT scan – pros:  ability to sit in comfy chair for extended time period in operator’s booth watching scan in real time and listening to radiology techs bitch about their hellish shift (points for variety here).  cons:  transferring heavy-ass bariatric patients from bed to trolley and back again, getting lost on the way to imaging and looking silly.
  2. semi-professional typist – tired of actually doing your job?  seek out the nurses working on their LPN to RN or RN to BSN or whatever and offer to type their papers for them!  pros:  they do your work  for you extremely happily while you type and will buy you coffee if you whine enough or look at them with a pained expression.  cons:  APA format sucks, possible repetitive stress disorder. . .
  3. code lurker – pros:  excellent slacker position for newbie hospital CNA, lots of exciting things to learn, no bodily fluid splashes.  cons:  may get pulled into doing compressions, may get asked to get exotic piece of necessary equipment from storage room way the hell across unit, thereby defeating slacker purpose of job

 

Disclaimer:  these positions are temporary at best.  As always, your best bet is to keep moving, because a rolling stone gathers no moss and a CNA in motion tends to remain. . .employed!