What I’m realizing in this process of school work + clinicals is that they definitely compliment each other. There is no way I could incorporate everything I need to know for tests, the NCLEX, & my future career if I was just memorizing material. My first day on the maternity rotation, I saw a vaginal birth. That was cool until the attending nurse asked me to suction the baby (<1 minute after birth) and get her vitals. Just a little scary. I’d never gotten a pulse on anyone less than 40 years old. I learned pretty quickly though and the next week when we talked about taking vital signs on newborns, I made sure to take good notes. Nursing school is like no other I’ve been to; there’s stress, pressure, studying, memorizing, more memorizing and then there’s the implementation. Our success at any of the previous has the potential effect on a future patient’s health…that’s why I’m always studying.

The clinical bag* for Med-Surg always had this:

*not that I carried a bag while I was on the floor this summer during my med-surg rotation. After a couple of weeks of searching desperately for each of these things each Monday night before 7am Tuesday clinicals, I started keeping them all in a little tote. I’d empty my pockets into the tote before throwing the scrubs in the laundry, and then fill the clean scrubs from the tote the next clinical day. I still managed to wash quite a few alcohol swabs.
my little notebook. Mine was from the dollar store, about the size of my palm, and fit nicely in my pocket. I made my plan for the shift, broken down by hour, in here, and made lists of the questions that I wanted to ask later. I have pages of abbreviations with little questions marks beside them – UC? (ulcerative colitis), R/O? (rule out), 2/2? (secondary to). I started writing out my meds in this – what is it, how does it work, why/when/how/how often are they taking it, are they taking the right amount, how will we know if they have taken too much, and how will it react with the other med they’re taking? I soon realized that many of my patients were on the same drugs (stool softeners for pts on opioids, magnesium for those with borderline mag levels, proton pump inhibitor to lower gastric acidity, etc) so having the info already written out, ready to read off to my clinical instructor when we pulled meds was really handy!

2 black ink pens – since I invariably lost one during the shift. remind me to tell you the one about the nurse, the checkbook and the rectal thermometer.

watch with a second hand. I really resisted this one, and went the whole first semester without one, doing all my evals with the second hand on the clock in the classroom. But then I couldn’t count resp rates or take a pulse one morning because my patient’s room didn’t have a clock and I knew I was going to have to break down and stop by the drug store on the way home and get a $30 watch.

penlight, for shining in people’s eyes and checking for PERRLA pupils, and looking into the cabinets where the canisters of NG tube drainage are kept before you go reaching your hand in!

stethoscope, labeled indelibly, of course. It was surprising how many folks laid their stethoscopes down around the unit. The big cargo pants pockets were good to stash mine in, especially when I had a patient on contact precautions and was going to be using the one in the patient’s room all day anyway.

lip balm. tricky, this one. I always washed my hands before and after putting it on. But the nice minty smell and the familiar ritual of lip balm was really important to me while I was getting acclimated to the unit.

tiny bottle of hand sanitizer, rarely used because my unit had three handsinks every two feet.

a super compact OB tampon, because, hello! white scrubs!

two granola bars. After a week, I realized that I had to bring food that I could eat using sterile technique. I never *felt* like my hands were clean, even knowing that I’d been wearing gloves and washing them constantly. It made me happier to eat things in wrappers.

at least 10 of those little alcohol wipes, good for wiping down the earpieces of the afore-mentioned stethoscopes in the contact precautions rooms. for that matter, I put a couple of the big dinner napkins sized individually wrapped alcohol wipes in my pocket when I had patients on contact, because the DynoMaps and glucometers all had to be wiped down as they left the room.

I also always had a letter sized piece of paper, like my write-up from last week, folded lengthwise in my pants pocket, half sticking out. When I took vitals (since I did it the old fashioned way, without the fancy machines), I could write down BP and HR and temp on the back of that paper, using my own leg to bear down. It worked really well, even better when I started writing down the time beside the numbers so that when I got out to the chart and opened up the paper, I could tell the 8am numbers from the noon numbers!

*****

For my Psych rotation this fall, the bag is pretty different. First off, it’s actually a bag, and I have no pocket-stuffing to do. We’re wearing professional clothes on the unit, and we’re not carrying ANYTHING in our pockets. We’re also not doing any writing or note taking while with the patients. So, my little notebook stays with my pens in my bag until I can come back to the breakroom every hour or so and make some quick notes. No wallet, and only my car key ring, since I can’t lock my bag up, just lock it away from the patients. I never carried my cellphone this summer either, except on a day that I knew something sketchy could happen child-care-wise, and then I kept it in the break room on silent and checked it every hour for missed calls. No stethoscope – I feel pretty confident it would go on the same list with belts and sharp objects. A bigger bottle of hand sanitizer, though, since I’m in an older facility and there’s just two easily accessible sinks on the unit that aren’t that easy to get to all the time. Granola bars, lip balm, and tampons still essential, but they all stay in the bag, along with a bottle of water.

There are a thousand differences between med-surg and psych, but the most obvious at the moment is that all the time I spent writing up meds and labs and chief complaints and medical history before I did any patient care for med-surg is now spent after interacting with the patient, writing up our conversations, analyzing for therapeutic communication techniques, writing nursing notes about the shift, looking at the files and finding that things are sometimes quite different from how the patient perceives them. Off to write up my observations from today, before I forget them forever!

Part of the stress of clinicals for me was thinking that I needed to walk onto the unit with a BSN. Not so at all. I am a student, I remain well-supervised and I only do the things that I and my clinical instructor both know that I can do. I do spend a lot of my time thinking outside of that scope of practice – constructing complicated plans and imagining what sorts of consults I’d call in for this patient and when I’d call the pharmacy about which lab result. But really, right now I am only independently responsible for a nurse aide’s scope of practice. I can and do practice the skills of a registered nurse (practical skills like med administration and sterile dressing changes and patient education and cognitive skills like care plans and critical thinking about evidence based practice). Realizing exactly what I needed to bring with me to clinical, skill-wise, was like a huge weight was lifted from my shoulders.

It’s difficult at times, to write these care plans full of interventions that would take days or weeks to implement and follow through on, when I know that I’ll only care for this patient in actuality for a few hours and likely only be able to act on the simplest of care plans. But it’s all about the practice of thinking like a BSN prepared RN – I am writing as if I was the nurse I hope to be in a couple years.

I stumble into the kitchen where Grampi has already made coffee since he’s been up since dawn. I mumble good morning and he pounces.

Grampi: What do you know about Prilosec and Coumadin?

kati: Wow. Um. Can I get my coffee first? Let’s see. Prilosec is cimetidine, yes? Over the counter medication for heartburn? an H2 receptor blocker? Okay, I’m waking up now.

Coumadin is warfarin, a blood thinner. You’re taking it to keep clots from forming because of your atrial fibrillation (when the atria quiver instead of pumping efficiently). Clots are bad, they could mean strokes or pulmonary emboli, so we’d like to prevent them.

But according to my textbook, cimetidine and warfarin are bad business together, because they both are metabolized by the same enzymes in the liver. And I can’t remember at 7am if cimetidine ramps up the enzymes (lowering the active levels of drugs) or slow the metabolism of those enzymes (raising the levels of active warfarin). I do remember that there’s a pretty strong caution not to use them together if it’s avoidable, because one of them affects the level of the other.

And I remember that last night you said that your docs were having a tough time getting your INR stabilized between 2 and 3 (INR measures how the warfarin is working, how it is affecting the clotting factors of the blood). So, no, Grampi, in my two semesters under my belt student nurse opinion, you should not take Prilosec and Coumadin unless your doc specifically says it’s okay. And even then, I’d like to know why she thinks it’s okay.

Grampi: Hmmph. You are learning something at nursing school, aren’t you! Here – look at the rest of this. Now, why am I taking…

It was a little scary to realize that I’ve already taken a certain role in the family, only two semesters into nursing school. It’s the same role that Grampi was in while he was a practicing veterinarian (“What do we do about this weird red spot on Muffin’s belly?”), but it’s not one that I was prepared to assume until I graduated. Last January, when my friend who is in the midst of a chemo regimen for metastatic breast cancer started throwing out names of drugs and interactions and cautions, and said “Well, I’m sure you know about this already”, I had to admit that no, no I didn’t know any of that. But now I can talk with her about the recent switch from one drug to another, and the whys and hows of that change.

I also know that I could have stammered that I had no idea about Prilosec and Coumadin and we would have had a lovely conversation about the front page of the paper, but I knew that stuff! And that’s a great feeling – that I didn’t just learn it for the test – that the knowledge is in there, retrievable upon command. Perhaps because it is so new to me, I can pretty easily translate it out of medical jargon and into plain English. And that is a skill that I hope I never lose, because patient education and the ability to communicate clearly with patients is absolutely essential to how I want to practice as a nurse.

It’s nice to know that I felt pretty comfortable doing patient education on P450 enzymes in my grandfather’s kitchen, and I’m not the least bit ashamed that I ran upstairs after my first cup of coffee and pulled up my powerpoint notes on warfarin on my laptop to make sure I had told him the right thing*.

* According to my notes, cimetidine strongly inhibits hepatic metabolizing enzymes, therefore drug levels of these substrates (one of which is warfarin) will rise (and in the case of warfarin, increase the risk of bleeding and blows one’s INR out the target range).