1. a) My personal goals: Become more familiar with all the paperwork involved in patient care so that I can be more helpful to my preceptor by dealing with it myself.
Evaluation: There is so much paperwork involved that it will take some time to become proficient at filling it out. I was able to create the parent and baby bands to be used upon delivery and fill out the consents as well as explain and have the patient sign them. When I left the hospital last night I grabbed the paperwork packets for all new admission, epidural, and c-section patients so that I could look them all over at home and become somewhat familiar with them on my own time. As my preceptor saidsaid, most of them will still be completely foreign to me but at least this way I can be more proactive and reduce the number of repetitions needed to become familiar with them.
b)My professional goals were to check a woman’s cervix and witness a birth since I did not have the opportunity to during my last shift.
Evaluation: During this shift we took care of one woman being induced and another who was imminent for delivery. My preceptor checked the latter’s cervix and asked if it would be alright for me to check after her and the patient agreed. We suspected that she was complete, but when I immediately felt a head in her birth canal and no ring of cervix encircling it, I asked, “So this is 10 cm?” and my preceptor confirmed this, much to my patient’s delight. This was hands-down the highlight of my nursing career thus far. After that I was able to witness the birth and observe first-hand the nurse’s role during a delivery. My preceptor said next time I can be more actively involved after seeing one done by her.
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1. Personal and professional goals for experience(s) this day.
A. Perform the admission process on my own with supervision, including placing toco, FHM, finding pt in computer system, admission assessment and charting.
Evaluation: Success! I have been involved with a few admissions but never really had the time to do it by myself. My preceptor and I are usually so pressed for time that one of us will take one task while the other completes something else. But yesterday I was with the charge nurse, who is not assigned patients and she was very patient with me and let me take my sweet time while admitting a labor check patient. I seem to be getting better at placing the FHM, which is a good thing because it's a horrible feeling to be pregnant and see some imbecile unable to find your baby's heart beat. I always tell them when I've found even the faintest trace of it that I did indeed hear the heartbeat, but that I am just looking for a louder spot to place the monitor. This seems to relax them.
B. Actively assist with a delivery.
Evaluation: I was able to work with my preceptor to deliver a patient, who also happened to be an RN, vaginally on 10/29. The patient had an epidural and pushed for 2.5 hours, only to have the doctor use the vacuum and perform a last minute episiotomy (*full body shiver*). I learned that there is a LOT of bleeding involved with an episiotomy and watched in horror as it streamed down her perineum into the bag under her bottom that catches the fluids during birthing. My preceptor and I got the bed, warmer, and delivery table ready for the delivery and assisted the patient to push for the duration. Afterwards she told us that she couldn't have done it without our encouragement. I spoke with the patient briefly after the birth about breastfeeding and gave tips and advice for getting through the first couple weeks if it doesn't come as naturally as she thought it would. She was very receptive and encouraged by this and I was sad to have to leave her int he care of the night shift so soon after the birth.
3. Supervise team members to determine if work is getting done, if any work is missed, and if members need additional assistance with their work.
As charge nurse, this is the main thing that we did. We were constantly watching the FHM from the nurses station and making sure that things flow smoothly such as calling anesthesia, nursery, and paging doctors as needed. One example of making sure work is done is that Rm 2, an IOL, was having consistent late decels on the FHM for about 5 contractions that were coming less than a minute apart. A nurse was in the room with the patient and after a few minutes we stepped in to make sure that she had turned the patient's pitocin off as repositioning and oxygen had not improved the baby's heart rate over the last 20 minutes or so. The nurse had indeed already decided to stop the pitocin, so we were just there as backup for her. I found this simple act very reassuring, and told my charge nurse that as a new grad nurse it makes me feel very happy to know that the charge nurse is watching my patient's strip and assuring that I am making the right decisions in such cases. Nurses have a lot of autonomy in their patient's care, and when you see a bad strip it is at your discretion as to how to handle it, either with positioning, oxygen, bolusing fluids, decreasing the pitocin, or discontinuing it altogether. So I am glad to know that a more experienced nurse is there to ensure the most prudent action is being taken. The charge nurse in no way seemed condescending or punitive while checking in on the other nurse.
10/29/10- I had a busy and eventful day this day. I was following my preceptor for most of it, but took the opportunity to follow the department manager for 3 hours as well as attend the bed management meeting that afternoon for one hour, as explained above. As far as patient care that day, it was madness on the unit with one IOL having what my preceptor called "nasty decels." I really did not get to do too many skills this day, but ended up observing and trying to stay out of everybody's way as much as possible. We had two patients ready to deliver at the same time, and one of them was an RN who's husband works at at the hospital as a surgeon and none of the other nurses wanted to cover them while we attended our other very friendly laid-back patient who was ready to push. The surgeon was a very strong personality who had managed to royally offend just about everybody on the unit by trying to see his wife's chart because he "was the one who impregnated her anyway and he's a doctor." Apparently surgeons don't know about HIPPA? So we had to stay with that patient who looked as if she would be complete at any time while another nurse attended our other patient's birth. Unfortunately, the doctor for this other patient pulled my preceptor aside and said she was being unfair to her patient by deserting her just because the other patient's husband was a doctor. She was very upset, but the charge nurse said that she made that call and if the patient's doctor had a problem she could take it up with her and the department manager. Of course the surgeon's wife did not end up delivering after all until 2 hours later, just before shift change, but we had a great time assisting with this birth and the surgeon wound up loving us and videotaping us and gushing the whole time about how great we were. One interesting thing I got to see was my preceptor getting doused in amniotic fluid while helping the patient to push. This has apparently never happened to her before, and the second time it did I had gloves on and saved her another shower by blocking the flow with my palm as it was arching directly toward her head, for which she was much appreciative. Glad to be of service!
11/3/10- This day I followed the charge RN. We did not do much as far as patient care, but handled scheduling, new admissions, and assigning nurses to incoming patients. One of my main jobs acting as charge nurse was to shoo family and friends from standing in the hallways and send them on their way down the hall to the waiting room. My charge nurse was much appreciative to hand this task over to me for a while. I did get the chance to start 2 IV's, the second one successfully. I also drew blood for labs, performed a cervical check on a 1 cm patient for which absolutely could not find her cervix for the life of me, but put on my "Oh, yes, I completely know what I'm doing" face anyway while the whole time I was really thinking, "Warm and squishy... and some more warm and squishy. I got nothing." I also got to do an amnisure test on this patient to see if her water had indeed broken, which it had not. I shaved another nurses's patient and generally helped her get ready for a c-section. Interesting and depressingly enough, not a single vaginal delivery happened on this day. Every single patient was an induction of labor and wound up with a c-section either for the baby being breech in one case, or the rest who had "failure to progress."
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1. Personal and professional goals for experience(s) this day.
A. Follow the lactation consultant and learn how to help with proper infant latching.
Evaluation: Met. I had a very informative experience following the lactation consultant at the hospital. Got to see many examples of helping new and experienced moms with proper breastfeeding technique.
B. Master "baby wrangling" (finding the baby's heartbeat with the fetal heart monitor).
Evaluation: Met. I took it upon myself to adjust as many patients as possible when their monitors lost the heartbeat. This is something that I figured would only come with practice, and after spending 12 hours doing just that I feel much more confident!
11/5/10- Followed the lactation consultant. I learned how to work the breast pumps on the unit, how to determine the correct size attachments for each mom based on nipple size/shape, and how much colostrum to expect for the first few pumpings (just a few drops!).11/9/10- Another 12 hour shift working with my preceptor. We were actually pretty slow this day and one of our nurses even got floated to Mother/Baby. I was able to attempt an IV start on my first AA female, which sad to say I failed miserably. :) I could neither see nor feel a single vein in this poor girl's arm, but my preceptor helped me locate one and I gave it my best anyway. Later we had a new admit transfer from the ER complaining of spotting at 32 weeks and tingling of her head and arms (???). I did her entire admission assessment, computer charting, and got to watch the midwife do a speculum check, during which I got to get a gander at my first cervix (awesome!). Come to find out she had herself a nice hemorrhoid that bled when she wiped and the exam was over quicker than all the admission paperwork could be completed and she was sent home with instructions to call the office first next time!
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1. Personal and professional goals for experience(s) this day.
A. Help with a c-section.
Evaluation: Unfortunately, I still have not had a chance to help in the OR! This is rediculous because c-sections happen at at this hospital literally every day but by luck of the draw my preceptor has not had one on our shifts. I am hoping to attend one during my last shift next week.
B. To be so utterly pleasant and helpful to everybody on the unit that they will be lost without me and beg for the manager to hire me.
Evaluation: So far so good! :) I had a really great day with the charge nurse today and was actually able to take quite a bit off her plate for her. I did 3 complete admissions by myself, which entails a whole lot of computer work and questions. I also got to help my nurse manager who speaks Spanish ready a Spanish speaking patient for a c-section. She was actually less familiar with the paperwork and computer than I was and I was able to give her some pointers!
Description of days:
11/16/10- The day began with a teenager in labor at 32 weeks having a vaginal delivery of a tiny baby. The nursery team was on hand as they are experts in resuscitation and the baby would also be immediately transferred to the nursery. The baby, who was expected to weigh less than 3 lbs, ended up weighing 4 lbs 2 oz and was breathing and crying on its own immediately after delivery. I learned later that he took a bit of a downturn about an hour later, which often happens because they do not have the reserves to maintain the effort to breathe. His mother had received her 2nd dose of celestone (steroid for baby's lungs) 24 hours before, at least. We had a second delivery on a mom with a fever and ruptured membranes that evening of a 7 lb 11 oz baby girl who got stuck in the birth canal after her head had delivered. The midwife had a hold of this baby by the neck and was pulling as hard as she could but she just would not budge. I swear I thought she would break the baby's neck. She finally came out, though, but with her fist up by her neck so she had passed through the birth canal with one arm folded across her chest increasing her diameter. She came out completely limp with her arms dangling and I thought for sure her arm was broken. My preceptor snatched her as soon as the cord was clamped and yelled, "we need nursery! floppy baby!" and handed her off to the L&D transition nurses. They stimulated her and bagged her 5 times before she started breathing and crying on her own. The nurses said she was just stunned for a minute from the birth. After that the mom started hemorrhaging and lost 2 liters of blood. Her uterus was firm the entire time and she had no hematomas or lacerations, and another doctor came in to help do a speculum exam to visualize her cervix for tears. They did cytotec, methergine, and hemabate to no avail. They finally called her mother in to tell her they would be taking her to the OR for a D&C and possible hysterectomy to save her life if the bleeding didn't stop. I was pretty much trying to stay out of the way during all this and fetch things as I could. Her bleeding finally stopped on its own just before they took her to the OR. My preceptor asked me to put a foley cath back in her to prevent another hemorrhage, and placing a cath correctly the first time on the wreckage that was this woman's nether regions is probably one of my finest accomplishments! This situation had just about shaken my resolve to be an L&D nurse but seeing how all the nurses on the unit came together to handle the situation gives me confidence that I will never be alone.
11/17/10- Today I followed the charge nurse and did 3 admissions, 1 successful IV, and one unsuccessful. I have gotten quite good at getting moms on the monitors and finding babies' heart rates, thank goodness. I also got to physically assist during an external version to turn a breech baby, and the doctor had me dig my hands into this woman's belly to stabilize the baby's bottom while she flipped her around (it worked!), which was pretty much awesome. I gave a baby her first bath, even washing her hair in the sink one handed like I've seen all the nurse's do, as well as giving the baby her first bottle. Then I followed the nursing supervisor and observed her make rounds and assign beds and staff all over the hospital.
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11/22/10- My last day on the unit was very bittersweet for me. When I arrived I took report on two patients, one woman pregnant wither 3rd child who was there to be induced, and another 32 week pregnant woman being treated for premature labor. I did the admission on the induction on my own and attempted an IV start to no avail. I find that I often find the vein just fine and get the flashback of blood, but when I advance the catheter and remove the needle there is no blood return. I refuse to stick a patient more than once, so I always let my preceptor fiddle with it and see if she can get blood return (sometimes she just moves it a little and then it will work) and then re-stick them if needed. When the doctor came in at about 8:30 am to check the patient’s dilation before we started her pitocin, she was found to already be 3 cm dilated. To make a long story short, after only an hour on pitocin the doctor broke her water to speed things up and within 15 minutes her husband informed us she was very uncomfortable and ready for her epidural. We paged anesthesia, who arrived within about 15 minutes and placed her epidural. I was prepared to place her foley catheter immediately afterward (her epidural had not even taken effect yet) when she said she felt like she had to push! She had only been on pitocin for 2.5 hours (most women take 2 days for a successful induction) so my preceptor said to just keep my sterile glove on after placing her foley and check her cervix. When I did so, I felt a giant head already halfway down her birth canal. As I felt this, I looked up at my preceptor and apparently the look on my face said it all and without even asking what I’d felt, she called for the delivery tray. Things moved very fast after this, and I removed her foley because it was time to start pushing. When I placed her legs in the stirrups we could already see the baby’s head crowing. Whoa! The doctor made it in the door just in time for one good push that delivered a baby with hair so long it was in her eyes. I was able to transition the baby myself, which includes taking her vital signs. Counting a newborn’s heart rate for a whole minute is a bit like trying to see a hummingbird’s wings in flight, and I have yet to do it with any sense of confidence. This sweet girl was so pleasant though that she laid there quietly and allowed me to silently count with my mouth as fast as is humanly possible (try counting to 145 in 60 seconds… not so easy!). This was my last experience at this hospital, and it was nice to end my rotation with a freakishly easy, happy birth for everybody involved. Well, the mom might say otherwise since her epidural did not have a chance to take effect, but considering she was only even uncomfortable for about 25 minutes and had an intact bottom after only one push, I’d say she SHOULD be happy! It was very sad saying goodbye to everybody on the floor, and hugs were bestowed upon me as I made a complete fool of myself and cried as I walked out. I thought I would be much happier to finish my clinical hours because that means I’m only days away from graduation, but it felt so WRONG to be leaving. The last 6 weeks have been the most professionally fulfilling thing I have ever done in my life and the thought that I am no longer a part of their team in any way, shape, or form kinda breaks my heart. They all assured me I will soon be haunting their halls again (only this time as an RN!), but even the possibility that I might not get hired is enough to make me cry all the way home. I am happy to have walked away from this experience with new skills, a confirmed passion for L&D, and relationships that will continue thanks to Facebook.
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