Work is going well

At work I'm trying to juggle a whole lot of expectations.  Getting used to working steadily, getting up to speed on being an RN, earning the respect of my co-workers... all of these are important to me and all of them have different ways to be demonstrated.

I complained pretty vocally (at least here) that I was being 'punished' by being put into the med room several days in a row, but I have to now admit that the repeated experience is paying dividends.  I'm now comfortable walking in the med room, organizing my day's work and passing out meds to over 500 inmates all while holding true to the way I learned to pass out medication safely and legally.

And what does doing that earn me?  Well of course it earns me repeated exposure to it.  Not everyone is good at doing this and I've shown that I can do it better than most.  It also gets me added responsibilities... I get some RN tasks early in the day and then finish up my day in the med room.  Keeping my complaints to myself and just getting the job done well has earned me the respect of the LPNs that do this job day in and day out.  In fact when they have an issue with something going on in the med room, they now come to me.  I'm certainly not their first stop for help, but the fact that they see me as a resource in a job that they do daily is quite an honor.




Last week I also spent a couple days back on 4 Block.  At first I was quite unhappy about it.  I don't want to work on 4 Block so getting sent there is almost a punishment... but it IS something that will happen.  4 Bock needs nurses and when they have an unexpected opening (someone calls in sick) they need to call on someone to fill in.  The first day I was there last week I had another RN orientating me to the afternoon shift.  Yes, I had been our there plenty of times during my orientation but that was on first shift.  Second shift is it's own animal.  The very next day I was left on my own for the entire shift.  It hit me about half way through that day.... this was the first time that I had worked alone. My previous stints in 4 and 5 Blocks were with another nurse, and my time at the southside health center has always been (and always will be) with other nurses.  So in retrospect I have to take that as a good sign... they trusted me to get in there, get the job done and do it without someone to back me up (at least not having that back up right over my shoulder).

I even got to test out my RN emergency skills.  One of the days that I was in the med room a CO brought in an inmate during med pass.  Now while the med pass is going on there isn't a CO in the healthcenter.  That means that the RNs can't have inmates in to work on, so that's generally when they get to take their lunch.  At that time my primary job was to pass out Meds, but as an RN I was asked if I could see this inmate.  He was having an exasperated asthma attack and using his inhaler hadn't remedied the situation.  I only had a few seconds to decide what to do.

If I were an LPN it would be an easy decision... I would call the RN back from his lunch, make sure the innate wasn't in danger, then get back to passing my meds.  An LPN just doesn't have the authority to do much in that circumstance, so they need to get the help they need.  But I'm an RN.  I DO have the authority and even the responsibility to take action.  Passing meds IS important and does need to get done, but an emergency takes precedence.  So I called over to the LPN working the other med window and told her that I had to step out to care for another inmate and told her to cover my window for a bit.  Without pausing she nodded and told me OK.

That right there was a big thing for me.  This LPN had about a dozen years of experience compared to my nearly three months experience.   Yes, RNs do outrank LPNs and yes they do have to take orders from RNs... but she not only accepted that I could handle the situation, she accepted my decision making without being told exactly what was going on.  Even though I was going into what could be a real emergency, I was filled with pride.

So with that decision out of the way I took control.  I brought the CO and the inmate into the clinic and had the inmate sit down.  I told the CO to call the break room and get the other RN (I was prideful, but not cocky enough to think that I could handle any possible outcome!), and began to assess the inmate.  I found out that while he was in distress and wheezing pretty badly that he was still getting a good amount of oxygen and that his lungs were relatively clear.  These steps are important because if his lungs weren't clear then that would mean that it wasn't an asthma attack but something far more dangerous.

While his oxygen saturation was good, I didn't want it to get worse... something that would eventually happen if his asthma attack wasn't fixed or got worse.  I made sure he wasn't in heart failure then wheeled over an oxygen tank and gave him 2 liters of O2.  I can't give him more than that without a doctor's order.  Making sure he wasn't in heart failure was important as giving O2 in that case would actually make him worse.   Once I was sure he wasn't going to crash any time soon (his O2 saturation went up) I asked him if he had experienced this before, and if so what was done.  I was fairly sure that this could be fixed with a 'breathing treatment'.  A breathing treatment is the infusion of Albuterol through a nebulizor.  It's a lot more albuterol than you can get through a regular inhalor and should force him to open up and get the air he needs. He confirmed that that is exactly what was done in the past.

There are a couple problems with that situation.  First, I know there is an upward limit to how much albuterol someone should get.  I highly doubt that three puffs on his inhaler would preclude a breathing treatment, but I wasn't sure.  Second, I'm not sure that I can give a breathing treatment without a doctor's order.  It's not as though there is a standing prescription for breathing treatments.  Third... I have no idea where our nebulizor is and even if I did I have no idea on how to use it.  But until the other RN gets back this is my show.  So I got out all the equipment I would need besides t he nebulizor itself and started working out how to put it all together.

Several times while working on the equipment I returned to the inmate and made sure he knew he was doing ok.  He more than likely knows that he's doing ok.. not good by any means, but not bad either... but as arrogant as it sounds I know that hearing that from a licensed medical professional can make someone feel more calm.  And getting him to feel calm is half the battle.  If he was to continue worrying about what was going to happen he would only make the episode worse and possibly collapse his airway.  Not probable... but possible.  So keeping him calm was part of my job.

Eventually the other RN got back and assessed the situation.  Once he knew what was happening he got the nebulizor out and hooked it up (I was close in what I was doing... the only problem was that I was trying to put together an out of date set of equipment that would never go together).  The other RN started the treatment and once I saw that he had it under control I returned to the med window.

After finishing the med pass (which takes over an hour) I finally got to ask the other RN what I should or shouldn't have done.  I shouldn't be surprised with all the education I've had... but I did the exact right thing.  All the way down to NOT giving the breathing treatment.  Giving a breathing treatment DOES require a doctor's order and the only reason the RN gave it without one is that he and the MD on staff had previously discussed this patient and the RN knew that he would get permission.  Once I was back in the window and the breathing treatment was started the RN called the doc and go the permission.

I should mention that this happened without a doctor in the building.  If a doctor had been present I wouldn't have even bothered the other RNs lunch and gone immediately to the doc.  With the doc only available in an on call status I knew that the RN was the fastest and best option.

I was told by the RN that I did everything right.  I was commended by the LPN for taking control.  I was complimented by the CO on how I handled myself (he knew that I hadn't handled a situation like that before).  My education and almost as importantly my instincts both lead me in the right direction and even though I was scared that I was handling the situation wrong, I didn't let my patient see my nervousness.  I of course still have a lot to learn... I need to know when (and frankly, HOW) to call the docs when they aren't in the building.  I need to know where our equipment is and how to use it all.  But for now, I've never felt more like a Nurse!

Something else is happening that is making me feel good about my job.  All the RNs know that I'm not only new to this job, but new to being a nurse.  They are all very gracious in letting me know that if I have any questions that I can come to them.   I do try to figure out things for myself... I want to test if my education and instincts are leading me down the right path... but of course I often come up against things that I just don't know.  When I do go to the other RNs, however, I'm constantly surprised that I'm asking questions that they don't know the answer to.

For example... this week we are working on MARs.  A MAR is the Medical Administration Record.  It's a piece of paper that lists a patient's prescriptions and has spaces to sign off when the medication is administered.  Each MAR covers one month.  So toward the end of each month we have to set up new MARs for each inmate.  During my clinicals this was done via an electronic MAR, but here its done on paper.  The thing to know about a paper MAR is that it's a legal record.  Everything on it has to be 100% correct.  For each prescription it has to list the medication, the dosage, the time of delivery, the prescribing doctor, and the dates that the prescription is valid for.  Each MAR will also list the patient, their inmate number, their allergies, and their birthdate.

Again... this all has to be correct no matter how trivial.  So while I was checking over one MAR I noticed that all of the prescription dates were off... by one day.  In the computer (which is the ultimately final legal word) the prescription had started on July 10, 2013 (not the real date obviously, but just for example), and ended on July 11, 2014.  On the paper MAR the prescription was listed as July 10, 2013 through July 10, 2014.

So I had a bit of a dilemma.  Yes, it was off by one day.  But that error didn't effect October whatsoever.  My gut said that it has to be 100% correct, so this MAR would need to be discarded (and destroyed) and a new MAR would need to be made by hand.  Without knowing for certain though, and not wanting to spend 10 minutes transcribing the information if it wasn't needed, I went to another RN to find out.

He had no idea.  Neither did the other RN.  Neither did either of the LPNs on duty.  We finally had to go ask the Nurse Supervisor... and she didn't know.  She had to contact her supervisor.   Eventually it was decided that yes, this was an error and would need to be re-written.  Instead of everyone being upset at me for worrying about a trivial matter, I was complimented over and over again about doing the job right.

So... do I still get sent to the Med Line?  Yes.  Do I get sent out to other units?  Yes.  Do I still have a lot to learn?  Yes.  Do I feel like a real nurse and do I have the confidence of my co-workers and supervisors.

Yes!