April 30, 2012

Life in a Psych ER

The inpatient job is going well.  To date, every shift I was assigned to the ER.  At first, I suspected that it was because I have ACLS.  But I think it's because I do very well in chaotic situations with high patient flow...a skill I acquired at my last inpatient job back east where staffing ratios do not exist.

It's pretty cool.  I'm assigned 3-4 current patients along with a LVN or LPT (licensed psych tech, not a nurse but can a do a lot of what a LVN does including meds and charting).   I round on them and assess, then leave the majority of their care to their 2nd nurse.  The two of us do it all:  it's primary nursing at its finest.  I'm also blessed with some of the finest LVNs I have encountered out here, so I don't have to worry that things will get done and done right.  Because they do.

Then I assess and if necessary admit patients who come through the doors. There's 3-4 RNs (and I'm usually one of them) who work the front.  Patients are assigned to whoever comes up next in the rotation.  One day I started off the rotation.  One day I was the last nurse in the rotation.  It's a rather fair system, though some days luck is against me and every third patient that walks in--which means it will be mine--is off the chain.

Sometimes it's feast and I'll get a steady stream of patients.  Sometimes it's famine and I'll escape with just one.  Usually the start of the shift is slow and things pick up three hours in.  But you do not leave until the charge nurse releases you AND you have all your work done.  So if a patient walks through the door 5 minutes before shift change and I'm up, I have to start the triaging.  I don't have to stay until a disposition is decided (admit or release), but I have to get a point where I can hand off to the next nurse, then finish up any work associated with what I'd done to this patient.

5150s are almost always guaranteed admits:  they may not stay long with us but they're guaranteed admits.  Voluntaries can go either way.  It's kind of like a regular ER:  you get the patient in with the STEMI who needs to check in, and then you get the patient with the ear infection who just needs a script.  And like a regular ER, in 24 hours all patients, even the 5150s, need a disposition of some sort, whether they are admitted as inpatients, transferred elsewhere or discharged.  So it's like that, but with psych equivalents.

It's never dull.  I've met a wide variety of patients and seen so many things that you just can't make up.  If it wasn't for HIPAA I could have you entertained every single shift.  But I don't wish to run afoul of that, so I'll have to spare you most of the details.

I'm also not going to lack for hours:  I've been called three times in as many days asking if I could work.  Regrettably I had plans for all these days so I've had to say No.  But it's reassuring.

I'm only putting in for three shifts this week, as I have to work outpatient this week, plus I'd like some time off because the little one and I have an overdue lunch date coming up.  That's the best thing I like about this job:  complete and utter control over my schedule.  Well, I may not get every shift I put in for (hasn't happened yet but it could), but I can dictate what shifts I am willing to work and not be unpleasantly surprised by a schedule change.

April 23, 2012

So the doctor himself called

Ultrasound results are normal.  One fibroid is hanging out in there:  it is small and not causing problems, so he sees no reason to do anything right now.  If it does start causing problems, he told me to call him.  Otherwise, the uterus is enlarged just because it is...probably due to my age and the fact that I've spawned once.

I'm very relieved.   Back to homework.


No call from the nurse yet.  Bah.  Trying to be patient and not call her about my ultrasound results.  It's not working very well...bah x 2.

Did something new at the Y today:  ran/walked.  Usually I do the elliptical, or walk.  But I decided that two months of pounding away on the elliptical must have done something for my running ability, so I tried it out.  35 minutes of running/walking at a ratio of 3:2 (including warmup and cool-down).  This was a mini-milestone for me.

Mental note:  need to wear two compression brassieres while doing this.  Mental note two:  am happy that I need to wear two compression brassieres while doing this.  The little one's gift to me has lasted for 7+ years now.

I have my first week's schedule from the agency:  Tuesday through Friday.  I told them I was free all four days, and I was booked all four days.  They will call me at 0500 daily to confirm or cancel me.  I asked them to call...it acts as a back-up alarm in case I sleep through mine :)  Plus if I am cancelled that day,  I can always go back to bed or get some work done.  I don't know what units I'll be on though...I won't know until I get there.  So it'll be interesting.

I did hear a rumor that this agency lately has been booking and then canceling CNAs...hopefully this will not apply to RNs.  I figure if I score two shifts a week, that's great.  Three is great too.  I don't really want to work more than that, but I accepted four so I can cement the facility's routines in my head early while my orientation is still fresh in my mind.

I did hit WalMart for some supplies and a couple of new sets of scrubs.  This place screams for a clipboard with a storage pocket.

I jumped ahead on my schoolwork yesterday and plan to do as much as I can for the week today.  Last week wasn't impossible with the assessments and orientation, but it was tough.

April 21, 2012

My performance must have been satisfactory to the site...my agency called me at 0400 to ask if I wanted to work today.  That somewhat alleviates my concern about being able to get enough hours through them.

Me thinks I better get used to these types of calls...I've just set up the special ringtone for them.

April 20, 2012

Ah, bureaucracy

One of the positive things about orienting at the agency job site this week was that I have been too busy to even think about the results of the ultrasound.  So at least I didn't spend all week gnawing my fingernails to the quick, as I was busy dealing with highly psychotic patients.  I wanted to get inpatient work and boy, did I get it!  This place's minimum psych acuity level is stepdown.

But today is a day off, so I called the military clinic to follow-up on the test.  I was very pleasantly told that my results are in and that she will leave a message for my doctor's nurse to call me back with them.  However, she told me that the nurse has 48-72 business hours to return my call.

Translation:  unless I get exceptionally lucky today (ha!)...expect the call sometime next week.

Nothing I can do about it except now worry some more...especially since they didn't tell me, "oh, it's negative, nothing to worry about."  Instead I have to wait to talk to the nurse...and while my test result may still be negative and I just happen to be a victim of a P&P that requires only the specific nurse may discuss any test result with the patient, it's doing nothing to relieve my anxiety.


So the first week of agency work went well.  I oriented in a place that is very high-acuity:  two stepdown/ICU level units and an emergency unit.  No real difference between the two stepdown units except their names...so I will call them Stepdown 1 and Stepdown 2.  Stepdown 1 seemed calmer than Stepdown 2, but I may have also caught Stepdown 1 on a good day...or caught Stepdown 2 on a bad day.

The ER is like a psych ICU but with more handcuffs and very short patient stays, because after 24 hours in the ER patients need a disposition:  go inpatient, get transferred or be discharged.  And there are LOTS of patients walking/being walked/being carried through the doors.  It was like working at my last facility, only there's enough staff here.

I was blessed with three great preceptors.  They all had different approaches to their work, so I learned a lot.  They also had different attitudes about the place, from "great place to work!" to "CYA at all times."  I consider all advice seriously so it was interesting to hear the different views.

Of course there were bumps in my performance--after all, I am orienting to unfamiliar turf.  But overall my preceptors had good things to say about my work, and even the supervisor told me she heard positive feedback about me, so we shall see what happens.  I don't know if the agency will me call me today to start scheduling...we'll see.  

Meanwhile, I plan to enjoy the day off and (try!) not to think about the test results.

April 15, 2012

Happy Tax Day

I have not yet received my tax refund...it was supposed to be in on the 13th. I'm going to give it a week, then I'm calling the accountant to make sure he filed. We used a tax preparation agency--we always have, and trust me, it is worth every cent and then some.

I think our case was a little overwhelming to the preparer, who was probably expecting a straightforward filing...and to be honest, he was nice but not the sharpest crayon in the box. Nice, we are, but simple we are not: we're military with time in a war zone, three separate states (I do not share my spouse's state of residency), renting a house, purchasing a house, relocation, childcare, work expenses (me) plus my attending three schools in one year (two concurrently). We always come well-prepared for these thing so we had all our receipts and everything organized to a T. It's usually a 2-3 hour process.

But it was still too much for the guy...at one point he was kicking the trash can and saying, "I can't take this!" He needed two coworkers to help him get through it.

Heh. Mental note: don't use that particular branch office next year.

My rash is now down the dry and flaking skin stage. Still stings, especially when I smile, frown and move my face in any way, shape or form. I've found that mixing some oatmeal and cold cream (whipping, not Pond's) together, then applying it as a poultice has helped relieve the redness and discomfort immensely. Plus my skin smells so buttery, almost cookie-like.

I slogged through the rest of this week's assignments for school, then started downloading next week's notes and readings. The deadline for my assessments is Wednesday so I need to work on the guinea pig...er, better half, on Tuesday, since writing the bloody things up consumes so much time and effort. Also, I should be orienting at the new facility this week but the exact dates and times are still not definite, so let me do whatever I can to stay ahead of things.

I have to say I don't like taking two nursing classes concurrently. I'm learning and (so far) doing well, but I feel like I'm still missing things from each class. I'd rather take them individually and lose myself in each class, and really get all I can out of it. But it's too late to fix that...I'm making the best of it though.

April 13, 2012

Happy Friday the 13th

Picked up my agency ID badge and nearly had my first scheduling conflict: both jobs potentially wanted me the same week! But things resolved on their own without any problems.

The rash on my face is healing: it's now down to the very dry, "burned skin" stage. Still slathering on the hydrocortisone and Boots' redness serum, while being as gentle as possible with it. I was able to get made up for the ID picture though it's obvious something was wrong with my face. It also hurt, but not as bad as it had been.

I did discover the joys of cold milk compresses...I have a date with one tonight after I finish my homework.

April 12, 2012


Ultrasound went w/o incident. They told me nothing whatsoever...I have to call my doctor in a week for the results.

Well, this is going to be a fun 7 days.
The drug and background screens came back fine. My life as an agency nurse begins. I orient at the facility next week...talk about fast.

Of course, now that I'm officially an agency nurse, I bet every single psych facility in town will start posting per-diem job opportunities, or I'll finally get a call back on the applications that I did submit several weeks ago. Oh well.

Trying to stay calm and not worry...

Patch me up with duct tape and string...

Doc: "So how is the mole doing?"

Me: "I don't know, you have it. You tell me."

Remember the mole I had removed from my face a couple of weeks ago? Benign. Woo hoo!

Unfortunately, I developed a reaction to my prescription creme, resulting in a painful, stinging rash across my chin. Doc told me to stop the creme for now, let the rash heal, apply topical hydrocortisone PRN, and when the skin is healed restart the creme but only use it once a week for a few weeks, then gradually increase the dosage.

While it's healing, I'm also to lay off the makeup, which means the rosacea is on full display. Rosacea plus rash equals...well, be thankful that this isn't a video weblog.

Moving into the TMI part...you've been warned.



Today is the ultrasound for the fibroids. It's one of the lovely "drink 32oz of water before because you need a full bladder" types, meaning I will be greatly uncomfortable all afternoon. Oh well. Got to do what I have to do...I am a little worried about it though, particularly if they look and find it's not a fibroid. But I'm trying to put that thought out of my mind for now.

It's not working. I have been thinking about it all day. The better half has picked up on my feelings--I don't discuss medical issues with him unless we have something that we have to deal with, because he never handles medical stuff well. So I'm acting like this is a routine ultrasound for a routine problem that we've handled before...or at least I think I am. But I suppose after 18 years together, he can read me a little.

The last time I had this addressed was in 2009. They did a D&C and removed the fibroids and polyps that were in there. Of course, there's no guarantee that they won't grow back because they can and often do. And they must have come back in force for my uterus to be measuring 8-10 weeks pregnant when I'm not pregnant.


Not much I can really do right now except go for this test, then wait for the results. And then take things from there.

Moving on to lighter topics.

The 35 Days of Terror seem to be progressing. I look at the iCal task list and knock off the assignments as they come up, and squeeze in the reading and video viewing whenever I can. The health promotion class is fun: I keep sleep logs and journals, and have committed to making one positive change for my health...in my case, eating more fruits and vegetables every day.

Today is a quiz for the assessment class, which I will do in a bit. My better half has promised to be my guinea pig for the actual assessments, and this should be fun. I'll have to resist the urge to answer all the questions for him, since I know his health history--and his family history--better than he does.

April 11, 2012

So remember that recruiter that contacted me in January?

Well, after months of phone/email tag, we have met up.

I have now signed with a nurse staffing agency. I filled out the forms, took my competency tests, and pending a successful background check and urine drug screen, I will now be an agency psych nurse.

The agency provides staffing services to a couple of local psych places, all inpatient shifts on locked units. The salary is somewhat lower than what I'm getting, but there's no minimum shift commitment other than they'd really like me to work two weekends a month, and even that is a soft limit. Very flexible about shifts. They said I should have no problems picking up 40 hours a week...then again, my current job said that and that hasn't really happened.

I will be going to a union facility with a higher psychiatric acuity then where I am now: think 5150s and lots of them. This doesn't really matter to me. I'm used to 5150s from my time on the ICU at my last facility. My recruiter just wanted to warn me that because they're union it's hard for them to get fired and that sometimes means they get away with doing a crappy job. That also means that as an agency nurse, I will probably get the crap assignments. But I'm not after anyone's job there, nor am I there to be the nursing police. And I'm used to crap assignments from my first job. I'm just there to take care of patients and that's all: they have nothing to fear from me.

The facility I am going to is legitimate. I recently met the DON and ADON at an event...this was before I signed on with the agency.

I'm not giving up my current job...but to be honest, nothing has come down the inpatient per-diem pike there that would work with my schedule. Plus, with censuses dropping as the weather gets warmer (not an unheard of phenomenon in psych), I'm getting called off more. So I figured I'd keep the outpatient per-diem as I wait for inpatient per-diem, but diversify a bit and look at another facility.

And it's a chance for me to try out agency nursing. If it doesn't work out, I'll resign or work as little as possible. The only restriction I really have on me is that I can't work directly for the facility they're sending me to, not until 365 days have passed since my last shift there. But that's not an issue as I'd rather get in inpatient at my current facility anyway.

If all goes well with my screening and UDS, I should start orienting at this facility next week.

April 9, 2012

So starts the 35 Days of Terror

That is, the concurrent taking of Health Assessment and Health Promotion during the same session.

Day 1 begins. First thing that I did was log into each class, download the syllabus, and note every single due date for each course into iCal's task list. I find that by keeping track of what's due and when, as well as being able to check them off as I complete them, I can stay on top of all my coursework. Of course, since I'm Pacific time and the class is Central time, deadlines were adjusted...so a lot of assignments are--at least for me--due one day earlier than printed in the syllabus.

Second task: download all readings, presentations and assignments. I set up two new class folders and I downloaded everything that I could. Of course, things can change weekly, but at least I have material on the hard drive.

Third task: take a deep breath and keep telling myself that I can do this, that I've done far more difficult things.

Fourth: order equipment for assessments. *sigh* The costs of this course are beyond ridiculous...on the brighter side, the equipment is a tax write-off.

The assessment teacher decided to be sneaky and not post the materials on reserve until the first day of class--today--so I was not able to get a start on the readings. Actually, both course instructors decided to be sneaky and state that the classes will not be ready until today and not to download or submit anything prior to today as things may change. Which was understandable but annoying.

It's too late to bail now so here I go!

April 8, 2012

Happy Easter. Or Happy Passover. Or Happy Both. Or if neither, Happy Sunday.

April 6, 2012

If we hadn't moved, I would be graduating in May with my RN-BSN, instead of graduating next year.

Then again, given Former RN-BSN's uncertain status regarding the CCNE accreditation, I suppose it's not a bad thing that I had to transfer.

Still, I'd like to be done with being a student, at least for a while.

Oh well.

Rx: Repeat Serenity Prayer PRN.

April 5, 2012


So, I need to purchase about $200 worth of books for this assessment class, PLUS have access to basic medical tools. Though why the tools if actually hitting a knee with a hammer and other related tasks are only worth a small fraction of the grade? And of course, I already have two assessment textbooks at home…and of course, the syllabus specifically states that for assignments I MUST use the assigned textbook. I wondered if I've registered for the right section, so I shot my advisor an email to ask before I gave Amazon my money. And yes, it is correct.

All this for a 5 week class that is supposed to be 100% online? Feh.

On the brighter side, the school bookstore actually had a cheaper price than Amazon for most of what I needed, even the new versions…how rare is that? So I ordered used anyway since I'm rather peeved I have to buy yet another set of assessment and care planning books. I saved about $50. Sweet.

Pity the program didn't accept the last RN-BSN assessment class for credit though.

I read the course syllabus…at least I WILL be reading this textbook, and often: the first week's reading assignment is so large, it reminds me of the days of Nursing Fundamentals. So knowing that I will actually use this textbook takes away some of the sting of having to buy it. I'm starting on the reading as soon as possible: the teacher kindly posted the first week's readings online, in case people have a delay in receiving their books. I'm also glad that i'm taking this during what looks like to be a famine stretch in the per-diem front, as I will have my hands full.

I've been using some of the tips I learned yesterday to deal with our histrionic patient. So far, so good. I never thought in a million years I would say this, but I am far more comfortable handling patients with borderline personality disorder. But practice makes perfect, right?

Maybe it's because at 2 years on, I'm still relatively a baby in the world of psychiatric nursing and perhaps my elders are really actually wiser, but I do think about what follows and question this at times:

I fully understand the importance of limit setting and enforcement. I do. I also understand the importance of self-assessment and how I need to handle myself in an emphatic yet neutral manner towards them. But if a patient comes in to see me about something, I am going to talk to them if I can. I may not make them tea and cookies, but I'm going to take the minute or three to listen. Or I may tell them to come back later when I am free. I'm not going to say, "it's nothing, you're fine, go back to group," at least not without hearing the patient out first to see if it is nothing. And if it's nothing, then I'll tell them they're fine and go to group.

But sometimes I feel like the some of the staff takes things to the extreme—they seem so quick to brush off a patient or set rigid limits that seem to be over the top. Or they treat a patient on the cool-to-cold side. Or they downplay the patients' concerns as just being part of their Axis II-ness and don't seem to listen or even question if there is something really behind their behavior or concerns. They're very quick to do that once they learn it's an eating disorder patient, no less.

And maybe they are. And maybe they're not and they really listening and being therapeutic and it just doesn't seem like it. I don't know.

My supervisor said that the skills in handling different populations comes with experience. True that. I have to remember that eating disorders is not the usual population I deal with. I have to learn not a whole new language (since essentially psych is psych is psych), but just a different dialect.

April 3, 2012

Just when I feel like a Competent nurse, I encounter something that brings me back to Beginner

Or at least back to Advanced Beginner.

It was in dealing with a patient with histrionic personality disorder. And while I know about it, I haven't actually encountered a patient with it. Lots of experience with the borderline, antisocial and obsessive-compulsive personality disorders, but this patient was a first for me.

And try as I might, I was on the losing end of this battle...fortunately the team rescued me.

I admit, I feel like I let everyone down since I wasn't able to deal with her. But I'm trying not to be too hard on myself--after all, as a per-diem, I don't always get to stick around long enough to really form good relationships with patients. And it's not often that one gets to see personality disorders that aren't borderline...even with all the time working inpatient, I can't recall working with a patient with histrionic personality disorder. Borderline, antisocial, OC, dependent, avoidant, paranoid, schizoid (really!)...and of course, lots of NOS, which usually ended up having more of borderline flavor than anything. Now I can add histrionic to the list.

Since we haven't really had any of these patients before and I wasn't the only staff member that was feeling off-balance with her, the staff ended up having an impromptu in-service on the care and feeding of the histrionic.

And I plan to do a little more reading up on it...a coworker recommended an excellent treatment planning book that had practical advice and interventions, instead of just the basic theory and the neatly wrapped up ivory-tower case study of my psych nursing textbook.

Oh well. It's a reminder that even though I've learned a lot, I still have a lot to learn.

April 1, 2012

Darn darn darn

Playing with the course map for my RN-BSN program...because I've missed the history class that started last week, I was trying to come up with new combinations of courses over the next year to keep me on schedule for enrolling in the capstone (final) class in January 2013.

So far the only definite answer I have come up with is to take two history classes concurrently during the summer semester: the missed one and a state history one. Anything else pushes my completion date back even further...most have me taking the last class in May, and one combination even pushed it back as far as August 2013. I figured I could make up for lost ground by taking two nursing courses concurrently in the next cycle, but no.


I'm not sure taking two history classes concurrently is a good idea as I'm worried I may confuse material between the two (it's a federal government class and a state government class). On the other hand, it's not impossible...and could be done...might not be the easiest thing though. But I have three months to think on it.

In the meanwhile, doubling up on history means that I don't have to take the two nursing classes together in the next cycle. I'm debating about still doing it anyway. Right now I only have one per-diem job and this WOULD be the best time for me to double-up on something. It would free things up in the fall. It won't let me graduate any earlier because of how history classes #3 and #4 fall on the calendar, and these two classes are sequential so I can't take them concurrently.

Perhaps if I were to take history class #1 and #3 over the summer...then I could double-up on #2 and #4 in the early fall...and if I did take the two nursing classes together this next cycle and adjust the rest of the schedule, then I could start my final class in November 2012.

But then again...why am I thinking about killing myself in the rush to get this done?

Well, a lot of it is because I've been working on this BSN since 2009 and I just want to finally wrap up this chapter of my education. And...that's really it. No other real reason than I'm starting to get tired of being a RN-BSN student. I'd like to have the degree and start working on the next chapter in my education, which will be a nice little break while I decide what I want to do for graduate school.

Busy week of work ahead, so no time at the Y this work week. I'm trying to find out if my manager will let me take a couple of classes at the hospital: PPD (apparently at my job, one needs to be facility-certified in order to give and read PPDs) and EKG administration. (I've done EKGs before, but I would like to have a class under my belt). Plus there's some rumors going around that I want to investigate...but more on those later, when I know some more.