Transition to RN

Not for the Squeamish

Bridgette Williams — Thu, 13 Aug 2009 19:26:00 GMT

My first reaction about learning of myiasis was ... wow.

A rare occurrence in healthcare settings, myiasis is the infestation of maggots in mammals. Caused by eggs laid from female houseflies, the eggs grow to become maggots. The maggots live by ingesting living and necrotic tissue in the host. None of my nursing instructors had so much as mentioned this condition.

After learning an elderly patient, who presented in my facility with poor-healing wounds, had contracted myiasis, I wanted to learn more about it. I did a literature review of the condition. As a former nature museum docent, I knew about forensic application of insect identification. But I did not know insects such as houseflies could interfere with geriatric restorative care.

Myiasis can develop in a break in skin. Houseflies feed on various sources. Rotting food is a source, but flies are especially attracted to necrotic tissue and bodily fluids commonly found with purulent drainage within wounds.

Who's At Risk?

People at risk for contracting myiasis have co-morbidities. Those who are particularly at risk have limited mobility and a decline in mental capacity. Lacking the ability to perform self-care, bedridden patients are at risk due to incontinence.

Flies that commonly cause myiasis increase in number during the warmer months, so summer is the peak time for flies to reproduce and become pests. In healthcare facilities, it is common for patients and family to eat food in their room. Awaiting removal, open food is left on trays in the room. Discarded food lingers, if only for a short time, in trash receptacles near the patient. Flies are attracted to this.

If the female fly that causes myiasis is in the room, it will find a food source suitable for laying eggs. They are not picky eaters. So, the bedridden, immunocompromised patient is at risk for developing myiasis; if draining wounds or orifices such as the nares are not kept clean, there is an increased chance the fly will lay eggs in that area.

If the female fly lay eggs on broken skin such as a wound, the life cycle of the fly begins. After a few hours, the eggs hatch into larvae called maggots. The maggots are wingless, legless, eyeless and worm-like. As the maggots grow, the larval body changes and lengthens.

Maggots are nocuous because they eat living and necrotic tissues. The feeding on tissues can lead to infection and this can lead to sepsis. Redness and swelling is common; often the patient will complain of intense local pain and/or itching. Expect foul odor at the site.

The maggots will continue to eat and grow. Several days later, the maggots leave the host to complete maturation. Outside of the host, the maggots move to a dark, dry area to prepare for the next development stage: pupa. In the pupal stage, the maggot skin hardens and becomes dry and case-like. Inside, larvae metamorphose into flies. This life cycle is predictable: the hours and days for a fly to develop is temperature-dependent and calculable. So, the time of contraction with myiasis can be determined from the last stage of development when it was found in the host.

Nurses' Role in Treatment

Nurses are in a pivotal role to treat healthcare-associated myiasis. In nursing care, the goal of myiasis treatment is to remove the maggots and be a source of comfort to the patient. It is distressful to any person learning he or she is infested with maggots.

The nurse has to know the actions to take for treatment. Actions should be written in policy for the healthcare facility. At my facility, the VA in Baltimore, MD, the following steps are taken:

First, contact the healthcare provider (NP, PA or physician).
Second, using standard precautions, carefully remove the larva and preserve it by placing it in isopropyl (70 percent) alcohol within a leak-proof specimen container. This is important, as the preservative will assist the pathology lab with proper age calculation and identification of the species. Label the container with the patient's name, date and time you collected it and type of solution. Send this to the pathology lab immediately.
Third, wipe the infected area using either sterile saline, hydrogen peroxide 3 percent or Dakin's solution (0.125 percent sodium hypochlorite). Next, soak the infected area for 20 minutes using 1 part hydrogen peroxide (3 percent) mixed with 4 parts sterile saline or sterile water. Dispose of soiled dressings and linens in proper receptacles. Determine the patient's immunization status of tetanus and diphtheroid; immunize the patient if needed. Document what was done. Locate protocol for room sanitation. One of the best practices for treating myiasis is prevention.

Prevention is multi-service; all services within the healthcare facility need to contribute efforts to prevent myiasis. Cover all wounds. Change wound dressings, particularly soiled ones, frequently. Remove of all open food containers and empty trash receptacles frequently. Discourage storage of foods at bedside. Maintain hygiene for nose, mouth and any orifice leading into the respiratory system. Rooms with open windows should have screens in the window frame. Keep facility doors closed.

Prior to becoming a RN, I volunteered as docent for an insect exhibit at a museum in the Chicago metro area. I learned flies can serve a beneficent role as a decisive factor in determining time of death in a body. Last month, I reencountered these insects at my extended-care facility. This time, I learned these same flies can complicate nursing care. Myiasis, host infested with maggots, can be pernicious in a patient who has poor health due to co-morbidities. Nurses are vital to treat and prevent myiasis.

Resources

Department of Veteran Affairs. Policy Memorandum, 512-11/COS IC-015, April 2008. VA Maryland Health Care System: The Infection Control/Hospital Epidemiology Program (111/MD). Retrieved from the World Wide Web: Aug. 5, 2009.

Couppie, P., Roussel, M., Rabarison, P., Sockeel, M.J., et al. (2005). Nosocomial nasal myiasis owing to ochilomyia hominivorax: a case in French Guiana. International Journal of Dermatology, 44, 302-303.

Sherman, R.A., Roselle, G., Bills, C., Danko, L.H., Eldridge, N. (2005). Healthcare-associated myiasis: prevention and intervention. Infectious Control and Hospital Epidemiology, 10, 828-832.

Szakacs, T.A., MacPherson, P., Sinclair, B.J., Gill, B.D., McCarthy, A.E. (2007). Nosocomial myiasis in a Canadian intensive care unit. Canadian Medical Association Journal, 177, 719-720.

How Do I Chart That?

Bridgette Williams — Wed, 01 Jul 2009 18:35:00 GMT

"How do I chart that?" Has this question come up after caring for a challenging patient or after a crisis has occurred? Documentation in a patient's record is difficult for many nurses because information has to be both condense and clear. Recently, I attended a seminar about legal consequences of poor documentation. To my surprise, poor handwriting was not always the culprit.

One of most important lessons learned about patient documentation is that you cannot write how you speak. I never really learned this in nursing school. But I have observed doctors and nurse practitioners write in a specific structure when documenting patient care.

Example: you learn a patient is presenting signs and symptoms of low blood sugar. He tells you he feels his heart racing. You check his blood sugar, then instruct a nurse assistant to ask for assistance from the charge nurse. The charge nurse notifies the doctor as you remain with the patient. The doctor gives a verbal order to give an intramuscular injection of 1 unit (1 mg) of GlucaGen. The doctor arrives to assess the patient. The patient presents signs and symptoms of recovering from the hypoglycemic episode. You re-check the blood sugar and learn that his glucose level is within expected range.

So, how do you chart that?

First, write was observed - but don't write as you speak. Don't write, for example, something like this: "I found Mr. XYZ in bed in his room looking tired and sweating a lot. When I asked him what was wrong with him, he told me his heart was 'beating fast' and started talking weird. He was breathing really fast and starting peeing on himself. I checked his fs [finger-stick] and found out he was 45. I told the charge nurse what was going on and she called the doctor. The doctor said to give him a shot of GlucaGen and he was on his way over. The doctor was there in no time. I asked him if he knew what happened and he told me his name and was asking, "What happened?" I re-checked his fs like he asked. Mr. XYZ started to come through and he was no longer confused. I told him to stay in bed while the nurse assistant cleaned him up."

OK. Now, this tells the reader what happened, but it is not professionally stated. A more expected style to document: "During patient rounds, writer observed patient reclining in bed, sweating profusely. Writer assessed. Patient lethargic, incontinent of urine x1 episode. Used inappropriate responses to commands. He stated heart was ‘beating fast.' Blood glucose was 45. Charge nurse and attending notified. Verbal order to give 1 milligram (1 unit) of GlucaGen IM. Given right deltoid as ordered. Attending at bedside within 10 minutes of notification. Writer re-assessed patient. Patient asked, "What happened?" Verbal order to re-check glucose. Blood glucose 115. Writer instructed patient to remain in bed. Nurse assistant changed clothes and linens. Will have meal trays delivered to room. Will continue to monitor."

You immediately notice that the writer speaks of him/herself in third person. Sentences are short and actions are written succinctly; often articles such as "the" "on" or "in" are left out for improved clarity.

For me, at first it felt unusual to write in this manner because it was if I wasn't writing in complete sentences. But I learned charting in a patient's record is not the same as writing a research paper. The purpose of documentation for patient charts is to state what happened and what was done in a succinct and clear style. Personal opinions and abbreviations can lead to legal dilemmas.

Here are a few important "DO NOT" rules I learned from a nurse attorney:

DO NOT mention staffing or delegation matters in a patient's chart.
DO NOT mention medication errors in a patient's chart. In the patient chart, document only what was given.
DO NOT chart, "Patient non-compliant." Chart, "Patient did not adhere to or did not take medication."
DO NOT quote profanity used. Instead chart, "Patient used profanity toward writer/staff."
DO NOT chart the patient was "hostile." Instead, chart the actions that describe hostile behaviors.
DO NOT chart patient "incompetent." This is a legal court-ordered decision. Instead chart, "patient was incapacitated."
DO NOT chart "error entry." Instead chart, "Mistaken entry in chart" or "Written in wrong chart."
DO NOT chart "drug-seeker." Instead, report the facts of what was observed and what actions were taken.
DO NOT use abbreviations. Write out as much as possible. Definitely avoid slang abbreviations (i.e., OMG).

Million Dollar Wound

Bridgette Williams — Mon, 08 Jun 2009 11:55:00 GMT

For those of us who watched the popular 1970s television shows The Million Dollar Man or The Bionic Woman, one of the most notable facets was the integration of technology and biology.

Both shows featured a main character who incurred loss of function in a limb and was given a second chance to regain full independence thanks to the advancements of technology and health. The show appealed to lay and scientific people because the main characters were restored to full independence - with the added benefit of supernatural abilities.

This concept was once seen as pure fantasy, but in the modern times of research, biomechanical limbs are not far-fetched. In fact, they are increasing in common use. Research is the driving force to push advances in healthcare. For more than 60 years, the Department of Veterans Affairs has conducted research for veterans in its own division, the Office of Research and Development.

In April 2009, I had the opportunity to attend the first annual Veteran Affairs Research and Development Forum in Washington, DC. Facilitated by the Office of Research and Development, a subdivision of the Veterans Health Administration, researchers from VA medical centers throughout the U.S. were invited to present research conducted at their facilities. The forum featured notable people such as the Secretary of Veterans Affairs and the Under Secretary for Health. They spoke about the importance of investing resources to conduct research.

Collaborative projects from other agencies such as the National Institute of Health and the Department of Defense discussed the impact of collaborative research in military veterans' healthcare. Recognizing achievements in research, the forum focused on how research improved veterans' health. Key areas addressed included prosthetics, stroke rehabilitation, mental health.

Returning to civilian life and readjusting to daily activities without full function of all limbs creates new problems. In the past, prosthetic limbs have been cumbersome and heavy, and limited independent functioning. Often, newly amputated veterans abandoned their prosthetic devices due to the difficulties in manipulating and wearing them. Researchers at the VA had recognized this and conducted research to improve the efficiency of prosthetic devices.

The DEKA arm, for example, is a bionic arm that resulted from the collaborative efforts of researchers in the Department of Defense, the VA and private company owner/inventor Dean Kamen. What makes this device revolutionary is the greater range of motion and control that past prosthetic arms have not achieved. Previous electronically controlled prosthetic hands were limited to opening and closing. Delicate tasks, such as picking up a grape, were impossible.

The DEKA arm is a prosthetic arm with a hand that attaches securely to the amputated limb. Using small control buttons, the user is able to manipulate the arm and hand to perform a range of tasks. Sensing how much pressure is needed to pick up an object, the arm and hand allows the user to pick up heavy objects, such as a power drill, and delicate objects, such as a grape.

This 9-pound device is driving advancement in technology to improve healthcare. But certain medical conditions can result in loss of function in an arm.

Stroke, a leading cause in disability, is debilitating because of the lasting effects of the loss of usage in an arm and leg. More than 15,000 veterans who have a stroke are hospitalized annually. Veterans who have had a stroke face a long road, with rehabilitation as the focus.

The Baltimore VA is one of a handful of VA medical centers using robotics to rehabilitate stroke patients. Veterans who participate in this research are introduced to exercise equipment driven by robotic technology. Tasks are presented on a computer screen and the veterans, using their weakened limbs, completes the tasks on a robotic assistive device. Similar to a video game, tasks might include touching a moving ball. This repetition assists in recovery of function and strength in the affected limb. Recovering from a stroke takes physical and mental strength.

Always overlooked as a wound, nonphysical injuries sustained from combat are overwhelming to the veteran and the family. A two-star general who spoke of his experiences battling post-traumatic stress disorder gave "multiple combat tours with insufficient time to recover" as a leading component to mental distress in military personnel. The stigma of reporting a need for mental healthcare is apparent in the military due to the "...tremendous pressure to suck it up."

VA researchers have observed an increase in the number of veterans reporting post-traumatic stress and attempted suicides. The VA is conducting studies on effectiveness of using psychotherapeutic techniques such as cognitive processing therapy and prolonged exposure therapy. Both are types of cognitive behavior therapies, and require the veteran to address their thought processes when recounting the traumatic events.

I heard the phrase "million dollar wound" during the research forum. It can be applied to any healthcare need described here. Any wound incurred from serving in a combat zone cannot be repaired with a simple cloth bandage. Combat wounds are million dollar wounds because it takes VA research and other VA resources to help a veteran return to an optimal and independent functioning level.

For additional information:

VA Office for Research and Development: http://www.research.va.gov/

DEKA arm: http://www.cbsnews.com/stories/2009/04/10/60minutes/main4935509.shtml

Robotic-assistive rehabilitation: http://www.seattlepi.com/local/349981_robot05.html

PTSD research: http://www.research.va.gov/news/features/ptsd.cfm

Part of a Magnet Journey

Bridgette Williams — Tue, 28 Apr 2009 15:11:00 GMT

I was going to hold off on writing this particular blog, but it's tough to contain good news!

About 2 months ago, my nurse manager and his boss nominated me to be the Magnet Champion for my facility. I felt so honored. I couldn't believe it - that me, a "newbie" would even be considered for something this prestigious.

After the initial elation, I realized my facility and I had a lot work to do. Magnet recognition means excellence in providing care at all times. That's a tall order for any healthcare facility. The good news is that the Department of Veterans Affairs in Maryland - my VA hospital - has taken on this challenge.

I learned a great deal about Magnet recognition since I started attending the planning meetings. Interestingly, Magnet recognition is not limited to private hospitals, state hospitals or even my facility, which is a federal agency. The Department of Veterans Affairs has a total of 153 facilities, out of which three now have the Magnet designation: Tampa (the first), Portland and Houston.

What Does Magnet Mean?

So what is Magnet? Magnet facilities are formally recognized as healthcare organizations that provide excellent care. Magnet recognition began as a research study in the 1980s. As the name implies, Magnet recognition equates to recruitment and retention of nurses in hospitals. In other words, select hospitals consistently have high recruitment and retention of nurses in spite of critical nursing shortages.

From this research, 14 characteristics - the Forces of Magnetism - were developed. These forces include:

Quality of nursing leadership
Professional models of care
Quality of care
Quality improvement
Autonomy
Nurses as teachers
Image of nursing
Interdisciplinary relationships

Hospitals that earn Magnet status must exceed standards that define nursing practice. In 1990, the Magnet recognition was officially developed. Once a facility has achieved Magnet status, this designation is valid for 4 years.

How do facilities earn Magnet status? For starters, it's a journey. A strategic plan of at least 2 years is needed for a facility to submit papers for consideration to become Magnet. Like a journey, Magnet recognition can be broken down into phases on a timeline. The first phase is building and infrastructure, second is data collection with sources of evidence, third is submitting documents to American Nurses Credentialing Center (ANCC), and fourth is a site visit from ANCC (not The Joint Commission). The last phase is to submit updated demographics every year. Unlike visits from The Joint Commission, during Magnet site visits, all staff are actually encouraged to talk about the experience of working at that facility.

Why do hospitals want to be known as Magnet facilities? For starters, it's a booster for nurse recruitment. Achieving Magnet status means assurance of quality to patients. It is a framework to assess nursing practice. It encourages change in nursing practice. It attracts retains seasoned nurses and attracts new graduates.

Magnet recognition fosters a culture. Hospitals that are designated as Magnet have a distinctive culture. Nurses who work in Magnet facilities often feel empowered. Shared governance and data-driven decision making is emphasized. Innovation and creativity is encouraged in nursing practice.

The VA Maryland Healthcare System is comprised of four major components: a healthcare facility in Baltimore, another in Perry Point, Community Living Centers (similar to extended care facility) and outpatient facilities. For the VA Maryland Healthcare System to achieve Magnet recognition, all sites have to be on the same pathway to become Magnet.

My Role: Ongoing

A former nurse mentor once told me, "Charge nurse is a state of mind." At first I believed she had me mistaken for some other nurse. Me? A new grad? A charge nurse? That's insane. But repeating her quote in my mind led me to believe that not only is charge nurse a state of mind, so, too, is thinking like a Magnet nurse.

Like a charge nurse, a Magnet nurse is confident, knowledgeable about his or her practice and is willing to challenge the status quo. Like a charge nurse, a Magnet nurse is inquisitive and innovative. The charge nurse takes charge when on duty; staff report to this person. The magnet nurse exerts a charge and other nurses are drawn to him or her.

So, now the challenge is set. My role is to educate colleagues and other staff about Magnet recognition. The RNs, LPNs and nurse assistants who have assisted in my personal journey to be a VA nurse have been instrumental to my progress in orientation.

How do I get these colleagues to feel like Magnet nurses? My first step in doing this will be to sell the idea of Magnet recognition.

End of Life

Bridgette Williams — Tue, 07 Apr 2009 17:01:00 GMT

"He's dying."

I heard this hushed statement from a nurse assistant as she hurried out of room C-17. She had spent the last 20 minutes cleaning the patient and preparing him for bed.

"How can you tell?" I asked her.

"Because he's talking to his mother," she told me.

To me, that made no sense. This patient was 90 years old; how could he have a conversation with his mother?

I caught up to the nurse assistant before she disappeared into another room. "What do you mean by you can tell he's dying just because he's talking to his mother?" I asked.

"I see it all the time," she said. "They start to talk to family that are long gone. They see them and start talking with them when it's close to their time."

As a nurse, death and the process of dying is familiar to me. Before I became a registered nurse, I specialized in forensic facial reconstruction. In special cases in which scientific evidence could not help identify a person, I reconstructed that person's face onto a natural or a replica skull. I also volunteered time to assist with special museum exhibits involving insect identification in decomposing bodies.

But since working as an RN in a long-term care facility, death and dying are resonating much more with me.

Right now, my position as a new grad RN gives me the opportunity to care for military veterans. Nursing school emphasized how to maintain health in the living patient. But in the dying patient, some lessons on theory were not detailed.

Subtle Changes

In the 4 months since I began employment, four patients on my unit have died. All were elderly. All exhibited signs of impending death. Until I cared for a patient exhibiting these signs, I was not cognizant of the subtle changes that often mark the beginning of the dying process.

Working alongside my preceptor, I learned the signs of end-of-life. One occasion, I assisted my preceptor in the care of a man who was dying. I didn't know it at the time, but he had many common symptoms of impending death.

When I entered his room to do morning rounds, I saw he was very frail. I was clearly able to see all his bones on his body, with the rib cage and articulation of his joints as most prominent. I was even able to see the pulsing of his abdominal aorta. He was breathing with his mouth open using short, shallow rapid breaths; a moist cough followed each breath. I saw cracks on the edges of his mouth and deep furrows in his tongue. His face was gaunt and both his eyes and cheeks were sunken.

I found myself talking loudly to him; I was trying to wake him up. I offered him a cup of water. He focused his eyes on me briefly then his eyes returned to stare at the ceiling. He didn't blink or respond verbally. I touched his hands and wrist as I started to take vitals signs. His hands were cold.

When my preceptor came to check on me, she removed the blankets and turned the patient. His skin was blotchy with dark red demarcations over his hips. It wasn't present at the time, but my preceptor told me not to be alarmed to see seepage of stool. When the Dinamap beeped, I told my preceptor that his systolic blood pressure was over 180, his pulse was rapid and he had a temperature over 100 degrees F.

I asked if I should call the doctor. She obviously knew I was unaware of what I was witnessing, because she whispered, "He's dying, Bridgette."

I was speechless. This is what death looks like? My preceptor then walked with me outside the room to describe the physical changes and the rationales. By the time the shift was over, I realized I cared for a man in his final hours of life and didn't even know it.

End-of-Life Signs

Signs of end-of-life are multiple and occur simultaneously. A common sign is profound loss of appetite. Signs of dehydration include dry, chapped lips and deep fissures in the tongue. The loss of desire to eat or drink can result in anorexia. When a patient is diagnosed with anorexia, he or she reports feeling full with very little eating.

If anorexia is prolonged, the result is often the wasting syndrome cachexia, a loss of fat tissue, muscle mass and weight. This results in severe weakness. The patient is fatigued because the body is far below ideal weight. Cachexia is usually associated with late-stage cancer.

Another sign is changes in skin color. Particularly over bony areas, the skin appears reddened on pressure points. This is caused by immobility, shearing forces and breakdown in skin integrity. Bony prominences such as elbows, hips and knees are vulnerable to discoloration. Loss of skin integrity can result in wounds.

Two other signs, restlessness and vacillating levels of consciousness, presents as if the patient cannot stop moving or constantly tries to get out of the bed. Speech may be nonsensical, and the patient can have unusual or inappropriate responses to commands. Disoriented to person, place and time, hallucinations and purposeless gestures such as reaching out to grasp at the air are common.

Other signs are changes in respiration patterns and pulse. Labored breathing can manifest as short, rapid breaths with periods of apnea. Sometimes the shallow breaths hve a moist quality; this is often referred to as "death rattle." I learned to avoid this term because it causes stress for family members.

Rapid pulse can be indicative of pain and/or anxiety. Opioid medications such as morphine often are given to alleviate this symptom. Commonly used to alleviate pain and anxiety in the end of life, the effects of morphine are twofold: it desensitizes the pain receptors in nerves and promotes relaxation. Be aware morphine also can cause changes in bowel elimination.

Changes in patterns of elimination, such as constipation are common in end of life. Side effects from medications such as morphine can cause this. Also, weakness, immobility, and poor nutrition can lead to increase frequency of constipation. If constipation persists, impaction can result. Oozing of liquid stool is a typical sign of impaction.

How Nurses Can Help

I've learned that as a new graduate nurse, I'm at an advantage to assist in comforting someone who approaches end of life. As nurses, there are many simple things we can do to manage the signs of impending death in the patient.

Offer favorite foods in small, frequent servings. Avoid strong, odorous foods.
Decrease environmental stimuli, turn down the lights and increase ventilation.
To ease breathing, raise the head of the bed at least 45 degrees; place pillows under the head and under the back. Avoid deep-suctioning the lungs; this can cause pain.
Provide frequent oral care.
Place disposable pads underneath the patient.
Turn the patient every 2 hours or as much as the patient can tolerate.
Cover the patient with blankets to provide warmth.
Listen and speak softly to the patient. Ask for a chaplain to assist with religious support.

Paid for It With a Leg

Bridgette Williams — Tue, 10 Mar 2009 16:15:00 GMT

In nursing school, diabetes education didn't make an impression on me. My mind-set did a 180 after caring for veterans with lost limbs. The sequelae of this common endemic is etched in my mid as a life-altering, destructive disease. As a new graduate nurse, it is not unusual for me to see elderly military veterans missing a limb. What is a surprise is learning how that person became an amputee.

Working in a geriatric/long-term care setting, it has become common to care for patients who are missing a leg ... or two. Usually, diabetes is to blame. I used to believe inadequate health education about the sequelae of diabetes was the primary reason for the advanced disease progression. I had the idea that military veterans who sought healthcare for diabetes were not receiving enough information to effectively manage the disease.

It has only been a few months since I began my employment at a VA hospital, and already I learned other reasons why military veterans - mostly men - have lost parts or all lower limbs due to diabetes.

Military Culture

On more than one occasion, I cared for a veteran who told me about their life before the limb loss. Veterans from World War II, Korea and Vietnam performed in a culture that rewarded men who could meet the physical demands of the job. The foundation of military culture is the stoic self; physical virility is the spotlight and independence is embraced for survival.

When their service was over, veterans were hired in civilian jobs that were often physically demanding. Physical strength was the oil to drive the engine of employment for the male as a provider. The stress to maintain the expected role sometimes led to poor health choices. Often, these choices manifested themselves as obesity, which laid the groundwork for diabetes. So, early signs of diabetes - polyurea and polydipsia - were overlooked. A foot sore might have been ignored until it progressed to a deep wound that was beyond home care management and instead became a focus of deterioration of quality of life.

Some veterans are admitted to my facility, the VA hospital in Baltimore, with stage III or stage IV foot sores - sores are so deep that muscle and bone are exposed. After the patient is stabilized, he is transferred to my facility. Patients at my facility are referred to as residents because the focus of care is skilled nursing in a home-like environment.

New Nurse Training

As a new graduate nurse, I have been trained by the facility's wound nurse to change dressings (i.e., bandages) of wounds, particularly stage III and stage IV. At first, it was challenging for me to view deep wounds; it wasn't easy to see a resident's face as I unraveled dressings to reveal deep structures such as the Achilles' tendon and plantar fascia. Not to mention odor.

Complete composure has to be maintained; I cannot wince or grimace at the sight or smell of the wound. I know the resident experiencing it would rather not be in that position, to say the least. This is particularly true of the military veteran; he feels defenseless and undignified because he abdicated his ability to maintain the military stoic self.

Unstable blood sugar affects the ability of the body to heal; the progression of time for wounds to heal is decreased. Taking the resident's age into account, deep-staged wounds sometimes do not heal. Necrotic tissue develops around the wound. When caring for one recent resident, I did the best I could to help him maintain his whole leg. But his condition deteriorated, so the next step - amputation - was considered as a viable option.

My resident was transferred back to the VA hospital in Baltimore for re-evaluation for partial limb amputation. After consent, he agreed to amputation. He stayed at the hospital in postsurgical recovery. Within a week, he returned to my facility.

Now, the plan of care has changed; my resident needed to heal from the amputation and eventually relearn to ambulate. He now needed to learn how to maneuver himself in a wheelchair. His physical brawn tested in a whole new way, he is challenged to maintain the military stoic self. Dependence on others is needed for survival.

Orientation: Learning the Culture of an Organization

Bridgette Williams — Wed, 14 Jan 2009 17:50:00 GMT

As the word implies, orientation is the process of becoming familiar with the structure of a business entity, such as medical facility. Usually a standard format, orientation introduces an organization to new employees. Orientation tells of the history, goals and mission of a facility. It's also an opportunity for you to observe the culture of the organization.

Organizational culture mirrors the mission of the facility. In terms of the workplace, culture is the common qualities of employees that assist an organization to work as a cohesive unit.

To thrive, employees must be acclimated in that culture. A federal government agency such as the Department of Veterans Affairs (VA) - my employer - has its own organizational culture.

The mission of the VA is based on a quote from President Lincoln: "To care for him who shall have borne the battle, and for his widow, and his orphan." To address this mission, the VA is divided into three sections: Veterans Health Administration (VHA), Veterans Benefits Administration (VBA) and National Cemetery Administration (NCA). As America's largest employer of nurses, the VHA supports the VA mission by providing healthcare to military veterans and families.

I have observed two factors that distinguish the VA from other medical facilities: patient population and technology.

The patient population plays an integral role in learning the culture of the VA. A commonly held belief among is: military veterans sacrificed their own health to preserve the freedom of the United States. In return, they deserve the best healthcare.

Due to exposure to environments from abroad, military veterans are a dynamic health population. Often, veterans have healthcare needs unlike those of other Americans. As veterans return to America from the wars in Iraq and Afghanistan, many have debilitating long-term healthcare needs such as post traumatic stress disorder (PTSD), traumatic brain injury (TBI) or deconditioning. Often, common illnesses such as diabetes mellitus are combined with PTSD and/or TBI.

Technological Factor

The VA has embraced technology. More than half of patient-care tasks in the health administration section are computerized. Bar code medication administration (BCMA) is software that assists in giving medications to patients. Computerized patient record system (CPRS) allows me to chart patient care activities. Medication administration and patient charting are completely computerized.

The VA orientation was divided into three areas: organizational, nursing and unit. It covered the expected topics - benefits, payroll and security - and was straightforward. The lingo, on the other hand, was a completely different animal. The VA uses many acronyms; employees often use acronyms in their conversations. I remember someone asked me if GLTC is a part of VHA. After looking at the person as if she had grown a third eye on her face, I asked her what GLTC meant. When she told me that GLTC is an acronym for geriatrics and long-term care, I understood her question! Learning this lingo, specifically how to talk in acronyms, is significant to assimilating to the VA culture.

The third part, my unit orientation, was a blend of introductions and observations. Unit orientation is a great time to learn the pace of unit activities, the personalities of staff and the duties you're expected to perform as a RN.

Orientation Observations

As a full-time new graduate RN, my 12-week unit orientation is in full swing. I am finishing week 2 of unit orientation. Each day I shadow my preceptor, I learn something new. Most days follow a planned schedule, while other days, the events of the day dictated the schedule. Shadowing my preceptor, I observed the clinical application of the RN as a unit leader. Duties such as assigning patients to staff, delegating clinical tasks and admitting new patients are only a few of the day-to-day RN functions.

Equally valuable, I am learning how to problem-solve concerns with patient's and patient's family. Additionally, I am learning how to communicate effectively and diplomatically with all staff such as CNAs, LPNs, advanced practice nurses, allied health professionals and medical staff.

I look forward to the next weeks of unit orientation. Each day I am scheduled to work is another clinical opportunity to transitioning to an RN.

Tell Me About Yourself: Preparing for an Interview

Bridgette Williams — Tue, 16 Dec 2008 14:43:00 GMT

"So, tell me about yourself." When thinking about your last interview - whenever it may have been - this probably sounds familiar. For employers, it's an easy catch-all request. For interviewees, such an open-ended statement can lead to a (too) long answer.

I remember I got this request during an interview. My first thought was a panicky, "What am I am I supposed to say to that?" How could I frame my response to give the best impression of me?

I have experienced a few job interviews in my former careers and as a new graduate nurse. I've learned the do's and don'ts from personal mistakes. Regardless of the position I interviewed for, the principle of being successful is the same. The key to a successful interview is preparation for a first - and lasting - impression. Below are a few points to follow before an interview.

This is simple, but one of the most important things to do when preparing for an interview is to set the date and time. If the date or time is not convenient to the interviewer or you, the job interview will not go well. Worse yet, it may not happen. In the excitement of getting the interview-invitation phone call, it's easy to reflexively say yes to everything asked.

When I get a phone call from a nurse recruiter asking me to make an appointment for an interview, I immediately check my planner for available dates for a date uncluttered with engagements. I choose a day that does not include any exams or medical appointments.

Agreeing on a time is the next hurdle. The phrase "timing is everything" really holds true when setting a job interview. Opt for a slot between 9:30 and 11:30 a.m., or between 2 and 4 p.m. to avoid rush hour traffic.

Do Your Homework

Another important point is research. Always invest time into researching the company. It has been my experience that understanding the mission and purpose of a medical facility helped to understand how my skills and talents could contribute to goals of the employer.

Using the Internet, it's easy to check the facility's Web page to learn about its status (e.g., public or private; union or non-union). Research the level of care of the facility. Check the facility's areas of expertise and specific services it provides to patients. Also check the number of patients admitted, the number of nurses employed and staffing ratios on the unit.

Continue with research into the job position. Look for a job description and expected requirements to perform job duties of the position. Investing time to research the facility has helped me to prepare responses to questions mostly likely asked on an interview.

Responses to Questions: Practice

That leads me to something that always requires practice: responses to questions asked during an interview. A common one is, "Why are you interested in working at our facility?" I select aspects of my personal goals and incorporate them into what I have learned about the goals of the company.

"Can you tell me about yourself?" is another well known interview question, one that used to be a trap for me. I used to go on and on about my entire life, and I often missed the point of the question. The point of this question is to allow you to give a bullet list of significant events in your life that impact the job for which you're interviewing. In other words, in 2 minutes you should touch on personal experiences, such as where you were raised, plus your educational, employment and career accomplishments.

Another question that used to leave me speechless was the request to list my strengths and weaknesses. One thing I have learned is this question is not to be interpreted as a confessional. It is meant for the employer to understand what things you can do well and what (few) things you need to work on improving. Usually, I list 3-5 strengths and 3-5 weaknesses.

It has been my experience that nurse recruiters or nurse managers often ask about a difficult patient care experience. The best approach to this is to structure the answer into a problem, action and result. In other words, what was the specific problem of the patient, what did you do to manage the patient and what was the result?

In addition to preparing responses to possible questions in an interview, I prepare a list of questions to ask about the position. Nurse recruiters and nurse managers appreciate potential hires that ask questions in the interview. It scores brownie points. I usually ask what the typical nurse-to-patient ratio is for each of the three major shifts. I also ask about additional training opportunities and the process for employee evaluation.

Dress the Part

A final point is something that can't be overemphasized: attire. Trendy fashion is not the barometer to use to prepare for the job interview outfit. A blazer, shirt and slacks or a skirt are always a safe bet. I usually choose black, navy blue or dark grey for the blazer, slacks or skirt. For the shirt, white or ivory is best. And for jewelry, be conservative. Pearls work well. Usually, I tie my hair back; I wear light make-up and my nails are trimmed and manicured.

Before I earned my nursing degree, I had the opportunity to participate in the audience of a popular TV show. The theme for the show was how to dress for an interview. According to an editor for a well known magazine, an absolute must in dressing for an interview is to match the leg wear color, be it socks or pantyhose, to the color of the slacks or skirt.

The best advice I can give is to be your best you when preparing for a job interview. Good luck.

Creating My RN Resume

Bridgette Williams — Tue, 11 Nov 2008 19:40:00 GMT

Crafting your first resume? Be organized and specific

Have you ever arrived at a career fair with a resume you created the night before? Did your resume look overwhelmingly generic, with one or two bullets to describe your experiences in nursing school? I can relate. The first draft of my new graduate RN resume was a jumble. My bullet points were all over the place. There was no flow whatsoever.

I'd read a few resume books and attended resume-writing seminars, so I knew all my nursing experiences needed to be translated onto a 8.5 x 11 paper. Exactly how to translate the experiences was the tricky part. To tackle the problem, I divided my resume into parts: a skeleton, a head and a body.

Types of Resumes

The first part, the skeleton, is the basis for the type of resume. There are four types of resumes: chronological, functional, targeted or combination.

Chronological: Sections of the resume were created in a sequence of ascending or descending order of experiences.
Functional: Work experiences (paid, unpaid, academia) were mentioned and emphasized to meet criteria for a career field.
Targeted: Experiences (paid, unpaid or training) were focused on a specific job.
Combination: Mixture of chronological and functional.

Second is the objective. To me, an objective is as necessary as a head on a body. It provides focus and a sense of direction for a resume. Be specific. For example:

Entry-level RN position on a pediatric unit in a health care setting that offers opportunity to master clinical skills
Opportunity to apply recent nursing theory to clinical practice on a pediatric unit

Either objective is appropriate because both give the recruiter what to expect in the body of the resume.

The Body

The body makes up the majority of the resume. To assist in readability, it should have headers and sections. Each header should be one or two words to introduce specific section. For example, "Education" as a header will have bullet points to list academic training.

In my new graduate nurse resume, I used a header to show licensure. Using the header "Licensure" allowed me to list the state I became licensed as a registered nurse. I listed CPR in the "Certification" section and placed this directly underneath licensure.

Within the body of my resume, I created a section to list places I worked as a student nurse, and a separate section for clinical rotations. I'm glad I did. Nurse recruiters commented that listing specific tasks I had performed during clinicals - such as administering immunizations or performing gastric residuals - gave them specific information about my current skills. About 70 percent of the body of my resume was devoted to externships and clinical rotation experiences.

Include Computer Skills

My computer skills are strong. But, initially I did not mention them because I thought they were not important in nursing. After taking a nursing informatics course, I learned that it is vital to mention computer software skills, specifically documentation software. During several of my interviews, nurse recruiters commented on my computer skills and explained how their organization is interested to hire new graduate nurses with exposure to specific software programs in electronic documentation.

I listed information about accomplishments were in three sections: awards, presentations and volunteer activities.

Last but never least, a critical area on the resume is contact information. State how you can be contacted for an interview (e.g., postal address, e-mail address, phone number) to give yourself the opportunity to be asked for an interview. If the contact information is incomplete, the resume either sits on a desk or gets tossed into a trash can.

A Resume's Life Span? Short

A resume has a short life span. I learned that my resume will be viewed for no more than 5 seconds and by at least three people before I get the call for an interview. First, the human resource personnel or the nurse recruiters will review it. Second, the nurse manager reads it, followed by the nurse supervisor or charge nurse.

I learned the best resume is one that I create without a pre-format. As a new grad, all pertinent information describing my training and accomplishments needs to fit on 1 page.

Usually, I take a few hours to create the first draft resume. The next day, I look at it and check for composition, readability, misspellings and typos. I arrange sections so eduction, licensure, certification and nursing experiences are at the top on the first page. I ask a colleague or instructor to review the third draft. When I feel confident my resume is finalized, I keep both an electronic and hard-copy version, although many applications for new grad nurse positions are online.

Creating a resume, frankly, can be challenging and time-consuming. But it is time well-spent. A good resume is the first step to obtaining an interview.

Sometimes the Answer Isn't Letter "C"

Bridgette Williams — Thu, 16 Oct 2008 19:36:00 GMT

Well, now's probably a good time to tell you that as a new graduate from nursing school, you will have to take the NCLEX to practice as a registered nurse. Wait, you knew that?

What may come as a surprise is this: the NCLEX is a pass or fail test; the exam does not give a percentage score. Also, unlike exams you took in nursing school the, NCLEX is designed to test minimum competency to safely practice nursing.

Let's review the basics. NCLEX is an acronym for the National Council Licensure Examination and is administered by the National Council of State Boards of Nursing (NCSBN). The NCSBN is not a government agency, and the NCLEX is not a free test. In fact, you will be expected to spend about $200 to take the exam.

NCLEX is a "passable" exam on the first try. Most of the test questions are based on scenarios that you may encounter as a new nurse. The computerized adaptive test (CAT) format is used, meaning the computer selects the next question based on your performance on the last question. So, if you answered the previous question correctly, the next question will be more difficult. If you answered the previous question incorrectly, the next question will be less difficult.

Expect a range of test question items; the range is 75 to 265 test questions. When the computer has determined with 95 percent certainty the answered questions are above or below the passing standard, the test ends. In other words, if the computer can tell with certainty you had passed or failed, the next test question will not come up on the monitor. Instead, you'll see a blank screen.

The passing standard is at the application or analysis level. This means questions at this level use knowledge you have gained from your academic training and apply it to a specific clinical-based situation.

Preparing

So, how did I prepare? I used multiple sources to prepare.

First, I started by researching information from the NCSBN Web site and asking questions of my clinical instructors.
Next, I went to my local bookstore and library to browse NCLEX test prep books.
I looked into test preparation courses from reputable companies.
I paid close attention to the type of assistance the company offered for the cost. Some companies offer an online test bank with a book, while some companies offer face-to-face classroom time with a test instructor along with access to questions from their Web site and a book.
I checked with academic advisors in my school to find out if any discounts are available for test preparation courses with specific companies.
Last, I asked colleagues that took the test how he or she prepared for the exam.

About 6 months before I graduated, I started to answer NCLEX questions from test preparation books. I continued to look for information about the exam on the NCSBN Web site as I balanced my studies in school. I took an NCLEX practice exam, learned where my weak spots were, and focused them. I scheduled to take the exam 8 weeks after I graduated. I knew the longer I waited to take the NCLEX, the lower the chances to pass the test on the first try.

Shortly after I graduated, I gave myself a week off. No studying. No books. No practicing test questions. I spent time with family and friends. Earning my BSN degree was no small accomplishment, and I needed to reward myself.

After my mini-vacation, I started studying again by enrolling in a test prep course sponsored by my school. The test preparation course was a week-long, face-to-face class that was helpful at getting me back into the studying groove.

Practice, Practice, Practice

When I wasn't at class, I was at home practicing test questions. I learned quickly that the test could be as short as 1 hour or as long as 6 hours. So I set weekly goals to increase the amount of practice questions I could process in one sitting. About 2 days before the real test, I was able to do about 260 questions with little fatigue.

Another strategy I used was eliminating distractions. Before I sat down to practice questions, I ate a meal, turned down the volume on my answering machine and turned off my cell phone. If anyone knocked at the door, I didn't answer. During my established break times, I drank water and juice and used the bathroom (it took some serious willpower to not eat and study at the same time). I'm a late-in-the-day studier, so I worked on the tests between 4 p.m. and 12 a.m.

As I practiced test questions, I mixed easy with tough questions. An easy question would ask something like, "Where would the nurse assess pain for the classic sign of appendicitis?" I deliberately mixed simple with challenging questions because wanted to answer those easy questions correctly to keep me motivated as I pressed onward with more difficult questions. Also, I read the rationale for each question I answered. If I answered any question incorrectly, I practiced questions similar to it the next day.

Fighting Fatigue

As I continued my marathon of practice questions, my hand, wrist and eyes started to bother me. I felt fatigued, even though I took 15-minute breaks.

I began practicing test questions using traditional pencil and paper on alternating days. To give my eyes a break from the computer, I practiced drug calculations, and reviewed note cards on normal fluid and electrolyte levels and milestones in stages of development. Also, I invested in audio test prep books. When I felt worn out from answering questions or reading, I listened to audio notes on specific study concepts, such as nursing care for the elderly client with visual impairments.

Throughout my study preparation, I made sure to think positively and nurture my spiritual side. For me personally, reading particular Bible passages was helpful. I reminded myself more than 86 percent of new baccalaureate-prepared nurses passed the test on the first time. I told myself I would be one of those who pass the test on the first try.

Two days before the test, I stopped studying. I felt that if I didn't know the information by now, I was never going to know it. During those 2 days, I watched a whole bunch of movies and spent time with friends.

Test Day!

Test day arrived. Since I opted to take the test in the afternoon, I had a small cup of coffee and a light breakfast in the morning. In addition to bringing my ID cards and test authorization papers, I packed a bag of trail mix, a piece of fruit, a bottle of water and juice. The test center site was in downtown Chicago, so I used public transportation to get there, allowing an extra half-hour of travel time. No matter what, I didn't want to miss my opportunity to take this test.

As soon as the test administrator checked me in and gave me pen and paper, I sat down, closed my eyes and told myself that, yes, I can make it through this test. When I opened my eyes and looked at the first test question, I got nervous. I wasn't familiar with the subject matter and didn't know the answer.

But I calmed myself down and used process of elimination. It was one of the best strategies I learned as I practiced taking test questions, and I used it all the way through the NCLEX exam. I avoided the knee-jerk reaction to pick answer C.

Suddenly, the computer went blank. I wasn't sure which question number I was on. I looked at my watch. I spent a little more than an hour taking the test. Unbelievably, it was over.

When the computer screen went back on, I was asked about my demographics and given information about obtaining quick test results. I had to agree not to share specific test questions with other people. I got up from my testing station, returned the pencil and paper to the proctor and gathered my things.

I opted to wait for my pass or fail results in the mail. About 2-3 weeks after I took the exam, I learned I had passed it.

Taking the licensure exam was a big task that required a great deal of preparation time. The entire ordeal made me think of preparing to run a 5K race. It took months to prepare for something that took minutes to complete.

For more information about NCLEX, visit the NCSBN Web site: http://www.ncsbn.org/