Life after nursing school

The countdown to the end of nursing school is underway. My last exam is June 14th and pinning is June 16th.

I can’t believe we’re here! It’s hard to believe that 3 years ago I was plotting away with absolutely no idea that I was going to embark on a new career path in healthcare.

Graduation & Pinning

I’m not a fan of traditional pomp and circumstance, but I am so excited about the pinning ceremony. Part of my excitement is because nursing school has been HARD; It stretched me in every way I could imagine. This Associates Degree has been 2-3 times as difficult as my Bachelor’s degree (and I even took 21 units during one semester!).

In the past, nurses received a cap when they finished training. Now, we receive a pin. This is a tradition that goes back over 100 years. I see my pin as a symbol of the hard work it has taken to join the ranks of the millions of men and women who have gone before me. As part of the ceremony, our class recites a modernized version of the Nightingale Pledge, which represents our commitment to ethical practice and compassionate care. Then, we each receive a candle that is lit by a nursing instructor, which symbolizes the transfer of nursing knowledge.

Getting licensed

To become a Registered Nurse (RN), I have to take the national licensing exam (NCLEX-RN). The exam uses a computer algorithm to determine whether I have the minimum knowledge necessary to begin practice as a new nurse. This algorithm determines how many questions you have to answer, which can range between 75-265 questions. (I’m hoping for 75!)

To prepare, I’ll be taking a 3-day course to review everything I learned in the last 2 years.

I’m staying in Wenatchee!

It may come as a shock to those of you who know me as the city girl because I’m still about surprised myself. I’ve grown to love this valley and can see myself settling down here. The fact that I’m about to be an Aunt again makes staying here even more appealing (congrats to my little brother who is going to become a Dad this fall!). I’ll still be making regular trips to SoCal to enjoy the sunshine and visit my dear ones.

I’ve found a couple roommates and will be moving out of my sister’s basement this summer (shout out to her for housing me for the past 2.5 years!). I still hope/plan to buy an RV or tiny home and have a little house on wheels. But that dream has been bumped a little bit into the future.

Nursing

This summer, I’ll continue to work as a nurse at a local clinic where I float between family practice, pediatrics, and urgent care. I’ll also spend two weeks as a nurse at a camp for special needs adults!

In September, I’ll start a 12-week paid internship at our local hospital. Then, at the end of the internship, I’ll be assigned to work in a specific unit. I’m excited to get started but am looking forward to some down time, first.

I’ve decided not to pursue midwifery, which was the original goal when I went back to school. I’ve discovered that my fascination with pregnancy was really just an overall fascination with the human body. There are so many interesting things to learn… I expect to be learning new things about the body and nursing well into my 90’s (and given my awesome genes, I may actually make it that far!).

Who knows where I’ll land but I’m excited to take the next few steps. I have lots of non-nursing things I dream of doing once school ends, one of which includes some new blogs since I’ve neglected this site so much!

Nursing Pharmacology: Adrenergics & Cholinergics

I had a love/hate relationship with nursing pharmacology for my first year of nursing school. I loved the information but hated learning it. I didn’t figure out how to learn it effectively until we were 70% finished.

Since then I keep thinking, “there has to be a better way to learn nursing pharmacology.” I recently spent an hour with a new nursing student explaining how to remember adrenergic and cholinergic medications. So, while it was fresh in my mind, I thought I’d try recording an interactive whiteboard video with my strategy for remembering adrenergic, antiadrenergic, cholinergic and anticholinergic medications.

If the video doesn’t play, click here to view it on Edureations’ website. If you need a refresher on the anatomy and physiology of the autonomic nervous system, check out this Khan academy video.

If you watch the video, I’d love your feedback!

What’s in the video?

My go-to grid for exams

I like using this grid layout because:

  • There are similarities between Adrenergics and Anticholinergics (I think of an angry, flushed, constipated person)
  • There are similarities between Adrenergic Blockers and Cholinergics (increasing digestion and urination)

 

Adrenergic vs. Antiadrenergic vs. Cholinergic vs. Anticholinergic

How to remember side effects

Adrenergic and Cholinergic medications mimic or block the autonomic nervous system (ANS), which is made up of the sympathetic and parasympathetic nervous systems.

adrenergic cholinergic flow chart: fight, rest, sludge, dry

Adrenergic agonists

Adrenergic agonists turn on the sympathetic nervous system = “fight or flight” side effects like:

  • dilated eyes (to see better)
  • bronchial dilation (to improve oxygenation)
  • increased heart rate and blood pressure (to increase blood flow)
  • increased glucose levels (to get more energy to the cells hat need it)
  • decreased urination and gastrointestinal (GI) motility (it’s unlikely you’ll stop to use the restroom when you’re on the run!)
  • decreased uterine contractions (do you really want to give birth when you’re in danger?!)

Basically, all the blood moves to the important parts of the body (heart, lungs) and away from digesting. Drugs include epinephrine, norepinephrine, and albuterol.

Adrenergic blockers/antagonists

Adrenergic blockers/antagonists (antagonists are the “against” the hero in literature) turn “off” the sympathetic nervous system which leads to “rest, digest, pee, poo.” This is the opposite of “fight or flight.”

  • Increased uterine contraction (it’s a good time to have a baby!)
  • decreased heart rate and glucose (you don’t need as much energy or blood when you’re relaxing)
  • bronchial constriction (which is why some of these meds may be contraindicated for patients with respiratory problems),
  • increased GI motility and urination

Cholinergic agonists

Cholinergic agonists mimic the parasympathetic nervous system by increasing Acetylcholine (ACh). This results in “SLUDGE:”

  • Salivation,
  • Lacrimation (tears/crying)
  • Urination (Peeing)
  • Diarrhea
  • GI distress
  • Emesis (vomiting)

Basically a person with excess ACh is going to have fluid coming from everywhere.

Anticholinergics

  • Anticholinergics are the opposite of Cholinergics, they make a patient DRY by turning “off” the parasympathetic nervous system. Patients “can’t see, can’t pee, can’t spit, can’t sh*t.”
  • Another rhyme that represents these side effect is “Hot as a hare, dry as a bone, red as a beet, mad as a hatter, blind as a bat”.
  • Do NOT give anticholinergics to patients with glaucoma (The way I remember this is: it can be hard to see when you’re eyes are dry).

The tools I used

  • iPad mini
  • The stylus I used is too bulky. If I do this in the future I’m going to get a fine-tipped stylus like this one.
  • Interactive Whiteboard App
    • ShowMe (1st attempt)showme
      • The end product was, well… boring and my digital writing was surprisingly sloppy (see the image!). The tool was okay.
      • I wasn’t thrilled about the idea of having to either pay OR make my content shareable on their platform in order to publish it.
      • I liked that I could select a variety of colors (Edureation limited me to 5 colors).
    • Edureations (Final product)
      • I liked the ability to edit the video as I made it and I can share my file without paying or showme-vs-educreationsmaking it part of the Edureations’ database.
      • It was also easier to move components around on the screen and there was the option to include grids and lines.

This blog contains affiliate links.

Why I chose nursing

A few years ago I was working late when a co-worker said, “Why are you still here? It’s not like we’re curing cancer.” The reason was simple: it’s in my nature to focus intensely and invest significantly regardless of what I’m doing. This conversation prompted questions like: Am I making a difference in the world? Am I doing something I’m passionate about? When I’m old, will I have regrets about how I invested my time?

The conclusion to my soul search was that I wasn’t in the right career despite my success. I decided I wanted a career that allowed me to be empathic, strengthen others, distribute information/knowledge, be an advocate, and make a long-term impact on people. This change required significant sacrifice: I resigned from a high-paying position, relocated, moved from living by myself to living with family, and am utilizing my savings to go back to school.

After eight months in nursing school, I’m thrilled to say that nursing meshes more naturally with who I am than I ever hoped or expected. Here’s how:

Nurses look at the whole person including their emotional, psychosocial, and physical needs. As a nurse, empathy allows me to quickly hear what a patient is saying, brainstorm through a bunch of potential solutions, and identify the best strategy I can use to help.

Nurses advocate for patient needs and for the needs of the community. In many healthcare settings, a patient is completely and utterly dependent on others to do simple tasks they would normally do for themselves. It’s an honor to be able to represent these needs and ensure they get what they need.

The more patients I work with, the more convinced I am about the importance of empowering others. I am constantly looking for opportunities that allow patients to exert some level of control in an otherwise out-of-control experience.

Nurses educate patients. I am passionate about the human body and fascinated by disease processes and treatments. I love educating patients about what’s happening with their bodies and what they can do about it.

Nursing offers unlimited variety. There are so many different roles, settings, and specialties. There are so many things to learn. When I tackle a challenge there will always be another challenge on the horizon (and that’s just how I like it).

Overall, I’ve determined that I want to support patients and families who are unexpectedly experiencing some of the hardest days of their lives. I want to be challenged to become the best of the best. This is the kind of work that will allow me to look back and say that I lived a life that was meaningful.

 

If I was my patient, how would I feel?

THEY say “Remember apple, table, coin.”
Apple.
Table.
Coin.

I am angry.
You would be too.
Try not being able to speak.
Attempt to communicate and cause only confusion.

Try wearing a brief.
Sit in your urine and wait.
Then in your feces.
And to make the indignity worse
Allow a stranger to invade your privacy and
wipe. your. butt.
THEY did this to me. So I couldn’t be president.

Then skip all enjoyment of food.
Instead have a tube where sustenance goes
No. more. swallowing.
Water sipped could kill.

Maybe I’d prefer to die than to sit here like this.
D.N.R.
I told THEM not to help me.

I blame THEM for this arm that doesn’t work.
Then THEY extend my fingers just to make it HURT like *%#

THEY are trying to control me.

THEY tell me these are voice.
How would you like to be told your reality isn’t real?
*%$@ you.
I. Am. Angry.
You would be too.

Then THEY ask me, “What did we memorize?”
Why are they asking? Of course I remember.
Boat.
Bird.
Child.

 

———-

This is a piece about how I imagine it feels like to have Schizophrenia, dementia and a CVA (stroke) that caused dysphasia (inability to swallow, which means my nutrition is delivered to my stomach via a PEG tube) and a contracture of the arm and hand. It’s part of my reflection on CNA clinicals.

Asking a patient to remember three unrelated words is part of testing memory. It’s common for our minds to replace information we don’t remember with other information without us even being conscious of it.

Several times when I use the words THEY and THEM I’m referring to caregivers and several references are to delusions/hallucinations caused by Schizophrenia. I thought about differentiating them, but ultimately this piece is from the patient’s perspective and they may not be able to differentiate.

To prevent infections, a patient with a contractured hand will need to have their hand opened so it can be cleaned and dried. This can be extremely painful. So, this use of THEY refers to caregivers.

———-

Nursing school starts on Monday, so this may be my last post for a while.

Humans not diagnoses; Reflecting on CNA clinicals

This summer I took a CNA class in preparation for nursing school. Here’s what I learned.

Our patients are not just diagnosis. They are people. They have a history. Their feelings and experience—both past and present—matter deeply. I can imagine that it becomes easier to see them as tasks to perform instead of people to care for. But we can’t do that and still take care of the WHOLE person. And as nurses we are there to care for their whole person.

This experience has identified some of my fears and assumptions about getting old and being alone. These feelings are raw and unresolved and every day when I walk out of clinicals they are there.

But I value my time at the clinic because when I walk in my patient’s door I’m no longer focused on MY life. I’m focused on theirs. How can I make their day better? How can I prevent this conditioning from worsening and removing even more of their independence? What can I do to encourage them to be independent? Regardless of their diagnosis, I have the opportunity to do this with each of them. I love, that as a caregiver, I have the choice to be completely present with my patient regardless of what else is going on. For those moments they can and should be the only thing I focus on. And I can only pray that if I end up in their position that my caregivers will do the same.

When I first met one of my patients and they said they didn’t want me to be their nurse I was afraid to care for them. But I enjoyed it. We laughed a lot, even when doing things that demonstrate just how dependent they are on others. And as I laugh with them, a little part of me thinks, maybe it’s possible to be completely dependent and still joyful. Maybe that wouldn’t be the worst thing in the world. Maybe I could survive, and even thrive, if I wasn’t so independent.

One day I answered this sequence of questions dozens of times: “What’s your name?” “Are you married?” “How old are you?” “30 and not married! Why?” And every time I answered I became less sensitive to the fact that I am 30 and single. It allowed me to embrace the choices I’ve made.

I feel incredibly sad to leave my first patients. When I leave their room and think back on what it must be like in their skin, sometimes it breaks my heart. But my heart isn’t broken when I’m with them. They are not just the sad diagnosis and the dependent individuals. They joke and laugh with me. They yell and express anger at me or others. They are deeply human. The last few years have been a journey to embracing my humanness, And the truth is, as a human I won’t be able to fix their physical or mental problems. But that isn’t my job. My job is to be present and to do what I can to alleviate a little bit of their suffering.

Next stop: nursing school!

Thought I’d post an update on where I’m at with “going back to school and completely changing careers”.

I start Nursing School at Wenatchee Valley College in 17 days! It’s a 2-year ADN (Associates of Nursing) degree. As preparation, I completed a CNA course over the summer. I walked into class saying “I’m not sure if I want to be a nurse, or if I want to become a doctor.” But after spending 8 weeks with a phenomenal and passionate teacher and LOVING clinicals, I feel really comfortable with my decision to go to nursing school.

I’m currently working (very) part-time as a Nursing Assistant Registered and med aid at an adult family home which means I can give patients medication (which is scary and cool). I’m enjoying the work way more than I thought I would.

$800+ worth of nursing books

This fall I’ll take my NACES exam to become a Certified Nursing Assistant (CNA).

I was incredibly fortunate to receive an Opportunity Grant from the state of Washington that covers my books (check out the stack in my pic) and part of my tuition!  Plus the awesome Wenatchee Valley College Foundation gave each nursing student about $500-$600 worth of supplies including our lab supplies, a Littmann stethoscope (check it out in my pic) and our uniforms (navy blue scrubs with white shoes). Can I also just say I’m so glad to be in navy blue instead of white?

The more I learn about nursing, the less confident I am about what I’m going to do after I graduate. There are a ton of options within the nursing field, and I’m looking forward to exploring them. Maybe I’ll even become a traveling nurse. I am so happy with my decision to change paths and so thankful for the support of those around me.

Here’s to two years of craziness followed by who knows what.

How fats we eat become energy in the body

The farther I get into organic and biochemistry the harder it is to find information that uses minimal jargon, helps me find the big picture amidst thousands of details, and that connects the biochemical concepts with what I’m learning in Anatomy & Physiology. So, I decided to post what I recently learned about how the fat we eat turns into energy in the body.

STEP 1: When you eat lipids (i.e. fats), an enzyme in your saliva, called Lingual Lipase, starts to break it down. (Lingual refers to your tongue).

STEP 2: When your food combines with saliva it’s called a bolus. When you swallow the bolus it moves through the esophagus and to the stomach. In the stomach an additional enzyme, called Gastric Lipase, breaks down fats from milk (it is specifically meant for breaking down breast milk in babies). When the bolus combines with gastric juice it’s called chyme.

(image source)

STEP 3: Your stomach slowly squirts chyme into the duodenum (the first part of your small intestines) where it meets bile from your liver. Most lipids haven’t been digested yet because they are big blobs of fat and the enzymes can’t get to them. Thankfully, bile contains bile salt which emulsifies any undigested lipids. Emulsifying basically means that the big blobs of fat get broken into little droplets.

(image source)

STEP 4: The little droplets of emulsified lipids are now ready for Pancreatic Lipase to break them down. For example, triglycerides are broken into 1 glycerol and 3 fatty acids molecules.

Triglyceride to Glycerol and 3 Fatty Acids

(The idea for this image came from this image. I used ChemAxon’s Marvin demo to create the molecule structures.)

STEP 5: Because fat and water don’t mix, fat needs help moving through the body. In the small intestines they organize themselves so that portion of the lipid molecules that hates water (“hydrophobic”) is protected by the portion of the lipid molecule that loves water (“hydrophilic”). This is called a micelle.

(image source)

STEP 6: The micelle moves through the wall of the intestines (called epithelial cells or absorptive cells) via diffusion. Diffusion means they move from a place where there are a lot of them (high concentration) to a place where there are few of them (low concentration).

How lipids move into absorptive epithelial cells

(image source)

STEP 7: In the absorptive cells 1 glycerol and 3 fatty acids are are recombined into triglycerides (reverse of step 4). The triglycerides are put into protein “packages” called chylomicrons.

STEP 8: Chylomicrons exit the absorptive cell via exocytosis and end up in the interstitial fluid (the fluid between cells)

STEP 9: From the interstitial fluid, the chylomicrons enter openings in lacteals. Lacteals are specific types of lymph vessels that transport fats.

Chylomicons in Lacteals

(image source)

STEP 10: The chylomicrons travel from lacteals to lymphatic vessels, to the Thoracic Duct and then are dumped into blood where the left Subclavian and left Internal Jugular Veins merge.

STEP 11: The chylomicrons in the blood are quickly captured by cells throughout the body using Lipoprotein Lipase.

STEP 12: If the cell needs energy it breaks the triglyceride into 1 glycerol and 3 fatty acids molecules (same as step 4.)

STEP 13: The fatty acid is activated by Coenzyme A (CoA) and forms Fatty Acyl-CoA (this is a substitution reaction).

Fatty Acid to Fatty Acyl-CoA

Beta  Oxidation CycleBeta Oxidation of Fatty Acid

STEP 14: Fatty Acyl-Coa is converted to Enoyl-CoA by the enzyme Acyl-CoA dehydrogenase.

STEP 15: The double bond in Enoly-CoA is hydrated to form an alcohol group (-OH).

STEP 16: The alcohol group (-OH) is oxidized to a carbonyl group (an Oxygen that is double bonded to a Carbon; C=O).

STEP 17: The acetyl-CoA portion of the molecule is cleaved off and enters to Citric Acid Cycle. The remaining portion cycles back through the beta oxidation cycle.

(image source. emphasis mine)

 

Citric Acid Cycle / Kreb’s Cycle / TCA Cycle

STEP 18: Acetyl-CoA enters the Citric Acid Cycle. Acetyl-CoA combines with Oxaloacetic Acid to form Citric Acid (also known as citrate).

STEP 19: Citric Acid undergoes a series of reactions that reduce FAD to FADH and FADH to NADH2. Reduce means the molecule accepts/gains H+ (a positively charged Hydrogen ion). FADH and NADH2 enter the Electron Transport Chain.

Krebs Cycle

(image source)

Electron Transport Chain.
The Electron Transport Chain takes place in the mitochondria of cells. This animated video and this Khan academy video help explain this process.

Mitochondria

STEP 20: In the matrix of the mitochondria, FADH and NADH2 are oxidized. Oxidation means they lose a hydrogen ion (H+).

STEP 21:The hydrogen ions are moved across the Crista Membrane to the intermembrane space. As this happens, the intermembrane space becomes more positively charged than the matrix. As a result, the Hydrogen ion wants to move back to the matrix and this movement can be used to generate energy.

Electron Transport Chain

(image source)

STEP 22: The hydrogen ions get back to the matrix via the enzyme ATP-synthase.  This step is best shown in this video. As they move, the enzyme causes ADP and phosphate to form ATP (Adenosine Triphosphate).

ATP is the chemical that the body uses as an “energy currency”.

Medical insurance, pre-existing conditions and Obama care

When I went back to school to finish my Bachelor’s degree several years ago, my COBRA payment was somewhere around $450 per month. Due to a pre-existing condition I didn’t qualify for any less expensive options.

After graduation I worked as a freelancer. Taxes alone required saving approximately 50% of my income, which meant I had to bill $900 per month just to pay for medical insurance. As the work became harder to find the cost of medical insurance became a motivating reason to find permanent employment.

After three months at my new job my medical insurance kicked in! It was like getting a raise.

That’s when the mess began: I started to receive rejection statements on most of my claims. Each time I called I was given a different reason for the rejection (billing errors, pre-existing conditions, etc.). Each time my providers called they were given different reasons than what I was given. Meanwhile I was paying for all my health care out-of-pocket. After eight month we finally discovered the problem: my new insurance provider needed proof of continuous coverage. After multiple requests and “paperwork being lost in the mail” the paperwork was finally delivered!

So, when I decided to go back to school to get my Master’s I knew that continual medical insurance coverage was a deal breaker.

Being a die-hard “I pay my own way in this world” kind-of-person, it didn’t occur to me to apply for state coverage. Plus, when Obama care rolled out I remember reading countless articles with opposing views and first-hand accounts that left my mind reeling. In general it sounded like a crazy mess.

But then I found out that my employer’s COBRA was $650!

Feeling a little desperate, last weekend I spent a short amount of time filling out the application online. I received an error when trying to submit the application but they provided a number to call. When I called today I was connected to an incredibly friendly and helpful live person without spending any time on hold! He gave me specific instructions on what I needed to adjust. Within 5 minutes, and with a single click, I received confirmation that I qualified for Washington Apple Care.

I still can’t believe how easy it was. Granted, I’ve yet to experience what it’s like to actually use the insurance. But, I’m curious to see what happens next.