Will this be on the test?

I find myself giving test-taking tips at every tutoring session lately.

Five tips for taking tests in nursing school: *

• Read the question.

Seriously, read it. Stop, don't look down at the answers yet. Read the question once more, looking for these words or phrases: LEAST LIKELY, MOST LIKELY, PRIORITY INTERVENTION, NOT, FIRST. Underline them when you find them. You absolutely must know what the question is asking before you attempt to answer it. If the question makes you think of that awesome little song that you made up to remember the cranial nerves, go ahead and jot them down out to the side right quick BEFORE you look at the answers.

• Think of the patient.
  

When you study, think of how this will look in an actual patient. If I was in the room with someone who had a Foley cath in, what is the very first thing that I need to think about before that patient ambulates? My list of ALL the things to consider before they start traipsing about would include: where's the bag and who's going to hold it, when's the last time this person got up and should we sit and dangle first, are there any obstacles in the intended path and who will move them, and what other lines do we need to pay attention to (like IV poles, or wound drains, or whatnot). Now prioritize them. What must happen first? What can wait? What means Something Bad and what is an Expected Outcome?
Of those, I think that passing out onto the cold dirty hard floor of orthostatic hypotension has to top the list of Things to Pay Attention To. Having one's foley pulled out with balloon still inflated would be right up there as a very close second.

• ABC, 123.

When prioritizing interventions, as above, or in questions where you are asked to assess a patient and choose the most worrisome data, start as low on Maslow's pyramid as possible.
Airway Breathing Circulation
1 heart, 2 lungs, oriented x3 (who are you, where are you, when is it)
Risk for Powerlessness is always going to appear on my list of Relevant Nursing Diagnoses for any hospitalized patient. Always. Let's face it, laying in bed with no underwear does not increase one's self-efficacy. But I cannot assess anyone's psychosocial needs or even their pain level (which is usually next on my list after the ABCs and 123s) if they are currently not breathing or bleeding out.

• Do another med check.

Patient safety has got to be right up there at the top of the priority list. You have to do three med checks, but four can't hurt, especially if you're in a skills evaluation and you simply can't remember doing that 2nd one before you left the Pyxis. "Put on gloves" is always a good idea, along with "Wash hands and document". The phrase - siderails up times two bed low and locked call bell in reach - is burned into my brain forever. This stuff will find its way onto the written exams, too, so be on the look-out.

• "Call the doctor" is almost never the answer.

It seems like a good idea, I know. Interdisciplinary blah-blah-blah? They're going to have to write the orders? I know. But resist, for just a second.
Think about this - What are you going to say when she returns your page? Stammer, stammer, the patient uh, is, uh, doesn't look right and I think you should come down here. Click.
Assess before paging anyone - unless it's a code that you think you should call, and then holler away! Think through the information that a consultant is likely to ask you if you paged them - axillary temp, blood pressures for the last ten minutes, hematocrit levels, intake and output totals for the last 12 hours? What is the thing that made you worry about this patient and what information do you need to gather about that worrisome sign or symptom? Get it all written down, and then call (abcd - assess before calling doc).

*of course, I only know about MY nursing school. I know that all nursing students do skills evals, but I don't know if you will be able to talk to yourself throughout yours the way we were encouraged to do. I think these are pretty universal, and not just based on my Fundamentals professor. of course, your mileage may vary.

more emo - who can get enough?!

Peds is still kicking my affective ass. After the shower-sobbing reaction to my shifts in the PICU and NICU, I then had a series of less intense but recurrent crying jags last week after my first 12 hour shift on the unit. I am SO good at dissociating that I can't even really tell you what triggered them - but it was akin to the med-surg crying, based loosely around the idea that during those 12 hours, I could have done something or not done something to hurt someone and would never ever know it.

Therapeutic interventions recently employed:

• massage. wow. I said to the nice LMBT, "I feel like I can't breathe a full deep breath, like there's a little ball of silly putty right *there* in my spine and if I could just bend the right way, it would crack open and I'd be able to breathe again. I've also been doing a lot of crying, and I don't want any of that sadness to get stuck in any crevices of fascia and fester". She said, "I can handle that." And she did. She did something under the edge of my rib cage that made me think of my ribs as completely detachable. And she did a controlled version of a sternal rub that warmed me up for hours. No surprise, I cried on the table. But not out of control, not like I wouldn't be able to stop crying - more like the way you might cry when someone you love tells you a very sad story and you hold their hand while they talk. It was good. I felt so guilty picking up my backpack after she'd just spent an hour integrating my upper body bilaterally.
  
• tea. I don't know why, but I seem to only think of tea when it's chilly outside. I can drink hot coffee through the summer - though with admittedly less enjoyment, I do have to shoulder through it. But it's been a journey through the Stash Herbal Tea Sampler Box lately. The colors of the little packages are almost as soothing to me as the tea itself. And I had enough honey and didn't feel like I had to skimp or be judicious.
  
• art. went walking around a historic neighborhood with an artist friend yesterday, looking at amazing pieces of art. It was a Winnie-the-Pooh sort of sky and blustery wind, I woke up in a good mood and so did the kid, it was good all over.
• a productive-feeling new notecard system for Psych and Peds exams upcoming this week. I'll sign off in about five minutes to do more of these. I'm really hopeful that they will help me turn around the Bs from the second exams back to the As from the first exams of the semester.
  
• journalling. Psych instructor, who I have a complete identity crush on (I love her hair, her shoes, her style of speaking, her humor) mentioned it the other day in class, and I have meaning to get started again. I stopped at some point around the time I left my husband, catastrophisizing about supeonas and whatnot. It was intensely helpful Saturday night when all of a sudden, I was going to turn myself inside out with feeling alone and sad and completely helpless to fix either of those things.
  
• write-ups. I know, it's counter-intuitive that school-work would help me feel less overwhelmed. But what's happened is that I'm less afraid to include this emotional response in my weekly reflections. I think that my experience in Psych a few weeks ago (jesus, it seems like a year ago) helped me get a point of comfort, that yes, I am usually able to judge what's appropriate to disclose, and what's inappropriate. And yes, when I say something, and someone looks uncomfortable, it doesn't necessarily mean that I shouldn't have said it - it may mean that they are simply uncomfortable. And no, I shouldn't avoid writing the story about how the nurse said that some parents should be sterilized to me in the break room because I'm scared of getting her in trouble. It's good information for my instructor to have that this is the kind of thing that I'm trying to integrate on a weekly basis. This is an accurate reflection of the level of emotional processing that I am personally doing. Sure, not everyone is having this reaction; who would expect them to? But I am, and that's okay, and I want the prof to know it.
  

The other thing that's been really helping me this week is reading and re-reading the Love Letter to Nursing Students at Head Nurse. I can see myself in some of the things that she is excited about, and I am vicariously proud. A Love Letter to Nurse Preceptors will be forthcoming posthaste.

Smitten Kitchen is feeding me lately with images of amazing food, and reminders that food is something that I love, not just something that means dirty dishes and rotten potatoes. (though rotten potatoes are hands down the most disgusting thing that can happen in a kitchen, I think. You reach in and it looks okay and then you pull it back and it's... not okay. not not not okay.) I've purchased pumpkin and french bread. I cooked a mini pumpkin for dessert last night for the love of pete! I'm considering stuffing some onions! Come on!

speaking of amazing images, these pictures at deputydog are broadening my horizons and making me sit up and drop my shoulders. love love love them. We already talked about the 7 amazing holes list that he has, right?! wow.

Things that are not getting written about this morning - the upcoming parent-principal meeting regarding the kid and his second grade class (still not going well), the fact that I hurt myself with my menstrual cup and feel really annoyed about it, my continual brokeness and the recent crisis proportions, the chance to do an hourlong interview with a grad student doing research on single moms who went to community college and then a four year school, and the upcoming trip for the ANS Mid-Year Convention.

later, tater.

*psst. people on the left, don't tell the people on the right, but we hate them!

my friend reminded me of that paula poundstone bit recently.

Yesterday was tough - orienation for psych clinical, which I hadn't realized I was nervous about. Additionally, my usual clunky awkwardness was exacerbated by the fact that I spent four hours sitting in a room with Ponytail Perfect Priscilla and her flawless-skinned sister Elizabeth and their five friends, Polly, Perky, Baby Spice, Paris and Azaela. I am not a person who looks smooth and polished, not even when I think that I do to be honest.
I have unkempt and overly hairy eyebrows, which I pluck erratically. I have persistent adult acne, which I keep thinking I'm spend a portion of financial aid money to fix, but then get all caught up with utility bills and other luxuries. I have thrift store clothes, which no matter how carefully I inspect at the store and at home and after the inital run through the laundry, invariably have a stain on the butt, or a hole in the armpit or some such thing.
It's cool with me, usually, really it is. I have lived in this messy body for 35 years now and I'm okay with it, usually. But it's hard to remember that I'm good enough, smart enough and doggone it, people like me, when I am stuck in a room for hours on end with no reality check with folks that are cuter than me, slimmer than me, and doggone it, firmer than me.

So I went to water aerobics last night, and hung out with my people who have rolls, big ones, and not just boring old belly rolls, either. This group has ankle rolls and triceps rolls and I love them. I worried at first that my comfort was at their expense, that I loved these women because of that subconscious habit I have of scanning the room to see if I'm the fattest woman in the room. And I've decided that one of the reasons that I feel comfortable in the locker room is that I see other women who have thighs that look like mine. A whole room of women who have that canyon-y thing around their navel (I wonder if they know that if they squish their belly in the right way, it looks like either a butt or a bagel?!)! Joy. Happiness. Belonging.


The worst part of psych today was walking on the unit. After that, I was cool. I fucked up by not saying goodbye to the patient that I was talking to when we left the unit to have lunch and do our notes. I need to brush up on my open-ended questions. I kept asking informational, factual type questions, and then we'd sort of stare at each other for a bit, and then look back at the TV, or at the man who was grinding his teeth loudly enough to be heard across the room!

The other worst part of psych is that all summer I was in the swanky private hospital (which has places that are sorta gross and undesirable) to the federally operated hospital built in the 50s and not renovated since. Four and six beds to a room, with common showers and bathrooms! This weird yellow tile brick in the walls. Hallways that are pre-fab and feel like that ramp you walk down to get on the airplane. Staff bathrooms that make me regret heartily the bottle of water I carried with me. Big oil paintings of the President. A cafeteria that smells like mustard and old eggs, not sushi and oatmeal bars for breakfast. Where's all those footpedal faucet handsinks? Snort. Still giving patients Haldol?! Sure, it's cheap because it's so old. Course, that's the reason why most folks who can afford to don't use it anymore, because there's a thousand things safer and better...

off to look up whether bruxism could be a form of extrapyramidal side effect... Jo?

ow.

still burnt. applying aloe liberally. wincing each time I reflexively swing my backpack onto my shoulder. today, i managed to pull off the cute swingy shirt with crocheted sandals, but the sandals made little blisters on the inside of my heel and by the end of the day, I was carrying my shoes in my lunch bag and both of my bookbags in the other hand.

These blisters were invisible compared to what my marathon-running friend showed me yesterday. She said that the first aid stands were pitifully stocked and six miles apart. (I'm thinking to myself that I haven't walked six miles in years, if ever!) She said, "When it burst, I screamed out loud. But after a while, it just sort of went numb." She finished the race, within her time category. I stopped whining about my bra straps cutting into my sunburn for a while after she told the story.

Developmental exam yesterday seemed super easy - and stayed relatively on the surface of the EIGHT CHAPTERS of material it covered. I love the affect of the prof for that class, but she told us that to prepare for the test, which covered material with only one corresponding lecture, we should 'focus on the text'. No. the word you're looking for there is 'read'. When one focuses, one often has a shorter list than 250 pages to attend to. shrug. I thought I blew Health Assessment out of the water last Thursday and pulled a half-hearted 89. shake shake shake and roll.

I have a Fundamentals test tomorrow that is so difficult to study for - not because I've finished Barack's book, or because I had dinner with friends last night and tonight, or because I spent all weekend at a CPR class, getting a sneaky sunburn, and 'focusing' on eight chapters of developmental psych. It's hard to study for, because it's the mamby-pambiest material stuff of the class that already seems to slip out of my fingers each time I study it. I can't remember a bit of the last test, only that what I studied for that one was not on this one. The material we're covering is Stress, Sex, Aging, and Med Administration. I just don't trust that it's as easy as it seems. here's my study guide:

• Be prepared to be directive when patients are exhibiting signs of sensory overload or ineffective coping.
  
• Patients should use alternate positioning after hip surgery (though we never elaborated on this, and I felt I had pushed the boundaries of appropriate class discussion far enough when I asked if sex was considered to be an Activity of Daily Living by most texts).
• Old people are useful, and you shouldn't use baby talk when addressing them.
• If you need to give someone 50 mg of a PO med, and the tablets are 25 mg, then give the patient two.
  

I need to make a list of the random nursing questions I have. My addition today would be - why no more than three tablets at a time? Is this as random as provide patient care from the right side of the bed?

Speaking of stupid questions, let me leave you, gentle reader, with this gem. We had an information session about next semester today regarding how to register for the section of clinicals you want, and how it's not uncommon for 100 students to register in 3 minutes, so set your flipping alarms, and pay that parking ticket by Friday. After most everyone had left, Another Student asks if I know what exactly we'll be doing in clinicals. I have the same question, so AS and I trot up the Dr. Undergrad Dean. After a brief lead-in by AS, I say, "I mean, will I ever be alone in the room with the patient this summer?" Dr. UD looked at me carefully and said, "Yes."

I am going to have to be a bit more careful about what I say, lest I become the talk of the faculty lounge. Who is that short-haired sunburnt woman? Why is she always asking such ridiculous questions? Oh, don't worry, she came from a community college, and those students always have a difficult time transitioning.

How Could You?!

I work as a server. I have achieved a level of proficiency that may be termed "expert" within the Dreyfus Model. I'm good at waiting tables, and most days I enjoy it. However, after 11 years of restaurant experience, I am still startled when I receive an 11% tip from a table that did not exhibit any signs of dissatisfaction during the time we spent together. It violates my sense of fairness and decency and makes me kick things. It also makes me run through a mental checklist of the meal, questioning my service, my perceived level of rapport with the people at the table and missed clues that the whole thing was going to go pear-shaped when I see the credit card line. I used to get so full of righteous indignation about bad tips that I would rant about public-access cable shows about the wages of tipped employees in the state and flyers in parking lots about how to calculate 15 and 20% easily in your head.

Today, I had a table of four adults (clearly parents and a set of grandparents) and one 9 month old child. I'm often quite interactive with the kids at my table - I like hanging out with kids a lot when I'm not responsible for them. This baby was Cute, with all the adorable characteristics of that age - fat little fingers, quiet but smiley, huge rosy cheeks, content to sit in her highchair while the adults ate, happy to be on someone's lap, making eye contact and imitating facial expressions. There are few things more entertaining to me than trying to figure out what a 6-12 month old is thinking by watching their eyebrows. I digress (which may be foreshadowing for the piss-poor tip I got on this check).

Things that I think went right (ie, things that support my assumption that I would receive a 16-20% for the bill): Greeted table promptly, kept tea glasses refilled throughout meal, remembered to bring extra chili paste for Mr. Make It As Hot as Possible, acknowledged cuteness of child, was not flustered during service (last table of the shift, no other tables that I was dashing around to, splitting checks 5 ways on 4 credit cards and boxing up leftovers), eye contact with adults, pleasant interactions, ready with check presenter when older man reached for his wallet.


Possible reasons why this man left me $7 on $68:

• he is an asshole (again, not supported by my limited interactions with him)
• he never tips more than 10% (possible risk factor on this one - he was over 50 yo and white, which although certainly not causally linked, has been correlated in my experience with randomly shitty tipping behavior)
• he was angry that I was talking to the baby and wished I would have left the table so that they could dote on the kid without some stranger hanging out and showing off her impression of an octopus.
• he was not happy/comfortable with paying for these freeloader kids and not prepared to shell out $68 pre-gratuity. he didn't want to come to this fancyass highfaluting chinese joint anyway, he wanted to go to Bojangles.
  
• he thought that because we pulled two four-top tables together, they were considered a big party and gratuity is included.
• they were actually in a much greater hurry than I suspected and my take of them as "leisurely family lunch" was totally false.
• the fact that when I first approached the table, they had neither menus or silverware, commonly provided by the host staff when seating a table. this was a mystery to me, and I stated as much, then left to procure said items immediately. maybe there's more to this part of the story.

Part of the reason this kind of thing bothers me is that I will never never never know why this person chose to leave half the amount of money that I expected him to leave. (though, if pressed, I gotta go with the octopus imitation. come on, now. what was i thinking??) I can't ask, and oddly enough, my memory of faces is so poor that I wouldn't be able to pick him out of a crowd at Starbucks tomorrow even if I happened to have the balls to walk up and ask him why he stiffed me (which I know that I don't). I can't know if I did something akin to wiping my ass at the table and then mixing their sauce without knowing it, or if this is all about him, the way he always tips, the way his father tipped and his father before him. No, wait, his grandfather wouldn't have been eating out, unless he was a Rockefeller.

I also will never never never know if he was Non-compliant with American societal norms in restaurant tipping, or has a Knowledge Deficit related to confusion about automatic gratuity policies. What if he meant for me to have a 28% tip because he figured 18% was already in the tab? This one is good for snapping me out of Thinking Bad Thoughts about the dude, but doesn't really hold up to scrutiny, since all he had to do was look carefully at the bill and note the absence of a line that read "Gratuity Included: $15.23" or something.

Shit, maybe the guy can't do percentages in his head. Add it to the list.

The nice thing about being an expert in the field is that these tips are now the exception, not the norm and don't ruin my day the way they used to (when I was getting them all the time!). With all my gathered experience, I trotted off after cashing out and got myself a big ass cinnamon latte and forgot about it. (That Dharma and Greg episode is playing in my head right now - the one about Dharma's annual thought detox ritual when she says -Put it in a bubble. Let it float away - about 86 times in 20 minutes!)

Yep. Let it float away.


(edited to add: Move the decimal left one digit for 10%, then double that figure for 20%, or add half of that number to itself for 15%. Servers in my state earn $2.13 per hour in wages.)

(re-edited to add the link of one of old favorite blogs that i just remembered: Waiter Rant.)