#rn 2018

[livelovenurse-blog1]

An accurate representation of the fact that I’m capable of resembling that of a thriving human being during our five day break; I’m not making any promises this semester though ☀️🌻

[erica-the-rn]

The Importance of Creatinine

So, what the heck is creatinine, even?!

Everybody in nursing school had heard the term creatinine. We know that it has to do with your kidneys and, from what our teachers have told us, it’s a major lab value to know. However, what is it and how/why do we evaluate it? 

What Creatinine Is

To understand creatinine, we need to know what its origin is: creatine. Creatine helps to produce adenosine triphosphate (ATP). ATP is what gives our cells energy. We store creatine in our muscles and bones. When we perform exercises or body build, some creatine is converted, then, to creatinine. Roughly, only 2% of our creatine makes creatinine. 

Creatinine is the waste product resulting from creatine. Our bodies only excrete creatinine through the kidneys. That’s why there is a parallel between creatinine levels and kidney functions. Creatinine can be affected by a couple things, though. Generally, the more muscle mass on a person, the higher their creatinine will be. However, keep in mind our blood creatinine is measured in decimal points. So the difference is not seen drastically. 

Who do you think has higher creatinine levels? :)

While we’re not supposed to have a lot of creatinine in our body, we ARE expected to have some.

How do we evaluate it?

So, there are a couple ways to measure creatinine, however I’m going to focus on the big two: serum blood labs and creatinine clearance. 

Serum Creatinine 

For the average adult: 0.6-1.2 mg/dL

For serum creatinine, you follow all of your regular blood draw steps. Typically, this is collected in the red-top vacutainer. You’ll send this down to the lab and they’ll send your results to the patient chart or may even call the nurses station. 

Seeing a rise in your patient’s creatinine levels are usually associated with CHF, AGN or CGN, and Chronic Kidney Disease. The reason why is because when you have impaired functioning of the kidney, its not going to excrete wastes like it used to. See my CKD review for more help. :)

Seeing a fall in your patient’s creatinine is usually associated with a decline in muscle mass. This is seen a lot in muscle dystrophy.

Creatinine Clearance (CrCl)

For the average adult: 87-139 mL/min

So, the CrCl is collected with by 24-hour urine specimen. We want these patients collecting their urine, so remind them that after flushing the first urination of the morning, do not flush anymore of their urine. Show them where and how to collect their urine. If they are using a specipan, remind them that no toilet paper should go in the basin. We don’t want any tampering inside of the collection device. 

Seeing a rise in your CrCl could mean a couple things: pregnancy, high cardiac output, and possibly they’ve been exercising.

A decline in your CrCl is not good. This is indicative of impaired kidney functions. CKD, AGN, and atherosclerosis of the renal arteries. Dehydration and shock can also show low CrCl. 

[erica-the-rn]

Chemotherapy

What is chemotherapy?

Chemotherapy is a treatment option for cancer patients. It can be curative or palliative. It is described as cytotoxic, which means it is toxic to living cells. Most chemo-drugs are given IV and there is more than one type of chemo-drug.

Chemotherapy Drug Categories:

Alkylating Agents

Antimetabolites

Antimitotic Ages

Antitumor Antibiotics

Topoisomerase

As I call it, WILDCARDS (mechanism unknown)

Chemotherapy is often used with surgery or radiation, known as adjuvant therapy. The reason why is that chemo circulates systemically. So, while surgery may remove the local tumor, chemo helps to remove the metastasizing cancer.  Oftentimes, more than one type of chemo is used at a time. Obviously, the more you use, the more the cancer is destroyed. However, there is a downside to that. While chemotherapy has a tendency to destroy more cancer cells than normal cells, it is still actively reducing your healthy cells. Chemo goes after the cells that produce most rapidly, so most often affected are the blood cells, skin, and hair. 

Side Effects of Chemotherapy:

Nausea/Vomiting

Subsequent Weight Loss

Anemia

Fatigue

Changes in LOC

Skin Changes

Anemia

Neutropenia

Thrombocytopenia

Alopecia

Mucositis

Managing Side Effects of Chemo:

Patients experiencing chemo are going to have a couple problems that deal with their blood cells. 

Firstly, they are anemic. subsequently, they are going to have fatigue because of their anemia. We usually treat this with epoetin alfa. This is a erythrocyte colony-stimulating factor. It will help increase energy and erythrocyte count.

They are also neutropenic. This means they have a low white blood cell count. Our good old friend, WBC, helps us to fight off infection. So, when our patients are neutropenic, they are at a risk for infection. What we can do, as nurses, is help protect from infection and teach our patients how to prevent infection. 

These is normally called neutropenic precautions.

Handwashing is MOST important! 

Teach patients to perform oral and perineal care Q12h. 

These patients will likely have their own private room.

Visitors should be limited to healthy, infection free adults.

Teach patients to report any s/s of infection, as big or small as the sign may be.

Monitor WBC every day.

REPORT ANY SLIGHT FEVER, COUGH, SWEATING, SORES, PIMPLES, OR ANY SIGN OF INFECTION TO THE PROVIDER.

No fresh fruit or vegetables.

No live plants allowed in the room.

These patients are also experiencing whats called thrombocytopenia. Thrombocytopenia is decreased platelets and clotting factors. This puts them at a risk for bleeding. Along with their other symptoms (vomiting, fatigue, weakness, etc), this puts the patient at a horrible risk for injury. 

So we have what is called bleeding precautions:

Handle the patient gentle. Skin tears are very common. 

If venipuncture or injections have to be performed, hold pressure at the site for 10 minutes or until blood ooze has stopped. 

Apply ice to areas of injury.

Monitor urine for blood.

Use a soft-bristled toothbrush. 

DO NOT give the patient a water pick. 

Follow fall prevention protocols.

Use an electric razor.

Do not give aspirin or let the patient take aspirin.

Teach patients to blow their nose gently.

Nausea/Vomiting caused by chemotherapy is called chemo-induced nausea and vomiting. For patients experiencing this, we usually give Ondansetron(Zofran). What you need to remember is that Zofran causes drowsiness. These patients need to be told not to drive or operate machinery when they have taken this drug. Inform them to rise and change positions slowly. You want to prevent a fall at all costs because they are a bleeding risk. 

Chemotherapy Nursing Interventions:

Protect Yourself, too!

So, lets review some guidelines. Chemo is toxic to healthy cells. You need to remember that as a nurse. When administering chemo, make sure you have all of your protective equipment on. To take care of your patient, you must take care of yourself. 

Oral Chemo-Agents

If your patient has an oral chemo-agent, your biggest role is education. These patients need to know that they need to take these oral drugs every day at the same time. Teach your patients that skipping a dose can lead to resistance in cancer cells. Every dose they miss or skip is a step back in progress and a reduced rate in survival. 

Might I add, teach your patients not to crush or chew these oral agent. Most of them are for extended-release dosings, so crushing or chewing them can cause a bolus. 

IV Chemotherapy

Chemo is generally given in an IV. Most chemo patients will have a new IV site with each patient, however, some may have a port put in place.

Because chemo is a TBSA dosage usually, you will want to weight your patients’ every time they have chemo. Since they probably have been experiencing CINV, their weight is going to fluctuate.

A lot of chemo-drugs are whats called vesicants. These damage tissues FAST. You have to check your IV site frequently and make sure than infiltration is not occuring. Skin blanching, coolness, pain, and any leaking at the IV site are your s/s of infiltration. Please do not forget that this is a HORRIBLE adverse event that you want to prevent. 

You also want to perform your regular IV care. Monitor the site frequently and be mindful of the infusion rate. 

Oh my, that was a long review! Shoot me any questions. :)

[erica-the-rn]

Stroke Review (General Overview)

What is it? (patho)

A brain attack, stroke, is a medical emergency caused by interrupted perfusion to the brain. Our brain cannot store oxygen or glucose, unlike a lot of our other important organs. Therefore, it has to have constant perfusion to function. Whenever we experience a loss of oxygen to the brain for more than a few minutes, cerebral tissue dies. According to WebMD, the estimated time is 4 minutes before brain cells begin to die. 

What causes it? (Causes/Risk Factors)

There are two types of strokes: ischemic and hemorrhagic. Ischemic strokes are caused by a blockage of perfusion to the brain by either a clot or dislodged clot. 

Ischemic Stroke Risk Factors:

Hypertension

Atherosclerosis

Dyslipidemia

History of TIA

Diabetes

Sepsis

Congenital Heart Defects

Hemorrhagic strokes are caused by, obviously, bleeding in the brain. This can be caused by trauma, cerebral aneurysm, cerebral arterial rupture.

Hemorrhagic Stroke Risk Factors:

Cerebral trauma

Chronic HTN

Chronic Cocaine Use

Contact Sports

What does a stroke look like?

Aphasia or dysarthria

One-sided or unilateral weakness

Occasionally hemiplegia or paralysis

Drooping face

Headache

Visual Disturbances

Heart Mumurs

High Blood Pressure

SO, now the question is.. left or right hemisphere stroke? Quick to pick, here we go. :) The right cerebral hemisphere is our visual and spatial side. We recognize what we’re seeing and our body position in relation to the world we see. Those having a right sided stroke are going to experience more visual deficits and will most likely be disoriented. The left cerebral hemisphere (dominant) is the side responsible for language, math, and critical thought process. I remember Left-L-Learning-Language. They are most likely going to have speech problems, slowness, and aggravation or depression when attempting critical thinking.

What do we do? (Treatment)

Before you start treating your patient for a stroke, you need to know what caused their stroke. You need to get a CT without dye to rule out hemorrhagic stroke. Keep the patient NPO until the doctor clears them to eat or drink. They will most likely have a weakened sensation to swallowing. The last thing they need now is aspirating. Unless the patient is having a hemorrhagic stroke, you’ll keep the patient supine with a low (25-25 degree) elevated head of bed. You need to provide oxygen therapy to patients saturating in the low 90s or below percentage. 

If your patient has a headache or photophobia, keep room lights low and maintain a calm environment. 

There is a specific medication you can give your patients, if the doctor prescribes it. Alteplase is given to patients who have had a stroke in the last 4.5 hours. It dissolves the clot and increases perfusion to the brain. This SHOULD NOT be given to patients who have an active bleed in their body. 

There are also surgical options. An embolectomy may be performed. This is the removal of the dastardly clot. This is a common treatment for patients who are not eligible to receive Alteplase. Patients may also have a stent put in place.

What else?

Depending on why your patient had a stroke, how long after the stroke they received treatment, and the success and preservation of their cerebral tissue, you may have to discuss a few things with your patients.

If they had a stroke due to embolus or iscemia, discuss with them lifestyle changes. Yes, they have already now had a stroke. Yes, they already have an extra risk because of that. However, you need to inform them (1) change your diet, (2) take your medications, and (3) quit smoking! Strokes have been successfully prevented by taking action and making lifestyle changes.

If they have impaired swallowing, you need to meet with their dietitian, occupational therapist, and the patient. Discuss with them why they have to change the consistency of their diet. If they aspirate due to eating the wrong consistency diet, they risk aspiration. Aspiration can be fatal. Stress that to your patient, not just because its your job, but because its a human life.

And always... Remind them that there are resources:

http://www.stroke.org/

http://www.strokeassociation.org/STROKEORG/

[livelovenurse-blog1]

I slayed my Micro Biology final, y’all!

I start my RN bridge exactly four weeks from today!

[livelovenurse-blog1]

TEAS Disaster

I was scheduled to take my TEAS Exam in San Antonio, Texas at 8 am on 8.29.17; the deadline for the application/TEAS score submission for my LVN >> RN Bridge Program was on 8.31.17.

I live in a fairly small city a little over an hour away from San Antonio, and exactly one hour and thirteen minutes away from the testing facility. I left my house at 6 am that morning, and because there was a major accident on Vance Jackson, I was THREE minutes late for my test. When I got to the door of room where the TEAS was being administered, the proctor greeted me. I explained my situation and she proceeded to tell me, "It's not anyone else's fault but your own that you're too much of a cheap ass to have gotten a hotel here in San Antonio to be sure that you made it here on time.", and proceeded to slam the door in my face.

I was devastated. I thought I was surely going to have to wait another year to even be able to apply to the LVN >> RN Bridge Program.

LUCKILY, the director over my community college called the top of the chain of the branch of the sister facility (college) where that test was being administered and lit a fire under them for such behavior. She also called ATI and convinced them to transfer my funds to retest free of additional cost.

Today is 9.1.17; the deadline was extended by one day for me, and I'm retesting this morning. Send prayers, good juju/vibes my way, y'all!

[livelovenurse-blog1]

Rant From A Single F/T Nurse & F/T Student

I work the same amount of hours it takes most people four and five days to accomplish, in two. And on Sunday nights, which sometimes stretches in to early Monday mornings, after it's finally over, I go home with swollen ankles, tormented hips, screaming/throbbing feet, an exhausted mind and sometimes even a feeling of defeat, a shattered heart and bloodshot eyes from crying the entire drive home. And when I get home, I let my hair down. In this alone, I feel so much indescribable tension release from my body; and then I get to work. Forcing myself to stay awake for the next 48 hours straight to make up for the time lost to my job over the weekend, to finish homework and prepare for my upcoming lectures/exams/projects.

I don't come from money. I'm financially responsible for all of the bills as any normal adult is, along with financial obligations for continuing my education, only with the exception of rent and utilities (my parents' gracious contribution, to allow me to live under their roof as I transition to further my education and opportunities within my career).

If you, as a 'man', get UPSET and can't understand why I'm too tired or too busy to make time for you between all of this, I'm going to perceive you as someone who is being financially 'carried' and doesn't have enough responsibilities on their plate; who in return, has no respect for those of us who aren't blessed with such privilege, and have to bust our butts to make our dreams become a reality.

If you want my attention; attract me with your intellect and your understanding. Show me you're pursuing SOMETHING within your life, too. But, don't disrespect me if I have to work a little harder than you do, to get where I'm going. My time may be limited, my body and mind may be pained and I may be tired; but I am a DEBT/LOAN FREE student, and I believe in working hard now, so I can play big later. If that isn't attractive to you, then we aren't even on the same playing field, to begin with ☕️👌🏻🙌🏻

[livelovenurse-blog1]

🌻Last Clinical As A Level One Nursing Student🌻