Disclaimer: This blog does not necessarily reflect the views of the School Board or of the School System of Coweta County.

so i’ve been looking into all these programs the army offers

i can get money for school and money to live on

i’d have plenty of money so i wouldn’t have to work full time and go to school full time like i do now

i want to be able to focus on school.  i want to be able to meet with other students in my class to study, and it is nearly impossible while working full time.

i also think the army is going to give me a lot of life experience.  i want to meet people i would never have gotten to meet.  i want to do things i never would have gotten to do.  i think the army can provide that for me.

and when i get done with nursing school i will have a lot of experience in high-trauma situations that will make me attractive to employers.

i think this is the best opportunity for me.  i called a recruiter today.  i can even get a healthcare job while im in the army reserve to give me more experience.

everyone that i’ve told doesn’t even take me seriously.  i’m skinny and not athletic but i think this will be a life-changing experience.

i’m going to volunteer at my local hospital while i’m in school, too.  i’m so used to working all the time that i’ll be bored out of my mind if i just go to school.

this is the beginning of a huge journey! i am afraid.  i’m afraid i won’t like it and i will be stuck.  but i want to do this.  and i know i can do this.

Good Morning GASN Members!
Another baby step has been made!  Yesterday the Senate subcommittee voted on the budget and the 2.1 M for the School Nurse Program remained in the budget.  This budget now goes to the full Senate for a vote. The Senate gets 48 hours to review the budget so the vote will probably be on Wednesday.  We are hoping the full Senate approves this.  It still has to go back to the House and then to the Governor.  Please keep calling your Senators and Representatives!  This is our last chance to get the word out on how important this issue is!  Also, don’t forget Governor Perdue!  We’re so close!!! This could not have been done without you!  There is no doubt about that…. Thank you!  Have a wonderful Tuesday!
Respectfully,
Joanne Giel, RN
GASN President

I didn’t always want to be a nurse. In fact, the idea had never even crossed my mind. I have worked full time since I was 15 and I had only ever worked in retail. In Vegas, retail is huge. In this podunk town, retail means WalMart. There were no jobs in retail - actually, there weren’t any jobs anywhere. I ended up temping at the personnel department of the local school district until I managed to find a job a few months later. In a hospital. The county hospital.

I could count the times I had been in a hospital on one hand back then and I knew absolutely nothing about health care. It was a completely new world to me. I pushed paperwork in Utilization Review, where every patient is handled by a case manager.

Boy, have I seen some stuff. The second I decided I would enter nursing school, I knew I would stay at the county hospital to get my experience. Anything that can possibly happen happens at county. Private hospitals don’t get a lot of the stuff that county gets.

Anyhoo, I attended the university while working. At the time, my major was in psychology - big surprise. Everyone seems to major or minor in psych. People used to ask me questions all the time - “What are you going to do with your degree? What are your plans? What do you want to be when you grow up?” I never had an answer for them.

A friend in the office (a RN) kept after me to become a nurse. I told her I could never handle such a thing - blood, guts, shit, needles, death? No way… Back then I was squeamish and heartsick. I used to go home and cry every day over patients and the horrible things that happens to them. I still cry once in awhile, but it’s rare now.

So, this friend explained to me that nursing isn’t all floor nursing. She described all the different opportunities there are for nurses in the world. She also reminded me that health care is the one profession that never goes out of business. A nurse can always find a job somewhere. She had me teetering on the edge of deciding one day and then something happened… A patient died of a decubitus ulcer - a bed sore. This old man died because he didn’t get turned in his bed at a facility that was short staffed. That killed me.

It sounds ridiculously corny to say that’s what made me decide to become a nurse but that was it. And here I am…

I am starting the last of my prereqs this quarter and, if all goes according to plan, I’ll be starting the BSN program in the fall. It has not been an easy journey and I think it’s only going to get harder. I started this blog because I couldn’t find any information online to tell me exactly what to expect in nursing school. I’m hoping that, as I go through everything, talking about it will help someone else when they go looking for information.

know your hospital, make your birth plan concise and relevant, don’t go in with guns blazing trying to pick a fight, and be respectful without being condescending.  She also mentioned communicating well with your nurse.  I’ll add that your nurse is the one person who can make or break this for you.  It’s ok to request a different one if you’re not getting along–it’s done all the time.  The best thing you can do is have a convsersation on admission about the basic concepts of hypnobabies (maybe explain the lightswitch, definitely stress being quiet during contractions so mom can concentrate, explain why dad will be answering most questions, etc) and also about any specific preferences you have that might be counter to hospital policy, so that the nurse actually hears it (birth plans are not always read).

I will say first that I do agency work (which means I work at several different hospitals, not just one) in the Baltimore/Annapolis/Southern Maryland region, so my experience comes directly from those hospitals.  You’ll find that hospitals differ from each other, but also practices tend to vary widely even in different regions of the country.  I hear stories from other travel nurses of policies and attitudes that are completely opposite in various regions.  My point in this is to know the hospital where you will be birthing.  Go on the tour, ask questions, and like you’re doing now, find out what points are important for you so you/your husband/your doula can actually advocate well for you when the time comes.

Some things that are on standard birth plans just don’t happen in a lot of hospitals, and some hospitals are still in the dark ages.  I personally would recommend that if you need to have a birth plan stating a LOT of things will be different from policy, the best thing might be to choose a different hospital/birth location if possible.  You’ll note as an L&D nurse, I’m planning to birth at home.  ‘Nuff said.

So, some questions to ask the nurses on the L&D unit when you tour–
(Please note that many hospital “policies” aren’t policies at all, but just how things are routinely done.  Often you can overcome this with simple conversation or, for actual policies, a doctor’s order.  For instance, if everyone gets an IV and you don’t want one, your doc/midwife simply needs to write the order stating “no IV access needed until *previously agreed upon situation inserted here*” or for eating and drinking, your provider can write an order for a regular diet.)

-What is the procedure for admission? (Do I go to a triage room to be examined first, or straight to a labor room?) This is mostly so you know what to expect when you get there.  Please note that many places require all support people to leave, at least briefly, while they obtain your medical history because there are very personal questions being asked (about STDs, abortions, etc) and because this is a prime time to assess a woman for domestic abuse.  We can’t do that if her partner is in the room.  You can choose how and whether you’d like to get around that, or maybe ask if it’s something that is done at your facility.

-What is your policy on walking while in labor?

-What about after my water has broken?

-What is your policy on eating and drinking in labor?

-What is your policy on having IV access while in labor?  (some facilities will require it, some require for “high risk” moms (and you’ll want to ask what the definition is for that) and some leave it up to the provider.)

-Is it standard for the anesthesiologist to obtain consent for anesthesia on all moms upon admission? (some places do this and if you’re not expecting it, I could see how this might derail your thinking a little.  On the other hand, if you know they’re going to come talk to you about epidurals, general anesthesia, emergency c-section, etc, you can be ready for the conversation, bubble of peace firmly in place

-What is your visitor policy?  Can I have my husband and doula with me for the entire labor?  While I push? For delivery? In the OR?

-What is your policy on continuous monitoring during early labor? active labor? pushing?  Do you have telemetry monitoring (the kind Lyssa referred to where you can walk around and still be on the monitor) and if so, how many tele monitors do you have (some places have one for each room, some have one for the whole floor, some don’t have it at all).  You may also want to ask your provider(s) about how often their patients “require” internal monitoring.  In some places it’s reserved for emergencies;  howerver, in many places it’s used for convenience only, and it is explained to the pt as it is being inserted, not prior to doing so.  It’s much easier to measure and chart what’s going on with the baby when using internals, so be aware of that.

-What is your policy on photography and video during labor? during delivery? in the OR? after delivery?  (every place is different, and it doesn’t matter if your doc says it’s ok, if the nurse doesn’t agree or any other personnel in the room don’t agree, so you want to know what the rules are before going in)

-What is your policy on baby care immediately after birth?  Is the baby taken to a warmer?  Is the baby taken to a nursery for the bath or is that done in the room?  Do they even have a nursery?  Is mom allowed time to nurse the baby before the footprints, weight, shots and drops are done?  After you ask these questions, remember that YOU are the one who gives permission for these policies to be carried out, YOU can refuse any treatments for baby at any time, and that if the baby is healthy YOU can have the baby discharged as a patient so that the policies are not even an issue. 

- What is your policy on supplementing breastfed babies with formula?  When do you consider it “necessary”?  Do you ever give breastfed babies a bottle of water?  Do you give pacifiers to breastfed babies?  (Every facility will be different on this as well.  The safest thing to do is tape a sign to the crib like the one you get in class specifying that your baby is breast only, and you do not consent to any pacifiers, bottles, or formula.  Taping it to the crib in addition to talking to your baby’s nurse is important because many people will come in contact with and care for the baby in the nursery (nursery techs, pediatricians, the person doing the hearing test, other babies’ nurses, lab techs) and you will not have the chance to talk to them or even know that they are caring for your baby.  If the hospital requires formula supplementation for low blood sugar, you can specify that you want to breastfeed if that happens.)
Some other things to remember about common practice in hospitals:
 - Asking patients about their pain level is a JCAHO (the organization that accredits hospitals) requirement.  Most facilities now have a checking system in place and nurses are often reprimanded if they haven’t charted that they asked about pain every so often.  (this varies from every hour to every 8 hrs).  I get around this by charting that the pt requests I not ask and states they will let me know when they want something.  You may want to have a conversation w/ your nurse stating you don’t want to be asked about pain and you’ll be sure to let her know if you need anything from her.

- How you push is not a hospital policy issue.  It’s something to be discussed with your provider (midwife or doc) AND with the labor nurse assigned to you when you start pushing.  A lot of nurses count to ten and have you “purple push” and a lot don’t.  At some teaching hospitals you may have a physician with you the entire time you push.  At most hospitals, your nurse is with you the entire time and the phys literally steps in to catch, sews up any tears or episiotomy, and leaves.  Midwives in the hospital can fall anywhere in between that with some being very attentive and some being very busy w/ multiple patients or just more inclined toward the medical model and the fact that you have a nurse with you.  Find out what your provider does, explain what you want to do, and do the same when you meet your nurse.

- Perineal Massage is something again to be discussed w/ provider ahead of time, and with the nurse who is with you when pushing, since she is likely to be the one doing it while you push if you want.  There won’t be a hospital policy on this, and it’s also something your husband or doula can do, and if you’ve read up on it and he’s been doing it the whole time anyway, that might make the most sense, but will get you some strange looks from the staff

- Treatment of the baby at delivery is another one to discuss w/ ANY provider you might have, especially if you have a physician practice and you don’t want the baby manipulated (pulled on, etc).  Treatment of baby immediately after the birth is something discuss with the provider, but is ultimately up to the nurse.  Find out what the usual sequence of events is from your provider (do they deliver, clamp and cut the cord and hand baby to a nursery nurse at the warmer?  Do they deliver, lay baby on your chest, leave the cord alone and let you bond?  Do they hand the baby to the delivery nurse at the bedside and let her decide what to do?)  With some docs/facilities, just getting the baby on your chest for a few seconds after delivery before being whisked off to the warmer is an uphill battle.  In other places we would never dream of taking the baby away from mom in the first hours after birth for any reason short of a medical emergency.  So, find out the procedure from your doc ahead of time, THEN, talk to your nurse when you get there about what you actually want done.  If you need to, you can gently remind her that even if this is not routine for her, you are not consenting to having the baby taken from you.  Let her know what is important to you, and then, at delivery, you may want to remind doc “remember we talked about not pulling on the baby and leaving the cord intact until it stops pulsing”  Old habits die hard and if his/her habit is to clamp and cut before they even hand the baby to anyone, it might be done without thinking!  Another thing that is often done without thinking is that whoever has the baby (delivery nurse or nursery nurse) is generally rubbing and scrubbing the baby with towels/blankets to stimulate the baby to cry.  If you don’t want this done, you need to talk with your nurse about it before hand and remind at delivery.  Most nurses aren’t familiar or comfortable with waiting for a baby to pink up without this stimulation while still be oxygenated by the placenta/cord.  You may go through all that discussion just to have the nurse declare that the baby was blue and needed help, and do the rubbing and scrubbing anyway.  Letting the baby be and not drying him/her vigorously is just not done in most hospitals.

- Cord traction on the placenta is completely up to the provider you have at delivery.  Discuss ahead of time with ANYONE that might be the provider for your delivery and remind them at delivery.

- Circumcision is never done without signed consent, so refusing it in your birth plan really isn’t necessary.  Plenty of people don’t circ.  It’s something your provider will ask so they know whether or not they need to come back and do it, but I’ve never been in any situation where anyone just assumes a boy will get circ’d, and it fact, most people are happier when you choose not to.  Less work for the staff

- Induction methods and how long you’re “allowed” to labor before requiring induction will be up to your provider (midwife or doc) and not up to hospital policy.  That discussion needs to take place in the office and with the agreement/understanding of ANY physician or midwife that might end up on call.  If you have a big practice, you can have your doc/mw write out what you agreed to and sign it on an order sheet that you take to the hospital with you during your birthing time.  That avoids relying on the on-call person to order something they’re not used to, but doesn’t guarantee they won’t just order something else instead. 

You asked about natural methods of induction–there are many methods used, especially by midwives, especially in birth centers or at home, that are not pharmaceutical in nature.  The most natural are things like sex (semen softens the cervix, orgasm causes uterine contractions), nipple stimulation (releases oxytocin, causes contractions, can be done w/ hands or a breast pump, or nursing an older sibling), or I would consider AROM to be natural as well, although it is definitely an intervention that has risks (it releases hormones, helps the baby come down on the cervix and generally speeds up labor, but the biggest risk is cord prolapse and other risks include infection).  Then you have gentle herbal options like taking Evening Primrose Oil in pregnancy (softens the cervix), using a labor tincture that includes blue and black cohosh with other herbs (usually prescribed by a mw in my area, stimulates contractions), or other remedies like castor oil (not for the faint of heart, induces diarrhea which irritates the surrounding tissues (including uterus) and stimulates contractions).  One other option, if I’m not mistaken, I think there might be an HB “baby come out” cd for post dates moms that might be useful.  Hospitals tend to be pretty unimaginative in terms of induction, and using pitocin is the standard.  There are other drugs that are used to soften the cervix or induce labor, but I think the birth plan is referring to speeding things up once labor is established, and that’s really only going to be done with pitocin or AROM when you’re in the hospital.   The main thing I would find out from your provider is why/when they would want to induce/augment you.  Is there a time limit?  What if I get to 6 and don’t change my cervix for 2 hours? 6 hours? 12 hours?  What if my water is broken?  (my midwife has the attitude that as long as mom and baby are well, she’ll wait with me as long as I want to wait, and try to help with things like positioning to solve the problem if there is one.  many physicians are taught that 2 hours without cervical dilation is failure to progress, and is an indication for induction or c-section.  By the way, you do NOT have to induce immediately if your water is broken before labor starts.  If that happens, you should take measure to limit your chance of infection (no cervical exams, nothing in the vagina), verify well being of the baby (ie is baby still kicking?), and know how you want to proceed before speaking with your provider.)

Writing the Birth Plan
When it comes to writing the birth plan out, unfortunately, keep in mind the stereotypical nurse will groan aloud at the nurses station when she reads through your birth plan.  This is because often people come in with ridiculous requests (like getting a tub to birth in when there are no tubs on the unit) or worse, a stock birth plan found online with the blanks not filled in.  My suggestion is keep it concise and relevant.  No more than a page, bulleted points are great, and use actual conversation with your providers as your primary means of communication, with the birth plan being an easy reference tool for reminders that the nurse can keep or even post at the bedside.   The John and Mary birth plan has a lot of excellent points that you should be educated about and is a great starting point for you to decide how you want things to go, but is not necessarily going to be relevant to every birthing location.  For instance, the part about leaving the hospital if you’re checked and found to be less than 4 cm is excellent, and something you should be aware of and maybe even discuss with your provider.  But, it doesn’t need to be written in a birth plan because you’ll just do it if you’re in that situation.  You haven’t been admitted yet, and there’s no reason that you should be, and most places will be happy that you’re smart enough to know you’re not in active labor yet.  You may even want to write out your own birth plan just to get your ideas down on paper, and a separate, more concise one for your providers and hospital.  (I have one for myself that includes no unnecessary cervical exams–not something I need to write for my midwife, but something I definitely need to tell myself because I get curious and check myself way too often!!)

I hope this is a good reference for you, and please feel free to email me on or off list if I didn’t explain something well enough.  Again, these are based on my experiences in my area, and your mileage may vary!

~Becky

Markham Stouffville Hospital Chooses mTuitive’s xPert for Pathology^TM to Meet CCO Standard

Becomes the eleventh Ontario hospital to implement xPert for Pathology

Boston, MA-Markham Stouffville Hospital in Markham, Ontario has selected mTuitive’s xPert for Pathology synoptic reporting solution to meet Cancer Care Ontario’s 2008-2009 CAP/CS aligned data standard for pathology reporting.

Standardized pathology reporting increases the availability and consistency of cancer pathology information that is essential for treatment decisions, evaluation, and research.

mTuitive complies with the 2008-2009 CAP/CS aligned data standard developed by Cancer Care Ontario in conjunction with the College of American Pathologists (CAP) Cancer Committee, the Centers for Disease Control and Prevention and the American Joint Committee on Cancer. The CAP checklists1 for breast, lung, colorectal, prostate, and endometrium were amended to include the mandatory pathologic collaborative staging elements.

xPert for Pathology interfaces with all available Pathology and Laboratory Information Systems on the market which lends itself to wide use throughout the province. Other Ontario hospitals utilizing mTuitive’s xPert for Pathology synoptic reporting solution to meet the CCO data standard include Thunder Bay Regional Health Sciences Centre, The Scarborough Hospital, North York General Hospital, Lakeridge Health, Sunnybrook Health Sciences Centre, Rouge Valley Health System, Bluewater Health, Peterborough Regional Health Centre, Cambridge Memorial Hospital and Sudbury Regional Hospital.

About mTuitive: mTuitive, Inc. develops data capture and synoptic reporting software to assist health care professionals in recording clinical findings and maintaining compliance with established protocols and guidelines. Our unique method of capturing structured information provides valuable data for pathology, oncology, and cancer staging applications. Established in 2003, mTuitive, Inc. is based in Massachusetts. See us on the Web at www.mtuitive.com.

1. This material includes the Cancer Checklists and Cancer Protocols which are copyrighted works of the College of American Pathologists. Encoded within the Checklists are portions of the copyrighted work of the International Health Terminology Standards Development Organization, SNOMED CT. © 1998-2007 IHTSDO. The Cancer Checklists and Cancer Protocols are used with permission of the College of American Pathologists - which has also authorized use of SNOMED CT as encoded in the Checklists.

A study recently published in the March 2009 issue of BJOG: An International Journal of Obstetrics and Gynaecology has found that for about half of women who give birth, memories of the intensity of labor pain decline over time, for some women, their recollection of pain does not seem to diminish, and for a minority of women, their memory of pain increases with time.

I could not access the original study online but I did find an article published by Reuters Health Stories that summarizes the study.

As a labor & delivery nurse, I have heard many a time a mom in the throws of her second, third, or forth labor yell out, “I don’t remember it hurting this much last time!!”  It doesn’t matter if “last time” was 18 months ago or 18 years ago, anecdotally I personally have found that women do tend to “forget” the pain of childbirth.  It is interesting that this study did find that for about 50% of women, this is true.

But what I found most interesting about this study were the following two things:

#1) The study found that a woman’s labor experience (positive vs. negative) was an influential factor. The study found that women who reported labor as a positive experience 2 months after childbirth had the lowest pain scores, and their memory of the intensity of pain had declined by 1 year and 5 years after giving birth.  However, the memory of labor pain did not decline during the observation period for women with a negative overall experience of childbirth.

#2) The researchers found that women who had epidural analgesia remembered pain as more intense than women who did not have an epidural, suggestive of these women remembering “peak pain.”

Reading this article reminded me of the book Birthing From Within by Pam England, CNM, MA.  In her book, England writes a lot about a woman’s prior labor/birth experience and how much it can affect her future pregnancies and labor/birth experiences…especially the negative ones.  She writes about how important it is for a woman’s birth preparation and prenatal care to not just include learning about tests and birth technologies, but to include talking and exploring a woman’s hopes, secret fears, unresolved grief, self-doubts, and visions of birth.  England’s “Birthing From Within” classes use birth art as one way to achieve these objectives. 

Regarding epidurals (and again, anecdotally speaking) there have been many times in my practice as a labor & delivery nurse that an epidural doesn’t provide the mother with the relief she was seeking.  The epidural could be one sided, there could be a “window” of pain, or it could provide no relief at all.  It had always seemed to me that if the epidural never worked or more so if it worked for only a while and then wore off, that the women seemed to have less ability to cope with the pain for a variety of reasons.  In an article for Mothering Magazine entitled Epidurals: risks and concerns for mother and baby author Dr. Sarah J. Buckley MD writes:

“Beta-endorphin is the stress hormone that builds up in a natural labor to help the laboring woman to transcend pain. Beta-endorphin is also associated with the altered state of consciousness that is normal in labor. Being “on another planet,” as some describe it, helps the mother-to-be to work instinctively with her body and her baby, often using movement and sounds. Epidurals reduce the laboring woman’s release of beta-endorphin. 

Obstetric care providers have assumed that control of pain is the foremost concern of laboring women, and that effective pain relief will ensure a positive birth experience. In fact, there is evidence that the opposite may be true. Several studies have shown that women who use no labor medication are the most satisfied with their birth experience at the time, at six weeks, and at one year after the birth.  In a UK survey of 1,000 women, those who had used epidurals reported the highest levels of pain relief but the lowest levels of satisfaction with the birth, probably because of the higher rates of intervention.”

Certainly some food for thought… 

how would you know I am a Healer.

If you never felt sadness, how would you know I am a Comforter,

and if life is perfect, would you still know ME?”

Since life isn’t perfect, so we must look upon God to lead us.

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Despite the stressful 1st week of work, i have many reasons to be thankful for. =)

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I thank You, Lord, for the friendly individuals who saw my anxiety as a fresh graduate and lent out a hand in the times of need.

I thank You, Lord, for providing these understanding individuals who appeared at the right time to assist and encourage me.

I thank You, Lord, for the privilege to be healthy and well to provide care for the sick and being there to advocate and encourage.

Being a RN comes with a lot more responsibilities and expectations. Honestly, i was feeling overwhelmed for the first week at work. My thoughts were scattered, and constantly racing against the time.

i pray that as time goes by, i will be more confident and know exactly when to intervene and manage my time.

i remembered hearing a visitor saying something like this to a patient of mine, “it’s not what happened that matters, it’s how you reacted to it that matters most. Take your time to accept and adjust and be ready to move on…”

That’s it. It’s how i choose to react to the circumstance.

Some days will be a little bit messier & disorganized; some days will be calmer and steadier.

That’s the nature of the work. That’s the way it keeps nursing interesting.

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but somehow or rather, i felt mentally exhausted after days of work thou it has been fulfilling to participate in patients’ recovery.

That’s when i needed  to draw strength and be refreshed by God; and praise God for brothers and sisters in OCF & friends who have been a source of encouragement to me. =)

Be still and Know that He is God.

“Dear Lord, we lift up to You our deepest fears and ask that You would deliver us from them. Set us free from all dread and anxiety about the things that frighten us. Thank You that in Your presence all fear is gone. thank You that in the midst of Your perfect love, all fear in us is dissolved. You are greater than anything we face. In Jesus’ name, Amen.”

autumn leaves

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went to see dentist this am regarding my aching wisdom tooth.

did a OPG (dental imaging) and dentist suggested i go visit a specialist to get all 4 wisdom teeth extracted as the bottom left tooth isn’t looking great too. @_@”" reason was that he does simple extractions and mine looks like needing surgical extraction. So, referral to specialist was made. at first, 5th May was the soonest, then the nurse tried again, emphasizing the urgency that i am having an infection. It was then 23rd April. =S

then, the other nurse tried, and got me an appointment on 7th April the soonest. and i’m rostered to work. aiyak.

and antibiotic was prescribed.Clindamycin 150mg.

The feeling of self-medicating isnt so right; strange…hehe…1 tablet, 6 hourly. hmmm…who would wake me up at 1am for my tablet….the nurse herself, duh =P

upon reaching home, after much thoughts…i decided to find my own earlier appointment. heh. i searched online and called a few specialist clinic and found one for this wed. the soonest.

The reason being that i’ll have days off from wed…so it’ll be less troublesome to have it done during days off…

since the ache started on Friday, i became more cautious with oral hygiene…hehe, not that i dont normally…just extra cautious now with the thought of infection might be happening.

so, i bought antiseptic mouthwash liquid (which i never took) guess now it’s the best time to use it…and the smallest cutest toothbrush (so that can reach the hidden-away wisdom teeth) i could find in woolies. lol*

elmo

Thank God the pain settled a bit now.

early interventions saved the troubles.