Sunday's Specialty - Pediatric Hematology/Oncology Nursing

This week’s specialty comes to us from Nurse Teeny over at The Makings of a Nurse. She is technically not working as a Pediatric Hematology/Oncology Nurse (yet) but if you read through her blog you can see how much passion she has for this particular specialty. This passion is exactly why I asked her to share with us on this, and I am so glad she did! After you finish reading about this specialty, head on over to her blog to check her out!


Pediatric Hematology/Oncology Nursing

I may have no business writing this post, seeing as how I was in Peds Hem/Onc for a total of 168 hours...as a capstone nursing student...

But oh how I loved it! And now that I am a working RN in Critical Care, oh how I miss it!

And I will be back. :-)

Pediatric hematology/oncology nursing is working with kiddos who have blood disorders and cancer. It can be on an inpatient or outpatient basis. Your patients will range in age from infant to young adult (if they were diagnosed as kids, they'll often be followed by their pediatric doc into young adulthood for consistency). You will see a lot of hair loss, a lot of skin issues, a lot of nausea and vomiting. You will become an expert at central line management, blood and platelet transfusions, bone marrow transplants, and nutrition management. You will become allies with parents and family members, many of whom will become like extra staff members on the floor. They will have tips for getting that medication down the hatch (and will often be comfortable giving it themselves), they will know when their child is having a medication reaction before any symptoms appear and they will know normal lab values better than you in a matter of weeks (what's normal for these kids is NOT normal for the rest of the world).

If this is a specialty you are considering, I would highly recommend trying to get some exposure to it in nursing school to 1) Make sure it's for you and 2) Get it on your resume. It IS possible to get a job in peds hem/onc as a new grad but probably only if you do your senior capstone rotation in this area (or at least in either pediatrics or oncology). In the current job market, however, the pickings are slim. You will likely have to start somewhere else, then move over once you have your "1-2 years of acute care experience" (I really grew to hate that phrase).

Once you have worked in inpatient hem/onc, you can also move into outpatient care. Most hospital cancer centers have clinics where kiddos can come and get chemo or transfusions on an outpatient basis. They'll also need periodic checkups. In addition, since a lot of kids are immunosuppressed, usually doctors arrange for them to be admitted as inpatients through the clinic rather than the hospital ER if they have a fever or aren't feeling well.

The beautiful and poignant thing about peds hem/onc is that you get to witness just how resilient kids really are. I had patients in the middle of chemo who were riding their tricycles down the hallways and doing art projects in the craft room. They may feel like crap, but they'll be damned if that's going to keep them from going to the school room and making a potato battery. Even the ones who were dying wanted to "just be kids" for as long as they could. When one of my patients found out I'd be graduating in about two months, she told me she'd come back to the floor and bring me a graduation present. I was pretty sure that she wasn't going to make it to my graduation day but the fact that she was thinking of someone else in that moment was touching.

When I talk about the kind of nurse I want to be, many people scrunch up their noses and purse their lips and ask the age-old question: "Why?" Why would you want to work with sick kids? Why watch kids suffer and die? Isn't it draining?

No, it's not draining. It's sad on some days. It's fun on others. We have birthday parties and cupcakes and we wear silly hats and costumes. We celebrate the victories and cry when we lose a friend. We listen when the parents need to vent, and hold babies when mom needs to take a shower or get off the floor to grab a cup of a coffee and some fresh air. We acknowledge that it's just not right that anyone should be going through what these little ones go through.

But they go through it anyway, right or not. And we're there for them through it all. And I love it.

And yes, I will most definitely be back. :-)

For more information about peds hem/onc nursing, here are some helpful sites:
Association of Pediatric Hematology/Oncology Nurses (APHON) (http://www.aphon.org/)
Certified Pediatric Hematology Oncology Nurse Exam Information (http://www.oncc.org/getcertified/testinformation/cpon/index.shtml)


Thanks again Nurse Teeny, for sharing your passion for this specialty with us! I wish you luck and hope that you find yourself doing what you really want to do soon!

Sunday's Specialty - Rehabilitation Nursing

This week’s specialty comes to us from RehabRN. After you read what she has to say about Rehabilitation Nursing, hop on over to her blog to check out the rest of her posts. She has some great stories over there, along with some links to some really good articles.


Rehab Nursing...the good, the bad, the ugly

I like to tell people that my job as a rehabilitation nurse involves teaching people how to live. Patients come to inpatient rehabilitation for two main reasons: they need 24 hour nursing care and they need physical, occupational, speech or other therapies, and can tolerate them a minimum of three hours per day.

People come to rehab for a variety of specific reasons, too. They could be debilitated from a heart attack, pneumonia, surgery, or sometimes following hospitalization for a chronic condition. Many patients need to rebuild their endurance to go home. Most commonly, however, patients are sent to rehab following a stroke, traumatic brain injury or spinal cord injury. In addition, there are also specialized rehab programs for the blind and amputees.

In terms of where you work, you can work in many rehab settings with just an LPN license or as a diploma nurse. Baccalaureate trained nurses are often preferred. Your experience can vary, because you’ll need both those med-surg skills, such as starting IVs, tube feedings, inserting catheters, as well as other specialized skills you’ll learn along the way. You may assist doctors in performing procedures on the unit, such as changing tracheotomy tubes, lumbar punctures or complex wound dressings. Some facilities may also want you to maintain ACLS certification, others not.

Rehab settings may seem “slow” or “boring” to some new nurses, but they’re not always that way. You’ll learn a lot about prioritizing patient care when three of your six patients are due to therapy all at the same time, and you need to assess, medicate them and perform your treatments. In some units, you have hustle and bustle, then a little quiet time, then hustle and bustle and a little more time again. It just depends on your patients and a variety of other factors. As the Boy Scouts say, be prepared just in case the unexpected happens.

Many facilities may want nurses with two years experience, or they may hire you as a new nurse right out of school. Rehab nurses work in a variety of settings outside the hospital including clinics, long term care facilities, home health agencies, schools and outpatient rehab facilities, to name a few.

You will also deal with a lot of psychosocial issues in rehab, so I like to tell people that rehab nursing is a combination of med-surg and psychiatric nursing. These two factors can be very exhausting as a new nurse, both physically and emotionally. Besides med-surg and psych skills, rehab nurses are a vital part of the treatment team. We work with every kind of therapist you can imagine: physical, occupational, recreational, speech, etc., as well as medical staff, chaplains, and psychologists. Rehab nurses provide vital feedback necessary for the rehab hospital to get reimbursement from insurance via their care plans and their participation in team conferences.

If you are practicing in a rehab setting for two years, you may qualify to sit for certification exams, including the CRRN (Certified Rehabilitation Registered Nurse –see http://www.rehabnurse.org/), MSCN (Multiple Sclerosis Certified Nurse—see http://www.ptcny.com/clients/MSNICB/index.html) or other related certifications, depending on your area of expertise.

So where do you go from here? It’s up to you. In my short career, I’ve seen nurses in rehab go on to work in ICUs, wound care clinics, home health agencies and as case managers. One nurse I worked with even became a nurse manager of a rehab unit. There are a wide variety of places in which you can use your skills. Always keep your eyes open! Be willing to learn new things and the world is your oyster.

About the author:

RehabRN is a certified rehabilitation nurse working for the one of the nation’s largest healthcare systems. Read more about her working life at the Hotel Rehab at http://rehabrn.blogspot.com.


Thank you so much RehabRN for contributing! That was excellent information about Rehabilitation Nursing!

Sunday's Specialty - Med Surg

This week’s specialty comes to us from DreamingTree over at Med Surg Zone. She writes some great stories about her experiences as a Med Surg Nurse. After you’re done reading, jump on over to her blog to check out more!


Five years ago, I decided to go back to school for nursing. My background is in psychology, and I thought nursing would enable me to expand my career opportunities. In all honesty, it had never been my life's dream. In fact, throughout nursing school, I was the student who dreaded learning new lab skills. They often looked painful or awkward, and I could always see the potential for mortal harm to my patients if I screwed up. Classmates and family were used to me wondering if I should quit at any given moment. Gaining knowledge was great; potentially harming someone -- freaky. I share all of this because I was asked to write about my experiences as a med/surg nurse. I was the least likely in my class to become a med/surg nurse; and yet, here I am. I love it.

A medical/surgical floor is often touted as the best place for a brand new shiny nurse to begin. Why? A med/surg unit deals with a wide variety of patients: post-ops, chronic illness flare-ups (our "frequent fliers"), new onset illnesses (pneumonia, GI complaints, etc.), to name a few -- hence the name, Medical/Surgical. Our patients aren't sick enough to require continuous monitoring, but that could change at any point. We don't deal with many exciting procedures. Foley catheters, IV sticks, NG tubes, dressing changes, and some occasional suctioning are as good as it usually gets. Though, one day I assisted with a bedside chest tube insertion -- that was a bit more exciting! On a typical day, I may be taking care of six patients with the following complaints:

1. 73 year old with acute renal failure, diabetes, & cancer
2. 62 year old with syncope (one of the church drops)
3. 95 year old with bilateral pleural effusions, UTI, who is on aspiration precautions, &has a stage 1 on coccyx
4. 41 year old with chest pain
5. 68 year old with metastatic cancer
6. 64 year old with end stage renal disease due to uncontrolled diabetes, new onset UTI & pneumonia

Taking care of six patients with a wide variety of conditions can seem overwhelming. Truth be told, I've been known to groan as I read through kardexes. Organization is the key. On a good day, I have a routine that I follow. Coffee, kardexes, coffee, report, coffee, greet patients, review vital signs, review meds, last gulp of coffee, begin assessments & med passes. I have learned that a quick pop into each room after report makes my day a bit better. This gives me the opportunity to write my name on the whiteboard, let the patient know that I will be available shortly, and allows me to eyeball each person. That quick glance at the patient tells me a lot -- neuro status, respirations, safety -- all of which helps me prioritize the order in which I'll assess each person. It also tends to put the patient at ease -- someone is checking in and assuring him/her that they will be back.

Take a look at my list of six patients. Who would you have seen first? Who would you guess to be the most stable? The diagnosis doesn't always tell you what you need to know. I quickly learned that #1 was the most ill. This patient's condition had changed on night shift, and was worse when I got to him on day shift. Heart rate was tachycardic; he was diaphoretic, lethargic, edematous, had noisy respirations, and had crackles. When you see changes like this, routines go out the window. Put the patient on oxygen, check am labs, contact MD. End result? This patient received a dose of IV lasix and was transferred to ICU. An hour later, I was able to go back to my routine with my other patients.

The most stable patient was the one who passed out in church. Although this patient was stable, she wasn't a low maintenance type of gal. She wanted to go home -- NOW. Where was the doctor? Why weren't her home meds ordered? Why weren't her meds given first thing in the morning? What were her test results? In this instance, you have to be patient and diplomatic. If that doesn't work, beg & plead with the doctor to discharge the patient as soon as possible.

Right when you think you're getting your day back on track, something is bound to happen. Patient #4 may decide to have chest pain (nitro SL x 3, STAT EKG, repeat VS, call MD), and #5 has uncontrolled pain (lidoderm patches are wonderful). Throw an admission and a discharge into the mix, and you have one busy day. Oh, and don't forget to discuss patient needs with doctors as they round, phone calls to/from pharmacy due to med concerns, and critical labs to be addressed.

How do you manage a typical med/surg day?

1. You need a good brain. No, not the one inside your skull, but the paper kind that keeps you organized. Everyone has their own system. Ask around, try different ones out, and then use what works for you.

2. Never take shortcuts when it comes to medications. Look up unfamiliar meds, follow all precautions, and always check your 5 rights (three times, every single time). You really need to have a healthy fear of the harm you can cause.

3. Learn to always trust the nagging voice inside your head. If something doesn't look or feel right, it probably isn't right. That was certainly the case with my first patient of the day, and I have many more examples just like that.

4. Remember the Golden Rule. This applies to patients, aides, pharmacy, PT/OT, dietary, RT, secretaries, MDs, housekeeping, transport, and anyone else I failed to mention. Most interpersonal conflicts can be avoided by being kind and showing respect to all you encounter.

5. Ask questions!! Yes, there are stupid questions, but don't let that stop you. I've earned a lot of respect from people by being willing to admit that I don't know all of the answers. The more questions I ask, the more I learn.

6. Use critical thinking. When I was in nursing school, I hated some of the critical thinking exercises we had to complete. Now, I can't say enough how important it is to stop & think about all that you are doing. Do you really want to give heparin to a patient with critically low platelets? Do you really want to give that oral diabetic medication to the patient who's blood sugars have been low & hasn't been eating much? What about the patient with back pain? Would a lidoderm patch help more than the narcs? (yes -- I love patches...)

7. Have a sense of humor! Don't take yourself too seriously. If you can laugh on a crazy, busy day, you'll manage much better.

Again, I never expected to love med/surg nursing. I thought I'd give it a try because I was always told that it is the best place for a new nurse to start. After a couple years, I have to agree with that advice. Med/surg nursing exposes you to a variety of medical/surgical conditions, AND it enables you to hone your organizational skills. It really does teach you how to nurse on the fly.

Thank you so much, DreamingTree, for sharing with us! It definitely sounds like you get a wide variety of experiences in Med Surg.

Sunday’s Specialty – 1st Edition – Neurology Nursing

I am so excited about this first edition. When I contacted Jo over at Head Nurse to see if she would be interested in contributing I was meet with an enthusiastic “hell yeah”. I was honored that she was so willing to share her expertise with us. She is an amazing blogger. She tells her stories with honesty and hilarity all in one. She loves her job and it shows. I absolutely love reading about her experiences and am so thrilled that she agreed to share the love with us.


So without further ado, here is our first edition of Sunday’s Specialty. A look into the world of Neurology Nursing brought to us by Head Nurse. After you read about it, head on over (no pun intended) to Head Nurse to read more about life in Neurology.


Neuroscience, or: Brains: They're not just for zombies any more


I am a neuroscience nurse. Brains and spines and peripheral nerves are what I do. I got into the field totally by accident and stay in it for two reasons: first, I love what I do; second, when you say, "I work in neuroscience" to a skeevy guy at a bar, he immediately fails to make any nurse-related jokes he had in store and instead looks at you with new respect.


Neuroscience is interesting. It's never the same two days in a row. It requires smarts, creativity, endless patience, and a certain level of steely determination. It also keeps you young, makes your skin clear and luminous, and improves the color and texture of your fur.



Okay, not really. But you do get to work with some amazingly smart people.



WHAT THE HECK IS THIS "NEUROSCIENCE" THING, ANYHOW?


Neuroscience is anything that has to do with the brain, the spinal cord, or the peripheral nervous system. Anything from brain tumors to spine injuries to strokes to MS, ALS, or CJD can fall under this category. Basically, if you have a problem in your central or peripheral nervous system, you're a neuroscience patient.


The fascinating thing about neuroscience is this: once a surgeon gets his fingers into your brain (as it were), everything else in your body is affected. I tell my patients who are recovering from brain surgery that their recovery process is very much like trying to walk on a sprained ankle: the portion of their body that's getting the most use is also trying to heal at the same time.


This means, realistically, that I have to be aware of everything from heart rhythms to electrolyte balances to muscle strength on an hour-by-hour basis. Brains and spines and nerves affect *everything*, so you have to be flexible and have strong nursing skills all around.


WHAT I DO ALL DAY


Basically, caring for the neurological or neurosurgical patient is the same as caring for any other patient, with a few little tweaks.


If it's a patient with a spine injury, a lot of what I do is focused on preserving or restoring any function the patient can have below the level of the injury. Skin care and physical therapy are huge in these cases, and the patients can be very labor-intensive--things tend to go wrong suddenly with high spine injuries.


If it's a patient whose post-op from having a brain tumor removed, there's a fine line I have to walk between pain control and sedation. There are also issues with salt-wasting and diabetes insipidus and seizure control, depending on where the tumor was. And, of course, there are hourly neuro status checks, to make sure that nothing's busted loose or changed inside the brain.


If it's an occlusive stroke I'm dealing with, there's the whole science behind balancing declotting the area with TPA versus not allowing a reperfusion injury to occur. If it's somebody who's got one-sided neglect, care can range from teaching them that one side of the universe still exists to moving everything in the room around to reinforce that concept.


If it's something that affects the peripheral nervous system, or something like MS or CJD, well, whole books have been written on nursing care in those situations. Let's just acknowledge that the nursing care for patients with peripheral nerve injuries or demylenating diseases is complex and creative.


WEIRD STUFF YOU WON'T SEE ANYWHERE ELSE


Drains coming out of people's backs. Drains coming out of their brains. Real live cases of mad cow disease, without the cow exposure. Strange things nobody can identify. Worms in brains. Foreign objects in brains. People drilling into other people's brains at the bedside.

THE UPSIDES AND DOWNSIDES


Let's cover the downsides first: both the patients and the doctors tend to be strange in the extreme. If you don't have a lot of patience for deciphering what your patient who can't talk is trying to say, and if you don't have a lot of patience for doctors who apparently weren't raised on this planet, you won't last long in neuroscience. The work is hard--sometimes physically as well as mentally challenging--and sometimes heartbreaking...but that's the same all over nursing.


The upsides to doing neuroscience are these: you never get bored. Neuroscience is something that garners more respect than other fields, because it's seen as the province of extremely smart people. It's sexy as hell. And, if you're a big ol' geek like me, you'll find yourself fitting in perfectly with the group of smart, geeky, curious people you work with.

SOUNDS GREAT! WHERE DO I SIGN UP?


As I said, I fell into this specialty entirely by accident. If you want to do neuroscience on purpose, though, I would recommend that you find a good teaching hospital with a good neurosurgery and/or neurology reputation to work at. I emphasize teaching hospital because you'll have a whole lot to learn, and teaching hospitals attract people who, well....like to teach.


Med-surg experience is not necessary before you go into this specialty. The care is weirdly different in a lot of ways from straight med-surg, so the two don't overlap much.


As far as education goes, a good grasp of where the brain is (on the top) and where the spine is (down the back) is really all you need. Protocols differ widely from facility to facility, so you're likely to learn everything you need to know, and then some, once you start work.


I love my job. It makes sense to me, what the brain does and how it affects the body. I love my coworkers: they're smart, funny, and insane. I love my patients, who show me all the weird quirks the human machine can develop after an injury to its computer system. I say to all of you who might be interested in neuroscience as a career, c'mon in! The CSF is fine.

 
Thank you so much Jo, for giving us an incredible look into the world of Neurology Nursing!!