IV Starts L and D Style

I've failed at two of my two attempted IV starts in the past week. My preceptor said to me, "It doesn't get any better than this. In labor and delivery women have big, fat juicy veins." That made me think of what my son calls blood vessels: blood pipes. That's a much more accurate word for 'em, I think. When I think "vessel" I think earthenware, handles, a spout. Maybe a gravy boat. A vase, but one with useless little ear-like handles up at the neck, you know the style. Maybe blood tubes, but Tube Week has come and gone here on StudentNurse. Yes, I was sad you missed it, too.

But I think it *does* get better than this. First, I have to use lidocaine. Have you done that yet? You use an insulin syringe and make a little lidocainy bleb just under the skin and then wheeeeee! that vein in obscured or pushed to the side and suddenly you're going nowhere fast with that next fat needle. My precpeptor allowed me to go without the lidocaine, but I decided I would give my patient a choice (so, you'll be poked TWICE with TWO needles, but it might make the second stick hurt a wee bit less. What's it going to be gov'nor?) And, good afternoon, we're going 18 gauge here people. "What if they need blood products?" It's not like the needle is as fat as my pinky, but that monster obliterates those fragile hand veins. Gotta go for the forearm. You can't see 'em, you may not be able to feel 'em (especially with that bleb), but you know they're there.

So, I've gotten into the vein (check out the flashback in that hub!) and I've gotten the needle into the right spot, but then chickened out on the digging around for the vein because my patients were squirming so much (yeah, so much for that lidocaine). My precpetor was able to get it in with my start by pulling back a little and going a little deeper. And then blood comes kasplorching out on the chux ('cause remember it's that big fat needle in a big fat pregnant vein in that blood pipe-y forearm neighborhood...) and then, the final L and D challenge, you have to risk the whole IV start to draw blood because we don't want to stick these laboring women more than is necessary. So, I apply the Vac-U-Tainer (JC, how about some logo artwork?) and (with the first gal) popped four tubes in and wiggled four tubes out.

Oh yeah, L and D IV starts are a dream. Next time: no lidocaine for you!

So, I go to "work" and I'm all preening in the mirror beforehand. How do I look? And why do I care? Have you ever been in the nurses lounge on an L and D floor? Take a look around. Hair is neat, earrings and necklaces are worn, jaunty sweaters are thrown over festive scrubs. What's up? I have been in several photos now: Here's baby's first bath. Look at baby getting his first little beanie. Baby's first hepatitis B vaccine: aw, cute! And some of the posed ones: Here's our whole birth team.

But don't look at the shoes in L and D. My preceptor has some tennies with mesh and there's a blood stain on them. One of the midwives has a pair of dark blue Danskos that are really nasty looking. I notice lately she's been wearing shoe covers. I have my bright-white-from-last-year's-dark-days -of -all -white shoes just waiting to be oozed or kasplorched on. On average, a woman loses 500 ml of blood during delivery. That's two cups. And, name that bodily fluid, many of them make an appearance during labor and delivery.

NCLEX tip #2: When in doubt, assess.

PM Shift

Working the PM shift...wait, I can't call it "working" can I? I don't know what else to call what I'm doing (precepting the PM shift, doing the PM shift, riding the PM shift, studenting the PM shift?), so, let's just say "working" until someone comes up with a better word...

Working the PM shift is making me a somewhat lonely person. I can't call most of my friends when I get home (most are doing days, some are doing nights so one is reluctant to call those night-shifters at all because they're probably sleeping at noon in a room with tinfoil taped to the windows or something). The kids are asleep and Mr StudentNurse is grouchy waiting up for me. I drop the kids off at school in the morning and say, "See you tomorrow." Ouch. Have I mentioned that one of the reasons I went into nursing is that it's a good Mom Job? Have I mentioned that nusing student is not at all a good Mom Job? I do like working the weekends, though, I get to hang out with the kids in the morning (Well, I'm sleeping past 10 AM on the weekends. Can you blame me?) and afternoon and I get to kiss them goodnight at 2:30 (oops, sorry at 1430. That was a potential med error..) instead of at 0800. Sure, the hubby is grumpy when I get home, but it's a Saturday night, right? He can take it.

Did I already tell you how much I LOVE labor and delivery? I am going to cry and cry (and cry) when my preceptorship is over. My second patient tonight was in there with her family. She had on pajama bottoms and wanted "female providers only" (she's Muslim) and her mom was in there rolling on her back with a wooden rolling pin. She was a tiny little thing with an out-sized tummy and even at 8 cm and with no pain meds on board would politely say, "I'm having a contraction now," and breathe quietly. My preceptor let me take care of her with minimal help and, at first (with intermittent monitoring) it took me FOREVER to find that babe's heartrate, but by the end of the night I knew EXACTLY in what neighborhood I could pick up that hummingbird-fast heartbeat. I actually felt...competent.

Doesn't that picture look like it was taken with an electron microscrope? It's actually a close-up of that funky, swirly cauliflower that probably has a name but it's 0130 and I can't come up with anything anymore.

Name That Tube

There's a large aspect of nursing that deals with tubes. You're either putting in a tube, taking out a tube, putting something into a tube (or, well, yes) taking something out of a tube or you're checking tubes.

So, my preceptor tells me, "We're going in to see the patient and I want you to check her tubes." Got it. Check the tubes. I check out her iv site and all the tubes stemming from it(lactated ringer's, Pitocin. ampicillin) I assess the Foley catheter and, hm, what else. Right. Her IUPC (intrauterine pressure catheter to measure uterine contractions in millimeters of mercury). I brush my hands together in that "I'm done and I'm washing my hands of it" gesture and then my preceptor says, "Don't forget the epidural." *Another* tube (connected to a locked plastic box. Oh what fun it would be for some, I suppose to have that bag o' bupivacaine and fentanyl). And this for a relatively normal delivery. (Yeah. We'll talk about that whole can of monkeys later) Are you keeping count?

One of the fun activities I get to do is to d/c ("discontinue" for you non-nurse-y types) the epidural catheter. You take off all the tape which runs all the way from shoulder to waist and from left to right side. That tape is almost embedded in the poor woman's skin and, after labor, pretty much I want to baby the new mom, but instead I'm removing the hair from her back: ouch. And then taking the epidural catheter itself out is unsettling. I can d/c a nasogastric tube, I can d/c an iv, but something about pulling that thin (thinner than a pencil lead) tube out of someone's back (pull down, not up or out)... It doesn't give easily, there's resistance and it's coming from the spine. Tip: yes, that's it: tip. Check for the tip (it's black) because it could get left behind (I've heard tales of this occurring, "Why just last week..." began one).

So, I'm motoring right along in studying for the NCLEX. I'm on page 228 (almost done: just 1000 + more pages to go!) and I'm about finished with the chapter called Tubes! (It's really called something like Caring For The Patient With Tubes, but I like my title better. It's more festive and jazzy). My favorite tubes are the GI tubes. And by "favorite", I mean that I like the names: Lavocuator (the infamous pump-your-stomach tube), the Salem Sump, and the lovely Sengstaken-Blakemore tube (I think the Sengstaken-Blakemores used to live next door to me) for all your esophageal hemorrhage needs (well, many of those needs, anywho). And you gotta love the respiratory tubes. Cuffed or fenstrated, single or double lumen: you want 'em, I need to know 'em to pass my boards! Do not get me started on chest tubes. Should it bubble? Is it ebbing and neaping like the tides? A possibly deadly leak in the system or normal functioning of the equipment? I remember in our skills lab, the instructor was so confused she said, "Read the manufacturer's instructions."

Another unsettling thing. In Anatomy and Physiology (geez, years ago now) I learned that we're all tubes. The center part of our tube runs from our mouth to our anus. I don't know why being a tube bothers me, but it does so I'm going to move on now.

NCLEX tip number one: If the question asks you which symptom requires a call to the MD and "stridor" is one of the answers you should pick it.

That's one of our inaugural cupcakes. My mom made the cupcakes, I did the frosting and the kids sorted out and sprinkled the red and blue M & M's.