Monday, August 19, 2013

CPNE Journal

Again..a few years late, so please make note of that. Here is a journal about the emotional roller coaster the CPNE put me on.

I received my test date of March 12th-14th (Racine, WI) on January 1st after a great New Years Eve party. Use your imagination as to what kind of state I was in.  I quickly added up the weeks I would have to prepare for this exam.  Ideally I had wanted 3 months of preparation time.  Total amount of prep time – 10 weeks! AH!  From the moment I had enrolled in Excelsior and learned of the monster known as the CPNE, I had promised myself I would attend a workshop – no matter what!   I tried to figure out scheduling for work and frantically started researching workshop options, times and dates.  This did nothing but waste valuable study time for me.  I spent endless hours trying to find the best flight/hotel deals to random places throughout the country leaving from Michigan.  I quickly learned that going to a workshop would cost me almost at minimum $1000 or almost as much as the CPNE.
Finally, with encouragement from a past contact (Dana Dazet!) I bit the bullet and made the decision that I wouldn’t take a workshop.  I spent days and weeks fumbling around with equipment and trying to teach myself.  I ordered Rob’s Videos, Sherri Taylor online, Excelsior flash cards and did some of the online workshops through Excelsior.  Out of everything, I STRONGLY RECOMMEND the products from Excelsior.  Please do yourself a favor and take the documentation online conference through Excelsior.  I truly believe it was my saving grace when it came to the actual test time.  I wish Excelsior would put something together for the labs.  If they would have had that, I believe I would have been much more confident.   I also encourage you to set up advising calls from week 1 with Excelsior specifically with Civita and Amy E. Submit care plans to Dr. A – it’s free.
Skip ahead to March 11th. J  My husband and I left for Racine, WI.  Google maps estimated a 5 hour drive and that was if we were lucky enough to not hit traffic in Chicago.  We didn’t hit traffic, but it was a terrible down pour for the first two hours.  It was at some point during the drive I realized I had forgotten to pack pajamas and deodorant.  That’s when the nausea started.  We arrived at the Marriott in Racine 1 hour ahead of schedule!  Thank god!  We get to our room which had a terrible mildew odor.  Our window was covered with lady bugs (I think also known as Japanese beetles or something).   I was so stressed I didn’t even care. The room was decent in size but it was closing in on us because of all the CPNE crap I had insisted on bringing.  I didn’t even want to look at it by the time we arrived.  My husband was looking forward to getting away from his office a little bit as he wanted to get ahead on some work.  He sat down to pull out his work laptop and guess what? He had left it at home.  Again, my stomach sunk.  Were these all signs as to how the weekend was going to go?  My husband got over the fact that he had left his computer at work and dragged me out to get some food.  This was the first fast food meal of many throughout the weekend.
We were woken up in the middle of the night of someone trying to get into our hotel room.  I hope they were at the wrong room, but they were trying awfully hard to get in!  My husband opened the door to a guy walking away – drunk and stammering “sorry man, just trying to get into my girlfriend’s room.”  Great!  Another sign!  I was up by 5:20 on Friday morning.  I took a Phenergan because I thought for sure I was going to vomit. We opened up our drawers to find lady bugs in our clothes.  My husband went down and complained.  The only thing we got was a room switch.  I spent the rest of the day on edge and packing the fricken wound!  Around 1pm I started practicing my lab mnemonics I had learned 3 days before (yes, only I would do something like that!)  My husband tried to quiz me, which was helpful and confusing all at the same time.  By 2pm, I was feeling a little calmer.  I finally came to the realization that the CPNE was knocking at my door and there was no avoiding it.   I took an Inderal 10 mg at 2:45.
The shuttle service arrived at 3:30 pm.  There were 6 of us and we kind of sat there quietly for a minute and then one guy asked if it was our first time.  He was there on his second attempt – same site.  Then I blurted out my anxiety and a few others followed suit!  Yes, I became an entirely different person that I do not know for the weekend!
We were greeted in the lobby by the CA - Beth.  I had read about Beth in various posts about Racine and kind of knew what to expect.  She’s in her 70’s, runs marathons and rides motorcycles.  She did a great job at making us feel at ease.  She read the standard orientation and gave us ample amount of time to play with supplies.  I went through everything.  I was so happy to see that the gauze was in fact 8-ply - the only thing I had practiced with.  The wounds however were not the same as Excelsior wound kit!  One was extremely shallow – no depth at all.  The other one was way deep and just plain crazy, no idea how to explain it.  I decided to open up the gauze and to my surprise, it was totally different then the 8-ply I used!! Oh crap!! We were all panicking trying to figure out how to pack the wound and I was so stressed I just started laughing about everything.  Beth returned to find her set up labs completely torn apart – ooops!  We got slapped on the wrist a little bit because I guess we went a little crazy opening up all the supplies.  That’s when I started getting nervous, my thoughts were “Please don’t yell at us, I’m already nervous!”
Then the CE’s came in.  Yeah, they didn’t look like the ones in Excelsior’s DVD video!  For whatever reason, I felt immediately intimidated!  Guess what station I got first – WOUND!  I took a deep breath and asked if I could rearrange the wound, the CE responded with “you may do with whatever you want.” My start time was 1745.  Guess who couldn’t open the packages??  I went through 2 or 3 ABD pads and the sterile gloves stuck to the paper and I decided to use 2 or 3 pairs of those! The CE stood in pretty close proximity while I began packing with this gauze I was not used to working with.  I had the flat wound which was not working for me.   After 2 or 3 minutes, I decided I must have contaminated at some point.  Pulled it out, threw away my gloves and started over again.  I looked at the time and it was 1755.  Finally, I laid down the packing to the best of my ability and it looked like crap.  I covered it up with a 4x4 and could barely tape the ABD pad on I was so nervous.  I looked at the clock and it was 1800.  By 1759, I had already decided I would be failing my first lab station.  The CE asked me if I had completed all my critical elements.  I said “yes, but probably not in time.”  To my surprise, she said “congratulations, you have passed.” I let out a ridiculous gasp and almost cried!  The CA came running over to me and shushed me.  I thought for sure I had failed.  I was immediately rushed over to the IV drip station.  I had the same CE as an evaluator.  For this station I wrote out my mnemonic and followed it.  As I was verbalizing everything, the CE said “Sh, I’m right here, you don’t have to talk so loud.”  I didn’t even feel like I was talking loud!  I apologized and was embarrassed. I’m not a loud person, really!  My drops per minute came out to be 38 and I decided to contaminate the IV bag when removing the WHITE tab (not blue) from the medication. The white tab is very difficult to pull off! I have no idea on my time frame for this lab.  I reviewed my mnemonic one last time before verification and realized I had almost forgotten the signature at the bottom.  The CE did stand and count with me for one full minute.  “Congratulations, you passed!”  I was finally starting to feel comfortable.  Next up was IM/SQ.  I had to draw up 1.5 ml for an IM injection.  I saw the rulers coming out for dorsal gluteus, and knew right away I was going for vastus lateralis.  I put my hand on what I thought was the greater trochantor, and where I thought the knee was and went right in the middle 3rd.  The CE responded: “Thank you, leave that needle there in place and continue with what you would do.”  My heart sank as I finished knowing Beth would be coming over to review my injection site.  I signed the MAR, Beth came over and said “what’s the problem?”  Injection site was fine!  The CE said “have you completed all the critical elements?” I said “yes” she kind of gave me a funny look and I gasped hysterically again as I realized the needle was still in the site.  I quickly grabbed it and threw it into the sharps container.  Beth looked at me and said “Now what are you doing?” Obviously the entire flow of the lab had gotten messed up (theme of the weekend).  Anyways, another PASS!  Last but not least IV push.  2 ml over 30 seconds!  God is good!!     Just an FYI, no one seemed to be overly concerned with air bubbles.  
The last CE who had done my IV push lab was going to be my CE for my first PCS.  Did I mention I was the last one to be done with the labs?  She took me up to the floor and explained my patient to me.  My brain was fried at this point.  I was hungry and tired.  The CE was so nice and caring and I knew I needed to pass this PCS for sure. 

 I went back to the hotel and my husband took me to get some more fast food.  Then it was care plan time.  I threw a care plan together knowing I’d probably have to change it the next morning.  It was 11pm by the time I TRIED to go to sleep.  I was up at 3 am ready to puke again.  I sat on the floor of the hotel by the light of the bathroom and forced myself to drink water and eat some bagels with cream cheese.  No fainting was going to be allowed at my CPNE!  I took an Inderal at 6:30 and by 7:15 I was up on the floor still nauseated and feeling dizzy. 
My patient was an 87 year old female post hip pinning.  Areas of care assigned were medications (ended up only being 1 – Colace!), PVA assessment, Respiratory Management, Mobility, – OOB to chair/bathroom and I/O.   I feel like there was something else too, but I can’t remember!  Care plans – Risk for Falls and Impaired Physical Mobility.  I got in the room and everything just flowed except for the fact the patient wanted to talk up a storm!  I couldn’t get a word in edge wise.  My grid? Yeah, went out the fricken window!!  I think I did vital signs first.  The CE was great and just verified the numbers once I said them out loud.  No need for second guessing there and manual BP was done!  I spent a tremendous amount of time in this room and the CE worked right alongside with me.  We did a few things extra for the patient.  She was having some pressure areas on her elbows and needed some chap stick, etc, etc.  Finally I sat down to chart.  I went with “Impaired Mobility r/t right joint stiffness as evidenced by difficulty changing positions.  I had a terrible time coming up with patient responses, but made it work.  I actually went with “goal partially met.”  I had always heard stay away from that.  Apparently I was able to justify it because it was a pass!  I expressed my anxiety to the CE about time management and she thought I did a good job managing my time.
I arrived back to the hub room to find another student who had just failed her first PCS.   She was HOT, and that is putting it mildly.  I quickly learned that I would be assigned to the CE who had just failed her.  I popped another 5 mg of Inderal.  I told myself ‘just go with the flow.’  (Thanks TERRI BRADY).   
I sucked it up and smiled pleasantly and acted like I had my crap together!   Pediatric substitute – 87 year old man with COPD exacerbation.  Areas of care: Abdominal assessment, Oxygen Management , Respiratory Management – Deep breathing/Coughing – Pursed lip breathing (what the hell!), Mobility walk to doorway in patient room co-assigned with PATIENT TEACHING, IVAD flush!! And yes, the patient was being discharged in an hour. J  I quickly pulled a grid together and care plan.  I had a hunch this CE was into Activity Intolerance, so I went with that and Risk for Falls – no time to get fancy!  The CE brought the nurse over and I had no idea what to ask.  I didn’t even ask about baseline vitals.  I kept my head on straight and told the CE I wanted reference material and/or hand outs that may be available about pursed lip breathing and activity intolerance.  (The girl that had just failed was because of this pursed lip breathing!)  I know how to instruct on pursed lip breathing, but really have no idea about the rationale behind it.  The CE was gone for a while and came back empty handed.  I said ok, I’d like to speak with the staff nurse who was AWESOME, but thought I was kind of crazy.  She said respiratory therapy does all of that stuff and advised me to instruct the patient to “chill out if he’s out of breath.”  I asked her about pursed lip breathing and gave her a demonstration and she was like “again, respiratory therapy.”  I told the CE I was almost ready for my care plan review and wanted to make a few notes on how I wanted to present this breathing technique and the mobility issue.  The CE said she saw my demonstration and thought I had a pretty good understanding of it.  Care plan was approved and we both agreed I needed to get in there and get started.  She said she would remove some of the assignment if we ran out of time, but I would have to justify it.  Whatever, I just wanted to get started!
Ok, another animated talker!! Worse than the first one! Oh my goodness!  He was all over the place joking around and it was taking FOREVER to get anything started.  I decided to go right into vital signs.  The first hiccup of the PCS – BP up to 178/99.  I knew he was probably fine and they were going to be changing his medication soon.  I gave these numbers to the staff nurse anyways!  Here’s when the time starts ticking!  Ok, back into the room to work on vital signs – apical pulse.  An apical pulse with a-fib and exertional dyspnea was horrible to try and figure out!  I had looked at the pulse oximeter to get an idea so I could match it up, but was not sure of myself!  Oh crap!  I didn’t quite want to declare anything yet.  Next up I decided to do respiratory management and go into this BS speech I pulled out of nowhere about pursed lip breathing.  The patient repeated it to me telling me that he was a trumpet player and that he could do it forever.  It was a little ridiculous!  Finally, the CE interrupted and said I was doing a great job, but wanted to emphasize that pursed lip breathing helps bring up air from the base of the lungs.  I was so thankful for that!  I can’t remember what happened next, we were probably caught up with the antics that the patient was exhibiting.  At some point the patient switched over from his chair to the bed and I decided to work on respiratory management.  I instructed the patient to take deep breaths as I auscultated.  We finished this portion and the CE said we need to step out for a moment and sent me down the hall so she could call the CA.  Oh god, now it’s really over!  I went down the hall and twirled the little rosary around I had put in my pocket.  She came back, and said “your patient saved your butt!”  You didn’t instruct him to purse lip breathe while taking deep breaths, but he did it on his own!  Get back in there and let’s get done.  Unfortunately, respiratory therapy was in there.  She sent me off to go chart - nothing to really chart at this point!  When we finally got back into the room, where was I supposed to start off with respiratory management?  The CE instructed me to continue where we left off and I made sure to instruct the patient to PURSED LIP breathe upon exertion.  I did the mobility thing, told the patient to relax if he felt short of breath and then had him lay down for the abdominal assessment (after he had to make a little weewee).  He lied down and asked me if he looked pregnant.  Did I mention animation?  I somehow fit in oxygen management in pieces – it was a train wreck!  Finished that up and knew I had a novel to write.  I documented to the best of my ability and did not feel good about it.  I got the “I have to advise you your time is almost up and I will give you 5 more minutes.”  I had no time to double check what was written.  I went down the hall to a waiting area but couldn’t sit.  I was leaning on a ledge (playing with the rosary again) and Beth came out of a stairwell.  I saw her and I couldn’t contain myself anymore and started tearing up.  I felt I had poured my entire heart into that PCS and now I was going to fail on documentation!  She pushed me into a conference room and basically told me I was a big girl and to quit crying.  The CE came down and told us “It’s a pass.”  Oh thank god!! I was exhausted and mentally drained.   I returned to the hotel and my husband went and got me more fast food.  I took a nap for about 1 hour and then read unit IV in the study guide again.
Day 3 I left the hotel more nervous than other.  I took the Inderal and did not feel it helping at all. My heart was pounding and racing.  The thought that I was so close for it all to be over, but one slip up and I would be done, was terrible. My husband thought for sure I was going to have a nervous breakdown as he sent me out the door.
There were 5 of us left when we congregated in the hotel lobby. Only I and one other girl had a chance for a perfect CPNE. The others all had repeats to do.  I was so anxious, and the guy who was there on his 2nd attempt said “relax, you only have one more to do!” That was so thoughtful of him to say, and I hope he passed! We met in the cafeteria and Beth gave us our morning pep talk speech. She asked us how it was going in the patient’s rooms and if we were being sensitive to their needs. She elaborated on how hard it is if we have talkative patients. One of the girls started going off about how her patient spent all this time with her breakfast tray, but in the end wanted toast. The girl was upset because she had to make the toast. Beth warned her to watch the comments she was making, but she kept going with them. My eyeballs were about ready to pop out of my head! I couldn’t believe she had the audacity to speak like this in front of Beth.
My 3rd CE that I was assigned to was the same one who evaluated me on the wound and IV drip.  She was very nice though she made me quite nervous. I truly believe Beth asked her to make sure I did not go over my time limit based on all the events that happened during PCS #2. Here was my assignment: 75 year old male, (can’t remember the primary diagnosis, but he had diabetes)Areas of Care: Vital Signs, PVA assessment and Skin assessment on bilateral lower extremities, Medications 5 PO and Insulin, and ding ding ding – WOUND MANAGEMENT. My stomach dropped. She told me that the patient dictated his left foot ulcer dressing change to her. I went back and forth between Impaired Tissue perfusion, Impaired Skin Integrity and somehow landed on Impaired Tissue Integrity.  I could not decide on a second, easy care plan for the life of me! Then I overheard the patient complaining about pain – Acute Pain.  For the Impaired Tissue Perfusion I decided to make my goal “patient will verbalize understanding of current treatment plan” or something to that effect.  I thought great, I’m not going to know how to do this dressing change, so I’ll just let him tell me and have it be an easy goal met.
My planning phase started at 7:35, and I think I didn’t end it until 8:05, maybe even later. It was way too long and I have no idea where the time went! I knew I had 8:30 medications, and they all required BP’s and pulses. I busted in there, thank god he was done eating. I set his fluids aside and started on the vitals – all automatic except for a radial pulse (finally!). Since he had just eaten, I didn’t take the temperature. I don’t know where I got this idea that vital signs had to be claimed before medications, but I said “I want to declare my vital signs.” The CE looked at me with a blank stare and said “Do you really want to do that?” I said “Um, no, I guess I’ll retake them.” She said, “Do you have a full set of vital signs?” Then I realized I didn’t have the temperature. Oh boy, I was losing it already! I took a deep breath and tried to stay focused. The CE had to give 2 meds before me and I stood out there taking a ton of deep breaths. I gathered my medications so the CE could verify them. I could barely draw up the insulin I was so nervous. Managed to drop the insulin in the sink, it was awful!  I went into the room and opened up the packages, thank god none of the pills went flying.  Got ready to do the injection in the left arm and shook the entire time. I kept taking deep breaths to try and not let the nerves control me. I was supposed to put the patient back in bed since he was up in the chair. I thought that would be the best place for the dressing change. He refused and wanted to stay in the chair. I wanted to take a minute and go get the necessary supplies for the dressing change. Oh of course not, they were in a basin in the room. The CE suggested we have the patient prop his legs up on the extra chair in the room. Thank god, because I was no longer thinking at this point! The patient was talking the entire time. He was great, however hard of hearing, so lots of repeating on my part and he was a SLOW talker.  I could not get myself organized to do this dressing change. I really didn’t feel that I had that great of instructions. The supplies I had to work with some had already been open. I really had no idea what I was in for when I was going to pull off that bandage. All I knew is that it was some type of foot ulceration. I pulled the bandage off and all I could see were some 2x2’s in between the patient’s toes. I was relieved not to find a big, eschar tissue ulceration on the heel.  I decided to do the PVA and skin assessment first. His feet had a lot of pitting edema and I could not feel the pulses to save my life. I looked over at the CE and said, I’m having a hard time, should I attempt with a Doppler? The CE responded with they have not been using a Doppler.  Then she advised me to slowly move or push the fluid and I was able to feel the weak pulses.  Then it was time to move onto the dressing change. I have SOME experience with wounds and found myself immediately wondering if the technique I was about to do was correct. I stared at the kerlix 4x4’s in an already open boat wondering how to get saline on them. Oh boy, it was bad!  The CE finally directed me to hold the 4x4 over the trash and offered to pour saline on it for me. I went ahead and dabbed at the ulcers with the 4x4 not knowing if it was the right thing to do – all very silly, I know! I changed my gloves and searched for a q-tip to apply the ointment to the ulcerations underneath the toes. The patient wanted me to put some of the ointment on my gloved hand so I would understand the consistency. The CE interrupted and said “Erin is on a time limit, and she needs to finish up.” Had I mentioned he was providing me with step by step directions on how this was to be done? The CE held some 4x4’s in place for me (the patient wanted us to tape them) and then I wrapped it as quickly as possible with an entire kerlix roll. This was all something I would have done at my work in about 15 minutes and I think I was in there for about an hour. At some point, Beth poked her head in and said “Hi, same finish time?” The CE nodded and said “Yup.” I looked down at my watch and it was something like 9:45, my PCS end time was supposed to be 10:05. My heart went into my throat. I still had to do a second skin assessment area. I made a split second decision and looked at the back of the head (which I could not remember was called the occiput) I cleaned up my mess, pulled the trash and realigned the patient in his chair. I quick told the nurse the patient was still complaining of pain in his arm despite the fact the pain medication had been given about an hour before. I sat down, looked at my paper and realized I missed hydration status. Grabbed the CE and asked the patient to stick his tongue out and saw furrowing up the wazoo.  Sat down again and wrote the most inexperienced charting ever in the form of chicken scratch. I wrote my mnemonics out by the narratives so I wouldn’t miss a thing. It was horrible; I could not think of medical terminology at all or put together anything that flowed correctly. Then I heard the CA on the floor and I heard say “Yeah that would be a failure.” Oh geeze! Now what did I do? I think it may have been over the fact I reported the pain to the nurse so late. Then I heard “well, that’s ok then.” I kept thinking, if I’m going to fail, please come and do it now before I fill out any more documentation!  I got the “You’re time is up, but I will grant you 5 more minutes speech again.”  I had almost all my blanks filled in, but knew I probably wouldn’t have a chance to double check anything again. I looked at my evaluation page and tried to count boxes, nope, couldn’t even count. I think my final diagnosis was Impaired Tissue Integrity r/t diabetes mellulitis as evidenced by left foot ulcerations. The CE came back and I handed her the paperwork. I had to wait at the desk where I was charting and I sat there, prayed and played with the rosary. I heard her say my name and wave me over. She had a big smile on her face and said “You passed.” I let out a sigh of relief and apologized for my terrible charting. She said that I had everything I needed. I was a little emotional, but managed to contain myself. I tried to express to the CE that I was most nervous for that PCS and didn’t get a whole lot of response from her. I ran into the other girl who was on her way to having a perfect CPNE as well, and she managed to do it too! I waited for Beth and signed the strength book – again, with immature writing that made no sense. The girl who had the toast issue asked me what care plans I had used and I wanted to scream.  I told her I just winged it and wondered if she did not hear the statement about the Excelsior Academic Policy. She was waiting to do one of her repeats. Beth came down and hugged me and said “after all those tears yesterday, here you are.” I also met the director of the MPAC who hugged me as well. Then I got the simple paper congratulating me on my pass and of course the “you should go to Excelsior for your BSN talk.” I didn’t say it, but Excelsior is not getting any more of my money. I packed up my stuff and thanked everyone.  All of the CE’s cheered me out of the hub room.
I truly feel I was successful with my CPNE due to my ability to communicate effectively with patients and staff. Aside from my 3rd PCS, I did not let my nerves show at all with the patients. I did put grids together and I think that proved I knew my critical elements. However, I wasn’t able to utilize them to their full potential. That may have been due to lack of practice on my part. I’m happy it’s over – 4 days before my 30th birthday! 

I wish all the future testers luck! 

And when it gets tough................tell yourself this!

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