As a nursing student stuck with pages and pages of powerpoint slides, I needed a great study guide. But how could I do that efficiently? CRNA school doesn't leave me much time to fiddle with microsoft word... so I use this hack I learned back in nursing school to utilize the PPT slides as the foundation for my guides that I can easily study from.
I completed my first clinical rotation as a nurse anesthetist student and I can say it was amazing! Prior to starting clinical I was having doubts about whether I made the right decision to start CRNA school, but once I was hands-on, actually intubating patients back-to-back, titrating anesthetic gasses, adjusting ventilator settings and extubating, realized how much I truly enjoy it!
The orders that are written for our patients is essentially our toolbox. In the CVICU, we have autonomy to be able to titrate meds like insulin, heparin and pressors, but there will come a time when you run out of tools or you're not sure which tool to use. Effective communication with the provider allows you to get what you need, or further understand why you're using a Phillips screwdriver instead of a flathead.
As a student nurse, I rarely interacted with providers. If a question was asked and I knew the answer, I'd respond, but as for advocating for my patient when something went wrong, I never really got a chance to experience it. We can learn about proper communication skills in school, but when it actually happens and you're a nurse needing to discuss something with your provider, it's important that you know your stuff.
When a critical lab value pops up, running to the provider with just the memorized value isn't going to be very impressive. Go through these steps before taking that plunge (if it's not emergent of course).
1. Do you believe it?
You may be asked this question as you're standing in front of your provider. You may be stunned because the next words you were expecting were a set of orders that you can implement. But do you believe it? Is that glucose value of 345 true? Did you draw it off of a line infusing TPN? Did you forget to pause the K and flush beforehand? If the value isn't believable, first figure out why and if it was a mishap, you'll still need to let the provider know. So say it wasn't a mistake or a human error. What do you do next?
Figure out possible causes for the problem. Look for trends. See if you're giving your patient fluids that can cause their lab values to be out of whack. Review the patient's history. Are they anemic? Do they have DI or SIADH? Is their LVAD working properly? If not, maybe we're hemolyzing their RBCs which is causing their Hct to gradually plummet (something I recently learned).
You may not be correct, but coming to the provider with suggestions doesn't just make you look better and shows that you took time out to think, it helps you learn and strengthen your critical thinking skills.
3. "What do you think we should do?"
Try and figure out a solution to the problem. Maybe they need orders to be on ICU protocol for their electrolytes, maybe we can slow that drip down. Maybe there isn't anything we can do. Think about it and come up with a solution! I guarantee one day a provider will ask you, "Well, what do you think we should do?" Be able to give your suggestions in a clear and concise manner. Don't let nervousness trump your confidence!
Communicating with your providers is an essential skill that you must have. Preparing yourself will make it a lot easier and will allow the conversation to become a teaching/learning moment instead of you walking away feeling incompetent. Don't ever be afraid to be your patients advocate. There will be times when your right, times when you're wrong, but the best part is knowing that you've learned something from the situation and knowing what to do when it happens again.
Disclaimer: The original post was posted back in 2014, I've added some things and updates!
After doing my clinical rotations on general med-surg floors, interventional cardiology, neurosurgery and peds... I felt most comfortable and the most confident when I stepped into the ICU. I don't know what it is about it, but I enjoy every part of being on a critical care unit. It was never scary for me seeing patients with a Christmas tree of IV pumps with lines and drains literally coming out of every orifice. I wanted to be an ICU nurse and I made that dream a reality.
Update: Prior to starting this internship, I began working as a PCT (patient care technician) on a step-down unit at a different hospital. I know nursing school is difficult, but I worked my junior and senior year... while being the president of my class, nursing school senator, tutoring nursing students and sitting on multiple committees (maybe it was overkill, but it definitely helped me to develop my time management skills.)
The level 1 trauma hospital I was interested in offers a summer internship program, and I told the nurse recruiter I wanted the most critical unit -- preferably the CVICU. She gave me a weird look, and told me she couldn't make any promises, but she'll try. I immediately started looking up for backup units, but nothing else caught my eye. I honestly didn't think I'd get it at all, I just kept hoping and wishing that the manager would approve of a summer student.
Update: I made sure my resume and references were on point! I included my past jobs and a list of my clinical rotations. If I can find it, I'll do a comprehensive review of resume writing throughout the nursing profession spectrum.
The nurse recruiter called me a couple of weeks later, on my 22nd birthday and gave me the news that I'd gotten the internship in the CVICU. I was ecstatic!!! I treated my internship like a 3-month long interview. I didn't just roll out of bed every morning and follow the nurses around quietly. I started researching things and reading the cardiac surgery BIBLE: The Manual of Perioperative Care in Adult Cardiac Surgery by Robert M. Bojar. I brought a notebook with me to my internship, took notes, drew pictures and asked questions. I didn't do this to impress them, but I was genuinely interested. It was amazing to see patients getting their chests opened at the bedside, ECMO (extracorporeal membrane oxygenation) or just setting up for a post-op CABG. Although I couldn't function as a nurse at the time because I was still a student, I made sure that I was seeing as much as I could, whenever I could. Some of the nurses allowed me to pass medications, "shoot numbers" on the swan and it was the best experience. Fortunately, I stayed on as an intern through most of the rest of my schooling, eagerly applied there as an RN and obviously got the job! (it still hasn't hit me yet...)
My advice to anyone that has already found their passion in nursing is to pursue it! So many people told me that they absolutely positively don't hire new grads in the ICU's and that I should get a few years of med-surg under my belt before I even tried to pursue it -- especially the CVICU. While I believe any experience is great experience, I knew med-surg nursing wasn't for me and it didn't make sense for me to pursue something I knew I wasn't going to be happy doing. I have A LOT of work ahead of me, but I'm truly ready. I'm walking around with this RN name tag and it just doesn't feel real yet. I can't wait for the day that I can confidently tell someone that I am a Registered Nurse.
UPDATE: Now that I am a SRNA, I do not regret going straight into the CVICU. When I did a bit of travel nursing prior to starting CRNA school, I floated to med-surg and the ED. It is a completely different way of thinking as a unit nurse vs. the CVICU. Some new nurses need the structure just to get a hang of things. But I would definitely recommend an internship in the ICU as a student over spending time on a med-surg unit prior to going to the ICU. Even starting off on a step-down unit would be more beneficial (in my eyes) if you're interested in the ICU to continue on to CRNA school. Others may have a different opinion, but I do not think that I'm at a disadvantage because of my lack of medical surgical experience. I honestly think that coming from the CVICU puts me at an advantage over other ICU's because you get the whole gamut! You're going to see the swans, patient's with respiratory disorders, strokes, seizures, and obviously heart issues. A lot of the nurses interested in CRNA school came up to our unit to learn about the swan because they never saw it before and they for sure can ask about it in the interview... I'm totally biased, but it's just something to consider....
Nursing school wasn't easy...but you can make it so much easier in 5 steps...
1. GET ORGANIZED!
During my first semester of nursing school I got a HUGE desk calendar, (I now have a dry-erase vinyl wall calendar) a paper planner and the app iStudiez Pro. After I printed out all of the syllabi, I went through each class and wrote on the calendar when major assignments were due, when all of my tests/quizzes were and any simulation labs. I then wrote all this down into my paper planner and then typed it into iStudiez Pro.
Although it seems like a lot, you don't have to use the app if you don't want to (I found by the end of school I wasn't using it as much), but this helps you to see the BIG picture, while also going day-by-day. You are going to feel overwhelmed, you're going to feel like ripping your hair out, but once you get organized your stress level will decrease tremendously. Time management is one of the keys to a successful nursing school adventure.
2. READ THE TEXTBOOK!
There will always be that person in your class that doesn't read, only studies off of the PowerPoint Slides and get's all A's. Realize that everyone is different, everyone has their own learning style and what works for someone else may not work for you... get over it, don't be jealous, go figure out how you learn best!
If you're not the person that can gain nursing knowledge through osmosis, I'm telling you to READ. This doesn't take as long as you think it will if you read SMARTLY. SKIM the chapters the night BEFORE class. You'll be surprised how many "ah-ha!" moments you will have during class if you do this. MAKE notes either on your ppt slides or in the textbook of MAJOR topics that are being covered so you know what to focus on. After class, READ/SKIM the chapter AGAIN! Half of this material you're already going to know since you read beforehand and went to class. Reading your notes/chapters as soon as possible after class will help you to retain all of the precious information. While you're waiting for your lunch, take out those notes and read through them. Trust me, it helps. Instead of waiting the night before the test, by reading your notes/skimming the chapter daily, all of the information will be there. It's pretty stupid to learn the information once, forget it because you don't take a half hour out of your day to re-read, then spend countless hours cramming that information you should've known. Work smarter, not harder!
3. PROFESSOR WHO?
I can't stress this enough... don't be that one student that sits in class quietly, never participates, never goes to see the professor and expect to get a recommendation for a job/internship (I used to be that girl). Just because you're so incredibly smart and don't need any help, make up a question or just stop by to say hello and introduce yourself. It's not just for people who are at risk for failing, it is a NETWORKING opportunity! Remember that your professors are nurses too, they're actually nice people (well, most of them are anyways). And they have YEARS of nursing experience. They may have impossible exams and boring lectures, but they want you to succeed and they hold the key to your success in their hands! When you're ready for that job, you can feel confident that you have a professor that can actually speak to your abilities -- inside the classroom and out. Don't sell yourself short from what your professors can offer you. Your recommendations can make or break you...so stop being so shy and get to know them! Professors are your soon to be colleagues...remember that.
4. GET INVOLVED!
This one is very near and dear to my heart. As I mentioned before, I am quiet, shy and usually stay to myself. But I forced myself to get involved and I found skills/abilities I never thought I had! I got involved in the Student Nurses Association (SNA) as a representative. Two semesters later, I became the President, I sat on the Student Well Being Committee and I was the School of Nursing Senator -- on top of all of that, I was working as a Student Nurse PCT. Woah there.
While I think I may have gone a little overboard, I am entering into the field of nursing much more confident because of my past experiences as a leader. Students think that because they'll never want to be a charge nurse, or nurse manager, getting involved isn't really worth it, but it is, and here's how.
Networking is always useful. You have no idea how many people I've run into and through basic conversation have influenced my career in some way or another. You’ll make great friends and great study buddies through these organizations and you find out what other people are doing and how they're succeeding.
Your resume will be golden! Your GPA is only a portion of what potential jobs will be looking at. There are real benefits to getting involved!
As President, my school sent me to two NSANYS and NSNA conferences -- for FREE. Meals, airfare and conference fees all paid for! That meant weekend getaways to NYC, Kentucky and being able to meet nursing students, prominent nursing leaders, and tons of nursing representatives from schools and companies from across the nation. I was also invited to be a guest speaker at the ribbon-cutting ceremony for our new nursing sim lab. I met the President of the college, the current NYS Senator and a ton of other important people. I was even invited to go out to dinner with my Professors and the Dean of the Nursing School! Who gets to do that? My point is, you don't have to spend all of your free time in organizations, but it will change you for the better and make nursing school much more enjoyable.
Fast forward a couple of years: Because of the relationship I had with my professor, I received an awesome recommendation from her for CRNA school. It definitely helps to get involved!
5. HAVE FUN!
I didn't have much fun throughout nursing school. I worked, studied, and worked. I regret not making more friends and going to those ugly sweater parties. I'm telling you to go out and make sure you have fun! Find a healthy way to relieve the stress of nursing school. You don't have to party hard or put your life in danger, but learn to manage your time effectively so that you don't get burned out. Get a free massage from your school (some schools have this), get a mani/pedi, go for a nice bike ride or run. Make sure you get away and when you get away you're not talking about nursing school!
Organizing your life, reading the textbook, developing a relationship with your professor, getting involved in extracurricular activities and just having fun are all ways you can enhance your nursing school experience. Don’t feel like you have to do it all, make sure you find the right balance so that your academics don’t suffer.
What are some ways that you’ve enhanced your nursing school experience? I’d love to hear from you!
I split this initial post into two because I can get a little long winded. However, I did some interesting cases this week, so I'd like to share!
Today I did anesthesia for ECT's (electroconvulsive therapy) and a Thyroidectomy.
My first day, I did 11 ECTs. Yes, 11. It is a wake up call because you think you're good at bag-mask ventilation... then you do ECTs and realize how much you SUCK. Haha... no seriously... everyone told me that's how it was going to be, but I thought I had my masking skills down. Uh no.
People really hype up intubation and it's obviously a skill you need to have to do this job, but people don't die from not being intubated. They die from not being able to VENTILATE ! So, please, don't downplay masking. It's essential to keeping your patient alive.
I’m going to keep it 100% with y’all. For the longest time I thought they didn’t even do ECT's anymore. Forreal. If any of you have seen the 1975 film, One Flew Over the Cuckoo’s Nest, its portrayal played a major role discrediting its use. As psychotropic medications came into play, performing ECTs diminished, then over the last 50 years or so it’s regained its reputation many disorders such as severe depression and other affective disorders.
Here's the rundown of how I learned to do ECTs:
Monitors are placed on the patient (HR, BP, SpO2, nasal cannula w/ETCO2).
Special leads are placed on the patients head (I did bilateral ECTs).
Once the patient is prepped, the medication Methohexital is given. It is considered the "gold-standard" and is a barbiturate that works on the GABA (a) receptors causing sedation.
After the patient is asleep, a small dose of succinylcholine, a paralytic is administered. Rocuronium/Sugammadex can also be used.
A special bite block is placed in the patient’s mouth that has an oral airway implemented into it.
Begin bagging the patient with the Ambu bag.
The patient is shocked, then the patient will seize.
Seizures lasting longer than 120secs generally require immediate administration of Propofol or Ativan.
During this time, you are monitoring the patients vital signs, and maintaining a patent airway.
The electric shock causes the activation of the autonomic nervous system with a parasympathetic discharge causing a brief bradycardia or pause (yes, it looks like your patient just went asystolic, but don’t push the code button!)
After this, a sympathetic response causes an increase in heart rate and blood pressure causing profound hypertension and tachycardia that can last 3-5 minutes. Antihypertensives such as Labetalol can be used if the hypertension is sustained.
Glycopyrrolate or Atropine is also given as a pre-mediation if the patient is bradycardic at baseline or if they become bradycardic from the procedure.
After the patient seizes, you continue to bag them until they begin spontaneously breathing!
Usually the patients aren't here for their first time. Look up what they've received before and prepare those drugs.
Some additional things that I've learned,
Other medications like Propofol and Etomidate can be used, but with some caveats. Etomidate doesn’t blunt the sympathetic responses to the seizure, and also lowers the seizure threshold causing a longer seizure. Propofol has its benefits of blunting that response. Methohexital is used because it does not change the duration of the seizure. Propofol can also be used but it can decrease the seizure duration. Ketofol = Ketamine & Propofol has been shown to also be a great alternative to general anesthesia & paralysis. However, at my clinical facility we did not use this approach.
Some contraindications: Recent MI, stroke, aneurysm, & osteoporosis
Onto the Thyroidectomy...
This was a cool case to do because I used a NIM (nerve integrity monitor) tube. This tube has special leads in it that connect to a monitoring system to ensure that the Recurrent Laryngeal Nerve (RLN) is not damaged during surgery. It literally acts like the game Operation. You touch the nerve, & the machine buzzes! Pretty cool.
So, to jog your memory, the RLN innervates the posterior and lateral cricoarytenoid muscles, which adduct and abduct the vocal cords. Remember, ADDuct = together, ABduct = apart. The Superior Laryngeal Nerve has two branches, the internal and external. The internal is sensory, and the external is motor. The external SLN provides innervation of the cricothyroid muscle and tenses the vocal cords! Bilateral injury to the RLN will cause stridor and paralysis of the cords... this can lead to re-intubation then tracheostomy. If you have unilateral damage, this will cause hoarseness as it only causes ipsilateral paralysis!
There are over 120 CRNA schools in the United States. Figuring out which CRNA school to attend can be very hard. I personally recommend applying to 3-5 CRNA schools. Traveling for interviews and application fees can get pretty expensive!
In the following video, I discuss what you should consider when looking for a CRNA school. The CRNA school comparison chart is being updated and will be available in November!
I had every intention of integrating board review into my everyday routine as a CRNA student. I figured, we’re constantly doing “board prep” by learning the material right? But interestingly enough, I found myself still going through an intensive 5-week plan to prepare myself for the NCE or the National Certification Examination (no one actually calls it this). In the nurse anesthesia world, it’s “boards.”
When you decide to start CRNA school, one of the biggest challenges is realizing that life doesn’t stop for you to get through your program. Unlike my undergrad days where all I had on my plate was school, the occasional fight with the boyfriend or girl drama, there weren’t as many distractions and stressors as there are now.
“Me-time” suddenly turned into “Me + Nagelhout + 8 hrs sitting at my desk.” I don’t want you all to develop that equation every single day because it only equals one thing = STRESS.
Before starting your semester, whether it be the first or last, make a schedule (Read about preparing for your semester HERE). It doesn’t have to be extremely detailed hour to hour, but write down the important things like class time, clinical, study time, family appointments, etc. Then, find at least, 1-2 hours where you can do something that you love. It doesn’t have to be all at once, it can be as little as 5 mins in the morning and night each day. If you have a family, then schedule time to spend with them. It can be going to the park every other weekend, or having a special dinner. Make sure these things are in your schedule and the time is accounted for.
This isn’t going to make CRNA school stress free, but it will provide the structure that you’ll need to remember to take care of yourself! Make this a guilt-free time where you can do what you like and not think about anesthesia for one moment. It may sound crazy, but depriving yourself of the care that you need will lead to major mental distractions during your study sessions, making it less productive.
While it’s great to say that I sat at my desk for 8 hours “studying,” my mind was elsewhere. I was mentally and physically exhausted, but I continued to push myself because I thought that’s what you have to do while you’re in CRNA school. I learned quickly that it’s not an effective strategy…at least not for me. I started off CRNA school with a ticking stress bomb… like I said, life doesn’t stop.
My positivity and faith were the two things that prevented me from having a complete breakdown.
It blew up before I could even throw the bomb further away… I ended a very long relationship immediately before starting CRNA school. Any stability that I had, my #1 support system and foundation crumbled right before my eyes. Our family lost two great friends months apart, then less than 6 months later, my grandfather passed unexpectedly. It was a whirlwind of events… but I remembered that while nothing can bring those people or relationships back, it furthers my purpose, my dream and to make them all proud.
It was a whirlwind of events… but I remembered that while nothing can bring those people or relationships back, it furthers my purpose, my dream and to make them all proud.
I take out a decent amount of time during the week for blogging, Instagram shenanigans, running and relaxing bubble baths. I treat myself because I know I worked hard that week; I know I deserve a break from studying. “Work hard, play hard” has officially become my motto.
I take my break, relax, then get back to business.
What are some self-care practices that help you?
Love to hear from you, please comment in the love box below.
Feel free to share on social media!
I’ve got a year and a half before I finish schooling…and the first thing on my mind is the NBCRNA Boards. I recently purchased Apex, and so far I absolutely love it. First of all the content of the modules is in a format that’s easy to read and understand. It is mostly in short paragraph/bullet point format with nice diagrams and pictures. In addition, it includes workbooks that are associated with each module.
The CRNA school interview is a daunting task. It’s a major event separating you from acceptance to your top school. Adequate preparation is needed to be a successful candidate.
There’s no specific recipe that you should follow to stand out during your interview, but there are things you can do to prepare to sell yourself with humbleness and grace. The most important thing is,
I applied to CRNA school the moment the application was available on July 1, 2015. My recommendation letters were already in, and I was scheduled to take the GRE the following month. Once I took the GRE's, my scores were received by the school August 25 and my application was officially marked as complete. 2 weeks later I received a notification that my application was being moved to the interview round! (This is why I stress preparing for your interview once your application is in). A month later, I was at the school, a nervous wreck, interviewing for one of the 16 seats in their 2019 class.
Whether this is your first semester or last semester, it’s important to get organized prior to it starting. Most courses will post your syllabus beforehand, so print them out (or not) and have them ready! Some schools do not provide a syllabus for you (I just learned that) So if you don’t have a syllabus…I’m sorry, that’s quite devastating.
At my current clinical facility, drugs are drawn up in the morning, then locked in the anesthesia cart in the room. My first day, I was told to draw up the drugs and even though I'm a nurse, figuring out which syringes they wanted to use slowed me down the first couple times. Here's a quick guide to how I draw them up. It's best to draw your drugs up in order of what you'll be using, that way you won't forget anything.