Friday, April 30, 2010

Easy-as-Pie Flan Recipe

Undoubtedly, flan is one of my favorite desserts. It is easy to make and delicious to eat. Last week I had my best friends over for dinner and we made this recipe. Try it out and let me know what you think!


1 cup and 1/2 cup sugar
6 large eggs
1 14oz can sweetened condensed milk
2 13 oz cans evaporated milk
1 teaspoon vanilla
1 teaspoon cinnamon
Preheat the oven to 325 degrees.

The first thing I do is mix 1 cup sugar, the eggs, evaporated and condensed milk, vanilla and cinnamon in a bowl. Basically everything but the 1/2 cup of sugar. Wisk it together until it is well blended.

To make the caramel you pour 1/2 cup sugar in a saucepan on medium to high heat.

Tip: The trick to making the right consistency is to not stir the sugar too much. I know this seems counter intuitive but you want the sugar to melt and burn a little bit.

When you see the side of the sugar starting to look like this, gently stir the sugar just enough so it doesn't burn and become bitter.

Once your caramel is done and has a thin consistency pour it into the bottom of your ramekins. We used 8 small ramekins but you can also use pyrex dishes if you don't have anything else, or one large ramekin if you have that too. The important thing is that it needs to be oven safe.

Next, pour the flan mix into the ramekins. You will need a baking dish large enough to hold the ramekins because they will need to be baked in a water bath. Put the ramekins in the pan and pour enough water in so that it rises just above halfway on the ramekins (about 1-2 inches of water).

Bake at 325 for an hour or until you can touch the top of the flan with the back of a spoon and it springs back. You want it to have the consistency of custard. Be careful removing the pan from the oven because the water will be very hot. Set the flan out to cool for 20-40 minutes, then eat and enjoy!

BTW, I forgot to add the cinnamon in this recipe so what I did was just sprinkle a bit on top of each ramekin before I stuck it in the oven. It worked fine but I do recommend mixing it in whenever possible. :)

Wednesday, April 28, 2010

ICU Tip: When in doubt, gown up!

Wow, this has been a pretty crazy week. From heart patients to a massive GI bleed and crazy families to boot. I can say without a doubt I could not be happier that it is the begin of my weekend!

Spoiler Alert: This post might be a little graphic for those that don't appreciate gory details.

I remember in nursing school and when studying for the NCLEX, isolation techniques and universal precautions was a big thing. For some reason I got a lot of those question on my board exam.

"When leaving an isolation room which do you remove first?"

A. Gloves
B. Mask
C. Gown

Uhhh. Whichever has the most blood on it? I have to admit though, the far off voices of my nursing instructors were ringing in my ears this week. You know its going to be a long day when you come in to get report and one of your patients is in trendelenburg, getting three lines placed. He was admitted for persistent nausea, vomiting, diarrhea and an acute drop in his hematocrit. The residents get his central and arterial lines in place and I begin chasing after the eternally long list of orders I have. Three units of packed red blood cells, 2 units of FFP, labs, bolus of bicarb. and the ever so fun job of inserting the foley catheter (for you non-medical folks...take a wild a guess at where this goes and you're probably right). As I'm explaining to him the procedure and setting up my sterile field, he nervously asks, "Have you ever done this before?"

"Oh my dear, I wish I could say I never have, but unfortunately I have inserted more of these than I can count. It's definitely not the highlight of my job." Probably not completely reassuring but its true. Being a nurse in the VA hospital means that 95% of the patients we have are male. I am not a stranger to the male anatomy, to say the least.

Anyways, at this point I am still drastically behind and in the meantime am putting out fires with the family of my other patient. A whole other post in and of itself.

Luckily the nurse who precepted me as a nursing student was my neighbor and was able to help me catch up on stuff. The next thing I had on my list was NGT lavage which I haven't done since nursing school. Diana was nice enough to get everything together while I caught up on charting. In nursing school we were always taught that if there was any possibility of being splashed by any bodily fluid, you wore a gown. Add a mask if necessary. Keeping that in mind, I watch Diana as she begins inserting his naso-gastric tube and my patient begins heaving like mad. I grabbed some gloves and the suction and jumped to try and help save my patient (and my clean bedding of course). This whole time I'm praying that he doesn't start throwing up all over. Of course he does, but luckily it wasn't too bad. Still it was enough to make us realize that the tube we had was too small and would be clogged up to quickly in order to do a lavage.

So here we go....Round Two!
We get a bigger NG tube and I was smart enough to grab two gowns and masks with face shields. I bring them in the room and offer the gown to Diana and she declines. "No, its fine." Huh? Ok, well she was my preceptor at one point....maybe it will be fine?

Could not be more wrong.

Within the next few minutes the patient, the bed, the floor and yes....I was completely covered in old GI blood, and vomit. The worst part. I had short sleeves on, so the space in between my gloves and my rolled up sleeves was completely covered in coffee ground emesis. At this point all I could think was, "Note to self: Next time wear the gown!"
At least my patient and I survived the horrible night and we even laughed about it later. Also, luckily I was smart enough to have recently put an extra shirt in my locker. (Another great ICU tip: always have extra scrubs!)

Just another day in the ICU.

Monday, April 26, 2010

A typical night in the ICU

"Miss? Are you there?"

"Yes sir, how can I help you?"

"Do I have something on my feet?"

"Umm, well you have the blankets on your feet. Why? Would you like me to get you some socks?"

"No, I need you to take my shoes off. I keep telling everyone, I don't want any shoes on!"

"Sir, you have no shoes on. You don't need shoes while you are in the hospital."
I hesitate.

"Sir, Do you know where you are?"

"So I don't have any shoes on?"

"No, my dear. You don't have any shoes on. In fact there aren't any shoes in the room except the ones I'm wearing" I pat him on the shoulder and begin covering his feet up with the blankets. "Sir, do you know where you are?"

*long pause*
He had fallen back asleep so I turned and headed away from the room.

"Miss, can you make sure no one puts my shoes on? I just don't want any shoes on."

"Of course, I'll be here all night and I promise no one will put your shoes on."

"Thank you dear," as he trails off and falls back asleep.

Saturday, April 24, 2010

ICU tip: Watching Trends

If there is one thing I could tell people about staying prepared for anything in the ICU it would have to be to always, without a doubt, watch your trends. I am nerotic about checking the trends on my charting. Heart rate, blood pressure, cardiac output, fluid balance are all things that I like to pay attention to in terms of where they are heading.

Example: The other day I was taking care of my second open heart patient. I was still on orientaiton, but since we were short staffed and they had no one to precept me, I was placed on my own for the last four hours of my shift. When I received the patient around 1:00pm his heart rate was somewhere in the 80's. Normal Sinus Rhythm, no ectopy at all really.

By 4:00pm he was somewhere along the lines of 99-103 in his heart rate. I brought it up with my charge nurse and my preceptor. "Did you check his lytes? What's his potassium and mag. levels at?" "How much fluid has he gotten? What's his CVP? (central venous pressure) His pressures look fine."

"I know his pressures look fine and his lytes are fine...all replaced and on top of that his CVP is 12, right where we want it. But his heart rate is in the 100's now."

The respone I get from everyone: "He's probably fine, he's not really that tachy so I wouldn't worry." Even the doctors said they wouldn't be concerned until he reached over 120.

So here is where the trends come in. If the patient's heart rate was in the 80's upon arrival and has increased by 20 beats per minute in the past 3 hours...where do you think he will be by 7:00pm? (this btw, is conveniently the time when our incredibly intimadting CT surg. attending comes to do his me, the man is scary)
Yup, you guessed it...around 7:30pm the surgeon comes by and my patient is trekking along at a heart rate of 130. Definitely not a good thing for a fresh, post-op CABG patient. I also noticed he had started to shiver a bit, despite the fact that his temperature was completely normal.

My alarms are going off, meanwhile the ICU team (who is also scared to death by our CT surgeons)is trying to decide what to do and probably trying to stall until CT surgery arrives.

To make a long story short the outcome was fine. CT surgery came by and I explained to them the trend I had been noticing. The treatment was much different than expected though. Probably a mix of the patient coming off sedation from the OR and not being properly sedated in the ICU meant he was slightly waking up...while he was still intubated.
We increased his sedation, gave him demerol for the shivering and then ended up giving vecuronium (a paralytic)to help him relax and not tense up so much. This is why I love our scary but brilliant CT surgeons. It worked like a dream and my patient went back to normal. At least long enough for me to give report and get home...far away from the craziness that is the ICU.

Friday, April 23, 2010

Basil-Spinach Pesto

Last week I had my grandparents over for dinner. At first, I was dreading it because my family is a little bit crazy (isn't everyone's though?) but it ended up being really great! It was the first time they were able to see my new place after moving in December. I made some really great things for dinner and I want to share a few of my recipes. Here is the recipe for the pesto I made!

1 cup Fresh Basil
1 cup Fresh Spinach
1/2 cup Extra Virgin Olive Oil
2-3 Garlic cloves
a few pinches of Salt
1/4 cup Slivered Almonds

Tip: You can also add some Romano Parmesan cheese but I didn't with this particular batch.

If you have a food processor great! If not, just use a blender, it works just as well.
This recipe is great because all you have to do is throw all of the ingredients in and blend. I have a mini food processor so I tried to do it in parts in order to prevent the blade from getting too clogged up with the basil/spinach.

I'll be honest, when I do recipes like this I usually end up improvising on the portions, if you want it a little more creamy you can add more almonds, if you want more of a basil flavor you can ditch the spinach and just do basil. I probably ended up using a little more olive oil and garlic in mine.

The pesto came out really well and unfortunately I don't have pictures of the dish I used it in. I ended up cooking some orzo and steaming baby asparagus spears to go with it. Cover the orzo with the pesto and toss the baby asparagus into it or just lay it on top for a nice presentation. Or you can use it on raviolis or any other type of pasta or even spread it on a sandwich. Enjoy!

Open Heart Orientation

One of the things I love about the unit I work on is that it is sort of a “catch all” ICU. We have everything from medical patients to surgical, neurology to cardiac. Anything that comes through the O.R. or E.D. and is in critical condition is ours. Granted we are not a trauma hospital so we don’t see too much of that, but considering our patient population (I work at a veteran’s hospital) we see some pretty rugged and sick patients. Many who suffer from multi-organ dysfunction related to alcohol and drug abuse.
We are a teaching hospital, which is great because it is a place that is very conducive to learning. It can also be a challenge because you are dealing with people who are doing just that….learning.

Where I work we have on average 2-6 (I think) open-heart surgery patients a week. We have a phenomenal set of cardiothoracic surgeons that I feel incredibly honored to work with. In order for us as nurses to take care of these patients we have to go through a process. Gain at least (usually) one year of experience, take a class on open-heart surgery, pass a written test and then precept with another nurse for a total of three post-op. open-heart patients. Translation: It’s a big deal.

Luckily I squeezed my way into the class that was running last year. I wasn’t even done orienting to the ICU but I knew that our nurse educator comes around only once a year, so I slyly asked my manager to put me in it with the argument that I had already seen an IABP (intra-aortic balloon pump) inserted at the bedside.

Long story short I was able to go to the class and amazingly I was asked last week to come in for my first open-heart orientation! I’ve only been working on my own for about six months and there were definitely people on the list above me who had priority to orient first. Still, where there is a will there is a way and I can officially take care of a patient from the O.R., directly after open-heart surgery!

The first day I was called in to take my first ‘heart’ patient the surgery went so well, they finished about an hour sooner than they expected. I was so proud of myself because despite being a night shift person, I crawled myself out of bed early enough to grab some coffee, navigate the crazy dayshift parking and still have ten minutes left before my shift was supposed to start. As I’m strolling down the hall, excitedly telling everyone I was now orienting to hearts (as we call them), my charge nurse comes around the corner…

“Andi, the heart is already here, honey! I left you a message!” (She’s so cute, she always calls everyone ‘babycakes’ and ‘honey’)

“Shoot!” I thought as I threw my lunch box behind the nurse’s station and ran towards the room. I had missed the most important part! When these patients come out of the OR it is truly a mess of lines and frantic people trying to get this patient stabilized after the trauma of surgery. I affectionately call it the spaghetti factory because usually there is a minimum of six IV lines and a plethora of monitoring cables that even the most type A, organization freak will have a hard time sorting through. (hint: I am definitely one of those type A nurses, it’s a common trait amongst us ICU people)

Luckily my old preceptor gave me a good tip for the next two days.
“When they tell you to come at 11:30 for the heart. Come at 11:00.”
Haha,thanks Julie!
I came at 10:45 the next day and the patient didn't come out until 1pm, of course. I love cardiac patients and I can’t wait to take care of them more often now. I have a few more posts coming up about the other two patients I took care of. I definitely learned a lot and I have a few good stories to share too.
In other news, I’ve decided to start doing a recipe section on this blog. I love cooking and sharing recipes and for the most part I try to make healthy meals so I can take them to work. Next post: Pesto orzo with baby asparagus!

Thursday, April 22, 2010


One of the reasons I started writing this blog is to write about everything I experience in my nursing career and the ICU. I remember when I started my job last summer I was so nervous and desperate to find any tips to survive that I searched “New Grad ICU blog” on google. Haha. Yes, I was that desperate. I told myself that if and when I survived the three-month new grad. precetorship at work, I’d start a blog. One that would share the tips I have learned along the way in surviving not only the ICU but also the beginning of a nursing career in general. I find that just hearing someone else’s stories and knowing that their are other people who have gone through the same thing is incredibly comforting.

Now that I’ve started writing, I think the purpose of this blog is beginning to morph into something much broader. There is so much I encounter in my job that is beyond the boundaries of the medical field. I have come across issues of cultural diversity, political differences, women’s rights, death and faith. I don’t expect to be followed by hundreds of people out in this vast world of Internet blogging. Realistically, I think I just want a place to write about the growth I am encountering as a person, as a woman and yes, as a nurse as well.

Something I have been grappling with lately is my identity as a woman. Earlier this week one of the nurses on my unit told me she noticed I had gained weight.

Here I was, sitting innocently in the break room. Trying to peacefully have my fruit and yogurt before what I knew was going to be an insane day. It was my second orientation day taking care of a fresh post-op, open-heart surgery patient. (Post on that soon to come!)
“Oh, look at Andi! She’s eating so healthy!”

“Yeah, my doctor told me I’ve gained some weight since last year so I’m trying to eat a little bit better.”

“Oh yeah I was noticing that yesterday.” (She motions her arms away from her body around her hips, making the motion of being very wide.) “You’ve gotten bigger!”

I was stunned.

“Yeah, I think working the night shift has been a little hard on my eating schedule.” I tried to hide the feeling that the wind was being knocked out of my chest.

There have been a couple of instances like this that I have come across recently. Not necessarily about my weight but about my worth and value as a woman in general.

“A man is looking for the mother of his children for a wife.”

Hmm, so you’re telling me that the only value I have in a relationship and to a man is in my ability to bare and mother children?

Most of my life I have struggled with issues of weight and beauty, value and self worth. Our society has so many expectations that are placed on us as women. We are expected to be gracious and nurturing, strong and resilient in all circumstances. We are told that beauty fits a very specific prototype of the typical 5’8” and 125lb, perfectly presentable female. We are told that, to be desired as a sex object by men brings us power and affection. We are taught that the “perfect wife” is one whose entire life goal is to serve her husband and raise his children. We grow up surrounded by role models that have fallen victim to the fallacy that to be valued as a woman is measured in how desired you are by a man.

Not until recently though have I started to truly question how many of those expectations I have internalized for myself. How much of that message do I choose to make my own standard in determining my worth?

I do need to loose a few pounds. I’m not overweight but I am almost outside the range for my height, so healthily speaking… I could afford to loose a good ten pounds or so.
I wish I could tell you that were my only reason or even a reason at all for my recent change in eating habits. It’s not. I want to loose weight because I am tired of feeling ugly and undesirable. I am tired of not fitting into my clothes and I’m tired of constantly being afraid of mirrors and always comparing myself to those around me who are, what I consider to be, pretty and thin.
It is exhausting to constantly feel like I am unworthy because of what I look like or because I am not the image of what we are told is desirable. I just wish I was good enough…simply because I am me.

So here I go, on an attempt to become healthier and a mission to loose weight. For now I know I am not doing it for the right reasons and because of that I might fail. Still, I know it is something I need to do and in the meantime I hope that along the way I will eventually stop doing it for the sake of everyone else and start doing it because I love and value myself…simply because I am worth it.

Tuesday, April 20, 2010

Why I love the ICU

One of the things I love about nursing is that it’s an all-encompassing profession. There are so many avenues you can choose from. Wound care to pediatrics, intensive care to consulting. The range is vast and wide. It was always disheartening for me to see my friends in school who struggled through med-surg. Many of them were phenomenal people who would one day be wonderful nurses…. just not med-surg nurses. Midwives, labor and delivery, rehab and psych nurses. I could see their place in our profession so clearly. Unfortunately you still have to survive nursing school to get to that point and the truth is you will use the basis of medical-surgical nursing in almost any field you choose. It is in many ways the foundation of what we do.

Over the past months since starting in the ICU I have been going through the process of discovering exactly why it is I love my job.

Why do I love the ICU?

I love the ICU because it is challenging. I love it because it is the perfect mix of physiology and psychology of the human life. I love it because I have a greater autonomy with the care of my patients. I love it because it is fast paced and yet incredibly thorough and detail oriented. I love it because I know I will never get bored or complacent in my job. But most of all, I love it because in the absolute worst and most frightening time in someone’s life, I can be the person that will make all the difference in that patient’s day. I have the ability to help restore dignity, health and comfort into someone’s life. I have the ability to bring compassion to a dying person’s family. I have the chance to give the absolute best care possible to a person who is vulnerable, scared and broken. I can make a difference in someone’s life.

Do you love what you do? If so, then why?

Sunday, April 18, 2010


I graduated nursing school last March. It has been just over a year since then and almost exactly a year since I passed the NCLEX board exam. The day after I took the boards I had an interview at the hospital I had done my preceptorship at. I had been lucky enough to be placed in the ICU as a student and even more lucky that they were one of the few, if not the only hospital that was hiring in the area. Yes, yes I know...there is a nursing shortage. Well, unfortunately in California that couldn't be farther from the truth. As a matter of fact most of my fellow classmates still do not have jobs. New Grads, even ones with a B.S.N or M.S.N are having a hard time finding work.
At any rate, I remember being completely elated to have the opportunity to even interview and so thoroughly relieved to be done with the NCLEX. Life was finally starting to settle and the years of hard work were about to pay off. I ended up getting that job and three days after my interview I got a call from one of my best friends sometime around 1:30am. "Andi, CONGRATULATIONS!"

"Wait, wait why are you saying that?!" I yelled loud enough to wake up every roommate in the house.

I had been up all night, waiting for the BRN website to update its list of licensed registered nurses. My friend had found my name on the list miraculously before I did and had the glory of being the first to tell me I was, officially, a Registered Nurse. Moments later I get a message from another one of my best friends. She was crying because she knew how incredibly hard nursing school was for me. Working full time, school full time, 18 hour days, five to seven days a week, studying non-stop. In that moment I took a deep sigh of relief and knew my life would be completely different from then on out.

A year later I can confirm that my life has changed so much in so many wonderful ways. The ICU can be stressful, hell, being a nurse can be stressful! Still I am so thankful to love what I do and I hope I can share that with those that are on this journey through nursing as well. I don't know much being a new grad, but I definitely have some good stories and I hope you will come along for the ride. Whether you are a nurse or not I believe the basis of my profession is something we all need a little piece of...caring, compassion, encouragement, laughter in the hard times and an appreciation for the life we have been given. Welcome to On Call RN!