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natrgrrl 8,615 Views

Joined: May 6, '06; Posts: 412 (16% Liked) ; Likes: 108

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  • Feb 22 '09

    Consider yourself hugged. I know the feeling. I graduate this May - I too have been dealing with the same problem here. Where are you? But on the bright side, if you've been in LTC you might have a better chance than someone who has not had that... Good luck to you :heartbeat

  • Aug 30 '08

    pt came in due to chest pain (9/10) ,positioning pt at supine position aggrevates the pain as reported by the so. pt also is nauseated. pt's vital signs are bp 150/100 t=37.5 rr=28 and p=68. (pulse is weak). ecg was taken but it really shows that pt really has a heart problem by just seeing the pqrst pattern. our clinical instructor told us that pt is at risk for mi although there is no physical exam results yet.

    assessment: chest pain (9/10), supine positioning aggravates the pain, nausea, b/p 150/100, t 37.5c (99.5f) rr-28, weak pulse of 68, pqrst on ecg shows a heart problem.
    in looking up the signs and symptoms of an mi you discover this:
    • extreme anxiety and restlessness
    • substernal pain or pressure
    • feeling of impending doom
    • fatigue
    • nausea
    • vomiting
    • low grade fever
    • dyspnea
    • diaphoresis
    • tachycardia
    • hypertension
    • bradycardia and hypotension when the inferior wall of the heart has infarcted
    • s3 and s4 sounds
    • sudden death
    determination of the patient's problem(s): based on the symptoms the patient has and information about mis, this man is most likely having an mi. while chest pain is not always a present with mis, any complaint of chest pain is always presumed to be of cardiac origin until proven otherwise. in ccu parlance the 3-ps of a heart attack are pain, puking and perspiration and this man has pain and nausea (the next best thing to vomiting). with the hypertension (150/100 is classified as mild hypertension) and the scenario telling you the ekg is showing a heart problem there is definitely something going wrong with this man's heart physiologically--this is not a risk--it is a real problem right now.
    problem: chest pain
    diagnosis: acute pain r/t deficient blood supply to cardiac tissues aeb patient's report of chest pain of 9 on a scale of 0 to 10 and report that turning supine aggravates the pain.

    problem: altered heart function
    diagnosis: decreased cardiac output r/t altered rhythm aeb ekg changes and weak pulse of 68.

    problem: anxiety
    diagnosis: anxiety r/t unknown danger aeb hypertension (b/p 150/100), increased respirations (rr-28) and nausea.

  • Aug 27 '08

    Quote from mary c
    after 9 weeks orienting on my floor, the time has come to fly solo. i was just wondering the pertient info you all relayed during report (i've obviously given it with my preceptor there, but i wouldn't mind seeing how others do it in black and white).

    what i am terrible at is a) clustering care. i always feel like i am running back and forth because i forgot things. i have a little brain i created that is pretty amazing, but do you have any other recoomendations for clustering/organizing care? b) calling drs. i sound unsure and i babble on. i was critiqued pretty strongly on this. i get so nervous to call drs and my brain shuts down and i never know how to say or what to say. any advice from other new nurses?

    anyways, maybe it would be a benefit if we could discuss the stuff that makes us nervous and give advice on things we've seen or done that have worked? :typing
    at my job we use sbar for communicating with md's.

    s - situation
    b - background
    a - assessment
    r - recommendation

    dr. jones, this is deb mcdonald rn, i am calling from abc hospital about your patient jane smith.
    situation: here's the situation: mrs. smith is having increasing dyspnea and is complaining of chest pain.
    background: the supporting background information is that she had a total knee replacement two days ago. about two hours ago she began complaining of chest pain. her pulse is 120 and her blood pressure is 128/54. she is restless and short of breath.
    assessment: my assessment of the situation is that she may be having a cardiac event or a pulmonary embolism.
    recommendation: i recommend that you see her immediately and that we start her on 02 stat.
    this is an expample i obtained off the internet.....of course, i would want more in my background s/s such as o2 sats, pts description of chest pain, etc. always write down what you want to say before you call the doc, and always know your labs! hope this helps!

  • Aug 25 '08

    When I approached him by calling his name, he smiled and said “Hi, I am fine. Are you here to play with me?

    I smiled back and replied. I was so pleased to see that little wonder until I remembered his diagnosis.

    I asked to myself, Is this the one who is battling Leukemia?

    At the same time, I asked God about the little one’s fault to be cursed that way. I got no answer and feel like crying. But soon I maintained my composure and involved in the routine work. Later that night I could not talk to him because he was sound asleep.

    At the morning, when I went for the routine assessment he asked me what his vitals are and I told him the findings. I was surprised when a 4 year old kid behaved that way. I was shocked again when he asked me about his treatment plans and his role.

    He also took my breath away when he asked me not to be surprised by his actions because he knows that he has Acute lymphoblastic leukemia (he even know the type) and wants to be involved in the treatment process.

    I was completely speechless to see a 4 year old child speaking like that. After a while, my shift was over and I had to leave. It was also my last night that week so I was kind of excited for the day off.

    That day at home I tried to get rest but couldn't. I was thinking about that smart kid and his nice smile. It was not the first time I saw a kid in that situation, but surely it was the very first time I saw a kid acting like an adult.

    I tried to distract myself from thinking of him and started to watch movie. It helped me a lot when my friend asked me to go for a shopping. We went to a beautiful shopping mall, and bought some fancy dresses. The other day passed the same way.

    Again, it was time for my day duty. Once I entered the ward, I was looking forward to see that wonderful child. After the nursing reporting, I came to know that he is on Induction therapy of treatment. My co-worker also mentioned that he helped to select the vein for IV insertion. I could not be more stunned. Later when I went to see him, he screamed, “Oh you were the night nurse the other day, I recognized you, did you take enough rest?”

    My heart melted after hearing that. I knew I was being emotional and weak too. I could not resist and cried in the bathroom. At that day, I got chance to talk with his parents. I was so cheerless to know that he is their only kid. The father seemed to be brave but the mother could not hold her tears. I actively listened to them, whatever they had to say and also answered some queries they had. They were so proud of him.

    Days passed watching his magical ways of handling his problem. Each day with him was a learning day for me. His braveness, courage, hopes taught me a lot. After 14 days of hospitalization he was discharged. He was so happy to go home and had a plan about things he wanted to do. We were also glad to send him home with improved condition. After some time we heard that he is receiving further treatment at nearby hospital from his home. His father used to call us at times.

    After a year and half, when I was visiting one of my relatives at the same city, I ran into his parents. I saw a newborn baby with them, but I did not see him. I was so terrified so ask about him, but I did.

    His father replied, “He is with us”.

    I was so relieved until I found out the truth. When we further talked, I came to know that he did not survive from the Consolidation therapy. It was so hard for me to hear that during his last moments he asked a promise from his parents that they will have another baby soon.

    I still remember when he said this “If I die, you all should remember my days before I die, not the day I die”. He was brave, courageous, hopeful, hilarious, funny, amusing, adorable, charming and so on. I could not be more inspired by anybody else.

  • Aug 25 '08

    I worked with a surgeon in OR who had a sense of humour and even gave these collections of hardened belly button matter a name. Umbiliths! (Lith = Stone)

  • Aug 20 '08

    If you are SURE it's a pressure derived ulcer then stage it. I would on the other hand just DESCRIBE what you see. I'm not a Doctor
    Is it open? then......
    Note Anatomical Location (i.e., sacrum, tibia, L iliac crest , T3 area)
    being vaque is ok just get the general area
    Measure it from length to width x (head to toe) to y (left to right) axis Note depth i.e., 0.3 cm and undermining (under lip of wound) in clock referance i.e. 0.3 cm at 1 oclock
    Fibrin - dead tissue in % to overall wound bed (i.e., 10% - 30% -80%) - it's yellow & stringy
    ANY Readness generalized, Swelling generalized, drainage (*color) Odor, Echar?
    Pain on pain scale. If no to any then say so!!! Means you assessed!!
    Granulation tissue % or lack there of - red beefy cells in wound bed

    See any bone or tendon? State yes or no

    What about the periwound? Macerated, Red - inflammed, calloused or

    Example: L tibia 20cm x 10cm. 50% fibrin 50% granulation. Edema noted at pitting 3+ Redness to periwound. Odor noted, Slight eschar noted at 2 oclock 0.4cm x 0.2 cm 0.1 depth No undermining No tendon or bone observed. Denies pain. Moderate serous drainage. Periwound intact.

  • Aug 18 '08

    Just be sure if you make a med error, assess the patient to determine if any adverse effects, notify Dr of error. And above all, if you were not the one who made the error, when completing med error form do a complete investigation of all facts and previous documentation, before turning it into your supervisor. Good luck on your new job!

  • Aug 15 '08

    The national statistics on the number of medication errors made every day is scary.
    Even with the 5 rights and doing things exactly by the book it is still possible to make an error and there is not one nurse out there who hasn't made one. We all do or will and the thing to hope for is that there was no harm.
    Reporting the med error should not be a punitive thing. Report it factually. Most facilities have a form to use. DO NOT write in the nurses' note that a med error was made. You should chart: Lasix 20 mg order. Lasix 40 mg given. MD notified. No new orders. Patient stable.
    Sometimes it's a systems error and your reporting it could fix the system. I had to do the med pass one day when I was the day supervisor. It was on a very busy sub acute floor. The meds were written for 8am and 9am. Off I went. I got to the last room at about 9:30....oops...that patient was supposed to get a Fosamax at 7am before breakfast. How would I, or someone else not familiar with the residents, know that?
    So I wrote up the med error report and came up with a new system. Any early med or any med given outside the normal pass would be written on an index card on the front on the med book. System fixed and the resident suffered no harm. My co-workers thought I was crazy for writting myself up but it fixed the problem. The nurses from the other units and the agency nurses found it extremely helpful to have the index card there.
    Good luck with your career and please, if you make a med error, don't beat yourself up. You're only human.

  • Aug 12 '08

    Oh I am so happy for you!

    I wish you many more "good" days!

    Also awesome that you were actually able to remember some of the residents names!

  • Aug 8 '08

    My co-workers and I were sitting at the nurse's station the other morning after a rough 12-hour shift. It was the first time we had sat for longer than 10 minutes all night long. We were sleepy, exhausted and a tad irritated.

    As we sat resting our poor feet, the student nurses arrived on the floor. Taking in their crisp white uniforms, we glanced down at our wrinkled scrubs. Noticing their bright, shiny faces, I sneaked a peak at my co-workers. Our hair hung in our faces, mascara streaked under our eyes and on top of that, we could barely put three words together to form a sentence. We were whooped!

    I spoke first.

    "I remember those days."

    My fellow nurses nodded agreeably.

    My charge nurse spoke next.

    "Should we tell them to run now...before it's too late?"

    We all laughed, then instantly sobered.

    I got to thinking....If I were a nursing student again, what would I want to know? What would have made my transition from student to graduate nurse easier? If I were mentoring a student, what would I tell them?

    I would tell them that being a nurse means you have met your goal. You did it! You are now one of us. So jump in, hold on and get ready for the ride of your life.

    As a nurse, you are required to be many things: We are teachers. Doctors do not have time to teach patients what they need to know about their condition. That's where nurses come in. You will learn how to do a little teaching each time you are face to face with your patients. We are counselors. At times, we must help our patients and their families to utilize coping skills. Sometimes all we need to do is listen. Sometimes, we are the enemy. Some patients really do not like to be told what to do. Sometimes they are angry or scared. They will lash you.

    Nurses do not learn everything they need to know in the first day, the first week, the first month. There is a steep learning curve. Give yourself time to adjust to your first job. Don't beat yourself up because you don't think that you are learning fast enough. AND don't let others beat you up either. If someone seems to be giving you a hard time, tell them nicely and with a smile, "I am still learning".

    As a nurse, you will learn to use every resource at your disposal. That means fellow nurses, reference books, the pharmacist, the social worker, and the doctors. After a while, you will learn who enjoys sharing their knowledge, and who doesn't.

    As a nurse, you will be witness to miracles and to mayhem. You will learn to be compassionate, but strong. Sometimes challenges will invigorate you and some will exhaust you. Be cautious when making friends with fellow nurses. Be aware that not everyone is as they seem. If your work environment feels stifling and toxic, it probably is. Staying positive in a toxic environment is extremely difficult. Don't feel bad if you decide to leave for greener pastures.

    As a nurse, you will have good days and bad. You will see people at their best and at their worst. Sometimes it will seem as if you aren't making a difference, but even if you touch one person's life, you have done your job.

  • Aug 7 '08

    Pay attention and hope you get a good orientation. Learn what you can from the nurses you orient with but don't necessarily follow their lead in everything. Many nurses take "shortcuts" that aren't too kosher. Follow all the basic rules you learned in school. LTC is a lot different than hospital work. Really if you have a choice it's good to do some time in med-surg before going to LTC. It develops all your skills and especially sharpens your assessmernt skills. If that's not a choice, do the best you can. Ask or look things up if you don't know. The policy and procedure manual is your constant resource. I still look up any med I don't know before giving it after nearly 25 years in nursing. The advice about doing it right and worrying about picking up the pace later was right on target. Best of Luck. LTC needs good RN's.

  • Aug 7 '08

    Just as a FYI, dry off your alcohol before you poke, as alcohol converts to a sugar and will raise your blood sugar. Have a great day!

  • Aug 6 '08

    It is not unusual to have additional visits if you are the on-call nurse. I have worked 15 hours straight on days/weekends when I had call. That is nowhere near typical but it can happen. Ironically, the call visits were often the most satisfying because (unless it's an admit) there is a specific focus for the visit and the pt is usually very grateful that you have come to help, keeping them out of the ER or hospital.

    I have worked in HH for seven years. Doing performance improvement in the office now, but really loved being out in the field. You are able to really focus on your patient, and you get a much more realistic view of their life and how they are handling their medical issues. Sometimes the HH nurse is the only "company" these people get and they really look forward to your visit. They will want to show you photo albums, feed you coffee and homemade pie, and play that song they wrote 40 years ago for you on the piano (although this can add some time to your day, it always made me feel good to take the extra time when I could and give these people some companionship and human validation).

    As someone said earlier, I too have been in some really nasty homes and also in some incredibly beautiful places. For the nasty places, take shoe covers, use your newspapers as a bag barrier (like we're supposed to every time LOL), and be careful where you sit!

    The documentation demands are usually what run people out of HH. Do as much as you can in the home, try not to end up with a back-log, and remember it will get easier with time. But DO document well - remember, it's only you, the pt, and their family or friends present, the only witness you will have if needed is your own documentation, so make it good. Good luck, I hope you love it as much as I do!

  • Aug 6 '08

    LPNs function dually as charge nurses and floor nurses in LTCFs. Much of the time, they are the only licensed nurse in the entire long term care facility. LTC LPNs pass medications, supervise CNAs and medication aides, report changes in condition, assess, gather data, perform wound care, document, communicate with nurse managers and family members, provide patient teaching, do blood glucose monitoring, administer injections, give IV meds (if your state allows this), and so much more.

  • Aug 6 '08

    I work at an ALF-101 unit facility- and most times I am the only LPN in the building. At first this was REALLY scary to me !!! Sometimes I still play the "what-if" game with myself. But once you get to know the CNA's at your facility and if the patient happens to have a private duty aide, they will alert you of anything that seems suspicious. Once you get to know your residents, you can tell when something is off as well. Falls are my most common emergency. Don't stand the people up right away-check ROM, if one leg is shorter than the other (hip fx), pulses of ext., check for bumps on the head, and if the person says they hurt-BELIEVE THEM-even if they aren't all there!(call their POA if they arent able to communicate) Send them out for evaluation right away! Elders bones are brittle and break so easily!

    You may not think you will learn new skills, but you will. Working your way up from an ALF is a good way to start. Looks great on your resume and you can go to home health, ltc, and it is a fabulous place to work if you are persuing your RN (schedules are great and stress level is not so bad) This is just my personal opinion.

    I have had emergency situations as well-and the saying is-"when in doubt, send them out!" Many ALF's are not equipped with a crash cart, so be sure you know your BLS, where the AED is, and have a phone on you at all times to call 911. The family and PCP will need to be notified, and you will have to fill out an incident report and complete nursing notes.

    Policy and procedure for you facility is key, make sure you know where to find a copy and read through it!!!!