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solneeshka 4,840 Views

Joined Jul 4, '08. Posts: 289 (34% Liked) Likes: 236

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  • Dec 7

    Something is wrong with a facility that would fire someone for making a med error that the nurse actually reported herself and then went to great lengths to make sure the patient was okay. They should have given you a raise. To answer your question, yes, you are being overly dramatic. Unless you never nurse again, you have not made your last Meds error! And even if you don't work as a nurse again, you'll make a Meds error at home at some point :-) If your facility had not scapegoated you but rather practiced an environment of just culture, everyone (including them) could have learned from it and all of their patients would be safer. Shame on them. Get another nursing job, we need more like you!

  • Sep 27

    I worked in med-surg for a year out of nursing school and made the move to the OR last summer. The benefits: TONS. The down-side: none. Really. Maybe I just have the magical "OR" personality that you hear about, but I can't imagine how anyone would prefer med-surg over the OR. Of course, there are a wide variety of experiences in the OR. I work at a large teaching facility, so the MDs are used to answering questions and they are reasonably well-behaved. Some of the stuff I read about here (like swearing during a procedure), I couldn't imagine happening at our facility. It also helps that because we are so large, everyone specializes so you only have to get really good at your particular area (ortho or neuro or whatever).

    The following comments are based on my experience.

    In the OR, you don't have to arrive until the start of your shift and you get to leave when it's over. (On the floor, you generally have to arrive early - unpaid- to start looking up your patients and their orders, and you don't leave until you're done with report and all your charting, which may or may not be as soon as your shift ends.) In the OR, most of the charting is relevant and useful information; on the floor, most of it was not useful, not especially meaningful, sometimes downright made-up, and really not ever looked at by anyone unless that patient happened to sue.

    In the OR, you get lunch breaks and usually at least one other break during your shift. (On the floor, you're lucky to have time to go to the bathroom, let alone have 1/2 and hour to eat a sandwich and breathe during a 12-hour shift.) In the OR, you have the one patient that you're working on for the time that patient is with you. You may have several things you need to focus on about that one patient, but there is no such thing as having 3 or 4 (or more) other patients also waiting for you to do something for them. There are no call lights, halleluia! There is no standing in a patient's room for 20 minutes with your phone going off every 3 minutes, helping them to and from the bathroom because they refuse to use a urinal. There are no multiple requests for extraordinary pain meds that the patient knows the MD has DCed. There are no QH vital signs. There are no family members! (Not once the patient is out of pre-op.) There are no "code-browns." There is no getting stuck in a lonely patient's room while they decide that the middle of your 9:00 meds round is a good time for them to tell you their life story.

    I will tell you this: last week, I had my worst day in the OR ever. It was still better than my best day ever on the floor. There actually is one downside and that is that because I worked nights on the floor and I work days in the OR, I lost my night differential so now I still have to pick up shifts on the floor once in a while to make up the difference in pay. It makes me so sad to have to do that! Whenever I head in for one of those pick-up shifts, I can feel my stomach tighten up with the lack of knowledge of what's going to slam me in the face this time. The OR is not 100% predictable, but it is much, much, much more predictable than the floor. That allows you to be prepared and have more control over how things go. Part of my problem on the floor is that I am someone who cares about giving great care to my patients, and it makes me angry when I don't have the resources to do that. Nurses who don't give a crap (and unfortunately, there are many) don't mind the floor so much, and I think they prefer it because they have so much more autonomy and it's so much easier for them to get away with under-working. You can't do that in the OR. You're on a team there and everyone has to pull their weight. But the team-work is the thing I like about it the best.

    Things to ask about in the interview:
    How long is orientation? What determines when you come off? (Our policy is that orientation lasts as long as the nurse needs it to. The ballpark is a year, unless you have previous OR experience.)
    What hours are the shifts? Is it straight days, straight nights, weekends or weekdays, etc.? What's the policy for working weekends?
    Why is this position available? What happened to the person whose spot you're looking to fill?
    What's the turnover rate like in nursing in this department? Do nurses turnover quickly or do they tend to stick around?
    How do the doctors treat the nurses? (No one is going to say, "Oh, they're just awful!" But you might be able to glean some information based on how they handle the question. Do they give a tempered response or do they enthusiastically tell you the MDs are great?)
    Who would be your preceptor? Can you meet with him/her during the interview?
    Ask the interviewer what they see as the best things and the biggest challenges of working there.
    Be sure to emphasize the benefits of your med-surg experience: you can start IVs if needed (although OR nurses don't generally do this, which is why they generally suck at it and it can be handy to have someone who can do it), you've been in codes more than any OR nurse probably, you have a good grasp of how the different areas of the hospital work, if you need to deal with patients coming from or going to the floor then you know the issues that the floor nurses face preparing patients for surgery or caring for them afterward and can be an effective liaison, you are accustomed to intradisciplinary work, etc.

    You'll do great! I think everyone should work OR!

  • Sep 10

    If you've already done an assessment on a real live patient, then you have already learned that they don't work in the real world like they did in nursing school. When I think of the unbelievable detail we went into in nursing school...sigh...we should be so lucky to have enough time to assess ROM on all major joints! Individual fingers! Wow. Sticking with head-to-toe is a good start (that is, don't get distracted from one system to another). Keeping your patient focused also helps, because they tend to want to leap in and tell you what's on their mind. If you stick with the head-to-toe format, though, you will eventually get to whatever it is they want to talk about. When I was in nursing school, I made a cheat sheet that reflected the documentation system of the hospital I was in. That way I could make really quick notes using symbols or circling pre-printed words on the sheet so that I wouldn't forget the details that I knew for sure I was going to have to document later. As for how to do the documentation, it's definitely best to do it as you go, if you are talking about general documentation for the whole shift. You don't want to stop your assessment in the middle to chart what you've looked at so far, and then come back to finish doing your assessment. But if you wait until the end of the shift, you'll forget stuff, that's just how it is. Plus, what if there's a change in status during the shift, and you have nothing documented from the start of the shift? You don't want to have to explain that.

    In my experience, there's no substitute for real experience. Practicing on friends and family didn't help because it didn't even come close to mimicking the environment of a hospital. You'll get used to all of it over time, and develop a pattern that works for you. Here's what I do and it works for me:

    1) "Good morning, Mrs. Jones. I'm Susan, I'm going to be your nurse tonight. Can you tell me your first and last name please? And your date of birth? Thank you." I'm checking the armband as the patient responds. Don't worry about calling them by name and then asking their name. If they genuinely aren't oriented to person, they won't remember the name you just called them.

    2) "Can you tell me today's date, please? That's right, and can you please tell me where we are right now? That's right, and can you please tell me what it is that brought you in to see us? That's my understanding, thank you." Now I know her orientation and have talked to her enough to know her LOC. "Are you having any pain tonight?" This will help make sure you don't do something painful to them in your assessment, as well as direct more detailed assessment of a particular system as needed. It also tells you your 6th VS .

    3) "I'm going to shine my flashlight in your eyes for just a minute now. Can you please look over my right shoulder? Thank you. Now follow the tip of my flashlight with your eyes. Thank you." PERRLA, hearing.

    4) "If you could lean forward for me please, I'm going to give a quick listen to your lungs. Could you take a couple of deep breaths please?" Posterior lung sounds. "Thank you, you can sit back now. Can you please give me a couple more deep breaths?" Anterior lung sounds. "Thank you, just one more now, I'm going to get in under your right arm here. Thank you." RML sounds. "Do you feel like you're breathing okay lately? Yes? Great."

    5) "I'm going to listen to your belly now, you can breathe normally for this part." Before my stethoscope actually reaches the belly, I say "Are you having any abdominal pain?" so that I know this before I start messing with them. Assuming no, I listen. "Thank you. Now I'm going to press in a little bit. You'll feel pressure but let me know if you feel any pain." While I'm palpating the abdomen, I say "When is the last time you had a bowel movement? Today? Great. Any trouble urinating recently? No? Great. Any nausea or vomiting? No? Great. Your appetite's been good? Yes? Great."

    6) "Can I have your hands for a minute please?" Check pulses.

    7) "Now I'm going to check your feet and see if there's any swelling." While I check for LE edema, I'm also checking pulses. "If you need to get to the bathroom tonight, are you able to do that on your own, or do you think it would be best to have some help?" Their answer, coupled with shift report, lets me know if they'll need help with this. It's not the same as assessing gait or mobility, but this is the part where they tell me they are weak, or their left leg cramps up at night, or whatever. (I always stress that we really don't want them to fall while they're here, and it's not their usual environment, so if they feel like they would like any help at all, please please please call, even though of course I secretly hope they don't need the help, but I definitely do want them to call if they do need the help). Best would be to have them get up out of bed and let me see them walk, but the reality of life on the floor usually doesn't allow for that. Sometimes they are up and I can see, and at some point during the shift I'll see if they can get up or not (this is a good argument for not charting assessments *immediately*, although you can always go back and made additions or corrections).

    8) If I know or suspect or have been told the patient has mobility issues, I will ask them to roll to their side so I can check out their skin on the backside. Oh boy, never take anyone's word for this one! You can't even rely on asking the patients, they don't always know when they have a pressure ulcer starting.

    Unless I'm spacing something big, anything else I do is driven by their diagnosis (e.g., if I know they're in for chest pain, I'll ask about SOB on exertion and circumstances surrounding the pain). I know we always had to listen to heart sounds in nursing school but we did not assess or chart heart sounds on the general medicine floor where I ended up working. If heart sounds are relevant to a particular patient's diagnosis, the MD is following it. This may be different on a cardiac floor or tele floor. Pretty much anything I need to chart, I can pick up from having done the above assessment. And all I have to think about is my introduction, which by now rolls of my tongue without my thinking about it (and I consider all of those orientation questions to be part of my introduction) and then 4 points: eyes, lungs, abdomen, feet. I usually forget about radial pulses until after I've done the feet, I'll be honest about that, but checking the pedal pulses reminds me. Keep in mind you don't have to specifically be asking about a particular body system in order to be assessing it.

    Okay, I've gone on too long. Hope some of this is useful to you!

  • May 12

    Try ambulatory surgery. Lower acuity, fewer add-ons.

  • Mar 15

    I work for a very large facility and we do hire ADNs into the ICU. They favor BSNs all around, but it can happen. If you can't get into an ICU then I would go for med-surg. ED and ICU are both considered critical care, but working in the ED will not prepare you for an ICU as well as med-surg will. It's easier for you to learn the difference between med-surg and ICU than it is to learn the differences between ED and ICU, if that makes sense. You can get working on your BSN while you're in that first year of med-surg, and then once you graduate you can start applying for ICUs with a year of nursing under your belt. You can absolutely do this!

  • Feb 17

    If you've already done an assessment on a real live patient, then you have already learned that they don't work in the real world like they did in nursing school. When I think of the unbelievable detail we went into in nursing school...sigh...we should be so lucky to have enough time to assess ROM on all major joints! Individual fingers! Wow. Sticking with head-to-toe is a good start (that is, don't get distracted from one system to another). Keeping your patient focused also helps, because they tend to want to leap in and tell you what's on their mind. If you stick with the head-to-toe format, though, you will eventually get to whatever it is they want to talk about. When I was in nursing school, I made a cheat sheet that reflected the documentation system of the hospital I was in. That way I could make really quick notes using symbols or circling pre-printed words on the sheet so that I wouldn't forget the details that I knew for sure I was going to have to document later. As for how to do the documentation, it's definitely best to do it as you go, if you are talking about general documentation for the whole shift. You don't want to stop your assessment in the middle to chart what you've looked at so far, and then come back to finish doing your assessment. But if you wait until the end of the shift, you'll forget stuff, that's just how it is. Plus, what if there's a change in status during the shift, and you have nothing documented from the start of the shift? You don't want to have to explain that.

    In my experience, there's no substitute for real experience. Practicing on friends and family didn't help because it didn't even come close to mimicking the environment of a hospital. You'll get used to all of it over time, and develop a pattern that works for you. Here's what I do and it works for me:

    1) "Good morning, Mrs. Jones. I'm Susan, I'm going to be your nurse tonight. Can you tell me your first and last name please? And your date of birth? Thank you." I'm checking the armband as the patient responds. Don't worry about calling them by name and then asking their name. If they genuinely aren't oriented to person, they won't remember the name you just called them.

    2) "Can you tell me today's date, please? That's right, and can you please tell me where we are right now? That's right, and can you please tell me what it is that brought you in to see us? That's my understanding, thank you." Now I know her orientation and have talked to her enough to know her LOC. "Are you having any pain tonight?" This will help make sure you don't do something painful to them in your assessment, as well as direct more detailed assessment of a particular system as needed. It also tells you your 6th VS .

    3) "I'm going to shine my flashlight in your eyes for just a minute now. Can you please look over my right shoulder? Thank you. Now follow the tip of my flashlight with your eyes. Thank you." PERRLA, hearing.

    4) "If you could lean forward for me please, I'm going to give a quick listen to your lungs. Could you take a couple of deep breaths please?" Posterior lung sounds. "Thank you, you can sit back now. Can you please give me a couple more deep breaths?" Anterior lung sounds. "Thank you, just one more now, I'm going to get in under your right arm here. Thank you." RML sounds. "Do you feel like you're breathing okay lately? Yes? Great."

    5) "I'm going to listen to your belly now, you can breathe normally for this part." Before my stethoscope actually reaches the belly, I say "Are you having any abdominal pain?" so that I know this before I start messing with them. Assuming no, I listen. "Thank you. Now I'm going to press in a little bit. You'll feel pressure but let me know if you feel any pain." While I'm palpating the abdomen, I say "When is the last time you had a bowel movement? Today? Great. Any trouble urinating recently? No? Great. Any nausea or vomiting? No? Great. Your appetite's been good? Yes? Great."

    6) "Can I have your hands for a minute please?" Check pulses.

    7) "Now I'm going to check your feet and see if there's any swelling." While I check for LE edema, I'm also checking pulses. "If you need to get to the bathroom tonight, are you able to do that on your own, or do you think it would be best to have some help?" Their answer, coupled with shift report, lets me know if they'll need help with this. It's not the same as assessing gait or mobility, but this is the part where they tell me they are weak, or their left leg cramps up at night, or whatever. (I always stress that we really don't want them to fall while they're here, and it's not their usual environment, so if they feel like they would like any help at all, please please please call, even though of course I secretly hope they don't need the help, but I definitely do want them to call if they do need the help). Best would be to have them get up out of bed and let me see them walk, but the reality of life on the floor usually doesn't allow for that. Sometimes they are up and I can see, and at some point during the shift I'll see if they can get up or not (this is a good argument for not charting assessments *immediately*, although you can always go back and made additions or corrections).

    8) If I know or suspect or have been told the patient has mobility issues, I will ask them to roll to their side so I can check out their skin on the backside. Oh boy, never take anyone's word for this one! You can't even rely on asking the patients, they don't always know when they have a pressure ulcer starting.

    Unless I'm spacing something big, anything else I do is driven by their diagnosis (e.g., if I know they're in for chest pain, I'll ask about SOB on exertion and circumstances surrounding the pain). I know we always had to listen to heart sounds in nursing school but we did not assess or chart heart sounds on the general medicine floor where I ended up working. If heart sounds are relevant to a particular patient's diagnosis, the MD is following it. This may be different on a cardiac floor or tele floor. Pretty much anything I need to chart, I can pick up from having done the above assessment. And all I have to think about is my introduction, which by now rolls of my tongue without my thinking about it (and I consider all of those orientation questions to be part of my introduction) and then 4 points: eyes, lungs, abdomen, feet. I usually forget about radial pulses until after I've done the feet, I'll be honest about that, but checking the pedal pulses reminds me. Keep in mind you don't have to specifically be asking about a particular body system in order to be assessing it.

    Okay, I've gone on too long. Hope some of this is useful to you!



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