solneeshka 4,302 Views
Joined Jul 4, '08.
Posts: 289 (34% Liked)
*** It's the way these things work. If it is require training or education for your job either they have to hire those with the education they want, or pay for them to get it. It's like ACLS. If your hospital requires ACLS for your position they have to not only provide you with the training, but pay you to do it.
I am sure it's not a bad thing for the hospitals to hire people in a little bit of extra debt to the company store, a little extra lock on the handcuffs. It's true if they hire BSNs they don't need to do tuition reimbursement, thin I am sure that's written off anyways.
There is a dearth of research into the effect on current nurses to have this stepwise path: would also make a good study. Though it would be qualitative and the haters would immediately disregard it.
Patients, I don't know. The powers that be seemed convinced.
I'm kinda perplexed by a few things in this scenario. First, why does someone who got only 1 cardiac stent need Neo???? Was this a cath-lab patient? He sounds super stable given that he's eating and peeing and reading his Kindle....not the kinda patient I would expect to need a pressor especially after such a small procedure in which many ppl are D/C'd the next day. Had he had an MI? We're his troponins elevated or was this a scheduled thing after a positive stress test? Also if he was bradycardic all night i would have thought Neo wasnt the best pressor. Maybe dopamine or levo could have helped. It just seems strange to me.
Regarding the sugar, maybe his body was in a higher metabolic state given the recent procedure and ?MI and therefore his body just handled his usual dose of Lantus differently.
Did we ever get the answer to this whodunnit -- or howdunnit?
What was the IVF infusing? Any dextrose in any of them?
Apply! This kind of thing is not that unusual, and you have a great reason to give to your "new" employer - you realize how much you loved working for them in the first place and you want to go back! Keep in mind that it might close doors at your current facility, unless it's very large. But based on what you say, it sounds like the right thing to do.
It's posts like this one that make me glad I work at a gigantic teaching facility. The place is crawling with residents, and on the medicine floors, crawling with hospitalists, even at night. Everything (usually) moves fast; you call for help, it starts coming out of the woodwork. (Unless the team gets lost on the way to the call, because we are that huge - it happened to me on the very first code I ever called - funny in hindsight, not at the time!) We have the number for our RRT posted in patient rooms, so *anyone* can call, even a family member. It does not get overused at all. I would say there are more overhead pages for codes than for RRT. But we all know about it, it's a great ace up your sleeve.
OP, I don't remember now if you did suggest rapid response to the other nurse, but if not, there is nothing at all wrong with doing that, even if that nurse is more experienced and you are new. If it were me I would think, "Would I call RRT if this were my patient?" If so, then I would be strong with the language: "Why don't I call a rapid response for you? Here, you go back in with the patient, I'll make the call." Just because another nurse is more experienced than you are doesn't mean he or she doesn't sometimes second-guess themselves. Maybe it was on her mind and just knowing it was on your mind, too, would have been enough for her to go ahead and do it.
And yes, as some have noted there are no guarantees that calling a rapid response would have improved her outcome, but the whole point of having a rapid response program is to increase the chances of improving a patient's outcome, so probably, it would have! At least the patient would have sooner been on the radar screen of those who give a higher level of care. You were thinking along the right lines, and the next time it comes up, you'll have a better idea of how you'd like to handle it. That's called "gaining experience."
A lot depends on whether or not you have another adult living in the household. Are you married? If so, does your husband pick up the slack? If so, then your kids will be like a bazillion other kids all across America who don't have full time stay-at-home mothers (that is, just fine). If you are the only adult in the household and have to make other child care arrangements (my situation), it can be tricky. My son has survived, but we've been at the mercy of the willingness of various family members to help out. It would be one thing for my son to be at home without me but with his father until 8:00 pm when I get home; it's another thing for him to be at my aunt's house until 8:00 pm, then I need to get him home and that's when we're just starting our evening routine. Not the end of the world, we've been okay. This may be a short-term situation for you, you never know when something part-time might open up, and if you already have your foot in the door, you'll be better positioned to move into a part-time role. You both will survive!
I'm willing to be at home he has more than a turkey sandwich, diet cola, and some jello throughout the day. While ideally the Lantus should be a dose that keeps someone's blood sugar steady over the course of 24 hours, a lot of type 2 diabetics are on doses high enough to drop them. If his A1c is 8.5 is average glucose is around 200. If he's taking the Lantus at bedtime after a large dinner, his bg might be 300-400 at home when he takes that same 30 units.
Also, what did the BMP glucose show? If he was on neo all night, his fingers might not be well perfused, which can result in an inaccurate result. Clinically, it definitely sounds like he was hypoglycemic, but maybe not 14
Or it may have come out favorable Bc the op didn't do an incident report. Wasn't there a mistake regarding lab specimens not too long ago as well?
All nurses! Put on your sleuthing caps because I cannot figure this one out and it's driving me crazy. Had a pt last night who had a carotid stent placed yesterday afternoon. He had come out of the OR on neo with a MAP goal of 80-90 and still had the neo going. He has DM, day RN had not done the 17:00 accucheck by 19:00, so after report she did it. He was 219 and she slid him according to his scale, 2 units of novolog. We kind of laughed about how little that was, but if that's the scale, that's the scale. By then, he had already had a couple of sodas (diet) and some jello. He was complaining to me that he was hungry and his nutrition orders had advanced so he could have real food. It was about 20:30 by this time so I told him I would do his HS check before he ate and then I'd get him something to eat. He said he usually didn't slide himself at night, he just took his lantus, which was not on his orders. I explained all this to the NP, she said if that's what he does at home, let's do it here, skip the HS novolog and she added his home lantus to his MAR (31 units). I got him a turkey sandwich with mayo, a salad with French dressing, and another jello. He also drank 4 sodas over the next couple of hours (they were all diet). At some point after he ate, I gave him his lantus (probably 21:30 or so).
He had napped all day so of course he didn't want to go to sleep. He stayed up until well after 03:00 reading and watching movies on his kindle. Finally around 03:00, he had to pee (had great urine output all night), so I got him the urinal and then helped him move from the recliner to his bed. They were almost right next to each other, but he wasn't shaky or anything, he moved just fine.
All night I had been trying to wean him off the neo with mixed results. Not long after he went to bed, his BP started to rise so I turned it off. It actually started getting really high (mapping in the 100's, SBP 160s bumping up into the 180s sometimes). The NP and I noticed how now we seemed to have the opposite problem, but at least he didn't need the neo anymore and he'd be able to go home in the morning. I went in pretty frequently (maybe every half an hour) to have him reposition the arm with the art-line, just to make sure we were getting a good reading because he moved around a lot in his sleep. Also cycled the cuff enough to be confident the art-line was correlating. Around 05:30, I noticed blood all over his non-art-line arm and realized he had pulled out one of his PIVs. I cleaned it up and noticed it was all wet underneath, which I took to be from fluids that were no longer running into his arm. I cleaned his arm up, dried it off, and placed a dressing (although it really had already clotted off by then).
While I was in the bay, I noticed that his heart tracing was looking goofy. He had been bradycardic all night with bundle branch block, and really didn't deviate all night. But now I can only call it irregular and funny looking, BBB but odd. I called the NP who was in the SICU at the time, she said she'd be down in a minute to look at it, but in the meantime, draw a BMP on him. (She had not ordered PM labs because he'd just had them drawn when he arrived around 15:00 and everything looked good, we were expecting him to go home in the morning.) When I was drawing them from the art-line, I noticed that that arm felt wet, too. Then I noticed that all of him felt wet. Then I realized he really hadn't woken up much during all of this. I grabbed the accucheck and (are you ready for this)...14! Another nurse repeated it, again 14. I didn't even know it could register that low. We pushed an amp of D50 and I hung a 250mL bag of D10, we rechecked and he was 209. A resident had shown up coincidentally during this and called up for a SICU bed, asked us to get him up there asap. By then, the pt was already oriented. I explained to him what had happened and he just kind of nodded his head knowingly. (His HA1C had come back at about 8 and a half, so this was probably not his first hypoglycemic rodeo - just not well controlled.)
After the accuchecks but before the dextrose, his BP dropped fast, down to systolic 80s. After the D50, it was very nice, systolic 130s, mapping in the 80s, and his heart tracing was nice and steady (BBB, but even). Wait, I did turn the neo back on when I saw that low BP, I forgot about that. That might explain the improvement in BP, but not in the tracing. After I got back from dropping him off in the SICU, I looked up the BMP I had sent earlier. His K went from 4.2 at 15:00 to 3.2 at 05:50.
These are all the data points I can think of that might be relevant. So what the hey happened?!?!? How does someone with a BG of 219 who gets 2 units of novolog and 31 of lantus, and is eating like a cow, drop to 14?!?!
I so need to do this...
You know, I have not thought previously about possibly not needing an order for a drip started in the OR. If that's the standard in our facility (and I will need to find out!), then I guess all of my angst has been for nothing. We in PACU chart in the same system that anesthesia charts in, so the meds admin In the OR and the meds admin in PACU is all on the same page, one seamless flow. It would definitely show that anesthesia started the drip. And I made several notes about my call to the MD and discussions with the charge nurse, I even made notes in there about the MAP goal that was on order in the *other* system and how we were doing at various times. Hooray! I think that if I'm not totally saved I at least have a defense, and I don't hate myself or think I'm an idiot anymore! Thank you, fine people of allnurses! And I promise to report the scenario through our risk management system.
Agreed! Thank you for the replies!
We nurses spend too much time nursing the charts and not enough time nursing our patients. Sigh...
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