Latest Comments by KatieMI

KatieMI, MSN, RN 29,082 Views

Joined Jan 24, '10. Posts: 1,966 (75% Liked) Likes: 7,622

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  • 3

    Quote from EllaBella1
    To be honest I'm a little more concerned about the fact that you weren't aware that your patient had a mastectomy in the first place. It should have been passed on to you in report, but you also should have done a thorough enough assessment to notice something like that.
    Nowadays even radical mastectomy with full dissection is not considered to be contraindication for breast reconstruction. Some of them even preserve nipples, and the results has to be seen and felt to be believed. Plus, more and more women undergo breast augmentation, lumpectomy with limited dissection, simple mastectomy with following plastics (the "Angelina Jolie procedure") and all kinds of other surgeries with their breasts. The results can look incredibly "natural", and, unless you really palpate tissue and ask the patient, you might never even suspect that what you see was her belly fat one day.

    Being honest, how frequently an average RN conducts careful visual inspection of breasts and their palpation as part of her routine assessment?

  • 2
    AceOfHearts<3 and Dodongo like this.

    Quote from gmprojects93
    Please dont lose sleep over this. Very common mistake. Ive seen nurses do this a million times and the patients were ok - this happened frequently when a patent came up from ER and had recieved a 2.5 liter saline bolus through an IV on a mastectomy arm. Its an old mastectomy; not saying this is not important; patient safety is always a main priority; i could be wrong but, but my thinking would be shes on dialysis, so even if some fluid build up happened, the dialysis will soak up the extra built up fluid. Carry on! And go be an awesome RN!

    Additionally, for hard stick's, maybe an UltraSound tech can help you inserting an IV. US machines and techs are great for this (check if you need an MD order though). Additionally, if that doesn't work, you can always suggest a midline insertion, or if the family allows it, you can get an MD order for a PICC line for long term IV access especially for an infectious PNA. Check the DNR status though.

    I would like to add also that these are just suggestions,- always check with your hospital's policy regarding IV access and central line insertion and never practice outside your RN scope of practice
    First, the author did not make any mistake. See above why.

    Second, and this is a common mistake indeed, dialysis won't "soak up" fluid from extravascular space. It works only for intravascular volume, and has nothing to do with extravascular, intracellular or any other volume. Furthermore, HD can be performed in different regiments to remove more or less water and more or less solutes, depending on patient's fluid and lytes status. The decrease of edema or pleural transsudates happens AFTER HD because of induced fluid shifts, NOT because HD somehow "sucks out water". But no HD in the world can remove water from lymph system by any means at all. It just doesn't work this way.

    Should it be different, then lymphedema wouldn't be such a devilishly difficult to manage condition. But it is. These patients can be critically dehydrated with 15+% volume loss, and their edema will be still there and not bulge for a millimeter.

    Third, "DNR" doesn't mean "do not treat". Patients with DNR status receive the same treatment as everyone else, including line placements, abx, chemo (curative and palliative), vents, etc. "DNR" status implies as not mandatory only actions performed under code protocol and nothing at all outside it unless patient/family requests otherwise and the care team agrees with it.

    And the fourth, the described case is precisely the one when a good nurse might need to fight the policy for the benefits of common sense. Placement of midline or PICC is more invasive and carries more risks than PIV, leaving alone EJ, TLC or other types of central lines. Why would you like to subject the patient to these risks just for the sake of some silly piece of paper written by someone who still remembers the nonsenses nurses were taught decades ago?

  • 4
    Fiona59, Here.I.Stand, canoehead, and 1 other like this.

    On the one hand, definition of what is considered to be "able to ambulate" can be different between hospital and real life outside it. If patient "ambulates safely" within his room or even within unit, it doesn't authomatically mean that he would be able to do the same in his own house, or to walk those endless corridors. As a facility is responsible for a patient's well-being up to the last second of him/her being within it, it seems logical to ensure "safety" by, for example, not making patient ambulating and providing wheelchair even if he can perfectly walk on his own.

    Secondly, I've noticed that the wheelchair seems to be included in what I name "entitlement package". There is a group of patients who really think that being pushed around in wheelchair, wiped after using toilet, given more of "good meds", calling for assistance for every trivial reason, etc. is somehow included into their hospital stay program. At least, that's how they describe "good care" if someone bothers enough to take time and speak with them. The very same people request home health care RN to come every morning to wipe them or provide them with wheelchairs during their outpatient visits although everybody just saw them jumping cheerfully out of their trucks. These "clients" are commonly "frequent fliers" as well, and they can be given what they demand just to keep things calm. After a while, some genius up there in Ivory Tower of Administration might start thinking that "customers" for some reason enjoy wheelchairs and "implement a policy of improvement" of this part of "our most wonderful customer service", thus mandating their use in all circumstances.

    And, last but not least, something tells me that even in absence of such policy there still be that most impenetrable argument of "we ALWAYS do it this way here". Ingrained habit plus rationalization, one of the worst combinations to fight in human psyche

    In this context, I find it interesting that patients who sign out AMA seem to be not authomatically "offered" wheelchair and expected to walk out of there on their own. I'd seen nurses and aides getting very grudging about pushing out a patient who signed AMA paperwork but was clearly not fully ambulatory and needed help to get into private car with family waiting in it on "drop in/off" spot. Also, several times when I was in ER I was told that I had to stay in my room and that walking 50 feet to the ice machine in the corridor was "unsafe" (I was quite obviously able to walk, A, Ox4 and not on any monitors or oxygen at that time). Once I signed my AMA half an hour later, it suddenly became perfectly OK for me to get water myself and do not bother my poor CENA who was clearly at the very end of her wits and will that night.

  • 20

    There is no scientific evidence that placing peripheral IV on the same side as mastectomy (radical or otherwise) after 20 years can cause lymphedema or any other complication if these complications did not develop within first 5 years after surgery. For the first 5 years, data is mixed.

    "Never place an IV on mastectomy side, doesn't matter what because it is unsafe" is one of old wives' tales which are still taught in nursing schools despite of being disproved for decades. Relax.

  • 1
    Orion81RN likes this.

    Semi-livable job pay is what LPNs and MAs get. Something tells me that the OP makes more than that... quite a bit more.

    Re. the rest of issue, it is the question of what exactly the OP dislikes so much. She surely can move up onto totem pole but the rest of the issue - namely, the people, the "customers", the atmosphere and the whole rest of it - won't go anywhere. It doesn't matter where exactly in healthcare industry it will be, or even in some expensive-and -difficult-to-get-into outcrops of it (legal, insurance, marketing, even research) - you'll get the same kind of folks and their attitudes you're already sick of. There only one difference between someone in scrubs trying to explain you why and how she completely misinterpreted and missed multiple and ominous signs of incoming "event" and a bureucrat trying to explain you why his insurance company won't pay for an expensive new drug for treating of the result of that "event" is the cost of the pieces of cloth which these two use to cover their butts. They even use the same argument: "this is not within my scope of practice" (read: "I do not want to do that for whatever it takes").

    With that being said, it is completely up to the OP to figure out her talents and quircks and think outside of the box about how to apply them in socially acceptable and financially ptofitable way. I would be torn hard between certified yoga instructor, guide specializing on European medieval tours and opening artisan bakery, all plus blogging like crazy.

  • 1
    brownbook likes this.

    Standard ACLS strips:

    1). 3 degree QRS is ALWAYS brady (6 or less complexes on your standard strip)
    2). 3 degree QRS is ALMOST ALWAYS misshapen, usually wide, and can be different in shape with each contraction.
    3). 3 degree QRS is ALMOST ALWAYS regular (unless something else is going on; for studying purposes, assume that it is always regular)
    4). 2 degree type II PR can be normal or prolonged, but it is ALWAYS the same. 3 degree it is ALWAYS different with each contraction

    The principal difference between 2 and 3 degree is where the ventricular impulse of QRS comes from (answer this question yourself and write it here, so we know that you got it). The existence or absence of escape rhythm source makes ECG and clinical differences, and that's how you differentiate between these two.

  • 0

    Quote from Robert.CFRN

    And the United States is the least racist nation on earth, and allows more legal immigration than any other nation on earth. Yes, that's right. All left-wing hand wringing and campus self-righteousness to the side, that's the simple truth.
    You might want to see the rest of the world one day, my friend, of which you evidently know not what you do not know. You also would benefit from exposing yourself to areas which do not belong to healthcare.

    I was many times on American Physical Society conferences, one of the most prestigious scientific meetings of the world. 90+% of participants there were accent-speakers from literally every country of the world, nobody had problems with it. In this circle mentioning someone's accent is as acceptable as "n" word. Nobody, ever, is sent to any sort of courses or classes. These people manage things like cyclotrones, supercomputers and national labs. What exactly is wrong with them all... or, indeed, with some people here? With some unsavory experiences in my past, I suspect the latter might be the truth.

    (it seems that the evening with Shakespeare directed my mind toward British English

    P.S. if the OP was admitted in school of nursing and made it into clinical stage, that alone means that her English was deemed to be good enough for "normal" level of nursing communication. If someone "expressed concerns" that it "might" be inadequate, then it should be, with good deal of probability, the problem of that someone, not the OP. It might be a completely benign problem like a slight loss of hearing but it still doesn't justify assessment of the OP's nursing abilities bein based on her accent alone.

  • 3
    Lil Nel, ICUman, and AceOfHearts<3 like this.

    First snow day today.

    First weekend for the last three weeks that I am home. I was so much looking for it! So...

    - sourdough rye (4 loaves)
    - sourdough half-rye (1 loaf)
    - challah
    - baguettes (2, one of them is gone already)
    - 25 Chrismas buns (Elisabetan time recipe, with many spices, apples and nuts)
    - 24 Big-O cookies ("everything plus oatmeal" type, original recipe from famous Zingerman's bakery in Ann Arbor) for my co-workers
    - marzipane and flavoring mix for stollens - both have to stay in fridge for a week. (zesting of 5 pounds of citrus fruit was needed)

    Plus, we put up our three and cleaned the house.
    Time to grab some tea and watch "Hamlet" with Sir Christofer Plummer. It is my at least 100th time but it remains one of my favorite interpretations.
    Day well spent.

  • 0

    Look for big names. John Hopkins and University of Michigan/Ann Arbor are still mostly in-class, for one example.

    Just keep in mind that such programs cost accordingly and that many of them still do not provide preceptors (although they might offer more help in finding them). Where they do it, NP students often placed in locations which medical schools refuse, such as inner city community clinics and even prisons, which severely limits the value of expirience.

  • 2

    Oh, why I never was in your unit? We would have many lovely talks for sure.

    Really, I was in exactly that place for years and never cared for it. I have very atypical set of interests for someone living in Midwestern nowhere, in addition to being European, wide traveled and absolutely not in any social network. But I am an introvert and went to work for working, not for socializing. You very well might be different.

    If you feel that you start to overgrow your unit and team, go for it and look for greener pasture. Just do not try to make up your social life by going into grad school. Good quality NP school full time with even part time work means very little and very sporadic hours that can be spared for anything besides work, study and sleep. Part time school schedule allows marginally more freedom but still not that much to do anything serious. And when you finally got together as students, all talks rotate around JNC8 or something equally not exiting.

  • 8

    "Acute" LTACH is med/surg on high dose steroids and not a place I would recommend for start. "Subacute" (also known as "acute rehab") is a possibility.

    Figure out what exactly you struggle with and what you do good and play from there. The aforementioned acute rehab will give you time management skills for lifetime, for one example. Try smaller facilities if you are not comfortable with constantly changing preceptors and faces.

  • 7
    kalycat, BeckyESRN, Woodenpug, and 4 others like this.

    Quote from FolksBtrippin

    I feel you on the disrespect.

    Reading your post is cathartic for me.

    If families have the luxury of demanding ice and water, it is a credit to you, that you have very successfully seemed calm enough for them to have no idea how precipitous the situation is.

    You would be justified in asking them to leave. I don't know if your supervisor would be okay with it; but morally you would be justified.

    For what it's worth, I respect you.
    The thing is, families behave this way not because they feel comfortable and reassured but because of fear, anxiety and total, complete lack of understanding of what really is going on.

    There is a bunch of research about unhealthy coping mechanisms and these behaviors are studied well beyond healthcare. "Un-doing it", displacing, acting out, trivializing (positive and negative), substitution and aims reduction (momentary, not long term) are just a few of other perfectly human, mostly ineffective stress coping mechanisms. Nurses use all of them as well, and so do doctors, cops, bankers, truckers and everybody else.

    I consider knowing how to effectively fight unhealthy coping while not alienating patient and family and teaching healthy and positive strategies as one of the highest possible achievements in nursing as well as in clinical medicine. And it is indeed possible, but it takes lots of time and patience of a saint. Both of them naturally run rather short when you get a human being belonging to some place right between ICU and ECU under your care with no sensible help and family getting onto your neck right away with ridiculous nonsense.

  • 1
    meanmaryjean likes this.

    Smells like a great deal of scam for me.

  • 13
    Orion81RN, matcha-cat, kalycat, and 10 others like this.

    Quote from wondern
    That's fine. We can totally agree to disagree.
    Absolutely. Just please do not remove the Life Vest because family "wanted" the patient to have bed bath right away.

    (yes, I saw it done by someone who passed NCLEX)

  • 0

    Quote from chrisjk
    You need to go to a class to improve your pronunciation pronto!! Sorry, I have no sympathy if you've been here for 15 years. Living in south Texas, I have a different take on this probably. My last job I was made to feel "inferior" at times due to not speaking Spanish. We live in the USA; IMO English should be "it" as far as what is spoken in the public arena. If people want to speak their native language, do it in the privacy of your home. It used to be called the melting pot; now people feel that they don't need to assimilate. Want to be regarded as a professional? Gotta do the work.....if you have a patient crashing, you'd better be able to tell the doc what's going on clearly and succinctly so that he/she can understand. People put their lives in our hands; it's a sacred trust. Also, it's "hypocrite" and grammar also is important( at least it used to be; I guess things have really changed). Sorry; old-school nurse here.
    When YOU, with your Southern Texan speech (which would, at best, go as "weird" up North) would made to go to that "pronunciation class" after moving to Boston, MA, then and only then I or any other foreign-born medical worker would do the same. Not before that.