Content That Kooky Korky Likes

Content That Kooky Korky Likes

Kooky Korky 14,354 Views

Joined Feb 12, '10. Posts: 2,531 (51% Liked) Likes: 3,208

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  • Aug 26

    Quote from RNinCali15

    Sour,

    Not sure how you think insulting my capability as nurse is constructive.

    I provide excellent patient care, and know exactly what a healthy patient looks like. I have over ten years experience in healthcare, and have four children. I also have a deeper understanding/appreciation on the NICU, something in which few nurses can say they have. Each of my kids were in the NICU, and one of them was a golden hour. So please, save that anti-new grad bulling attitude for a prepubescent new nurse.

    .

    Charming.

  • Aug 26

    Your non-nursing experience does nothing for you as a new grad to your management. Your attitude sounds terrible and you sound incredibly overconfident. I'm sure the care you have provided in the last year is fine. Sour was not insulting your nursing care. Simply stating a fact that there is no possible way for you to know everything in 9 mos.

    you ou might be a fantastic nurse. None of us can tell that. But your very confident statements about all this experience you seem to think you have and deserving more complicated patients purely because you think you are so wonderful is probably playing into your assignments.

    I do agree that while in a NICU, you do need to be getting more acute patients and some critical ones sometimes to make sure you are learning. But im sure all those experienced nurses on the unit would be wasting their experience and knowledge on a feeder/grower. They out in their dues and you will need to as well. If you are that unhappy with the assignments, find a new job that is willing to just dump critical babies on you and hope they survive.

  • Aug 26

    Quote from RNinCali15
    [COLOR=#777777]to me[/COLOR][COLOR=#777777] [/COLOR]
    [COLOR=#777777][/COLOR]







    Sour,

    Not sure how you think insulting my capability as nurse is constructive.

    I provide excellent patient care, and know exactly what a healthy patient looks like. I have over ten years experience in healthcare, and have four children. I also have a deeper understanding/appreciation on the NICU, something in which few nurses can say they have. Each of my kids were in the NICU, and one of them was a golden hour. So please, save that anti-new grad bulling attitude for a prepubescent new nurse.

    Furthermore, it is a new rule that each nurse needs at least 30% exposure to ICU assignments for a couple reasons. The first being that a stable intermediate case has the potential to shift to an ICU case quickly. Secondly, the unit has had days when those "experienced, always in ICU nurses" were not working. Nurses who were only placed in intermediate assignments felt out of sorts in their ICU assignments and complained. How is that what is best for the unit?

    Take your bad attitude and anti-progressive nature someplace else Ms. Grump.
    Your dream job happens to be in a specialty that's know (in my experience) for being the most protective of it's patients as far as acute care goes. I read Sour's post as a call to acknowledge the primary motivators of your unit's leadership vs a personal attack. You'll have to gauge this next bit for yourself, but coming from a long-time ICU charge nurse (me) one thing that often gives me pause in making assignments is dangerous overconfidence. Is this the vibe that you're leadership gets from your novice peers? Perhaps your charges are all anti-progressives, too?

  • Aug 26

    I provide excellent patient care, and know exactly what a healthy patient looks like. I have over ten years experience in healthcare, and have four children. I also have a deeper understanding/appreciation on the NICU, something in which few nurses can say they have. Each of my kids were in the NICU, and one of them was a golden hour. So please, save that anti-new grad bulling attitude for a prepubescent new nurse.
    Hooooo boy. I sincerely hope this isn't your attitude in the unit.

  • Aug 26

    Quote from RNinCali15
    Hello all,

    I have been a nurse for almost nine months now and work in the NICU. This was my absolute dream job, and I worked so hard to land it. While I was on orientation I felt challenged as I was learning SO many new things. I have been off orientation for a while now and have have been stuck with feeder grower patients for over a month. My unit favors nurses with many many years experience and assigns them the sicker kids, daily. They are never given an intermediate assignment.

    I am talking more about the nurses who have less than 2 years experience getting mostly the stable ICU cases and some intermediate patients. We are supposed to be mixed around the unit, with at least 30% ICU exposure. I have also (politely) asked my charge nurse to assign me anything ICU because I need the exposure. Usually I am given an excuse, and the next day I am back with the feeder growers. Managment likes me, and there has never been an issue with the care I have provided my patients. I don't understand. I am just about at my wits end with this matter. I did not go to school to be a daycare provider who rarely uses her brain. I understand that an intermediate case can shift quickly, but I need consistant exposure to vents, bcpap, umbilical lines etc to remain competent. Ugh!

    Advice?
    They probably care less about what you "need" and more about the safety of the patients. While you patiently wait for your day to come, learn all you can where you're at right now. At nine months in, I doubt you know it all ...even when it comes to the most stable babies.

  • Aug 26

    Quote from SunnyPupRN
    When Big Pharma and For Profit hospitals charge $47 for 50mg of Benadryl
    for inpatients, and inpatients don't even have a say in the matter because nobody KNOWS the price until they ask for and itemized bill...or outpatients cannot make informed choices because you cannot ' shop around ' for the best price, or even a fair price for an MRI because nobody at the front desk even knows the flat rate for imaging - or the flat rate is price gouging so that between the insurance companies and the deductible patients are faced with a coercive monopoly...THAT kind of profiteering is well beyond a $3500 bill. I'm not talking about small business....for that, I certainly agree. I am talking about big healthcare, the kind that woos doctors and nurses with gifts and gadgets to pedal their drugs to patients. Those are billion dollar companies whose CEOs are running off with the steak and leaving the bone and gristle for the rest of us. As patient advocates, we should all be angry.
    Small businesses, as you said, often struggle, and no, not everyone should get a free pass.
    In 30+ years as a nurse, I've never had anyone try to "woo" me because I was a nurse.

  • Aug 26

    I'll never forget my husband, who died of cancer. Before I met him he had lived in Pocatello ID, which has a high LDS population. He'd had some unpleasant dealing with some Mormans and harbored a prejudice against that group.

    During his last week of life, prior to his final hospitalization and death, he was sitting in the garden and a couple of Morman missionaries came by. My husband was a skeleton at that point in time.

    He politely told the young men that he didn't have time to talk to them, that he was just spending time with family. He would never do the wrong thing, just because he was suffering.

  • Aug 26

    OK- I get it. But the post was about pet peeves, and y'all is mine. And wikipedia is an anonymously sourced internet site- not EBP!

  • Aug 26

    Quote from Here.I.Stand
    I agree completely with most of the other posters. A tool is one more thing that would need to be done on an already full to-do list... actually those big task lists are a big part of the problem. As others have brilliantly said, it puts the RN's eyes onto a computer/worksheet and takes them off the patients. It is no substitute for the RN laying eyes and hands on that patient. Plunking a RR onto an extra worksheet sheet ("extra" because it has already been documented on the VS flowsheet) is a task...noting the character of respirations, noting the patient's mental status, noting the "look" they have on their face is nursing assessment. Plunking a HR and BP on an extra worksheet is a task...noting at the color and temperature of their skin, and noting the patient's mental status is nursing assessment.

    A couple side stories: a while back I had a patient who was on trach dome all day, who had been guppy breathing but never *looked* like he was breathing comfortably. He was also minimally verbal so difficult to assess his mental status. I arrived for my 2nd shift with him. The previous day he would give me these big vacuous smiles whenever I talked to him...like he didn't necessarily understand me but was trying to be social. Well I go to assess him, and immediately feel something is off. His breathing doesn't look comfortable, but as the previous nurse said "it never did." But he had this expression on his face that reminded me of a dead fish, and he made no eye contact. The dr. came in and I said I really think he needs to go back on the vent. Something was off. MD ordered an ABG "to confirm," and his pCO2 came back in the mid 60s. It wasn't his RR or any other quantifiable number that told me something was off; it was his look and mental status.

    Another time while orienting in my former LTACH, we went to assess this one patient. Her HR and BP were a bit higher/lower respectively than her baseline but not terrible, but she was flushed and confused. She was becoming septic and we got her transferred into the ICU pretty quickly. Again, our clues were not worksheet-quantifiable numbers...turns out her WBCs were elevated, but labs weren't resulted for a couple more hours. So based on the info we had at the time, our clues were her mental status and the look/feel of her skin.

    I really don't see a substitute for nursing assessment; and proper RN : pt ratios, elimination of extraneous charting, elimination of customer service tasks, etc. that allow the time and focus to perform said assessments.
    I agree that it is the bedside assessment that most often reveals "something is wrong" even though objectively numbers may not be "that bad". Which is exactly were the Novice to Expert nurse model goes along.
    But I think even though a nurse may detect something is wrong, it often depends on the hospital culture and the MD how they react to it. In the hospital that requires to call a rapid response to ensure that those concerns are taken seriously, the attitude from MDs changed significantly. Now I work in a different hospital in which the nurses struggle at times with the MDs . My current place has a huge threshold to call a rapid response, which I do not agree with. The whole goal is to detect deteriorations earlier and prevent a code.
    In the hospital with the trigger program I took care of a young man in his 20s with complex neurological problems. His vitalsigns including oxygen looked ok, he was step down. But - when I did a quick follow up assessment some hours into my shift I found that his skin color had changed in a subtle way plus his breathing looked "odd" and I noticed just looking at him that the chest was not expanding as much but the abdominal area was shifting with breaths in a weird way. His lungsounds were diminished anyways and just more dim on one side. But when I looked at his neck I felt that there was a subtle deviation to the side. I called a rapid response asap as I was sure something was not ok, the patient was also not mentating as before.
    Low and behold the rapid response team comes and they are somewhat puzzled about me calling them - - but go to work for an in depth assessment. In the meantimes the xray techs come and do a bedside x ray. While the team is at the bedside, the respiratory status suddenly gets visibly worse and the pat requires a non re-breather mask. They decide to move him over from step down to ICU since something is going on. We were very quick getting him to the ICU. When I went over again to bring some of his clothes they told me to come and look at his x ray : His heart was pushed to the other side significantly due to a tension pneumothorax, which they relieved in the ICU asap. It was somewhat puzzling that this patient did not have more early symptoms but they thought because he was younger plus darker skin the signs were subtle. Point is - if I had not called a trigger event, the patient would have coded for sure probably soon after and changes of a good outcome not as good. Other members of the rapid response team told me later that at first they felt it was "nothing" when they entered the room but since the hospital has this policy they had to do an in depth assessment, during which the problems became significant.
    The program has not saved everybody but really decreased the amount of codes and bad outcomes. They also implemented other rules with it :
    If somebody got a rapid response within the first couple of hours after admission from the ER, critical care, post surgery it automatically translated in a thorough investigation as the patient should not be on a med/surg floor when not stable. That also cut back on pat coming up from the ER and ending on a non rebreather mask after an hour or so - now on a floor with less resources...

  • Aug 26

    Quote from Lev <3
    I am on my hospital's nurse practice counsel and recently the discussion turned to nurses failing to recognize declining patients before it is too late. Before I was an ER nurse, I was a floor nurse. When you have 5-7+ patient to juggle at a given time you can barely focus your attention on one patient for minutes at a time in the midst of endless med passes and documentation. What is your hospital doing to improve this issue? I am aware that the EPIC charting system has an Early Warning Score (EWS) built in based off the vital signs. However, even a slight change in mental status (including anxiety) and decreased urine output are two possible signs of deterioration other than changes in vital signs. I am trying to create a generic electronic tool that nurses, particularly med-surg and telemetry nurses with high patient loads, would fill out 6 hours into the shift which will help them determine when to be alarmed and notify the physician to intervene. What do you think about this issue and my idea?
    That would be another form to fill out at the end of my shift. Taking my time and attention from face to face patient interaction... where I COULD notice a change.
    Overworked nurses need mandatory education to teach them to use their assessment skills, and not focus on documentation.
    In other words.. look at the patient..instead of your computer screen.

  • Aug 26

    Quote from chare
    Yes, I did. The post in question stated that a rapid response is to be called when vital signs are outside of established parameters (emphasis added):

    It is incumbent on the bedside nurse to contact the attending provider and ensure that appropriate alarm limits are identified for patients based upon their baseline values, and not an arbitrary set of numbers.
    ... and also asking for an order is one thing, but overcoming a schmolicy which says that monitors' settings cannot be changed is totally another one.

    I had to sign AMA from ER less than a month ago because nurses there physically couldn't live their lives with one patient' BP below 100/70 (baseline 90/60 when active, the time was 3 A.M. and I had two doses of Benadryl IV at that time, so it was in mid-80th for systolic, asymptomatic otherwise). One of them practically threw a tantrum, yelling over the phone to her supervisor that the poor doc "refused to theat my patient who is in shock according to criteria". No explanations were enough for them, because they had policies and criteria. I had to run, sleepy as a bat.

  • Aug 26

    Quote from blondy2061h
    Did you read the post I quoted? The person said the facility she worked at wrote people up if they didn't call a rapid response if vitals were above or below parameters. She didn't mention any exception for patients' baselines, hence my question.
    Yes, I did. The post in question stated that a rapid response is to be called when vital signs are outside of established parameters (emphasis added):
    Quote from nutella
    […]
    The way it works is that if a patient VS are outside of the established parameters, for example HR above 120/min or less than 50, O2 sat less than 90%, RR above 30 per minute or less than ... any change in mental status…
    […]
    It is incumbent on the bedside nurse to contact the attending provider and ensure that appropriate alarm limits are identified for patients based upon their baseline values, and not an arbitrary set of numbers.

  • Aug 26

    I agree completely with most of the other posters. A tool is one more thing that would need to be done on an already full to-do list... actually those big task lists are a big part of the problem. As others have brilliantly said, it puts the RN's eyes onto a computer/worksheet and takes them off the patients. It is no substitute for the RN laying eyes and hands on that patient. Plunking a RR onto an extra worksheet sheet ("extra" because it has already been documented on the VS flowsheet) is a task...noting the character of respirations, noting the patient's mental status, noting the "look" they have on their face is nursing assessment. Plunking a HR and BP on an extra worksheet is a task...noting at the color and temperature of their skin, and noting the patient's mental status is nursing assessment.

    A couple side stories: a while back I had a patient who was on trach dome all day, who had been guppy breathing but never *looked* like he was breathing comfortably. He was also minimally verbal so difficult to assess his mental status. I arrived for my 2nd shift with him. The previous day he would give me these big vacuous smiles whenever I talked to him...like he didn't necessarily understand me but was trying to be social. Well I go to assess him, and immediately feel something is off. His breathing doesn't look comfortable, but as the previous nurse said "it never did." But he had this expression on his face that reminded me of a dead fish, and he made no eye contact. The dr. came in and I said I really think he needs to go back on the vent. Something was off. MD ordered an ABG "to confirm," and his pCO2 came back in the mid 60s. It wasn't his RR or any other quantifiable number that told me something was off; it was his look and mental status.

    Another time while orienting in my former LTACH, we went to assess this one patient. Her HR and BP were a bit higher/lower respectively than her baseline but not terrible, but she was flushed and confused. She was becoming septic and we got her transferred into the ICU pretty quickly. Again, our clues were not worksheet-quantifiable numbers...turns out her WBCs were elevated, but labs weren't resulted for a couple more hours. So based on the info we had at the time, our clues were her mental status and the look/feel of her skin.

    I really don't see a substitute for nursing assessment; and proper RN : pt ratios, elimination of extraneous charting, elimination of customer service tasks, etc. that allow the time and focus to perform said assessments.

  • Aug 26

    Quote from Lev <3
    I am on my hospital's nurse practice counsel and recently the discussion turned to nurses failing to recognize declining patients before it is too late. Before I was an ER nurse, I was a floor nurse. When you have 5-7+ patient to juggle at a given time you can barely focus your attention on one patient for minutes at a time in the midst of endless med passes and documentation. What is your hospital doing to improve this issue? I am aware that the EPIC charting system has an Early Warning Score (EWS) built in based off the vital signs. However, even a slight change in mental status (including anxiety) and decreased urine output are two possible signs of deterioration other than changes in vital signs. I am trying to create a generic electronic tool that nurses, particularly med-surg and telemetry nurses with high patient loads, would fill out 6 hours into the shift which will help them determine when to be alarmed and notify the physician to intervene. What do you think about this issue and my idea?

    While I like the idea of a tool it will most likely not change anything in practice. Because it is not timely enough. If something is not ok, it may not make a difference 6 hours later or such.

    One of the hospitals I worked at implemented a mandatory rapid response program that actually did change patient outcomes.
    The way it works is that if a patient VS are outside of the established parameters, for example HR above 120/min or less than 50, O2 sat less than 90%, RR above 30 per minute or less than ... any change in mental status. And the important element is that it is mandatory to call a rapid response for that - no exemption. So physicians do not give nurses a hard time as it is policy and the rapid response team provides the other set of eyes that you do not have as a busy nurse.
    That policy saved lives. Some nurses did not want to call a trigger or the MD tried to convince them to "lay low" but leadership was very adamant and made sure they know that they will be written up if they fail to call a trigger.

  • Aug 26

    With all due respect, I think focusing on making another tool for nurse's to complete is contrary to the rest of your post about overworked, overwhelmed nurses. Nurse's are too busy to notice patient changes because they are overwhelmed, so let's add more checklists/documentation?? Um, no. How about we add more nurses??


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