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Joined Aug 8, '10. Posts: 433 (41% Liked) Likes: 375

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  • Feb 16

    Quote from PatMac10,SN
    I think nurses should be able to. Even if it is only when there isn't a Doc available.
    How many times will you be able to intubate? How will you maintain proficiency? How often will the doctor not be available? If this is an ER without a doctor being available I think the state and Federal agencies should be made aware for possible penalties. How much will you leaving your patients to intubate affect other nurses? Who will push the medications if you are intubating? Can the RTs at your hospital give all the medications AND set up the ventilator while you are at the head of the bed which might be for awhile if you are not able to get enough intubations to maintain proficiency? What about the liability? If you are not able to maintain proficiency and botch up the airway badly or even cause death, neither the BON nor the legal eagles will be kind if you can not demonstrate you were able to maintain an adequate skill level. Just recertifying every 2 years in ACLS or PALS is a joke and demonstrates nothing. Just saying "they can why can't we" is not good enough as a defense. Even Paramedics have felt the pain of losing a skill like intubation. Too much emphasis is placed on a skill without embracing the responsibility which goes with it. There are several EMS departments which will not allow Paramedics to intubate children. There are also EMS departments which will not allow Paramedics to do ETI and supraglottic devices or BVM are the only options. If one does not get the experience through many, many intubations, you will suck at it. Ask any CRNA how many intubations they must do to be really good and not do more harm to a patient. Just wearing a Paramedic patch or RN pin does not automatically make you proficient at a skill.

  • Oct 7 '15

    Try to get a serious focus on your health and fine tuning your body to accept night shift until you pay your dues to transfer.

    Become a q3 eater. Package small portions in little containers to munch on easily and quickly throughout the night. Eat a well balanced light meal for your main break.

    Drinks lots of water. Night shifter workers are dehydrated constantly.

    Avoid sugar loaded products and caffeine. Yes, no coffee or only in moderation at the beginning of the shift. Drink green tea which may have some caffeine. Read the labels.

    Get a routine which might be simple stretching before and after work.
    Drink a warm non decaf beverage and read something when you get home. Get to a quiet place or personal space in your home or favorite park and in your mind.

    Make sure your shoes are comfortable. Simple as it sounds, it sets the mood for the night if your feet hurt.

    Try to at least take a long brisk walk on your days off.

    Once your body adjusts, your mental outlook will gradually get better.

    Cut yourself some slack. You are new. Night shift people tend to be a crusty bunch at first but most will warm up to new comers eventually. Don't be afraid to ask for advice.

    But, until then, focus on your body and health. Keep work at work. I don't even wear my clothes to and from work. Once I clock out, I change clothes and become who I like most. My personal space might be sitting on a beach for awhile after work and appreciating I can do that because I work in a profession which allows me to live just about anywhere. Remember you work to LIVE and not live to work.

    Doing 12 hours shifts you are only spending 36 hours at work. The rest of that time is yours. Make plans on your first day off to do something in the afternoon. Make an appointment to pamper yourself. Go to the mall and window shop. Meet a friend for a movie and/or dinner or late lunch. Make a list of all the stuff you haven't done lately like a museum, the theater, a concert or some attraction in your community or nearby.

  • Oct 3 '15

    Quote from Murse901
    Are you serious? All of that, and you still don't get the difference between state EMT-P licensing and NREMT-P.

    Quote from Murse901
    Repeat after me: Eligibility for state licensure is not the same as eligibility for National Registry.
    I have posted links. I have quoted from the links. I don't know how many more ways I can come up with to make this easier so you can understand it.


    The NREMT is an organization which most states use to give their EMS exams including the Paramedics. The NREMT essentially tests at the very basic minimum standards for each test to make it fair to the states which only require the bare minimum of the US DOT National Standards for the curriculum. Some states feel 600 hours are enough for Paramedic while others might want 1000 - 1200. One state wants the equivalent of an Associates degree and one states sorta wants that. Regardless of the number of hours for the minimum requirement, the test is the same for Paramedic no matter how many hours of training. A few states few the NREMT tests at a standard too low for their liking so they use their own state test for Paramedic.

    Once you take either the NREMT or a state test which "certifies" you have met the bare minimum for testing knowledge, you apply to the state for a license or an official certification to work as a Paramedic in this state. Just having the NREMT certification alone does NOT allow you to work in that state.

    I posted a link which describes how many states allow for other professionals such as RNs to obtain their Paramedic license without going through the whole Paramedic program which usually are not taught at a college level. If a state reviews the RNs applications and feels that person has met all the educational requirements and whatever additional things like all the weekend certs and school accreditation along with some ride time, the state may have an agreement with the NREMT to allow this person to test for the Paramedic exam. This again is only a certifying exam to test a basic knowledge. I repeat, again, the NREMT does not provide the license but merely contracts with states to provide a test to those who meet the requirements for Paramedic in that state. The NREMT also has a few requirements like being 18 y/o to take the test which for Paramedic that is the same in all states. The states which allow 16 y/o to test for EMT-B will use their own state exam.

    The RN who holds a BSN and has over 1000 hours of just clinical experience in school along with a couple years of experience in the ICU and/or ED along with about 40 hours of extra skills training and a few states want 40 ALS patient contacts by far exceeds what some Paramedics get for education and training. It is not uncommon for a Paramedic student to not have any intubations or IV sticks on a live patient. Some Paramedics may not see 40 patients in a year depending on where they live so their clinicals might just be killing time at an ambulance or fire station.

    But, again, the NREMT is an organization which is contracted to provide a test...period. The NREMT does not license. It can also make an agreement with each state to test a professional whom the state feels have met the minimum requirements to be a Paramedic. With the wide variations in EMS education throughout the US, this is only reasonable.

    Read the NREMT website and the different state EMS sites which myself and others have stated as allowing RNs to bridge relatively easily to Paramedic.

  • Aug 3 '15

    Quote from kvromero11
    I want to do both. Jack of all trades. I think itd be best to agree to disagree, because I see an RN and EMT-P certification to be very equivelant. I dont down play anything. I know both professions are totally different. One is long term, one is short term. Like I said, in my state they are both equivelant, and a paramedic needs to be able to everything an RN can and vice versa.
    I do believe in education too. I believe in being well rounded too. My goal is to make myself the most competitive applicant. So if I can be competant as both a medic and a nurse it can only benefit me.
    I can see where your dislike for medics are on your previous post. I understand it.
    I believe your answer to my question is stick with the BSN program. CCRN over CCEMT. And I am assuming you are not a medic either so you cannot answer my second question. Thank you for chatting with me :-)
    Telling you what you don't want to hear is not a dislike for Paramedics. Like many who started in EMS and then went on, we learned the difference between a tech certificate (Paramedic, LPN) and a degreed profession (RN, RT, RRT, SLP, OT, PT etc). Your state requires about the same number of hours for the Paramedic cert in total as some RN and other allied health program require just for clinicals. The minimum education requirements are not equivalent. Looking also at the scope of practice for Paramedics in Maine, it is the same as most states which is still very limited. Do not criticize the Paramedics who have gone into nursing to actually do critical care at the bedside and on transport. You too could be seen as a "Paramedic hater" by those giving you the street smarts advice when you get your RN and see the difference.

    Maybe you should see what RNs actually do in an ICU before making your decision. I would suggest you go to a hospital which has a little better rating. Do not judge all hospitals by the standards of yours If you feel the nurses have no skills or critical thinking abilities. I seriously doubt this is totally true but more hearsay from the Paramedics around you. You seem to have a very low opinion of nurses now even though you want to be an RN and everything you have posted probably are the words of some Paramedic who feels street smarts trump education. Unless you have respect for nursing as a profession, it will be a waste of time for you and someone who could have had your seat in a nursing program.

  • Aug 3 '15

    Are you sure about only CRNAs and lifeflight RNs intubating?

    NPs, RNs and RTs who work on specialty (neonatal, pediatric) also intubate in your state.

  • Aug 3 '15

    Not turning it into a nurse vs medic argument.

    By the time you have finished with all the Paramedic stuff and you go through the ADN program your hospital will have gotten its Magnet status. How do you think you are going to get the necessary ICU experience in the ICUs if you can not get hired by one?

    You miss the critical thinking and problem solving that goes into being a medic.
    You actually think RNs don't have critical thinking skills? Now that is insulting. Talk about no respect.

    Airway/cardiac specialist and quick descision maker without a doc writting every order for you.
    Did you know that Paramedics function by protocols which are DIRECT WRITTEN ORDERS for everything a Paramedic does and must have direct contact with med control for anything which is not in their protocols or exceeds them? A Paramedic is also limited by their state's scope of practice. An RN has a very broad state scope of practice.

    Who has been advising you? There are reasons why some of us left EMS to move into the ICUs. Why do you think more Paramedics go on to be RNs than RNs to Paramedics?

    Right now you don't know what you don't know and it sounds like a Paramedic is talking down the nurses and telling you education is BS while skills rule.

  • Aug 3 '15

    Quote from kvromero11
    Silver Surfer,

    I think you misinterpeted. I am currently enrolled in a BSN program-, and am half done my paramedic program. I only have four more prereqs to do. I am enrolled in a UNIVERSITY. The ADN is offered through a community college. Here the flight paramedics and nurses are expected to perform the same set of skills at the same competency. They are equals. In medic school you are already taught how to intubate (I did my first one 2 days ago). I plan on getting my BSN eventually, I just was wondering if it would be smart to get my ADN in a year then bridge to my BSN. The service I am taking my medic course through offers perdiem spots 8, 12, 16 and they always have shifts available. My work schedule in not a real issue.
    There is a local university here that has a Medic to RN bridge course,
    Nope. I didn't misunderstand you.

    Why would you dump the BSN program for an ADN when you are already halfway finished.

    Having the same "skillset" such as intubation is not the same as having the critical care knowledge and background. There the RNs and Paramedics are NOT equals. Learning to stick a tube down someone throat is just a small part of the equation. EMT-Basics can also intubate in some states. Maintaining that tube with multiple drips and devices are another. If you want to just compare skills, the RN wins without a question and with ICU education and experience. If an RN works on a Specialty team like pedi or neonatal, they may be the primary intubators for their unit. They may need 20 intubations a year for each age group to maintain competency. Plus, they already have the knowledge of the medications required for intubation and know what to do with the patient once they are intubated to keep that tube. Patients don't just lay there quietly without any meds or life support until extubation. There are also all the other acute care issues which must be addressed and this is for the entire shift along with at least 1 - 2 other patients to care for at the same time who might be critical in the ICU. Once they are on transport, they are able to do their jobs just like they were in the ICU.

  • Aug 3 '15

    You are messing up your goal of being a flight nurse.

    1. You have a job at a Trauma Center. Chances are that hospital will hire you when you complete your BSN. Thus, you won't spend 2 years as an unemployed new grad RN especially if you have an ADN.

    2. Most of the NE is going with BSN and have a goal for their states to be "BSN in 10". Many flight programs want BSN degreed RNs. People might tell you it doesn't matter whether you have a BSN or ADN and maybe it didn't 20 years ago. But, it will be at least 5 - 6 years before you become an RN with an ADN by the route you are taking. A lot can change and it probably won't be to lessen the requirements to be an RN.

    http://nursing.connectwithmhs.org/wp...na-Barnes3.pdf

    3. You will need at least 3 to 5 years of ICU experience as an RN. Many hospitals are now Magnet and want BSN degreed RNs for their ICUs.

    4. You need to prepare for the future and not just a quick cert right now. Your long range plans to be a Flight RN requires several years of preparation as a NURSE. Those who have said "the ADN has always been good enough" are finding themselves left out when there are hundreds of applicants who have gone the distance.

    5. Where are you going to work as a Paramedic? Very few EMS jobs are going to be flexible enough for you to go to nursing school or at least not for the first year or two.

    6. If your goal is to be a flight NURSE, skimping or taking shortcuts for nursing school is not going to benefit you. The bridge programs also just cut you some slack on a couple of classes but sometimes the material missed in those classes can be vital in bringing the whole process together.

    Also, is it a university or a community college which is offering the bridge program? Universities usually offer Bachelors and higher...not ADNs.

    7. It is a lot easier to go from RN to Paramedic than it is Paramedic to RN. There are programs which allow RNs to take 2 weeks of additional training and take the Paramedic exam. Some states allow the RN to just challenge the test if they have ACLS and couple other weekend certs. There are RNs who teach the Paramedic classes at some colleges and universities.

    8. Trying to compare CCRN and the CCEMT is a total joke. To take the CCRN you need over a year of actual work experience in an ICU as an RN. There are also separate CCRN exams for the different ages groups which you will need over a year of work experience in each unit to take the exam. The CCEMT is a 2 week merit badge teaching very watered down introductory level critical care overviews. If you are lucky the might take one day to give you a walk through of an ICU. Some Paramedic schools even tack this course on (at a very high cost) as a selling point for their new grads who have ZERO experience as a Paramedic since there are no prerequisites for the CCEMT.

    9. To be a Flight RN, it does not matter if you have 30 years of experience as a Paramedic. To be a flight RN you will still need to meet all the requirements which may include BSN and still have 3 - 5 years of work experience as an RN in critical care. They do not just automatically move you to the next seat. A Flight RN brings critical care knowledge and skills to the team which are highly specialized and not something which can be learned in a weekend cert class.

    10. Following through with #9, it is easier to teach a few skills like intubation and central line placement to someone who has advanced education and who has already worked in the lCUs with these procedures and devices than it is to take someone who has very little exposure to these lines and tubes and the only critical care knowledge is from the CCEMT which again does not really teach anything about critical care nor give the necessary experience.

    11. As an RN (with a BSN) you may have the opportunity to work in many ICUs such as Neuro, Cardiac, CV, Pedi and neonatal. All of which would be great for making you a better Flight RN. As a Paramedic you can not work in any of these ICUs except as a tech to assist the RNs.

    12. While you are going off to be a Paramedic and trying to gain work experience as one, remember the prerequisites you took to get into nursing school have a time limit. You may need to retake most of the math and science classes.

    If you are looking for shortcuts, just scrap the goal of being an RN. Go to Paramedic school. Earn as many weekend merit badges as you can. Work a couple years on an ambulance if you can find one which does emergency response. Then you can apply as a Flight Paramedic and work with an RN who has lots of critical care experience.

  • Aug 3 '15

    Quote from buncee
    That is the whole point of being ACLS certified, to begin ACLS treatment if you are the first to respond. Paramedics aren't Doctors, but they can administer medications without a doctors order.
    Negative. Paramedics have written standing orders called protocols. They must work under a Medical Director who determines what they can and can not do.

    This is no different than what a nurse has with standing orders on the floor or in the unit. Code Teams and Rapid Response teams also have their standing orders signed by the physician overseeing those teams.

    ACLS is barely worth the paper it is written on these days. Anyone can take the course if they meet the minimum entry requirements for ECG recognition and work in some are where a person might code. This includes licensed, certified or just assistive personnel. It grants you nothing in the way of scope of practice set by your profession, state or facility. Your facility might require it as a way to meet some job description but should not replace protocols or education provided by your facility. Years ago it was an achievement to pass this course and employers could be fairly confident you were capable of providing ACLS as a competent provider. Now if you can sign your name on the card you will get one.

    Several places don't even require their nurses or other code team members to have the AHA ACLS. They have their own competency training in place or offer their own form of it. UCSD's ART/BART Resuscitation program is an example.

  • Jun 19 '15

    Quote from Gemi523
    Any patient with a trach collar should have a humidifier. Humidifiers come with the Fi02% dials. In my opinion, the order was written inappropriately and the charting is messed up. really scary to have nurses charting things they have no idea about.

    A patient is on a high flow device. i.e. trach collar. In order to use a trach collar appropriately, the FLOW RATE must be set at 10-12LPM. THIS DOES NOT MEAN the patient receives 10L of oxygen. This is where the dial comes on. You adjust the dial percentage to a patient saturation to maintain 93% as written. That is why you get here more "noise" as you turn the dial to a lower flow. Because more air is escaping into the atmosphere. The higher you turn up the dial, you hear less "noise" because all the oxygen is being delivered to the patient through the trach collar.

    The order should had been written, adjust trach collar Fi02 up to 60% to maintain sats greater than 93%. 10L of oxygen delivered from a simple face mask or high flow cannula is approximately 60% Fio2.

    Its almost unnecessary to even chart the flow rate of 6L. If the trach collar is used appropriately, it should ALWAYS be at a flow rate greater than 10L. Thats a given. The only thing you should really be charting is the fi02. By charting 6L at 40%, you aren't using the trach collar appropriately. So you really don't know how much oxygen the patient is REALLY getting.


    Im an icu nurse x 8 years. I know this. Or ask a respiratory therapist.
    I agree with most of your post but there are some major concepts which need to be cleared up.


    The "FiO2" dial on oxygen devices are not allowing "air to escape". These O2 devices are ran by what is known at a Venturi system based on the principle of Bernoulli and air entrainment.

    http://www.respiratoryupdate.com/mem...sk_Venturi.cfm

    For every part of oxygen, X amount of air must be entrained to blend for the set FiO2. Due to the ability to entrain large liter amounts of air, this makes a venturi device "high flow" and should meet the patient's inspiratory demands. But, the higher the FiO2 the smaller the opening gets and the less flow is entrained. This is why these aerosol devices are most effective at low FiO2s (less than 50%). Know the limitations of your device as patients might increase their flow AND FiO2 demand.

    Venturi and Bernoulli are the basic principles of ALL oxygen equipment. The goal is to deliver enough flow to meet patient demand and in the case of a trach mask achieve the goal of humidification. (This is also why some hospitals have a policy of no bubblers on Nasal Cannulas less than 4 liters but that is another discussion.)

    Also note that water particles can change FiO2 and/or the total flow delivery which is why humidifiers are not placed on Venturi masks or most low flow masks like Simple and non rebreathers.

    Too many get caught up in the 1 L = 24%, 2 L = 28% crap which is only good for exam purposes and does not address the many different devices for O2 delivery or the many patient factors which influence FiO2. Some very bad adverse patient events have occurred because health care providers have tried to utilized that very over simplified concept on all devices. Hence you get the 2 L NC patient who is a mouth breather when sleeping and gets placed on a 2 L simple mask. Some also see the simple mask and the venturi mask as being the same. If one can run at 2 L so can the other. Now you also get some with this way of thinking for the trach mask.

    Some RTs or RN managers will just tell the nurses to run a humidifier at 10 L minute or more just so they don't have to try to explain Venturi.

    What some LTC facilities have done to avoid errors is run the humidifier off compressed air (wall or industrial size air compressor) at 8 - 12 L/M and bleed in O2 into the circuit. The delivered FiO2 will vary depending on the flow from the compressor but at least those who have a difficult time understanding the O2 devices can chart "liter flow". The humidifier will also be turned to 100% to close the opening and make it quieter.

    If the FiO2 device is set at a specific O2 and the correct liter flow is set, the patient will probably get close to that FiO2 provided they are not breathing more for inspiratory demand than the delivery device. Luckily, these are high flow devices meaning they entrain a lot of air but the higher the FiO2 the less air will be entrained. THAT is where some get into trouble. They believe the patient is getting "100%" FiO2 when the dial is set at 100% but there is no entrainment. If the patient is breathing hard and fast, they will entrain from around the mask. If the mask is improperly placed, definitely not 100%. A trach collar is effective at lower FiO2 just like the Venturi mask.

    There are a few high flow humidifiers which can go up to 40 or even 60 liters if demand is great. Sometimes the RTs will hook up two humidifiers on a Y connectors. They will run both humidifiers at the same FiO2 to achieve a more precise percentage. The patient will have their flow and FiO2 demands both met. Some may have seen RTs adjusting the flow setting on a ventilator. Flow must meet demand.

    BTW: For all who had EMT or Paramedic training prior to becoming a nurse, a non-rebreather mask is not a high flow device. It is a low flow. Changing the flow on it to decrease "FiO2" does the patient a big disservice and accomplishes very little. Also "rigging" devices when you do not understand the basic principles of oxygen delivery is dangerous even if you have been told someone has always done it that way.


    All the "text book" percentages on low flow devices (NC, simple mask, non rebreather mask) you memorized for a test were based on a mathematical formula for an "average" sized person breathing at rest a VT of 500 and a RR of 12 with a consistent inspiratory liter flow for a MV of 6 Liters.

    References;
    The above link, Respiratory Update is Dana Oakes' website and has all the books available online for reference.

    From Nursing Times, a good explanation of devices;
    Short-term oxygen therapy | Practice | Nursing Times

    Here is a good article for Pediatrics. The basic principles are the same. Notice how much Total Flow decreases through a Venturi device as FiO2 increases.

    http://pedsccm.org/FILE-CABINET/Prac...fs/4OXYGEN.PDF


    Take an RT quiz.
    http://www.actx.edu/respiratory/file...ry_devices.pdf


    RT Book of Calculations. This should also be a MUST READ for all critical care nurses.

    Respiratory Care Calculations, 3rd ed. - David W. Chang - Google Books

  • Jun 19 '15

    The principles still apply for O2 delivery devices regardless of location (ICU or SNF). You just have to know what type and have some working knowledge of each device.

    Most of my info and references pertain more to LTC. In California we do not have RTs in SNFs, LTC or even on the med surg floors. The education is left up to nursing which is why some of us have tried to get as much info as possible. You will eventually see fewer and fewer RTs everywhere as reimbursement dwindles even more for that profession. So, study up on the O2 stuff.

    I did list what some facilities have had to do in order to prevent errors. That included running the humidifier off compressed air and doing O2 bleed in. But, when some will then switch to the O2 flow meter for the humidifier you will again get error. Some don't notice the flow meter when looking at the humidifier.

    The other is to tape the insert for FiO2 which comes with ever bottle to the bottle.

    The other issue is some charting systems on med surg, SNFs or LTC facilities only allow for liter flow. That will need to be addressed. The same for CNA charting.

    Overall, consistency. Pick a system, educate, re-educate and stick to it with frequent QA monitoring.

  • Jun 19 '15

    Quote from Gemi523
    Any patient with a trach collar should have a humidifier. Humidifiers come with the Fi02% dials. In my opinion, the order was written inappropriately and the charting is messed up. really scary to have nurses charting things they have no idea about.

    A patient is on a high flow device. i.e. trach collar. In order to use a trach collar appropriately, the FLOW RATE must be set at 10-12LPM. THIS DOES NOT MEAN the patient receives 10L of oxygen. This is where the dial comes on. You adjust the dial percentage to a patient saturation to maintain 93% as written. That is why you get here more "noise" as you turn the dial to a lower flow. Because more air is escaping into the atmosphere. The higher you turn up the dial, you hear less "noise" because all the oxygen is being delivered to the patient through the trach collar.

    The order should had been written, adjust trach collar Fi02 up to 60% to maintain sats greater than 93%. 10L of oxygen delivered from a simple face mask or high flow cannula is approximately 60% Fio2.

    Its almost unnecessary to even chart the flow rate of 6L. If the trach collar is used appropriately, it should ALWAYS be at a flow rate greater than 10L. Thats a given. The only thing you should really be charting is the fi02. By charting 6L at 40%, you aren't using the trach collar appropriately. So you really don't know how much oxygen the patient is REALLY getting.


    Im an icu nurse x 8 years. I know this. Or ask a respiratory therapist.
    I agree with most of your post but there are some major concepts which need to be cleared up.


    The "FiO2" dial on oxygen devices are not allowing "air to escape". These O2 devices are ran by what is known at a Venturi system based on the principle of Bernoulli and air entrainment.

    http://www.respiratoryupdate.com/mem...sk_Venturi.cfm

    For every part of oxygen, X amount of air must be entrained to blend for the set FiO2. Due to the ability to entrain large liter amounts of air, this makes a venturi device "high flow" and should meet the patient's inspiratory demands. But, the higher the FiO2 the smaller the opening gets and the less flow is entrained. This is why these aerosol devices are most effective at low FiO2s (less than 50%). Know the limitations of your device as patients might increase their flow AND FiO2 demand.

    Venturi and Bernoulli are the basic principles of ALL oxygen equipment. The goal is to deliver enough flow to meet patient demand and in the case of a trach mask achieve the goal of humidification. (This is also why some hospitals have a policy of no bubblers on Nasal Cannulas less than 4 liters but that is another discussion.)

    Also note that water particles can change FiO2 and/or the total flow delivery which is why humidifiers are not placed on Venturi masks or most low flow masks like Simple and non rebreathers.

    Too many get caught up in the 1 L = 24%, 2 L = 28% crap which is only good for exam purposes and does not address the many different devices for O2 delivery or the many patient factors which influence FiO2. Some very bad adverse patient events have occurred because health care providers have tried to utilized that very over simplified concept on all devices. Hence you get the 2 L NC patient who is a mouth breather when sleeping and gets placed on a 2 L simple mask. Some also see the simple mask and the venturi mask as being the same. If one can run at 2 L so can the other. Now you also get some with this way of thinking for the trach mask.

    Some RTs or RN managers will just tell the nurses to run a humidifier at 10 L minute or more just so they don't have to try to explain Venturi.

    What some LTC facilities have done to avoid errors is run the humidifier off compressed air (wall or industrial size air compressor) at 8 - 12 L/M and bleed in O2 into the circuit. The delivered FiO2 will vary depending on the flow from the compressor but at least those who have a difficult time understanding the O2 devices can chart "liter flow". The humidifier will also be turned to 100% to close the opening and make it quieter.

    If the FiO2 device is set at a specific O2 and the correct liter flow is set, the patient will probably get close to that FiO2 provided they are not breathing more for inspiratory demand than the delivery device. Luckily, these are high flow devices meaning they entrain a lot of air but the higher the FiO2 the less air will be entrained. THAT is where some get into trouble. They believe the patient is getting "100%" FiO2 when the dial is set at 100% but there is no entrainment. If the patient is breathing hard and fast, they will entrain from around the mask. If the mask is improperly placed, definitely not 100%. A trach collar is effective at lower FiO2 just like the Venturi mask.

    There are a few high flow humidifiers which can go up to 40 or even 60 liters if demand is great. Sometimes the RTs will hook up two humidifiers on a Y connectors. They will run both humidifiers at the same FiO2 to achieve a more precise percentage. The patient will have their flow and FiO2 demands both met. Some may have seen RTs adjusting the flow setting on a ventilator. Flow must meet demand.

    BTW: For all who had EMT or Paramedic training prior to becoming a nurse, a non-rebreather mask is not a high flow device. It is a low flow. Changing the flow on it to decrease "FiO2" does the patient a big disservice and accomplishes very little. Also "rigging" devices when you do not understand the basic principles of oxygen delivery is dangerous even if you have been told someone has always done it that way.


    All the "text book" percentages on low flow devices (NC, simple mask, non rebreather mask) you memorized for a test were based on a mathematical formula for an "average" sized person breathing at rest a VT of 500 and a RR of 12 with a consistent inspiratory liter flow for a MV of 6 Liters.

    References;
    The above link, Respiratory Update is Dana Oakes' website and has all the books available online for reference.

    From Nursing Times, a good explanation of devices;
    Short-term oxygen therapy | Practice | Nursing Times

    Here is a good article for Pediatrics. The basic principles are the same. Notice how much Total Flow decreases through a Venturi device as FiO2 increases.

    http://pedsccm.org/FILE-CABINET/Prac...fs/4OXYGEN.PDF


    Take an RT quiz.
    http://www.actx.edu/respiratory/file...ry_devices.pdf


    RT Book of Calculations. This should also be a MUST READ for all critical care nurses.

    Respiratory Care Calculations, 3rd ed. - David W. Chang - Google Books

  • Jun 19 '15

    Quote from Gemi523
    Any patient with a trach collar should have a humidifier. Humidifiers come with the Fi02% dials. In my opinion, the order was written inappropriately and the charting is messed up. really scary to have nurses charting things they have no idea about.

    A patient is on a high flow device. i.e. trach collar. In order to use a trach collar appropriately, the FLOW RATE must be set at 10-12LPM. THIS DOES NOT MEAN the patient receives 10L of oxygen. This is where the dial comes on. You adjust the dial percentage to a patient saturation to maintain 93% as written. That is why you get here more "noise" as you turn the dial to a lower flow. Because more air is escaping into the atmosphere. The higher you turn up the dial, you hear less "noise" because all the oxygen is being delivered to the patient through the trach collar.

    The order should had been written, adjust trach collar Fi02 up to 60% to maintain sats greater than 93%. 10L of oxygen delivered from a simple face mask or high flow cannula is approximately 60% Fio2.

    Its almost unnecessary to even chart the flow rate of 6L. If the trach collar is used appropriately, it should ALWAYS be at a flow rate greater than 10L. Thats a given. The only thing you should really be charting is the fi02. By charting 6L at 40%, you aren't using the trach collar appropriately. So you really don't know how much oxygen the patient is REALLY getting.


    Im an icu nurse x 8 years. I know this. Or ask a respiratory therapist.
    I agree with most of your post but there are some major concepts which need to be cleared up.


    The "FiO2" dial on oxygen devices are not allowing "air to escape". These O2 devices are ran by what is known at a Venturi system based on the principle of Bernoulli and air entrainment.

    http://www.respiratoryupdate.com/mem...sk_Venturi.cfm

    For every part of oxygen, X amount of air must be entrained to blend for the set FiO2. Due to the ability to entrain large liter amounts of air, this makes a venturi device "high flow" and should meet the patient's inspiratory demands. But, the higher the FiO2 the smaller the opening gets and the less flow is entrained. This is why these aerosol devices are most effective at low FiO2s (less than 50%). Know the limitations of your device as patients might increase their flow AND FiO2 demand.

    Venturi and Bernoulli are the basic principles of ALL oxygen equipment. The goal is to deliver enough flow to meet patient demand and in the case of a trach mask achieve the goal of humidification. (This is also why some hospitals have a policy of no bubblers on Nasal Cannulas less than 4 liters but that is another discussion.)

    Also note that water particles can change FiO2 and/or the total flow delivery which is why humidifiers are not placed on Venturi masks or most low flow masks like Simple and non rebreathers.

    Too many get caught up in the 1 L = 24%, 2 L = 28% crap which is only good for exam purposes and does not address the many different devices for O2 delivery or the many patient factors which influence FiO2. Some very bad adverse patient events have occurred because health care providers have tried to utilized that very over simplified concept on all devices. Hence you get the 2 L NC patient who is a mouth breather when sleeping and gets placed on a 2 L simple mask. Some also see the simple mask and the venturi mask as being the same. If one can run at 2 L so can the other. Now you also get some with this way of thinking for the trach mask.

    Some RTs or RN managers will just tell the nurses to run a humidifier at 10 L minute or more just so they don't have to try to explain Venturi.

    What some LTC facilities have done to avoid errors is run the humidifier off compressed air (wall or industrial size air compressor) at 8 - 12 L/M and bleed in O2 into the circuit. The delivered FiO2 will vary depending on the flow from the compressor but at least those who have a difficult time understanding the O2 devices can chart "liter flow". The humidifier will also be turned to 100% to close the opening and make it quieter.

    If the FiO2 device is set at a specific O2 and the correct liter flow is set, the patient will probably get close to that FiO2 provided they are not breathing more for inspiratory demand than the delivery device. Luckily, these are high flow devices meaning they entrain a lot of air but the higher the FiO2 the less air will be entrained. THAT is where some get into trouble. They believe the patient is getting "100%" FiO2 when the dial is set at 100% but there is no entrainment. If the patient is breathing hard and fast, they will entrain from around the mask. If the mask is improperly placed, definitely not 100%. A trach collar is effective at lower FiO2 just like the Venturi mask.

    There are a few high flow humidifiers which can go up to 40 or even 60 liters if demand is great. Sometimes the RTs will hook up two humidifiers on a Y connectors. They will run both humidifiers at the same FiO2 to achieve a more precise percentage. The patient will have their flow and FiO2 demands both met. Some may have seen RTs adjusting the flow setting on a ventilator. Flow must meet demand.

    BTW: For all who had EMT or Paramedic training prior to becoming a nurse, a non-rebreather mask is not a high flow device. It is a low flow. Changing the flow on it to decrease "FiO2" does the patient a big disservice and accomplishes very little. Also "rigging" devices when you do not understand the basic principles of oxygen delivery is dangerous even if you have been told someone has always done it that way.


    All the "text book" percentages on low flow devices (NC, simple mask, non rebreather mask) you memorized for a test were based on a mathematical formula for an "average" sized person breathing at rest a VT of 500 and a RR of 12 with a consistent inspiratory liter flow for a MV of 6 Liters.

    References;
    The above link, Respiratory Update is Dana Oakes' website and has all the books available online for reference.

    From Nursing Times, a good explanation of devices;
    Short-term oxygen therapy | Practice | Nursing Times

    Here is a good article for Pediatrics. The basic principles are the same. Notice how much Total Flow decreases through a Venturi device as FiO2 increases.

    http://pedsccm.org/FILE-CABINET/Prac...fs/4OXYGEN.PDF


    Take an RT quiz.
    http://www.actx.edu/respiratory/file...ry_devices.pdf


    RT Book of Calculations. This should also be a MUST READ for all critical care nurses.

    Respiratory Care Calculations, 3rd ed. - David W. Chang - Google Books

  • Jun 4 '15

    Quote from SaoirseRN
    No, actually, if you actually read what they are saying, THIS is the same. I think you've taken your idea of a "tyrant" and substituted that definition for what is actually being discussed here. I know that your definition of tyrant exists. Of course it does, but you seem to be reading a completely different thread than I am.
    Waving a PT off because the pt is medically unstable is not the same as these bullies. Unless you are actively in the face of every staff member and the family, you are no where close to these nurses. Bully Extreme would be a good term but tyrant also fits since they want absolute control but are quick to blame others when things go bad.



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