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medicmatt44, ADN, RN, EMT-B 2,584 Views

Joined: Sep 26, '10; Posts: 27 (15% Liked) ; Likes: 9
Unemployed RN, Respiratory Therapist, Puppy Petter; from US

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  • Jan 31 '13

    Just start sending resumes. Holy Cross in Taos, Christus St. Vincent in Santa Fe, Presbyterian in Espanola (has several hosps in different towns), Alta Vista in Las Vegas, Miner's Colfax in Raton, San Juan Regional in Farmington.

    Each town has a different flavor, lots of variety. All "small town" feel, some more rural than others.

  • Jan 18 '13

    Bravo, medicmatt44! Nothing like the voice of experience!

  • Jan 18 '13

    I was at banner Boswell for my med-surg and critical care rotation and I was very impressed. If any ER opening was available for new grads I would absolutely apply. From what I have seen banner accommodates new graduates one at a time per position so you would need to check their website for openings. Boswell is a great hospital and don't let the "old people" demographic scare you, you learn a lot about polypharmacy and about how absolutely fragile the older population can be.

  • Jan 4 '13

    To amplify what my friend Esme said:

    It's very important to understand what that NG tube, probably a Salem sump tube with the little blue pigtail, is, how it works, and why we care.

    Before Salem sump tubes were invented, all we had were single-lumen tubes to suck out stomach contents. What's the problem there, you say? Well, if suction has removed all liquid stomach contents and it keeps sucking, what you get are little punch biopsies of the stomach mucosa, and this is not a good thing. So, some clever person (perhaps a Salem witch) figured out that if there were a way for the suction to have something else to suck on, to break the vacuum in the stomach, like air (and any other fluid that happened to accumulate too, of course), then this would protect the stomach from having vicious little hickies from suction at the eyelets down below and bleeding and such.

    The air vent on the salem sump is that solution. Air should always be going down the blue lumen. How do you know if that's happening? Well, you can put your ear near it and hear it, or put your thumb over the end of it briefly and feel suction there, but the best way to see is that there should always, always, always be air bubbles coming up the main lumen to your suction cannister. Now you know something important: if it isn't, there's hickifying going on down there, and that's a bad thing.

    The air vent lumen should always be patent (open) all the way down. If it isn't you can do a couple of things (after you have determined that some fool has not turned off your suction outlet). One is to untape the tube and pull it back an inch or so, and then put it back. You can also push some air (not fluid) down the blue lumen. Yes, you may have to do this all dang day long, but you will often be rewarded by a gush of gastric goo, which is what you wanted anyway.

    What's going on if there is no air coming up the main lumen and there's goo coming out of the air vent? Well, (assuming your suction is still turned on and plugged in properly) your main lumen is probably occluded and goo has nowhere else to go but up the air vent, and you should probably think about replacing the whole tube. But before you do that, if it's not otherwise contraindicated, shoot some NS down both lumens, and follow that with air down the air vent lumen. See if that doesn't get things moving properly. If not, do the wiggling thing as above. If that doesn't work, get the ok to replace it (or have the physician or NP come and replace it).

    Some Salem sumps come with little plugs in the blue lumen. They're supposed to allow air entry and prevent backflow but they don't always really do a great job of it. If you can still verify air entry past that plug and bubbles are going up the main lumen, it's fine. but if it's gotten grubby and acts like an actual plug, get rid of it, or what you have is now a gastric mucosa-grabbing single-lumen tube.

  • Jan 4 '13

    I just graduated on December 12th 2012. I received my ATT on the 28th of Dec and scheduled my NCLEX-RN for today Jan 3, 2013.

    From the moment I graduated I began studying (for about 20 days) and I took the Kaplan course the very next day after graduation! I took the Diagnostic and got a 67% which I was told was really good. Here are the rest of my scores

    Qbank-450 questions answered, 60% avg

    QT6-64%-tired of studying-when I got this score I scheduled!
    QT7-Skipped! Studying is sooo overrated, LOL!

    Readiness Score-64.5%-taken on/around study day 5

    I have read so many stories of others studying for months at a time. I'm the type of person who goes all in when I study. I studied from the moment I woke up until the moment I fell asleep with my laptop in my lap. At this moment my neck is in agony from staring at a computer screen so much and I think I lost some vision too, LOL! But I have to be honest...I was scared to take it as soon as I did. But I also didn't think I could be any more prepared.

    I didn't use ANY other formal study guides! Just the Kaplan course materials and the "Study Guide" that is floating around this website.

    I went to the test center in a daze not believing this was actually happening and I had the same thought as I was sitting there testing. I was praying SO HARD for the test to end @ 75 questions! I clicked "next" answering question #75 and then question #76 was there! I wanted to fall out of my chair! Lol! I said to myself I just need to get the next questions right because my life depended on it (Dramaqueen I know)! I really didn't want to go to 265! I answered that question and had a SATA next. My test screen went blue at question #77! I didn't feel like crying like a lot of people. I felt like I did my best and I hoped it showed!

    As I was walking to my car I tried the PVT. And I got this message: "Delivery successful...Our records indicate that you have recently scheduled this exam. Please contact your Member Board for further assistance. Another registration cannot be made at this time."

    So I think this means I'm an RN!!!

  • Jan 3 '13

    The issue with A fib is that blood stagnates in the heart, usually the left atrium and left auricle. This blood clots. The most common concern is that a clot moves from the atrium into the left ventricle and is "thrown" to the brain....stroke. To be honest, I don't know if such clots ever form on the right side of the heart and move to the lungs causing a PE (for a PE, we most often worry about clots from the deep veins of the legs...a DVT). If the clot forms in the left side of the heart, I'm not sure how often it gets pumped out of the heart and then moves into the coronary arteries, where it can cause an MI (heart attack).

    As I said, the most common clot related complication of A fib is a stroke. Both PEs and MIs can 'cause' A fib.

  • Jan 3 '13

    Care Plans keep coming up in class after class and GrnTea is trying very hard to help you understand the parts of a nursing diagnosis, what allowable components can be used and how the 3 parts work together to form a cohesive picture that someone can look at and have a good idea of what the main issues going on are.

    Even if you already submitted your assignment, I don't think you really have it implanted in your head how to construct and use a nursing diagnosis. If I were you, I'd keep working here to build some good diagnosis samples regardless of this single assignment, as it will make things easier for you in the long run.

    I'm a student too, and was lucky enough to read through Esme and GrnTea's posts on this topic before care plans even came up in school. The way they explain the 3 parts and refer students to NANDA as the difinative source set me up to do very well once care plan assignments started hitting my plate.

  • Jan 3 '13

    Quote from ala2ch
    ummm thanks for the comment GrnTea but I want to tell u that ineffective breathing patterns related to immobility and stasis of secretionsand ineffective cough secondary to pneumonia manifested by the presence of diffuse expiratory wheezes and rhonchi on right lower lobe and the use of accessory muscles when breathing and increased anterioposterior chest diameter is one diagnosis I am sure there is no such diagnosis in NANDA list (ineffective
    cough ...)
    You lost me here. It may be one diagnosis in your mind, but "ineffective cough" is not a nursing diagnosis.

    If what you are saying is, "I think my patient has {ineffective breathing pattern}. He has this because he has {pneumonia}. I know he is breathing ineffectively because I have observed {immobility, stasis of secretions, and ineffective cough, use of accessory muscles, expiratory wheezes, rhonchi, and increased AP diameter}," that doesn't hang together either. It's too much of the everything-but-the-kitchen-sink in there; a lot of that list does not support your diagnosis and does not appear in the definition, defining characteristics, and related factors. Note, "related factors" are the things that would cause the defining characteristics.

    I'm looking at the nursing diagnosis right now, and this is what I see, verbatim:

    "Ineffective breathing pattern (00032). Definition: Inspiration and/or expiration that does not provide adequate ventilation.
    Defining Characteristics: Alterations in depth of breathing, altered chest excursion, assumption of 3 point position, bradypnea, decreased expiratory pressure, decreased inspiratory pressure, decreased minute ventilation, decreased vital capacity, dyspnea, increased AP diameter, nasal flaring, orthopnea, prolonged expiration phase, pursed lip breathing, tachypnea, use of accessory muscles to breathe.
    Related Factors: anxiety, body position, bony deformity, chest wall deformity, fatigue, hyperventilation, hypoventilation syndrome, musculoskeletal impairment, neurological damage, neurological immaturity, neuromuscular dysfunction, obesity, pain, respiratory muscle fatigue, spinal cord injury.

    You will note that pneumonia, ineffective cough, immobility, stasis of secretions, wheezes, and rhonchi do not appear here as causes for inspiration and/or expiration that does not provide adequate ventilation. They don't appear in the defining characteristics of what constitutes inspiration and/or expiration that does not provide adequate ventilation, either. So let's try that again.

    "I think my patient has an ineffective breathing pattern. He is breathing ineffectively because he has ...." what related factor(s) from the list, exactly? "I know this because I see that he has ..." what defining characteristics from the list, exactly? You have to have both related factors and defining characteristics to support a diagnosis, so saying he has increased AP diameter and uses accessory muscles isn't enough by themselves.

    I think your problem is that you have fallen in love with the "ineffective breathing pattern" diagnosis without fully understanding what it really means. It doesn't mean what you think it does, so you throw in everything you can think of that has something to do with a pulmonary condition to make it fit. It doesn't. Yes, it does make a difference.

    Now, try looking at the nursing diagnosis, defining characteristics, and related factors for impaired gas exchange and see if any of that works better.

  • Jan 3 '13

    "ineffective cough secondary to pneumonia manifested by the presence of diffuse expiratory wheezes and rhonchi on right lower lobe and the use of accessory muscles when breathing and increased anterioposterior chest diameter"

    Think of the way you document your nursing diagnostic process in three parts, alas, not in the usual order you see. "I think my patient has (diagnosis). He has this because he has (related to) .... . I think this is true because I have observed (as evidenced by) .... ."

    Taking what you have written here, you think this person's ineffective cough is caused by pneumonia, and you think that this is so because you have observed wheezes, rhonchi, use of accessory muscles, and increased AP diameter. While this is a lot of details, the cause-evidence-effect thing doesn't hang together. You don't know that he has an ineffective cough because he has an increased AP diameter, etc., etc. How do you know his cough is ineffective? He might have a terrifically effective cough even if he does have an increased AP diameter, etc., etc. You have not proved your case or told me why you think it's true.

    Common problem, to pick and commit to a sexy-sounding (or plausible-sounding) nursing diagnosis and then try to cram a lot of plausible-sounding details in it. Alas, in this case as in so many others, because you have not really understood cause, effect, and evidence, you have not chosen a nursing diagnosis that you, the nurse, can then treat yourself. This is what a nursing diagnosis is. When you find yourself writing something like, "Administer antibiotics as ordered" for a nursing diagnosis, you're on the wrong track.

    In this case, you have fallen in love with "ineffective cough." Alas for you, there is no such nursing diagnosis in the NANDA-I, which is the definitive list of nursing diagnoses (get the 2012-2014 edition stat from Amazon-- you can thank me later). So now we go back to looking at your patient for the diagnostic clues you have observed. You don't give a lot of them besides the rhonchi and dyspnea. So looking in my NANDA-I, I want to see what kind of nursing diagnosis has what you observed in your ptient as defining characteristics. There's "Ineffective breathing pattern," defined as "inspiration and/or expiration that does not provide adequate ventilation," which includes much of what you doubtless observed. The "related to" includes possibilities like spinal cord injury, anxiety, obesity, pain, respiratory muscle fatigue, and a host of other things. If this were what you observed, you would then be able to say, "I think my patient has an ineffective breathing pattern because he has (related to) pneumonia with hypoventilation and fatigue. I know this because he is (as evidenced by) tachypneic and dyspneic, and is using accessory muscles to breathe." See how that works?

  • Jan 3 '13

    This is my first time on this website. I will be starting Nursing 2 on January 22. I am finding this very helpful and hope to see more questions and answers like this to help me along my journey.

  • Jan 3 '13

    Part of the blame for this needs to go to nursing schools for hammering into students brains that "real" nursing = hospital nursing. There's no legitimate reason 90% of nursing school clinicals need to be in the hospital. Students should spend at least 50% of their time in settings like home health, LTC and subacute. That's where the future of nursing is and where the majority of these students will end up working.

  • Jan 3 '13

    If you are strongly interested in joining the military one there is another option. Focus on finishing your BSN and then go to work in a high demand area such as ICU, Psych Nursing, or Emergency Nursing. Once you have one or two years experience in those areas then talk to an AMEDD recruiter. The attitude change may surprise you.

    Caveat #1 if they direct commission you as an ICU nurse be sure the recruiter puts it in WRITING. If it isn't in writing he or she is LYING to you. LOL

    You talked about the National Guard. Have you talked to an Army Reserve recruiter? Air Force, Navy, Coast Guard and Public Health Service also recruit nurses. the PHS is an interesting branch that uses Navy ranks and sends healthcare workers to places such as Indian reservations or inner city public hospitals. If you want to get "combat" experience there is a job for you.

    A third option, although you are almost too late with already acquiring your BSN, is to talk to the ROTC. Find an ROTC adviser on campus and talk to them. They may not recruit you for the ROTC but they may have contacts with the recruiting command and may know someone who will help.

  • Jan 3 '13

    Quote from DoGoodThenGo
    Being as all this may, nursing education is a huge business in NYS, with ADN programs outnumbering BSN, so don't expect the former to simply roll over and die without a fight.
    Also, the (public) community college system in each state has tremendous clout with the state legislatures; they are not going to give up their nursing programs without a fight, and they will have a lot more support within the state leges than anyone seeking to eliminate ADN programs. That's one of the reasons the "BSN only" proposals never go anywhere (the "BSN in 10" concept might be more successful because it specifically does not look to eliminate ADN programs).

  • Jan 3 '13

    Quote from kristin6727
    I just heard from someone that NY is soon going to be doing away with 2-year nursing programs and making you go for your 4-year. Has anyone heard this? I am currently attending classes to be accepted into a 2-year program. I am worried that this is going to happen right when I get accepted. I was hoping to do my 2-year, get a job and then do the other 2 years with an on-line school.
    There is no such thing going on.

    What has happened is a law has been proposed in Albany requiring all future ADN (and the lone diploma school left in NYS), grads to obtain their BSN within ten years of graduation. You can simply Google "BSN in Ten", to find out more about the proposed change.

    So far the bill has seen little movement, and even if it were passed does not phase out ADN/diploma programs directly. Current RNs, graduate nurses as well as those currently enrolled in nursing school (as of the date the law is signed), would be grandfathered under existing rules and exempt from the requirement.

    Now indirectly it would be hard to say what impact such a change would have on two year programs. Many hospitals and or healthcare networks have announced they are only hiring BSN prepared nurses and or will do so in future. However this has been tried many times before, and whenever the demand for nurses strips supply a nurse is a nurse, is a nurse, and anyone with a valid license is hired. Therefore if the law is passed it remains to be seen how things will shake out.

    Being as all this may, nursing education is a huge business in NYS, with ADN programs outnumbering BSN, so don't expect the former to simply roll over and die without a fight.

  • Jan 3 '13

    I agree it's a problem. Those freaking call bells go off whenever I try to update my status.
    In fact right now, some guy wants his pain meds.
    Lucky for me I have a 1/2 hour window in which to give them.