Anna Flaxis, ASN 25,525 Views
Joined Oct 15, '10.
Posts: 2,864 (67% Liked)
I find that often, especially for new grads, it's not a "safety" issue so much as a confidence issue. You just don't THINK you can handle what you really CAN handle.
At the same time, new grads do need a lot of hand-holding that a lot of departments can't afford, because they need bodies out on the floor NOW.
As a result, these "sink or swim" situations are exceedingly common.
Personally, I do well with sink or swim. But I recognize that one size does not fit all.
My personal opinion, based on what you have posted, is that you should try to find a more supportive environment to first learn how to be a nurse- then, once you have your feet on the ground, transfer to something more specialized. I hate to tell new grads to cut their nursing teeth in Med/Surg, because IMO, Med/Surg *IS* a specialty- and it's not fair to that specialty to use them as a stepping stone or training ground for people that don't really want to be there.
And yet, at the same time, Med/Surg units are really fertile learning grounds from which to step off into something more specialized once you've learned the basics of nursing, such as head to toe assessment, pathophysiology and pharmacology, the "soft" skills of therapeutic communication, and of course, prioritization and time management.
There is absolutely no shame in admitting that you need more nursing experience before starting in the ED, and while I respect M/S nursing for its role as a specialty, there is no better learning ground for those who want a solid foundation before they make the leap into an area such a ED or ICU.
Yes, the catheter itself is touching the urinary meatus. That is unavoidable. However, it is possible to avoid touching the skin with the sterile hand. Would I stop and start all over again if my hand accidentally touched the skin? Probably not. But I would make every effort to avoid doing so.
You are correct that Betadine reduces microbial burden, it does not truly sterilize the skin. Catheter associated UTIs are a huge problem, and although prolonged dwell times are the most significant contributing factor, I would advocate for avoiding contact with the peri-urethral skin with the sterile gloved hand during insertion, simply as a matter of doing all you can to minimize risk to your patient.
That being said, one thing I have learned in nursing and life in general is to pick your battles wisely.
Under my state's Nurse Practice Act, I am not authorized to diagnose medical conditions.
The radiologist's impression and the assigned provider's diagnosis may differ because the radiologist simply gives their impression of what they're seeing without very much context, but the assigned provider does the clinical correlation, which is a synthesis of the "big picture"- i.e. the patient's age, past medical history, familial history, signs and symptoms, etc., and actually makes the diagnosis.
If it is a new diagnosis, then I defer to the licensed independent practitioner who is authorized to diagnose and treat medical conditions, stating something like "I'm not qualified to interpret (blank), and I don't want to misinform you, so I'm going to let the doctor come and talk to you about that." But, if it's part of a continuum, where the patient already has been given a diagnosis and we're monitoring progression of illness or response to treatment, then it is within my scope to discuss radiology reports in more detail- again, with the caveat that I'm only repeating what the radiologist said, but that the person's doctor needs to put it all together.
If it's a new diagnosis of heart failure, I defer it to the doctor. But if it's an existing diagnosis, and the patient wants to know their EF, I'll tell them.
It's really important not to be evasive, because people pick up on that, and it increases their anxiety as they imagine all the worst case scenarios. Avoiding disclosing results can easily come off as evasive, but when you verbalize a concern for not wanting to misinform, people tend to understand and appreciate that, at least in my experience.
Clear as mud?
Yes, you are allowed to disclose laboratory values to patients. As a licensed nurse, you should have a basic understanding of common lab values and what they mean, and keeping the patient informed of their health status is a basic function of nursing.
When you give supplemental potassium, do you not inform the patient that their K+ was low? When you give a blood transfusion, do you not inform the patient of their H&H? If you're monitoring serial troponins, do you not keep the patient informed of the results?
Lots and lots of practice exams. :-)
Peritoneal dialysis isn't that difficult. People do it at home all the time. In fact, many of your PD patients can probably show you how to do it.
Do you happen to work in a small-ish community hospital with a nephrology clinic nearby? If that's the case, I'll bet you a nickel that your hospital has an agreement with them, and it's an important source of revenue that your hospital doesn't want to lose, as well as an important service that the patients in the community need and would not have available if not for your hospital's willingness to make this arrangement.
Is it the ideal situation? No, for a lot of different reasons that I don't need to elaborate on.
However, I think you'll have a lot more success trying to find ways to streamline the process so that you can move these patients through as efficiently as possible while still prioritizing your ED patients than you will by putting up a lot of resistance to it. If it's education you need, then request education.
I found these:
floccillation /floc-cil-la-tion/ (flok″sĭ-la´shun) the aimless picking at bedclothes by a patient with delirium, dementia, fever, or exhaustion.
Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
[Gr. karphos, dry twig, + legein, to pluck]
Involuntary picking at bedclothes, seen esp. in febrile delirium.
Patient comes in by ambulance for Unspecified. On the way in, EMS throws in an 18g and draws blood for labs. Patient looks good, is completely with it, condition seems pretty benign, but need to check a few things. Order CBC, Comp, EKG, do orthostatics, send blood to lab, hang 2nd liter of NS. New ED Doc That I've Never Worked With Before picks up the chart. Orders something that makes sense (but I couldn't order it myself), and something else that seems unnecessary. But whatever. I don't have "M.D." after my name, so I don't question, I just do, and order the test that seems unnecessary.
A while later, Family Member comes out of room, interrupting report I'm giving to Esteemed Colleague so I can go to my federally mandated meal break 6 hours into my 8 hour shift (and I'm starving).
Family Member: "Um, yeah, I was wondering if anyone is ever going to come in and take some blood?"
Me: "They took blood in the ambulance on the way in. It's already in the lab."
Family Member: "Oh, okay, well I was just wondering because the doctor said he was going to order XYZ test, and I'm a Nurse Practitioner, and nobody ever came in and got blood."
Me: "Yeah, they got it in the ambulance. It's in the lab. XYZ test is being done right now."
Family Member: "Okay, well I just thought I'd check, because I'm a Nurse Practitioner...."
Me: Blank stare.
Family Member: Goes back into room.
I finish report and go for a latte since nothing's open at this hour, and I didn't bring a meal.
While I'm on my federally mandated meal break drinking my Latte Dinner, New ED Doc That I've Never Worked With Before apparently tells patient and Family Member that he's going to keep the patient for overnight observation, and Family Member goes home. NEDDTINWWB then asks me to do orthostatics and order another unnecessary test.
Me: "I did orthostatics already (pointing at the chart where I had clearly documented orthostatics on arrival, which were negative), his pressure was rock solid, but I guess I can do them again if you want..."
NEDDTINWWB: (Seeing my documented orthostatics for the first time and barely glancing at them) "Yeah, I think we should repeat them, and get ABC test."
Me: "Okay, but he's not on any blah blah blah medication for his blahbitty blah blah, because yadda yadda, so are you sure we really need this test?"
NEDDTINWWB: (Looking irritated) "Yes, the admitting doctor wants it."
Me, to myself: "Yeah, but if the admitting doctor knew what I just told you, he would think this test was just as unnecessary as I do."
Me, in reality: "Sure, no problem."
Sigh. So, I repeat orthostatics and order ABC test, a bit surprised that this A&O, reasonably healthy, middle aged, walkie talkie patient is going to be admitted for observation of his Benign Condition. This should be a slam dunk treat and street. There is nothing to observe.
Admitting Doctor Genius (really, no sarcasm here; he is brilliant and I'd let him take care of me and mine any day) comes and sees the patient, and says the patient does not need to be admitted (surprise). He does a great job of explaining the Benign Condition to the patient, and the patient is satisfied with the explanation and his disposition.
Next thing I know, my phone is ringing.
Me: "Hi, this is Stargazer."
Voice on Phone: "Yeah, this is the Family Member for Patient X. I want to know what's going on, because I thought he was going to be admitted and he just called me to say he's being discharged, and I'm a Nurse Practitioner, so..."
Me: "I'm sorry, but I can't give out personal medical information over the phone. I can tell you that we've run some tests, everything looks fine, and he's being discharged."
Voice: "Well, I'm not satisfied with that. Did they do Test X? I'm a Nurse Practitioner, so I know they should do Test X."
Me: "I'm sorry, I can't give out specific medical information over the phone. All I can tell you is that we ran some tests and everything looks fine, and he's being discharged."
Voice: "That's not good enough. Did they do Test X or didn't they? I'm a Nurse Practitioner and..."
Me: "Ma'am, I can't give out confidential medical information over the phone. I can let you talk to your family member if you like."
Voice: "I already talked to him. I want to know why he's not going to be admitted. I'm a Nurse Practitioner and I know he's "At Risk", plus I just had surgery."
Me: "Two Medical Doctors have examined him and have determined that it's not medically necessary to admit him. All of his test results are normal. He is being discharged. That's all I can tell you."
Voice: "Blahbitty blah blah Nurse Practioner yakkity schmakkity blah blah blip blip."
Me, to myself: "I don't care if you're the Queen of England, I'm not divulging PHI. You can go jump in a lake."
Me, in reality: "Well, maybe when you come pick him up, the doctor will still be here and you can ask him your questions."
I then very efficiently discharged the patient to the lobby.
The ER is no place for warm, fuzzy, hold your hand nurses.
One hard lesson I had to learn (and it took me over 20 years to learn it) is that it doesn't matter how good a nurse you are, and it doesn't matter how much you know. It's all about if people like you and how you are perceived.
Why should any further study be done?
The doctors do it where I work.
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