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MunoRN 56,490 Views

Joined: Nov 18, '10; Posts: 8,697 (71% Liked) ; Likes: 23,073
Critical Care from US
10 year(s) of experience

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  • Feb 24

    Quote from Skippingtowork
    You cannot drive impassable roads. Maybe I'm losing my mind here, but can someone post an official statement where nurses are permitted to drive themselves in during the midst of a blizzard or hurricane? I really would like to see that. Or if there is an official notice from your employer stating the same thing. Then and only then will I understand some of the comments on this topic.
    Healthcare workers are exempt in pretty much every single restricted travel event that occurs, healthcare workers are classified as "essential personal".
    From the standard MA state of emergency declaration:
    The vehicle travel ban shall not apply to: Healthcare personnel, including home healthcare personnel and personal care assistants

  • Feb 24

    I agree that a lot of nurses undervalue the importance of baths, oral, and peri-care in their overall prioritization, but I also come across an equal number of nurses that inappropriately prioritize these tasks above more important ones. While it's great when the handing off nurse is giving a well bathed patient, it's not so great when in order to give a great bath they've ignored the 10 different far more important things they should have been dealing with.

  • Feb 23

    I agree that a lot of nurses undervalue the importance of baths, oral, and peri-care in their overall prioritization, but I also come across an equal number of nurses that inappropriately prioritize these tasks above more important ones. While it's great when the handing off nurse is giving a well bathed patient, it's not so great when in order to give a great bath they've ignored the 10 different far more important things they should have been dealing with.

  • Feb 23

    Quote from NickICU-RN
    "Always and never.....the enemy of good Medicine!!!"

    From what I've gathered here the grand consensus is to do assessment based suctioning and then "Suction with Dignity", PRN.

    Although, some clinicians here are insisting that they NEVER EVER Suction, no matter what. My friend's mother was let go at a hospice facility, sounding like she was drowning on her own secretions, and when he asked to get her suctioned, the staff said they do not suction here. He said this haunts him to this day. (His exact words)

    again: "Always and never.....the enemy of good Medicine!!!"

    I get it..., nasal suctioning is considered torture at End-of-Life, but if you need to suction, at least use a No-Bite V and insert a suction catheter into the oral airway. This suctioning is the least traumatic suctioning you can do for your comfort care patients. This is the definition of "Comfort Care" and "Suctioning with Dignity", as long as it is on an assessment based, PRN basis. I don't think anybody was ever advocating for suctioning on ALL End-of-Life Care.


    Again, the "no-bite" suction catheter does not in any way make suctioning less traumatic, if anything it makes it more traumatic. All the "no-bite" part of it does is prevent the patient from being able to defend themselves. It's like saying if you're going to punch your patient in the face, you should tie their hands down so they can't defend themselves, because that's less traumatic.

  • Feb 23

    Quote from NickICU-RN
    "Always and never.....the enemy of good Medicine!!!"

    From what I've gathered here the grand consensus is to do assessment based suctioning and then "Suction with Dignity", PRN.

    Although, some clinicians here are insisting that they NEVER EVER Suction, no matter what. My friend's mother was let go at a hospice facility, sounding like she was drowning on her own secretions, and when he asked to get her suctioned, the staff said they do not suction here. He said this haunts him to this day. (His exact words)

    again: "Always and never.....the enemy of good Medicine!!!"

    I get it..., nasal suctioning is considered torture at End-of-Life, but if you need to suction, at least use a No-Bite V and insert a suction catheter into the oral airway. This suctioning is the least traumatic suctioning you can do for your comfort care patients. This is the definition of "Comfort Care" and "Suctioning with Dignity", as long as it is on an assessment based, PRN basis. I don't think anybody was ever advocating for suctioning on ALL End-of-Life Care.


    Again, the "no-bite" suction catheter does not in any way make suctioning less traumatic, if anything it makes it more traumatic. All the "no-bite" part of it does is prevent the patient from being able to defend themselves. It's like saying if you're going to punch your patient in the face, you should tie their hands down so they can't defend themselves, because that's less traumatic.

  • Feb 23

    I agree that a lot of nurses undervalue the importance of baths, oral, and peri-care in their overall prioritization, but I also come across an equal number of nurses that inappropriately prioritize these tasks above more important ones. While it's great when the handing off nurse is giving a well bathed patient, it's not so great when in order to give a great bath they've ignored the 10 different far more important things they should have been dealing with.

  • Feb 23

    Keep in mind these books aren't written using actual NCLEX questions, and sometimes the authors of these books aren't all that bright.

    As a general rule, NCLEX questions are written to determine if you understand the nursing process and if you can prioritize properly. If the question doesn't confirm that adequate nursing assessment has already occurred then the answer is the one that includes assessment. Aside from the fact that 8.9 by itself isn't an indication to transfuse, the first step would be to correlate that lab finding with a nursing assessment to give that number context.

    Same goes for the V-tach question, initial assessment would include determining whether the monitor is correct, but then assess the patient, I've had patients in a slower V-tach that stay in that rhythm for hours and just hanging out watching TV, so assessing how that finding on the monitor actually translates to the patient would typically be the correct answer on the NCLEX.

  • Feb 23

    I agree that a lot of nurses undervalue the importance of baths, oral, and peri-care in their overall prioritization, but I also come across an equal number of nurses that inappropriately prioritize these tasks above more important ones. While it's great when the handing off nurse is giving a well bathed patient, it's not so great when in order to give a great bath they've ignored the 10 different far more important things they should have been dealing with.

  • Feb 23

    Keep in mind these books aren't written using actual NCLEX questions, and sometimes the authors of these books aren't all that bright.

    As a general rule, NCLEX questions are written to determine if you understand the nursing process and if you can prioritize properly. If the question doesn't confirm that adequate nursing assessment has already occurred then the answer is the one that includes assessment. Aside from the fact that 8.9 by itself isn't an indication to transfuse, the first step would be to correlate that lab finding with a nursing assessment to give that number context.

    Same goes for the V-tach question, initial assessment would include determining whether the monitor is correct, but then assess the patient, I've had patients in a slower V-tach that stay in that rhythm for hours and just hanging out watching TV, so assessing how that finding on the monitor actually translates to the patient would typically be the correct answer on the NCLEX.

  • Feb 23

    I agree that a lot of nurses undervalue the importance of baths, oral, and peri-care in their overall prioritization, but I also come across an equal number of nurses that inappropriately prioritize these tasks above more important ones. While it's great when the handing off nurse is giving a well bathed patient, it's not so great when in order to give a great bath they've ignored the 10 different far more important things they should have been dealing with.

  • Feb 23

    I've come across varying views on futile care at different places I've worked, but one issue that always causes a lot of friction between doctors and between doctors and nurses is when a post-cardiac arrest patient is in status myoclonus, particularly when the myoclonus started in the first 24 hours after arrest and when there is evidence of anoxic brain injury, since there doesn't appear to be any evidence any patient has ever recovered from this state.

    We do have a few intensivists that will almost immediately declare these patients futile once they take over care, but others tend to just go along with the neurologists who are always hesitant to accept what appears to be a well defined prognosis of zero.

    Where things get testy is that the neurologists often ask that we withhold all analgesia and anxiolytics for at least 24 hours before they will agree that the patient's prognosis is irrecoverable.

    We've brought individual cases to our ethics committee who have overruled the request for holding analgesia and sedation and that the patient should be immediately transitioned to comfort care, but that it should be up to the nursing staff to implement a more permanent change in practice, so has anybody experienced a different routine practice for these patients or is this just as good as it's going to get.

  • Feb 23

    I've come across varying views on futile care at different places I've worked, but one issue that always causes a lot of friction between doctors and between doctors and nurses is when a post-cardiac arrest patient is in status myoclonus, particularly when the myoclonus started in the first 24 hours after arrest and when there is evidence of anoxic brain injury, since there doesn't appear to be any evidence any patient has ever recovered from this state.

    We do have a few intensivists that will almost immediately declare these patients futile once they take over care, but others tend to just go along with the neurologists who are always hesitant to accept what appears to be a well defined prognosis of zero.

    Where things get testy is that the neurologists often ask that we withhold all analgesia and anxiolytics for at least 24 hours before they will agree that the patient's prognosis is irrecoverable.

    We've brought individual cases to our ethics committee who have overruled the request for holding analgesia and sedation and that the patient should be immediately transitioned to comfort care, but that it should be up to the nursing staff to implement a more permanent change in practice, so has anybody experienced a different routine practice for these patients or is this just as good as it's going to get.

  • Feb 23

    Quote from Kitiger
    This is new to me, but - if I understand this article correctly - it is possible to recover from post-arrest status myoclonus. This article was published in 1998, so it may not be reliable. I'm interested it what others have to say.

    Early myoclonic status and outcome after cardiorespiratory arrest | Journal of Neurology, Neurosurgery & Psychiatry
    That actually refers to Lance-Adams syndrome which is a type of myoclonic disorder but is separate from anoxic status myoclonus, Lance-Adams is well known to have a potential for recovery. Patients with Lance Adams don't have significant anoxic brain injury on imaging or EEG (MRI is preferred), so a patient with no confirmed anoxic injury but who is having myoclonus shouldn't be assumed to have status myoclonus due to irrecoverable anoxic injury.

    Status myoclonus onset within 24 hours with confirmed anoxic injury however has never resulted in survival.

  • Feb 23

    Quote from KatieMI
    Totally agree.

    It is written in every single textbook, every guideline that EEG, evoked potentials, fPET, fMRI, MRA, etc. are not, in any case, predictable of anything. Yet, there are some neurologists who clearly abuse system under premice of "telling them what they want to hear" and "not robbing them of hope". Yes, there were bare handful of unpredictable "recoveries" (BTW, nothing that happened before 2003 - 2005 when fMRI and fPET scans got out of purely academic settings, can be relied upon) but overall chances are neglugible and what happens next is, IMHO, sometimes becomes borderline torture or corpse desecration.

    It is nor nursing role to tell patients all that, especially in our days of "customer servive" everything. But it can and should be RN role to alert higher-ups, risk management, social work, clergy and physicians/providers who feel comfortable speaking with families in distress and do whatever to make family hear the holy truth. And, of course, the first thing to be withdrawn must be "customer satisfaction".

    IMHO again, "ethics committee" must stop being a spineless gathering which issues "opinions". Once care is declared futile by people who are supposed to be experts, the patient authomatically becomes DNR for 72 - 96 h, and if no clinical progression is noted, "no code" with set data of care withdrawal within 72 h. If family still wants of wishes, they should be welcome to do whatever, but from the "care withdrawal" point of no return no insurance, and especially Medicare/Medicaid, should be allowed to pay a red penny for anything, as well as federally sponsored institutions must not be allowed to keep the patient on their premices.

    If family still wants to sue, good luck for them. At least, most $$$$$$ thus redisributed will not be spent on literally moving air to and fro a dead human body.
    The neurologists have come right out and said that they would rather wait longer than is probably necessary so that it doesn't weigh on their conscious, yet also ask that we withhold all analgesia and sedation despite the patient being in status myoclonus, which has got to be one of the more torturous and agonizing things for a patient to endure if they do have any sort of awareness at any level, which is where the disagreements come from. The nursing staff continues to give at least analgesia and just documents the order to withhold analgesia is not an acceptable order, but it would be nice to have a clearer understanding between providers.

  • Feb 22

    I agree that a lot of nurses undervalue the importance of baths, oral, and peri-care in their overall prioritization, but I also come across an equal number of nurses that inappropriately prioritize these tasks above more important ones. While it's great when the handing off nurse is giving a well bathed patient, it's not so great when in order to give a great bath they've ignored the 10 different far more important things they should have been dealing with.


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