Latest Comments by MunoRN

MunoRN 56,498 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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  • 0

    Quote from itsybitsy
    I guess I should do the same for providers promoting Islam and immigration... Domestic terrorists...
    I'm really not clear where you're going with that one.

  • 3
    herring_RN, elkpark, and BCgradnurse like this.

    Quote from itsybitsy
    But the entire 2nd Amendments purpose is the last 4 words: "SHALL NOT BE INFRINGED".
    The 2nd amendment states that the right to bear arms in the form of a well regulated militia shall not be infringed, it does not state or imply that an unrestricted freedom to bear arms shall not be infringed. "Well regulated" by definition does not mean unrestricted, it means the opposite of unrestricted.

    How the second amendment should be interpreted is an ongoing debate, but the founding fathers were clear the final interpretation is up to the Supreme Court, and the current interpretation, which comes from the most pro-gun rights Justice on the court, is that the government doesn't have the right to ban all guns or ban everyone from owning a gun, but the government absolutely can regulate what firearms are legal and who can legally own one based on excessive potential for harm.

    I don't know that there is much arguing that generally the founding fathers intended for the second amendment to provide the right of gun ownership where it's generally beneficial, and not where it's generally detrimental.

    As a gun owner, I find the biggest threat to my right to own guns are those that argue there is no responsibility inherent with such a right, and argue that the right of a criminally insane person to own a gun specifically designed to kill as many people as possible before anybody can defend themselves is no different the right of a person who has the capacity to differentiate right from wrong owning a gun to protect themselves.

    Quote from itsybitsy
    According to the 2nd Amendment, the right to bears arms shouldn't be hindered
    It says it should be well regulated, not that it shouldn't be hindered

    Quote from itsybitsy
    - everything the government has, in regards to specifically ARMS, the people should have access to.
    You take the 2nd amendment to mean everyone should have access to everything the military has?

    Quote from itsybitsy
    However, even with that being the point - AK-47's aren't protected, meaning that every U.S. citizen's 2nd Amendment rights' ARE being infringed upon. That's the argument. Law makers shouldn't be able to make these decisions, the founding fathers have protected the citizens in the Constitution FROM future law makers, as them themselves escaped a tyrannical government. They wished for their future citizens to have the ability to protect themselves, should the time ever arise that the government turns on its citizens.
    The revolutionary was fought with local militias using firearms that were otherwise used for lawful purposes, self defense and hunting mainly, so if you're arguing that the second amendment protects the type of defense and militia weapons used in the revolutionary war, then it clearly doesn't protect military specific weapons.

    Quote from itsybitsy
    But again, people aren't fighting about AK-47's, but you CANNOT simply categorize all semi-automatic weapons as "assault rifles" to ban them because they can be used for bad things. That's literally the point of guns in the 2nd Amendment - to protect yourself, by doing "bad things", possibly killing people/government to protect yourself. It's stupid to call for the ban of AR-15's. Why would you?!
    The term "assault weapon" refers to high capacity, high rate of fire weapons, the specific thresholds for each of these characteristics that would make something illegal is what such a law would define. It would not be limited to AR-15 variants since it's not the outward style of the weapon that matters. High capacity and high rate of fire weapons do not provide a primarily lawful purpose and are therefore not protected.

    Quote from itsybitsy
    I understand that, it was used as an example, because the backgrounds checks are used for the purpose of seeing if the person is a threat to themselves or other people. If you have depression, you may be a threat to yourself or other people. The laws aren't written that way, as there is no way to find that out unless you have the medical record, but I was playing devil's advocate, if they were, as in you see a person's mental health history, and deem them unsafe to sell a gun to. I still don't know if that would be right.
    Being prohibited from owning a gun due to a mental health justification is not based on medical records, it's based on a court finding of being criminally insane (you don't understand the basic difference between right and wrong).

    Quote from itsybitsy
    It would be a better option than the hysterics of "BAN ALL GUNS" though.
    I don't find this to be a commonly proposed action, that may well be an overstatement of the gun reform argument.

  • 2
    BCgradnurse and heron like this.

    Quote from itsybitsy
    All of these things need to be voted on by Congress. These are things Trump WANTS and what a large majority of his base WANTS. Just because they haven't been done, doesn't mean they aren't wanted by many people, or that they won't be done. Have you seen the wall prototypes? Oh, that wall is going up.
    What Trump said he wanted was a wall paid for by Mexico, a free wall is much different than a wall that's potentially more expensive than it's worth. Every administration for 30 years has added to the existing border wall, there's not disagreement that a wall is useful, the issue has been whether it's cost effective, what Trump promised was the ability to take the cost out of the equation, which as it turns out he actually had no idea how he was going to accomplish that.

    Quote from itsybitsy
    I think the vetting process is after the wall deal. I presume that's what's to come after we have secured our Southern border, as then we can focus on people traveling through customs, as we DO have a process for that already. We just want to make it better.
    He's already introduced his 'extreme' vetting plan, and it doesn't add anything to the process except for basing vetting broadly on race and religion. The problem is that there is simply nothing more to actually add to the process. It was discovered about 10 years ago that the vetting process didn't include some databases of allied militaries, those have since been added. It's not a matter of deciding we should add more vetting to the process, there just isn't more to add.

    Quote from itsybitsy
    People can't even figure out how many people are REALLY in this country illegally. How do you expect them to know who is voting and where? The voter fraud commission was disbanded because states refused to give their voter information. That WOULD help in identifying areas of voter fraud.
    States refused to given the commission people's voting records because it's people's voting records, according to the Constitution this isn't something the federal government can compel states to provide without due process, and there is no evidence to support that type of request. The fact that of the records they did receive they found no evidence of voter fraud, not a single case, likely played a larger role in disbanding the commission.

    Quote from itsybitsy
    It's not about voting more than once, it's who is voting. A single person could vote more than once, under different names. If you ever have time or interest, check out information on how many deceased people are still registered to vote. It's a real thing, since many people don't think to update that when a loved one dies, as it's not a priority, and most people don't even know they stay registered after death.
    The validity of all votes are confirmed by both local and state governments, simply being registered to vote does not make the vote valid, being registered to vote just starts the process of confirming that a vote is valid.
    It probably shouldn't be surprising that dead people neglect to de-register to vote, but it doesn't really matter, when votes are being processed they are matched against things like whether they are dead, whether they are registered elsewhere, etc.

  • 0

    The only evidence based use of the NIH scale is prior to tPA, where it can be predictive for the risk of hemorrhagic complications, otherwise it serves no established purpose in guiding care. Serial NIH scores can be useful if they are being used to evaluate the effectiveness of tPA treatment by an organization that is contributing to tPA effectiveness databases, but even then it's only indicated pre-tPA, 2 hours post tPA, and at discharge.

  • 0

    The currently available carpuject holders are the Hospira ones, Wyeth sold the Tubex licensing rights to Hospira. Does it have to be specifically the Tubex branded holder? You'll have no problem finding a Hospira holder if you're just looking for a carpuject holder.

  • 2
    VivaLasViejas and Kitiger like this.

    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.

  • 2
    AceOfHearts<3 and Kitiger like this.

    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.

  • 0

    Quote from djmatte
    No later than one hour after administration of any pain med. Nursing judgment based on onset of action. Also during normal vitals.
    Proper nursing judgement according to professional practice recommendation is to base the timing of reassessments on both the onset and the duration of action. And while the JC used to recommend reassessing PO pain medication "within one hour", they dropped that recommendation in 2003 after it was discovered that 'recommendation' actually came from a faux-practice organization called the American Pain Foundation, which it turned out was a front group for a number of opiate manufacturers with the intention of encouraging overuse of opiate medications. (Dosing by pain score and 'pain is the fifth vital sign' also came from this group).

    The current JC standard on pain reassessment is that "the hospital reassesses and responds to the patient's pain based on it's reassessment criteria". The hospital is only required to follow whatever criteria the hospital chooses. Requiring that pain must be reassessed and re-medicated "no later than one hour after" the initial dose is bad practice. The full effect of a PO opiate can take a full hour to occur, in most care environments, it's unlikely that a nurse can predictably be assessing at 59 minute mark, and if their reassessment must occur in less than one hour, then it's quite possible it's going to have to occur 15 minutes after it was given since there may not be another opportunity until 1 hour and 5 minutes after it was given. It's far more appropriate to reassess at 65 minutes than at 15 minutes and an effective an safe policy would have to reflect that. It's also unlikely that any physician actually intends that reassessments can't be done based on the known characteristics of the medication, so this would violate JC standards.

  • 0

    Quote from djmatte
    forgot to address the first part. Our hospital pain policy states to reassess pain no more than 1hr after any pain medication administration. I suspect most hospitals have some form of policy dictating frequency of assessment for various situations.
    You have a policy says pain reassessments can only be done at 1 hour? A common time to reassess pain aside from when you would expect it to take effect is when you would expect it to no longer be effective, why would you limit nurses to reassessing only the initial effect?

  • 0

    Quote from djmatte
    JC had no problem with range orders. They had a problem with interval of re-administration. They wanted specific parameters for second doses in any range orders. So MDs needed to provide PRN with an indication followed by when to give second or third doses within the overarching range. We got dinged on this because the JC took the same order and went to multiple nurses to gauge when/if the next nurse would give the next dose. They described the lack of parameters as "nurse prescribing".
    They found differing interpretations of range orders, which then requires that the facility establish a common understanding, the JC does not dictate what that understanding must be. You will certainly find surveyors or even entire teams of surveyors that might recommend what standardization to use even, even suggestions that are bad practice, this is one of the many reasons why DNV has surpassed the JC as a CMS surveyor.

  • 2
    Davey Do and sallyrnrrt like this.

    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.

  • 1
    Davey Do likes this.

    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.

  • 0

    Quote from djmatte
    Negative. It gives a clear instruction on when to reassess and when the second dose *should* be given. 1 hour after administration of the first. 1-2 q6...second dose 1 hour after. The ONLY written instruction is when to reassess and the parameters to give the second dose (1 hour after). If the order said something along the lines of "may give second dose whenever the hell you want for x pain score"...then certainly whenever. And it wasn't one surveyor. It was something their whole team sat down with us and had us develop a plan to fix it.
    Based on that logic, if the order hadn't said to reassess the patient's pain and give the remainder of the dose if needed, you would interpret the order to mean that you would given one tab, then not assess or re-medicate until 6 hours had passed?

    What specifically did the JC surveyors have an issue with in your case?

  • 0

    Quote from chare
    The applicable JC version of CMS regulatory requirements relating to range orders is MM.04.01.01 "Medication orders are clear and accurate" which states that a facility must ensure that there is "consistent interpretation" of range orders but does not establish any one particular interpretation that must be used. Their extended guidance refers to the American Society for Pain Management Nursing and APS joint position statements on Range Orders, which can be found here:

  • 0

    Quote from djmatte
    I'm not "confusing" anything. I'm taking a clear instruction as it's stated. Two parts in a single sentence : 1. Reassess in one hour 2. Give second dose of painful. I literally had this discussion last year with JC last year when we got dinged on our ordersets.
    If it said "if second tab not required at 1 hour, may not give remainder of range dose until 6 hours after the first tab" then you'd have a point, but it doesn't say that.

    I'm my facility's liaison with our regulatory auditor and I've had many conversations regarding range orders and it's never reflected what you're referring to and neither does their published guidance.

    The Joint Commission's standard on Range orders is that there must be a common understanding of how the order will be interpreted, so the only way to know for sure is to clarify the order. To assume the physician meant the order to be interpreted as meaning a second tab couldn't be given at hour 3 if it wasn't needed at hour 1 is a big stretch since it makes no mention of this and this would make it an irrational order.

    You'll certainly come across individual JC surveyor that don't have the understanding of the regulatory criteria that you would expect, which is why it's important for the facility to also have a good understanding of regulatory requirements.