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Double-Helix, BSN, RN 37,771 Views

Joined: Apr 5, '11; Posts: 3,452 (54% Liked) ; Likes: 6,875

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  • Apr 20

    Dialysis RN here. I've been in outpatient HD for 5 years, 3 of which as charge nurse. As foreign a practice as this may seem, and contradictory to what we learn in nursing school, this truly is the most efficient way of giving meds. Keep in mind:
    -This is an outpatient clinic setting where patients are stable and medications change very little
    -There are no narcotics of any kind. We give IV vitamin D, epogen, and Venofer. Occasionally an antibiotic.
    -"clean" and "dirty" are a big deal in this setting. You must prepare the medication in a clean area away from patients. Then, after donning full PPE (sheild,mask,gown,gloves) you administer and document at the chairside. You must remove and store all PPE before returning to where the meds are kept. If you tried to repeat that procedure for all patients on that shift, you would run out of time before their treatment ends and its now a missed dose. There can be 20-40 patients dialyzing simultaneously.
    -In our clinic we have a clean and a dirty nurse. The clean nurse is usually charge that day. She stays in the clean area preparing meds with preprinted labels. The dirty nurse double checks the dose against the order and administers so that there is no cross contamination between the clean med prep area and dirty chairside station.
    -The only potential side effect of an incorrect med being given is a minor change in lab results. None of these medications are fast acting. The first time a med is given we monitor for allergic reaction.
    -You work with the same nurse day in and day out. These meds aren't being drawn by a stranger. In this setting you know and trust your team mates. Outpatient HD is very much a team care model with many different caregivers at once (RN,CCHT,PCT)
    -In this state (NC) LPNs can administer IV push medications. Our unlicensed dialysis technicians push IV heparin that has been drawn up or checked by the nurse.

    The state auditors and Joint Comission regularly inspect and approve this procedure of medication administration

    Just my $0.02

  • Apr 19

    Giving a patient a medication for them to self-administer typically falls under "dispensing". You could either administer the medication before they leave, or have it properly dispensed by the hospital pharmacy if they are able to do that, which means properly labelling and packaging it for self-administration.

  • Apr 17

    Quote from Fizics316
    So wise I wish I'd never have asked. Thanks, sort of.
    She is among the wisest of us all.

    It is *possible* that you could get another job on another floor for a few more months to get that magic year of experience. My story: I just knew three months in to my first job that I was never, ever meant to be a hospital nurse and left (with six months in) for an ambulatory care job. Never looked back, never regretted it. Flash forward to now....there's a neat case management opportunity with the homeless clinic that is owned by the public hospital, and I know the doc! Woohoo!

    Guess what? To be an outpatient case manager I still need a year as a floor nurse. I can't get past the recruiter.

    So - Ruby Vee is dropping wisdom. And she's right. Four months seems like an eternity when you are a new nurse, especially when you are unsure whether you like what you're doing. Good luck.

  • Apr 15

    To those of you saying that you would only give medications drawn by another during an emergency situation, what makes this different? If your concern is that the medication wasn't properly prepared, don't you think that the increased stress and anxiety during an emergency is going to greatly increase the probability that an error will occur?

  • Apr 14

    I would agree that having another nurse draw up the med for you to give is adding an unnecessary extra step that is presents an opportunity for error, but I think some are also maybe being a bit irrational in what that risk is compared to other processes that occur prior to administering a med. We're also trusting that the pharmacy tech calculated, measured, and labelled the med correctly. As for charting who drew up the med, every MAR I've ever seen has some way for you to chart who drew up the med. It's certainly not an ideal way to do it, but the sky isn't falling either.

  • Apr 14

    Quote from smf0903
    ...and it's documented as to who prepped it in pharmacy. You have somewhere to go with a pharmacy-prepped med. If the proverbial crap hits the fan with a med that another RN drew up, they could throw you under the bus faster than you can say root cause. I am not a trusting person when it comes to my license, and it would be my name on the MAR, not the nurse drawing up the med.

    Just my .02
    Did you not see my comment "properly labelled?"

  • Apr 14

    Quote from Double-Helix
    This is exactly what happens when the pharmacy sends a pre-filled medication syringe or bag to an inpatient unit. You didn't see the pharmacist draw up the medication either, but do you go to the nurse manager and refuse to give the medications sent from pharmacy? No. You check the label on the syringe with your order and give the med and sign it out. It's not a violation in practice to give a medication that another trained and licensed professional prepared.
    Agree with this, so long as the medication is properly labelled.

    For those of you making the distinction between meds prepared by an RN, and meds prepared in the pharmacy. You are aware that most of these medications are prepared by a pharmacy technician, and the only time it is seen by a pharmacist is when he or she verifies the information on the label with the order.

    ETA: I find it sad that some of you have so little trust and confidence in your coworkers that you would refuse to administer a medication prepared by one of them.

  • Apr 9

    First off, you cut and pasted an email you sent to someone. A friend or someone higher up than the professor?

    Quote from jbernardo
    Although somehow I think that the instructions by the professor was not clear and that's why I failed.
    No one fails anything due to unclear instructions. You might not do as well, but failure because instructions were unclear is not common.

    On the table, there was some supplies, however, not everything was there, and a thin binder that was closed. During previous clinical exams that I took, I was always handed the MAR so I didn't think to look inside the binder.
    This time you weren't. Why didn't you look in the binder? Did you ever find out what was in the binder? Maybe it was additional instructions to find those items that were missing, so your instructor was CORRECT to say, "Everything you need is there."

    But, let's say the binder didn't contain information about the hidden items. You do realize that in the real world, supply doesn't always put things where they are supposed to, and we go hunting for them. It's part of the job. We DO NOT just used whatever is available that can cause harm to the patient....as you did throughout your clinical test.

    After, I went back to the table and since I didn't see the primary bag, and I had no idea what the enema looked like, I assumed the enema bag is what I should use because it the only thing that looked similar to the primary bag. I obviously couldn't do it because there are no ports, so I just hung the secondary bag.
    Why didn't you know what an enema bag looked like? Was there supplemental material for the class that you didn't review? Did you miss a lab session, so you weren't present when this was reviewed?

    After, I proceeded to give the IM injection and there was three vials that were there so I chose the Heparin since the other two vials seemed very small. Later I she told told me that Heparin is given SC, so it may have been the other two, but I'm not sure. Also, I didn't know how much to give since I was not given the MAR so I just gave 3cc.
    Last, I told her that I don't know what the enema was. Then, I saw the primary bag which was on the side of the nurse's station and the saline which was behind the counter. In my opinion, the instructions were so unclear from the start because all the supplies were not on the table and she implied that "everything I need is there."
    The sterile gloves were even in the closet which I asked for at the beginning and the mannequin did not even have a wound, she had to put a bandage on it in the middle of the exam. At the start she also kept referring to her sheet which had the three skills, instead of handing me the binder so I didn't think to look inside the binder.
    Sara thinks that I am 80% wrong because I didn't know my stuff enough to ask for the MAR, prepare my supplies to notice that what was on the table was incomplete, and realize that the enema bag can not be used as a substitute for the primary bag. Do you think it's right for her to fail me, or do you agree with me that the instructions were so miss leading and confusing, almost like a setup so I can fail again? Should the instructor also be responsible? Sorry if that this message is so long, but I wanted you to have write all the facts.
    You obviously didn't know your stuff. At all. Yes, it was right for her to fail you. Based on everything you said, why would the instructor be responsible for what you should have known but didn't?

    See, this is the exact opposite of what instructors look for in good students. Rather than hitting the books/videos/lectures/skills lab to do better next time, you want to argue that your failure was someone else's fault, thereby bypassing your obligation to learn the information and improve your performance. Given everything you have said here--and you admit that these are "all the facts," it is clearly YOUR fault that you failed.

    I had the exact opposite experience today with my student. I graded her care plan, and she got a 40%. She came to my office, and the first thing out of her mouth was, "Do you have some time to go over the care plan with me so that I know what I did wrong?" We sat for 15 minutes reviewing all my comments, and she ended with, "Now I understand what I did wrong. Thank you." As she left, I stopped her and told her that I had to commend her for her wonderful attitude and desire to learn. I told her, "THAT is what makes a great student." She got a little teary when I said that, and so did I in response.

    Ends up that I decided to allow a revision to the whole group for a final assignment grade that will be an average of the two grades.

    It would behoove you to take a lesson from my wonderful student. Go forward learning from your mistakes, rather than trying to manipulate a better grade when you clearly have not earned it.

  • Apr 9

    I would get the BSN instead of another major. CRNA schools are notoriously ridiculously competitive. Nearly all of your competition will have a BSN, and I doubt that an ADN plus a non-BSN Bachelors degree would be nearly as competitive. Just because you'd meet the minimum technical requirements (RN licensure plus a Bachelors of some kind) doesn't mean it would be a competitive applicant.

    I'd start your first job, then focus on the BSN program. Before you start worrying about the other pre-reqs you need (gen chem, organic chem, calculus, whatever), I'd see how demanding the BSN program is. The last thing you'd want to do is sign up for too many classes, overextend yourself, do poorly, and destroy your GPA. If your GPA is poor (especially your nursing GPA), you will not be competitive enough to get into CRNA school. Your first year of nursing will be hard no matter what specialty you're in, and ICU will have an even steeper learning curve. You don't want to juggle too many classes on top of it.

    The year of critical care experience is non-negotiable for CRNA school, and you'll be even better off if you can get a couple of years of experience. As an ADN, you may have a harder time finding an ICU position as a new grad depending on your job market. If your area is saturated with new grad BSNs, you may have to apply to ICU positions in less competitive regions in order to find a unit that will hire you. If your area is not as competitive, you may easily find an ICU job. I'd cast a wide net and apply to a ton of places, including units in less desirable locations, in order to increase your chances of landing an ICU job as a new grad. If you're limited to a specific geographic location, I'd apply to all of the ICUs that you can, and if you aren't accepted just start out in med-surg and eventually work your way into the ICU once you have some experience. California is a notoriously competitive new grad job market (I know BSNs from CA who couldn't get hired into med-surg or even LTC for 6+ months after graduating, and eventually moved to the south-east to find jobs); realistically, you may have a better chance if you relocate.

    I'd say best case scenario you get an ICU job straight out of school (which may require relocating, possibly to another state), start your BSN program right away, finish up your BSN and other prereqs during your first two years of nursing practice, get your CCRN, and apply. That means about two to three years after graduating before you can start your CRNA program (assuming you get an ICU job as a new grad, and assuming you are accepted to CRNA school in your first application cycle).

    Quote from GeminiNurse29
    If you're good at the hard sciences, and you are looking at things from a $$ point of view (which is fine), why don't you go for the med school goal?
    Strongly disagree.

    I completed all of my pre-med requirements before I realized I wanted to do nursing, and IMHO given your goals and background med school would be a terrible choice. You will need a Bachelor's degree in order to apply to med school, and being totally honest an online ADN-to-BSN degree would not make you a competitive enough applicant to be accepted. In order to follow a pre-med path, you'd need to be accepted into a brick-and-mortar 4-year college that would hopefully accept your ADN credits, complete enough courses to finish a major, and also complete enough courses to finish all of your pre-med pre-reqs (a full year of general chemistry followed by a full year of organic chemistry, simultaneously taking a full year of college physics, a full year of college calculus and/or statistics and a full year of college biology). Med schools won't accept any community college courses as pre-reqs, so even if you've taken biology/chemistry/calculus, you'd have to repeat it. You'd then have to study for the MCAT and go through the med school application process (which takes about 6 months). There's also the matter of your nursing experience. Once you have experience you could feasibly work PRN nursing shifts while simultaneously competing your pre-med classes, but when you first start out in nursing you'll have to work full-time (probably for at least a year) before you're even eligible to go PRN. There's no possible way that you could work full-time as a nurse while simultaneously completing your pre-med pre-reqs and Bachelor's full time.

    What I mean to say is that if you really want to be a doctor I'm sure you're totally capable of doing it, but it will probably take you at least 4 years before you could even start med school. Best case scenario ~ 3 years to complete a Bachelors degree and your med-school pre-reqs full-time, 1 year to take your MCAT, apply, and wait for the program to start (you apply in September and don't start until the next summer). In that scenario you would literally never use your RN license; if you did want to work as an RN part-time throughout this process (which would be insane, since you'd be taking full-time pre-med super-difficult science classes), you'd have to take a year off before you even begin this process in order to work as a new grad RN full-time before you drop down to part-time. There is absolutely no way that you could work full-time as an RN and simultaneously take and pass college chemistry, biology, physics, and math; you would die. As a full-time student, you'd be in a mountain of debt before you even start med school (which will tack on at least another $100,000 in debt), even if you did have a PRN nursing job throughout.

    In the CRNA route I laid out above, best case scenario you'd be starting school in 2 years, and during the period in between you'd be working full-time so you'd actually be making money. Conversely, in the med school scenario you'd be a full-time pre-med student/applicant for at least 4 years while making little-to-no money and amassing debt. Since it sounds like your goal is to work in anesthesia as soon as humanly possible, the CRNA route seems like the best bet.

  • Apr 8

    I vote bags of marshmallows!

  • Mar 27

    Quote from OldDude
    I'd go with gift cards to the local liquor store.
    This is my most favorite response ever.

    Also, I inherently cringed reading that FB was going to be involved with this unit-approved activity. But I'm very much against mixing social media with your professional life. Actually I'm not a fan of social media at all which is why I don't have it, but when I did I definitely didn't do anything related to my job.

  • Aug 13 '17

    What point are you at in clinical? Is this your first year of clinical experiences? I only ask because being placed in a geriatric-focused hospital/floor is super common for first semester of clinical.

    I guess my advice is to just focus on honing your assessment skills. Geriatrics is a good place to do this. Learn as much as you can from each patient and just bear in mind that whatever condition your patient has, some day as an ED nurse or whatever, you will very likely come across that condition again.

  • Jul 22 '17

    Quote from Emergent
    It means you had sex outside of the sanctity of marriage. You also had negative thoughts about someone in power. You kicked your dog three times, and picked your nose while driving. Additionally, you made politically incorrect comments and were disrespectful to the joint commission.
    ...and you ate young nurses.

  • Jul 20 '17

    If you're concerned about your license then you should be just as concerned about holding indicated meds without any apparent rationale other than what appears to be a personal bias. I get that it often feels like you're losing some sort of personal battle every time you give a patient an opiate where there is some component of seeking involved, but it's important to keep that separate from an objective assessment of whether or not the medication should be held, particularly in a post-surgical patient.

    It would be reasonable given that list to ask that it be condensed to a single long acting and prn order in addition to the toradol. but the doses are all relative and can't really be compared to every other patient, it's quite possible that giving a Norco or two to another patient is far more risky than giving an opiate tolerant patient 4mg of dilaudid.

  • May 23 '17

    Quote from kschenz
    I'd be filing a report for medical neglect. She may not meet the requirements for an investigation but you will have done your part as a mandated reporter. Poor kid.
    This is what I just finished doing. The person was kinda snippy with me (I'm sure working at those phone centers is awful) but it is done


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