Latest Comments by AngelRN27

AngelRN27 1,810 Views

Joined Aug 11, '12. Posts: 146 (29% Liked) Likes: 68

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    We tried that originally, but then apparently the spreadsheet wouldn't save right across all users on our intranet... not really sure why.

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    Fellow managers/supervisors:

    I work at an LTACH facility and recently we've been in somewhat of a census drought, which of course has led to census-related cancellations often--especially of nursing assistants. Our facility is small, so charge nurses on the floor handle cancellations and staffing issues for the oncoming shift. Currently we keep track of cancellations on paper, which are later transcribed into our electronic scheduling software by our CNO. The trouble is keeping track of who is due for cancellation--that is, who has gone the longest without being cancelled due to the census. It's a tedious process, and sometimes we get it wrong...

    I was wondering how you all keep track of this type of thing? Is there a software out there perhaps? I know it's likely that most facilities handle this type of thing with nurse supervisors, which we don't have here, but perhaps they're in the audience!

    Thanks in advance for any advice or insight.

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    I straddle the fence on this one...

    My university taught us both IV & foley insertion, as well as the maintenance of both. They were introduced with "theory" (common practice/indications/cautions) and then were followed up by "skills labs" which we were required to accumulate a certain amount of hours in, in order to then attempt our "sign-off." This consisted of a full walk-through and demonstration on a dummy. Each student had two attempts to pass this demo perfectly in order to get their sign-off. Only students who had successfully completed this process could attempt/practice those skills in the clinical setting.

    I appreciate that this is how my school handled most (if not all) hands-on skills. It made the majority of us more confident as we knew that we were taught the process from A to Z. We were also truly lucky in that our clinical professors usually worked on the units that we visited as clinical sites (at some point in their career-- or they worked on a neighboring unit, and had seen many of the nurses around) so we were often provided with awesome hands-on opportunities.

    That being said-- as many posters have mentioned, a skill such as IV insertion is something that requires a good amount of practice to get any good at, and that's something that will occur on-the-job. I don't necessarily think it's something that needs to be practiced in nursing school, although, again, I really appreciate that I was given the opportunity to.

    PS. I had no idea prior to this post that it was so common not‚Äč to explore these skills in school.

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    I realize that the CCRN is more comprehensive, but just as an aside, I passed the PCCN with 83% only using the resources provided by the AACN. No DVD's, no expensive reviews. Their resources are pretty good, so if you have a good amount of experience and a good foundation, don't spend too much money. My PCCN score was exactly the same as my SAE (self assessment provided by the AACN online) score, despite the SAE only having 50 (or 60?) questions.

    Good luck!

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    sapphire18 likes this.

    Quote from Nalon1 RN/EMT-P
    If you have issues with the tap water, your facility needs to fix that. The gut is not sterile, no need to use sterile water IMO.
    I could maybe see it in a neutropenic patient, maybe.
    ^^^ This. The gut is not sterile, so I'm not sure how effective using sterile water for NG/OG tubes would be. Did those of you who use this method at your hospitals have some sort of evidence-based back up for this practice? It's uncommon for hospitals to install policies without some sort of foundation outside of either research, practice norms, or some sort of association recommendation (such as the CDC, for example).

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    How new is this SOFA scoring? I currently work a PCU/ICU and haven't heard of this yet. We currently use the SIRS method. I am also PCCN certified (granted by the AACN) who uses the latest evidence-based practice and they still publish SIRS information.
    Just curious about how the SOFA scoring works, what it entails.

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    Maevish likes this.

    Hello BendyEm,

    I assume by "site" the NG, you are referring to insertion? (that's not really a term we use in the US) Personally, I have been working ICU/Step-down for 3 years and have never even heard of an MD inserting an NGT, that's like having an MD get a peripheral line for you! LOL. Anyhow, here RN's insert the NG with a medical order, verify on the spot via the classic method (air bolus and auscultation of the stomach) and then order CXR by protocol to positively verify placement. Tube feeding/med administration can begin after CXR confirms placement, if need be. My hospital does not require any in-house education for insertion of NG tubes. Usually, the newbies will ask for support anyway, but we do not need any sort of approval by our educator to insert as our nursing license covers this. Good luck!

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    I don't know that your practicum site/area plays a huge role in the direction of your career, IMO. I was lucky enough to get my first choice as my practicum site, which was PICU at our local, nationally renowned children's hospital. I loved it & learned tons, but it really had no bearing on where I worked thereafter.

    While I applied for jobs as a new grad, not ONE prospective employer ever asked me about my practicum site, though it was listed on my Resume at that time. I even applied at the same children's hospital that hosted me for practicum (where I was well-liked and had plenty of contacts) but I consistently got the "unfortunately, we aren't currently hiring new grads" spiel.

    My first job ended up being at a LTC/SNF which was rewarding, but not quite what I was looking for. I moved on to LTAC (see the LTACH threads-- this is comparable to ICU/Tele/ICU Step-down in larger hospitals-- except with ridiculous ratios!) and have been there for 2 years now...

    My point in all this is that, although you may have a clear picture of where you *eventually* want to be, there are plenty of paths that lead to the same destination. Not only that, but as sure as you may be now, many times nurses change their minds after being exposed to a certain area of nursing that perhaps they didn't even know existed...

    As a new grad, you really can't be picky. Just do great wherever you go and things will pop up for you! Also, take your time to gain valuable experience once you do get to critical care. In my experience, bedside expertise really makes a huge difference for our ARNPs and CRNAs... there is a world of difference between them, and those that sort of went straight into advanced practice.

    Good luck and have fun!

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    Our facility has a q4hr oral care policy (also shared between RN/RT when possible) but our policy for rotation of the ETT is qshift and PRN as someone mentioned above. We also use the Hollister holder as another poster mentioned. My facility hasn't had any ETT related breakdown for over a year, per administration, so I guess this policy/technology works. Generally, the tube "belongs" to the RT's, but depending on the pt load, the shift, what's going on-- RN's can rotate the ETT if need-be. Our RT's are big on teaching, so the majority of our RN's feel very comfortable with tubes. You should never go all-in if you don't feel safe or are unsure at all of the best practice. I prefer to have someone in the room with me (another RN or grab any RT) when moving the ETT, just in case...

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    Hmmm... not sure exactly what your preceptor meant, but in the clinical example you presented, everything sounds right. The interventions you mentioned (administering bicarb/initiating bicarb drip + increasing RR on vent) seem standard to me, especially for that pH. I would have to agree with FlyingScot's response.... but in this case we have more control because the pt is already on a vent...

    It all depends on the pt and the context.

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    I'm not sure that there is any one thing I could tell you to "review" to help... one of the biggest things you may need to get used to that we don't really work with much in LTC is lab values. You will get used to what is emergent and what is "okay," but you need to be aware of signs and symptoms associated with certain electrolyte imbalances or other abnormal labs. You also want to know what the usual treatment is. Apart from that (like most of nursing) you will do your learning on the job. It always helps to have a good foundation from nursing school, but that depends on a lot of factors, not just you as a student nurse. Plus, you can't really do that over LOL.

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    junebugjones37 likes this.

    Good Morning! I currently work night shift at a LTACH and I also started my career in LTC/SNF. Very big change, but if you're a quick study, critical thinker, a doer, and enjoy somewhat of a fast pace, you will do just fine. It helps immensely if you love to investigate and learn while on the job.

    While it is true that the night shift is a little "less busy" than days, that is really only true in regards to MD correspondence and (as the last poster mentioned) the absence of administration on the floor. Not that there is anything to cover up, but anyone will tell you that just the pressure of having admin. around sort of makes the shift more tense, so I appreciate not seeing them much LOL.

    The last poster also mentioned that one of the challenges on night shift is the lack of help and/or resources. Working nights in LTACH you have to be very creative and resourceful in solving problems as you will not have many people around to solve problems for you. Also, I'm not sure if this is just at my facility (although I've noticed this in a regular ICU as well) but most of the codes tend to be on nights. We also get more admissions on the night shift, believe it or not (that one is backed by national statistics, btw LOL).

    Anyway, make sure you learn all you can, investigate where necessary, ask questions, and you'll do well!

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    You definitely should not regret your decision to call a rapid response. In this situation, you were acting as pt advocate and perhaps saved the pt from a respiratory arrest or at the very least some respiratory distress. I do agree, however, that the medications should have been staggered somewhat. I know that the pt requested pain meds + ativan but seeing as they both depress respirations, I would have started with pain coverage then given anxiolytics afterwards. Either way, you did the right thing and it's all a lesson learned.

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    PierceTheVeil likes this.

    Some things you become accustomed to, others you don't. Some people can't deal with smells, others shy away from seeing sputum/respiratory secretions... it all depends.

    And I disagree that wearing a mask is offensive. It's part of PPE. I highly doubt that anyone would question your use of it, and if they did, PPE can easily be explained away...

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    Quote from HeartsOpenWide
    I started out in a specialty unit ((LDRP). I graduated with honors, sigma theta tau, took extra clinical courses through an additional collage, took a beginning midwifery course separate from my nursing courses, and became a certified doula during nursing school. There are your average students and your above average students. Some new grads do great in specialty units while others do better starting in med/surg. To make a blanket statement that new grads should not start out in specialty units is saying all new grads are equal; (I don't know how to say this without being rude) but that simply is not true.
    To be fair, graduating with honors and taking extra clinical courses/certification courses also does not indicate anything about your ability to function clinically in any setting. My nursing class had many stellar *academic* students that just weren't confident or adept when it came to performing skills or thinking on their toes in the clinical setting. It seems as though you are somewhat "blanketting" the topic as well...

    Clarification: I do agree with your point that not all students or new grads are the same; I also started in ICU Step Down and did just fine. Classmates of mine started in TICU and also did well. I disagreed with your argument as to why this is true, however.