Content That gigglestarsRN Likes

gigglestarsRN 3,383 Views

Joined: Oct 29, '12; Posts: 63 (35% Liked) ; Likes: 41
Cardiac stepdown unit; from US
Specialty: 1 year(s) of experience in Cardiothoracic

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  • May 9 '14

    Throughout my orientation, I found not just a preceptor, but a mentor, a colleague and a friend. I am forever grateful that, for me, she provided a safe environment free of hostility and judgment - but one conducive to teaching, learning and growing. I ended my orientation with many of her pearls of wisdom, nuggets of knowledge and the confidence to know I am on my way to one day being the nurse God created me to be. I only hope she knows how truly special she is!

    To my preceptor:

    With your many years in nursing, I know I am just another face; just another mindless new grad - clueless, jittery and slow. Although my face will soon fade from your memory, yours will forever be present in mine. Your razor sharp intelligence, your thick gritty exterior, your invaluable experience, and warm, compassionate heart have helped mold me into the nurse God has called me to be.

    The worst kept secret in nursing is the difficulty transitioning from 'student nurse' to 'real nurse'; and boy is that transition rough. No amount of schooling, studying, or clinical time will ever truly prepare you for 'real world nursing'. It much reminds me of the military. Basic training is absolutely essential in laying the foundation for a good soldier, but it will never prepare him for the gruesome reality of war. The process of such a transition is quite difficult and at times extremely painful. For this I am forever grateful for your willingness to help me weather the blustery storms that blow through the trenches of nursing. Thank you for being my battle-buddy.

    Thank you for sharing your wealth of knowledge with me. Thank you for showing me how to prioritize in the real world and explaining that not everything is a crisis. Thank you for nurturing my fragile, almost non-existent confidence. Thank you for not making me feel absolutely incompetent for asking silly, mindless, and seemingly basic questions. Thank you for teaching me to pop in a piece of gum when I feel the urge to cry in front of my patients. This will hold the tears at bay until I can make it to the supply closet; with this I can hold it together and remain a strong pillar of strength for my patients in the midst of highly emotional situations. Thank you for showing me what it really means to be a patient advocate.

    Thank you for forfeiting those sacred moments of 'down time' you rarely seem to find to instead graciously help me better understand those wonky tele strips. Thank you for always reassuring me and reminding me that everyone makes mistakes - even you. Thank you for reminding me that every mistake, every error, ever near miss must be taken as an opportunity to learn and to grow. Thank you for pushing me, for giving me just enough rope to feel uncomfortably independent, but not enough to hang myself. Thank you for reminding me that this unnerving phase in my nursing career is much like a jigsaw puzzle - the pieces are there, but figuring out how they fit together takes a little time. Thank you for your incredible patience with a bright eyed, bushy tailed, green-as-green-can-get new nurse.

    With this I must say, you were so very right. The tears, the long hours, the doubts, the frustrations and fear are all worth it when your patient tells you that yes, you were the calming presence in a painful, scary situation. Yes, to you I am just another face, but to me, you are the physical embodiment of the confidence, focus, peace, compassion, and patience I prayed for in a preceptor every night. Although I am only a few steps out of the gate and have many, many more to go- thank you for helping this turtle come out of her shell. I only hope that someday I can provide a scared, inexperienced, doe-eyed novice the same guidance you have provided me!

  • Apr 20 '14

    Just be honest. Did you get any feedback on which standards you failed to meet? If a potential employer presses you, you need to be able to clearly define why/how you failed and what your plans are to improve your performance. Don't play the blame game or act ashamed; move forward with confidence and a plan. That, coupled with honesty, is your best bet.

  • Apr 20 '14

    there is d5.9%, d5.2% and d5.45%. half-normal saline (0.45% nacl), often with "d5" (5% dextrose), contains 77 meq/l of na and cl and 50 g/l glucose.
    quarter-normal saline (0.22% nacl) has 39 meq/l of na and cl and always contains 5% dextrose for osmolality reasons

    table of commonly used iv solutions.doc
    chart of commonly transfused blood products.doc

  • Apr 20 '14

    This is a standard IV solution. I'm thinking that what may be confusing you is the way it is written. It is written a number of different ways:

    • D5 1/2 NS
    • D5/0.45 NS
    • Dextrose 5% in 0.45% Normal Saline
    • Dextrose 5% in 1/2 Normal Saline
    • 5% Dextrose in 0.45% Normal Saline
    • 5% Dextrose in 1/2 Normal Saline
    It is a hypertonic solution. A hypertonic solution is one that has an osmolality greater than 340 mOsm/kg. Hypertonic solutions exert more osmotic pressure than the extracellular fluid so when these solutions are infused, fluid gets pulled into the vascular system. You want to monitor patients receiving any hypertonic solutions for fluid overload, particularly if they are being given at a rapid rate of infusion.

    The osmolality of 5DW and 1/2 NS is 405 m/Osm/liter and it's pH is about 4.4. It contains 50 grams of dextrose and 77 mEq of sodium and 77 mEq of chloride. The remainder is just sterile water.

  • Apr 20 '14

    Quote from l.a.m.b
    loved your answer. can you explain to me how hypotonic fluids work and LR?
    Hypotonic solutions have an osmolality of less than 240 mOsm/liter. They exert less osmotic pressure than the fluid in the extracellular compartment which allows water to be drawn from the extracellular fluid. Blood cells will draw these solutions into them causing the blood cells to swell and burst. There is only one hypotonic solution in common use and that is 0.45% sodium chloride (1/2 Normal Saline). It has an osmolality of 155, a pH of 5.6, and contains 77 mEq of sodium and 77 mEq of chloride. Continuous infusion can cause dilution and depletion of electrolytes because of the small amount of sodium in this particular mixture resulting in hyponatremia. Because there are no calories in the solution, the patient is going to become calorie depleted as well if it is infused for a long period. Isn't it interesting that adding 5% Dextrose to it to make 5% Dextrose in 0.45% Normal Saline makes it a hypertonic solution?

    Lactated Ringers solution has an osmolarity of 275 mOsm/liter and a pH of 6.6. It contains 130 mEq of sodium, 4 mEq of potassium, 3 mEq of calcium, 109 mEq of chloride, and 28 grams of lactate. It is an isotonic solution. It is also called Hartmann's solution. It is primarily used to treat hypovolemia and when the patient's oral intake is limited, absent or fluid losses are very high. It does not, however, supply enough electrolytes for maintenance and does not contain any magnesium. The lactate is a buffer that when metabolized produces bicarbonate. Complications connected with the infusion of LR (Lactated Ringers) are overhydration, electrolyte excess (particularly sodium), electrolyte dilution, and calorie depletion. Patient can also develop metabolic alkalosis if LR is run over long periods of time. It shouldn't be used in patients with liver disease because the lactate is metabolized in the liver. You will commonly see LR used for surgical patients. Adding 5% dextrose to LR makes the solution hypertonic.

    Isotonic solutions have the same tonicity as plasma so that when they are infused into a vein, water neither enters or leaves the cells. These kinds of IV solutions are used to expand the extracellular fluid volume and do not cause any fluid to move from into or out of the blood cells. Isotonic solutions have an osmolality of 240 to 340 mOsm/liter. Other isotonic solutions are:
    • 0.9% Sodium Chloride
    • 5% Dextrose and Water
    • Ringer's solution
    • 2.5% Dextrose in 0.45% Sodium Chloride
    • 2.5% Dextrose in 1/2 strength Lactated Ringer's
    • 6% Dextran and 0.9% Sodium Chloride
    • 10% Dextran and 0.9% Sodium Chloride
    The only difference between Ringer's solution and Lactated Ringer's solution is that Lactated Ringer's has the 28 grams of lactate in it. Otherwise, the solutions have the identical other components.

  • Apr 20 '14

    OK - the error was due to a lapse of the "5 rights"... very common. Corrective action needs to focus on the behavioral choice, not the outcomes. After all, the nature of the error would have been the same, even if OP had given ASA instead of Tylenol. It was due to noncompliance with acceptable medication administration procedures - probably skipping steps due to perceived urgency & the fact that OP is a new nurse who has not really internalized the importance of "5 rights". If we're truthful, most of us experienced a similar event that triggered a higher level of awareness & focus on med administration.

    I'm glad that the patient did not suffer harm. I'm also absolutely certain that the OP has learned a valuable lesson & has changed his/her practice accordingly.

  • Mar 21 '14

    The best advice I've ever gotten was from my unit educator who told me to focus on what I do know instead of what I don't know. It is a simple change in your thinking that can make a huge difference in your confidence. When you come across something that you don't know, instead of thinking of all of the things you don't know about that it could be, think about what you do know associated with it, so you can rule those out. It will also help you ask more intelligent questions. For example, if your patient is suddenly bradycardic and you don't know why, eliminate what you do know first. Is it because they're cold? Vagal response? Sedation? Then when you go ask your charge nurse instead of just saying my patient's bradycardic and I don't know why, you can say "My patient is bradycardic and it isn't due to X, Y and Z, what else do you think it could be from?"

  • Mar 9 '14

    This was definitely one thing I didn't like about nursing school. You could give 50 nurses this same scenario and they'd probably all have different answers/rationales for what they would do. Honestly...this scenario is far too vague, there's no black and white answer for this. In the "real world" you would take several other things into consideration, like, is the pt symptomatic with this BP? Is the pt here for CHF exacerbation and fluid overload? What is the HR? Are they sinus or in an atrial rhythm? Is cardizem prescribed for HTN or for HR control?

    What I would do...

    If the cardizem is prescribed because of an arrythmia/tachycardia I would give it. You will probably have low blood pressure with a very fast HR, so in that case cardizem would correct the problem instead of worsen it. If it's strictly prescribed for blood pressure, I would hold it. kind of get a clue with the lanoxin, so sounds like this a patient who needs HR control....maybe this is what your instructor was wanting you to pick up on?

    I would still give the lasix if they are fluid overloaded. Sometimes CHF-ers "live" in the 80's and it's "ok" for for them because their LV function is so poor. You would not hold diurectics for this pt. But, if they are symptomatic with the low blood pressure, I would hold it. This is possibly a pt that is now too dry and needs fluid, so for this pt, giving lasix and the potential of lowering the pressure further would be a very bad thing.

    Prinivil...definitely would hold that symptomatic or not.

    Demerol....would hold if ordered in IV form for sure.

    Hope that helps!!

  • Mar 4 '14

    Quote from traumaRUs
    Wow - amazing you are asking about this. Staff has been discussing the need for more clinically based threads. Stay tuned for case studies coming soon.
    Regarding case studies. I always worry about submitting any detailed case study type scenario. What if a co-worker recognized me here, or someone put two and two together and figured out the hospital where I work. There are always a few super vigilant protectors of privacy that would only be too happy to nail a coworker to the wall for a very remotely possible violation of HIPAA.

    It would be nice if we could submit case studies anonymously to you guys, then have the case submitted by a staff member here. That would insure total anonymity.

  • Mar 4 '14

    Hi, I wasn't sure how to title this. And, yes, this is a non-clinical knowledge topic.

    Once in a while I'll read a really good, nitty-gritty topic here about pathophysiology, informative evidence based facts on the latest research about medications, fluid management, best practices in the clinical setting. I'm not talking about the latest and greatest in how to make patients and families perceive that we're doing a great job here, but the hardcore clinical stuff.

    There's a great thread in the ER section now about hypotension in the septic patient who has received antibiotics, fluid resuscitation vs starting pressors, and the latest research. I also enjoyed, very much, the case study thread. It really got me thinking. But, threads like those are rarities here.

    If we are truly professionals, why is it that most of the threads here are related to how much our co-workers and patients annoy us, how bad hospital administrations are, how to get unemployment if we are fired, etc. I'm not saying those topics lack merit. This is a social site and I'm certainly interested in all sorts of topics as well. It's just disproportionate.

    Shouldn't we be exchanging more knowledge here at All Nurses?

  • Feb 1 '14

    You can always tell when I've been hanging out on the forums too much -- I get up on a soap box. I'm amazed, though, at how many new nurses are grasping at straws to find "reasons" to quit their first jobs because they're unhappy and they're just positive that things are going to be better elsewhere. Even if there is no elsewhere in the immediate future. It's not THEIR fault that they're miserable -- it's the job. Or their co-workers are all mean and out to get them. (Probably because of their incredible beauty.) Staffing is a nightmare, the CNAs are all hiding and they're afraid they're going to "loose" their license. They'd better quit RIGHT NOW, so they don't "loose" that license. (I wonder if that one is as transparent to spouses who are looking for a little help with the rent -- not to mention those school loans you've racked up -- as it is to some of the rest of us.) The job is ruining their lives and their mental health -- they're seriously worried for their mental health if they don't quit right now. Where did all of these fragile people come from?

    Seriously, folks. The first year of nursing sucks. You have the internet and all of that -- how could you not know that the first year of nursing sucks? It does. We've all been through it. The only way to GET through it is to GO through it, but there's a big group of newbies every year who are SURE that doesn't apply to them. No one as ever been as miserable as they are. No one understands. They HATE going to work every day. Management is targeting them and they're sure they're going to be fired. They're concerned that their mental health might be permanently damaged by the trauma of staying in that job ONE MORE DAY. Given the inevitability of "loosing" that license and permanent damage to their mental health, it's all right to quit that job tomorrow, isn't it? Or maybe it's that their DREAAAAAAAAM job is opening up, and they've been offered the job. It's OK to quit this job to take their DREAAAAAAAAM job, isn't it?

    How do they even know their dream job is hiring if they have every intention of making their first job work out? What are all those job applications doing out there, floating around if they're serious about this job? You DID intend to keep this job for one to two years when you took it, didn't you? If not, shame on you!

    The first year of nursing sucks. You're going to hate going to work every day, and some of you are going to cry all the way to work and all the way home. You'll be exhausted, both mentally and physically and your normal hobbies and activities may take second seat to the job. You'll be constantly afraid of making a mistake, and you will MAKE mistakes. You'll feel incompetent. You may lose sleep because you're worrying about your job. Switching jobs isn't going to miraculously make you confident and competent. It's just going to delay you on your path through that first miserable year. It may even look bad on your resume, paint you as a job hopper. (I'm always shocked by how many new nurses are on their third or fourth job in less than two years who will assure me that they're not job hoppers. Honey, if you're on your third job in less than two years, you're a job hopper. Really.)

    Don't people have bills to pay? Or is it that no one feels responsible for paying their own bills anymore? How is it that so many people feel free to just up and quit a paying job without another one in sight? I guess I'm getting old, because I really don't get it.

  • Dec 16 '13

    I like that Acceptability to Patient, Sense of Humor, and Imagination were graded!

  • Oct 23 '13

    Dear Marty6001,
    That was an absolutely heart-rending and poignant description of your personal travail. My heart goes out to a fellow-nurse. I will keep you and your princess in my prayers. Just reading your post has made me a better person. Take care, my friend.

  • Aug 31 '13

    Me! Me! I love my job!

    I have loved nursing since I was is school. I can moan with the best of them, but even when I'm in the middle of a post-shift rant, deep down I wouldn't change it for the world.

    I learn something new everyday, I use my brain and my hands, I work with fantastic people, every once in a while I am part of a team that saves a life and every day I make someone's life just a little bit better.

    I like moving fast, I like the adrenaline, I like sharing war stories with my coworkers, I like the 10 minute lull on nights where we watch music videos, I like breakfast after nightshift with the gang.

    If you find your niche, whether it is a specialty you love, or the right workplace nursing is a fantastic career, I have been lucky enough to find both. I don't love every minute of it, I have bad days, things get on my nerves, but the good outweighs the bad.

    Good luck!

  • May 1 '13

    Have been working on my floor as a new nurse for a little over a year. Biggest advice being new to the floor:

    1. Learn you heart rhythms/arrhythmia's AND the interventions for them. You will see a rhythm changes, sometimes symptomatic, sometimes not. It's important to know what you can do to help the patients before you call the doc.

    2. Not sure how your units will be set up, but we pull a lot of the cardiac sheaths from the cath lab. Make sure you do as many as possible while you are on orientation with the help and know what to look for after pulled (hematomas (most common), retro-peritoneal bleeds, pseudo-aneurysm etc.)

    Get ready for lots of different chest pains, and the basic interventions for that. Knowledge of all the common heart medications is also helpful.

    All sounds scary, but I love working on my floor. Couldn't have picked a much better floor to start on, good nurse to pt. ratios. We get a lot of variety because we take a lot of new strokes and people with lung problems as well. We are more of an intermediate care floor. Too sick/complex for med/surg, not sick enough (yet) to need the ICU.