Don't be afraid to ask why...

[jodi_cmsrn]

As a new nurse starting out, I remember learning multiple new things every day. Our facility has a couple physician's that are legendary for their temperments. I have always been the type of person that wants to understand why I am doing something, and would always ask why?

Why are we doing this? Why are we doing this like this? Why is this going to work?

One day I was preparing a patient for an angioplasty and the patient had a critical high potassium level. Upon notifying the physician (and expecting a kaexylate order), I received an order for an amp of D50 and insulin. After asking every nurse on my unit, and looking in all the drug books I could find, I still didn't find the answer. I gave the medications, rechecked the patient's potassium level as instructed and sure enough it had improved.

When the physician arrived on the unit later (of course one of the famous temperments), much to the surprise of my co-workers I simply asked him, "Why did we do this, and why did it work?" He happily explained it to me, and actually thanked me for asking. He also told me it was refreshing to have a nurse want to learn and has continued to go out of his way to show me new things, and actually praises me to patients, co-workers and physicians.

Don't be afraid to ask "Why?" You just don't know what you can learn.

[kukukajoo, LPN]

Can someone please tell me the mechanism of action on this and why it works? I have tried to look it up and cant find anything

[Nursing_excellence, ADN, BSN]

On 1/3/2008 at 11:21 PM, kukukajoo said:

Can someone please tell me the mechanism of action on this and why it works? I have tried to look it up and cant find anything

I know this is very old post. But jic someone else is looking for answer. The insulin helps potassium uptake of the cells. And the d50 is to prevent hypoglycemia. Correct me if im wrong.

[KatieMI, BSN, MSN, RN]

1 hour ago, Nursing_excellence said:

I know this is very old post. But jic someone else is looking for answer. The insulin helps potassium uptake of the cells. And the d50 is to prevent hypoglycemia. Correct me if im wrong.

Kinda correct answer without details.

The reason why this method was used for patient before heart procedure is:

- dextrose/insulin combo doesn't actually removes potassium from the body but, kind of, places it in the right cupboard where it belongs. One of the last things one wants while doing something with the living beating heart is hypokalemia;

- kayexalate works slowly and OR has time frame;

- kayexalate means breaking NPO, and vomiting on the table is another last thing one wants to deal with when patient is sedated and something just pushed through a big artery is flipping around in his heart;

- kayexalate can cause diarrhea. This is yet another last thing one wants to deal with while doing angio, even if throught the radial approach.

[KatieMI, BSN, MSN, RN]

From that provider point of view:

I do see nurses who want to learn, although very few of them actually say so. I see way less nurses who want to think at all, and even less of them who are comfortable with doing one little step from "that's how we do it all the time".

Nursing undergrad education does not develop independent analytical model of thinking (for the fairness, not all grad programs do it too). In most cases I observe, a nurse who already made or was about to make a mistake of judgement is not able to tell me why she thought that way and not another, describe her way of coming to the conclusion and explain her action plan. Instead, she will tell one of the following: "we do it like this here all the time", "it is per policy/protocol/etc." and "I was just advocating for my patient". Either answer us the hard evidence that the nurse turned her brain off and refused to think while making the decision.

Every single time I am in hospital, there will be at least one nurse who would run "code sepsis" because "you are satisfying our criteria" and "it is just for your safety and because I care for you". She is not even able to integrate two basic facts:

- baseline BP 100/60 maximum, never goes over it; baseline HR 90 + horse level dosed albuterol, for which I am usually there for; so BP 87/55 and HR of 116 are probably warranting nothing but observation

- there are absolutely no other signs of infection. I am hanging near nursing station researching where nearby coffee machine is while waiting for the Solu -Medrol to kick in ?

Side effects of albuterol, Solu-medrol and other drugs are taught in school of nursing and are right in that poor Davis book gathering dust near Pixes machine. The nurse is supposed to know them. She is supposed to think, analyze the situation and make desicion to relax and continue to monitor the patient. She is plainly not able to do that and, consequently, I fire her. Later, I will have to battle additional $500 or so on my bill.

One of previous posters wrote how cool she "advocated" for the patient requesting oral Tylenol instead of rectal. Great job, except one little thing: acetaminophen administered rectally works much quicker and with more pain and especially fever - relieving potency due to lack of the first liver bypass. Rectal vs oral drug administration is NCLEX material which the nurse us supposed to know by heart and be able to educate the patient about it. What exactly this nurse proved to physician except that now her name is in that list of nurses "who call all the time and doesn't think, just do what she wants because otherwise she will just badger all hospital all night long about utter nonsense"?

The ultimate ending of this dutiful, task-oriented, caring, mindless, analysis-excluding model of thinking is what happened with Radonda Vaught who not only did not think about things that might happen with the patient sedated with Versed (and left her totally unmonitored) but also was not striken when the drug in the bottle looked like anything but Versed. She was "advocating for her patient" who was scared and she was on a dead hurryto relieve her suffering, follow the order and get back to whatever she was doing right before. She did not think, did not analyze clinical situation, did not even see what she was doing. Now we all know how it ended.

[Guest1144461]

7 hours ago, KatieMI said:

Kinda correct answer without details.

The reason why this method was used for patient before heart procedure is:

- dextrose/insulin combo doesn't actually removes potassium from the body but, kind of, places it in the right cupboard where it belongs. One of the last things one wants while doing something with the living beating heart is hypokalemia;

- kayexalate works slowly and OR has time frame;

- kayexalate means breaking NPO, and vomiting on the table is another last thing one wants to deal with when patient is sedated and something just pushed through a big artery is flipping around in his heart;

- kayexalate can cause diarrhea. This is yet another last thing one wants to deal with while doing angio, even if throught the radial approach.

I find Kayexelate falling out of favor in lieu of necrotic bowel risks anyways. I also find that most understand we do the D50/Insulin as a temporary measure, and that the real issue is WHY the patient is hyperkalemic.

Had a similar situation last night, ugh another reason why I dislike Bactrim...LOL

Anyways, I agree that nurses fall into two camps: those who want to learn and those who just want to check the boxes throughout a shift. I was referencing a CT scan once to a nurse recently and she literally didn't know where to see scan results on the EMR. Like she didn't even think about reading the results and I highly doubt she even read the daily progress notes. Scary stuff.

[KatieMI, BSN, MSN, RN]

1 hour ago, Numenor said:

I find Kayexelate falling out of favor in lieu of necrotic bowel risks anyways. I also find that most understand we do the D50/Insulin as a temporary measure, and that the real issue is WHY the patient is hyperkalemic.

Had a similar situation last night, ugh another reason why I dislike Bactrim...LOL

Anyways, I agree that nurses fall into two camps: those who want to learn and those who just want to check the boxes throughout a shift. I was referencing a CT scan once to a nurse recently and she literally didn't know where to see scan results on the EMR. Like she didn't even think about reading the results and I highly doubt she even read the daily progress notes. Scary stuff.

The REAL scare for me is when I admit a mildly dehydrated, pleasantly confused LOL in the second part of the day and next morning I see her sedated like a stone and tied to the bed.

What happened? Oh, they told me she was agitated at night. I do not know, I was not here, it is my first day, I know NOTHING. I did not access her yet (at 10 AM), I was busy with my other patients. If it helps, my CENA saw her and she told me she was sleeping peacefully, would you like me to call my CENA?

PM Psych consult, Haldol, Ativan, Zyprexa, no tele, creatinine, which was mildly elevated the day before, now is at the point you start to think about just calling interventional guys because you know that Nephro people will do it anyway but it will be late and there will be again no place till tomorrow. No fluids. 27 SNF meds, including Mirapex, Requip, Pepcid and, yeah, Bactrim for "UTI prophylaxis". Those mysterious "they" called "them" at 2 AM at night and told about Bactrim.

And, oh, I thought she might have UTI, she was soooo agitated, and, yeah.,. I just forgot, she vomited, can I get order for Zofran? Why no??? Oh,... Haldol and Zofran and potassium of 5.8... really, I never thought of it... we do it here every day!!

Did you see negative urinalysis from ER? No.

And, while you think what to do first with this human train wreck and shouldn't you just call ICU and beg that attending on your knees because that LOL is still very full code, this nurse makes her way in the room, tenderly touches the tied up hand of deeply sedated old woman and gently murmurs in the best (imaginable) tradition of Old Flo:

- huuuney, would you like to have a drink??

Why are you so upset with me?? Would you like me to call someone? I am just doing my job as a nurse.... what would you like me to do???