New RN With Questions

Nurses General Nursing

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Hello - I am a new RN and with the job market as it is I accepted a position with a SNF. I received about 12 days of training. Unfortunatley the person who trained me was a new nurse herself and has only been working as an RN for two months. Currenlty I am working nights and they have started me on the LTC unit while I get acclimated. The facility I work for has a pretty high acuity level on their skilled unit so I am hoping to learn alot over there when the time comes. However, I still have questions so here goes.

1) I learned in school that O2 should be 95% or better. However, when I ask other nurses in the facility how to check patient parameters they don't seem to understand what I am asking for. I have done some research and found that medicare reimburses when O2 is 88% or less....so should I not worry unless the 02 is less than 88% and/ or my assessment findings show other signs of hypoxia?

2) A resident has a stage II ulcer on her sacrum, currently Open to air, and the nurse reporting off told me her skin is really moist. I suggested an absorbent dressing be put on to collect the excess moisture and the other nurse agreed. So, I applied one during my shift. When I came in for my next night shift the reporting nurse said don't put a dressing on...I said I did it to collect the moisture and she said don't do that but couldn't give me her rationale behind that. Am I not understanding something here?

3) I have a resident whose pain is not being well controlled. I was told that they had to stop some of her meds because she was hallucinating. However, she continues to hallucinate and is aware that what she is seeing is not real. She stated why I can't I get more medication for my pain I am hallucinate wither way. Any suggestions on how I can best advocate for this patient?

4) On the SNF unit the LPN had a patient who pulled is PEG tube out. The LPN called the Dr. and he told her to insert a urinary cath before it closed. I helped her with the procedure. I was surprised this was in our scope...more stuff I never learned in school. ;-) the LPN said as long as the Dr. gives the order you can do it. This seem scarily broad to me...is this true?

Thank you!!

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Well,

no. 1: I don't understand what you are asking

no. 2: You should have MD orders. So, it should be fully assessed, documented, MD called, orders received about what you are to do for the wound.

no. 3: Assess current situation, document it, notify MD...

no. 4: True

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Sorry, all I can kind of address is the O2. If a patient has an O2 saturation of lets say 90 to 94% for many weeks or months, then that is just what they live with, it is the best they can be. If their normal O2 sat is above 95% and they are suddenly staying at 90% or less then you should "worry." It all depends on what is going on with the patient at that time, and what their "baseline" saturation is.

And be sure to pay attention to the patient more than the monitor. They can be 99% and in distress, and be 90% and be fine. Make sure the monitor is working properly, good circulation to the digit, etc.

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Specializes in OR, public health, dialysis, geriatrics.

Congrats on the job. Stop looking at it as "just a SNF job" and start thinking about the great prioritizing skills, time management skills, and talk about having to deal with a myriad of issues every shift. Once you get to a hospital, if that is where you decide to go, you will say "Give me the keys and send the rest of them home-I got the 12 patients!" As you secretly are amazed that the others are complaining about 5 patients as you remember running a whole wing and as the RN in house being the charge nurse for everyone!

Now on to your questions:

1. If you are 85 years old, COPD, emphysema, CHF, etc you will have lower than 95% O2 sats. Most of these folks live this way just fine and some conditions shouldn't have too much supplemental O2-messes with pH balances, etc. If sats were higher and now are lower or the patient is symptomatic-this needs reporting to the MD or charge nurse STAT.

2. What are the wound care standing orders at your facility? Has the wound care nurse or doctor written orders for "open to air." If not consult with the wound care nurse and MD about what they want. Since you are on nights make sure to mention this to the oncoming shift charge nurse-they usually have more time to call during the day since staff levels are higher.

3. Talk to the doctor about the pain control for this patient. Get the family involved as well-docs sometimes "listen" better to the families than to the nurses.

4. With orders yes you can do this. Sounds like the LPN is strong and a great resource-don't fall into the LPN vs RN trap. LPNs have saved this RN's butt plenty!

Good luck and remember the real education starts after nursing school. Pull out the books, ask for journal subscriptions as Xmas presents, learn from those who have been around for a while. You will do great.:yeah:

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Sorry, all I can kind of address is the O2. If a patient has an O2 saturation of lets say 90 to 94% for many weeks or months, then that is just what they live with, it is the best they can be. If their normal O2 sat is above 95% and they are suddenly staying at 90% or less then you should "worry." It all depends on what is going on with the patient at that time, and what their "baseline" saturation is.

And be sure to pay attention to the patient more than the monitor. They can be 99% and in distress, and be 90% and be fine. Make sure the monitor is working properly, good circulation to the digit, etc.

That is so true.It all depends on a person's body.I have a patient whoes blood pressure tends to run 180/110 (he is on a couple BP meds) and he never experience any high blood pressure symptoms and walks just fine!!

I also have a patient whoes pulse run in 50.

Another patient of my ..her diastolic tends to run in 60.

They all feel fine.

All you need to do is know the patients and what they run.If you dont know the patient then call MD,he knows his patient and will have an idea what is the norm for them.

Usually when the sats are 90 or above the patient should be ok.

As far as the dressing changes...well you should have right away notify the MD of any changes in the wounds,remember we can not treat we assess and follow orders.

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That is so true.It all depends on a person's body.I have a patient whoes blood pressure tends to run 180/110 (he is on couple BP meds) and he never experience any high blood pressure symptoms and walk just fine!!

I also have a patient whoes pulse run in 50.

Another patient of my ..her diastolic tends to run in 60.

They all feel fine.

All you need to do is know the patients and what they run.If you dont know the patient then call MD,he knows his patient and will have an idea what is the norm for them.

Usually when the sats are 90 or above the patient should be ok.

As far as the dressing changes...well you should have right away notify the MD of any changes in the wounds,remember we can not treat we assess and follow orders.

About the pain control...if the patient experiences toxicity then the drugs should be held and again MD notified.

I dont see any MD collaboration with your nursing care?

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Specializes in ICU, Research, Corrections.
That is so true.It all depends on a person's body.I have a patient whoes blood pressure tends to run 180/110 (he is on a couple BP meds) and he never experience any high blood pressure symptoms and walks just fine!!

What symptoms would you expect with hypertension - something to do with

walking?

His first symptom is going to be a stroke. Please get his meds adjusted so he

is WNL for BP.

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Specializes in Critical Care Hopeful.
Sorry, all I can kind of address is the O2. If a patient has an O2 saturation of lets say 90 to 94% for many weeks or months, then that is just what they live with, it is the best they can be. If their normal O2 sat is above 95% and they are suddenly staying at 90% or less then you should "worry." It all depends on what is going on with the patient at that time, and what their "baseline" saturation is.

And be sure to pay attention to the patient more than the monitor. They can be 99% and in distress, and be 90% and be fine. Make sure the monitor is working properly, good circulation to the digit, etc.

Brown is absolutely right. I can tell you as a former smoker that my SpO2 (while I still smoked; quit in January yay!) gravitated around 92-93% normally. I have seen emphysema, COPD, and CHF patients that had sats that were normally in the mid to high 80's. It all depends on the baseline and (if you are unsure what the baseline for that patient is) if they are actually in any sort of distress or not.

I have worked a long time in the field as an EMT with SpO2 and CO oximters and can tell you that we always treat the patient and not the numbers. There are so many ways to get false positives and negatives with those devices that it's not funny.

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Specializes in Hospital Education Coordinator.

be wary about "you can do anything with an order". MD's cannot delegate what is outside your scope of practice. review your Nurse Practice Act

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Blackheartednurse - It is true that you are not seeing any MD collaboration in my work...I never received a chance to do that during my training and am still uncertain as to when I should contact the MD. However, the posts from you and others are helping the picture become more clear. Currently, they have me working nights and not much has happened where I feel I need to call the MD. I worked a morning shift today just doing med pass on the skilled hall and it made me realize just how little I know. I am going to request more day shifts so I can get more familiar with the workings of each unit. So that if they want to keep me on nights, should something go wrong I will know what to do.

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Thank you ALL for your feedback - your knowledge is invaluable. Also, it is so encouraging to have you all out there willing to guide me along as I make the transition from school to work. It's actually quite touching. I'm sure I will have more questions along the way and will post them as they come. ;-)

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Specializes in Med-Surg Nursing.

02 sats 'should' be above 90%. Some people however are just fine with sats of 88%. Especially COPD or CHF patients.

The wound nurse(if you have one in your facility) should be consulted on appropriate wound care for your patient with the St II ulcer. Definitely get a Dr's order for either that or have the Dr assess the wound and make recommendations and orders for wound care.

If the resident is hallucinating, he or she could have a build up of a drug still in her system which is causing the hallucinations. Her pain though still needs to be addressed. Would transferring her out to the hospital be appropriate in this case to rule out other causes??

As long as you have a physician order AND it's within your scope of practice, it's ok to place that foley in the stomach in place of the PEG.

-------------good luck to you in your career.

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