Latest Comments by daveintexas8

daveintexas8 1,572 Views

Joined: Nov 3, '08; Posts: 35 (26% Liked) ; Likes: 15

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    I would look at it like know how we comfort patients and put them at ease by telling them ", don't worry, we see this kind of thing all day long..." Which is the truth.

    If I were to go to my facility, I would be sure to have my own PJs, shorts, etc. and just think of the money I am saving.

    I am pretty modest, too, and and the thought of a group of colleagues, medstudents "rounding" on me sounds horrific, but somebody is gonna see anyway.

    Most importantly is are they talented and you trust them. Good luck! You could use a prayer, and you'll get a mention in mine tonight.


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    NurseLoveJoy88 and xtxrn like this.

    Ughhh, trachs. My nemesis. I graduated almost 2 years ago, and work in one of the bigger hospitals in Dallas. I work on a very busy med-surg floor (I know, they are all busy, but ours can tend to turn into "ICU light"). My worst night was a couple of weeks after finishing orientation, and already had a full load of heavy patients. I got an admission, and this guy was THE WORST trach patient I've had. It was my first trach, he spoke only spanish (although I don't remember him ever really responding) and had terrible, projectile, secretions. It being my first trach, I was petrified, and thought I was gonna do something to kill him. It was the night that all new nurses have at some point. I was drowning, and I knew it. After I went into the med room and melted down, I pulled myself together, and got the charge nurse (who is now me ) to help me.

    Anyway, we are lucky in that we have an ENT floor, and most trachs end up there. For the last couple months, tho, we have had at least one, and usually two trach patients (one of which is a DNR now).

    I am much more comfortable managing and suctioning trachs now, as I've had each of these patients many times.

    It seems like when you ask people for advice, everyone gives you a different answer. How often to suction? I've been told if a patient is satting well, don't suction. I've been told to do it if it sounds like they have a lot of secretions.

    How many people go in until they feel resistance, and how many only go about the lenth of the trach, or an inch or so longer? I never go until I feel resistance. I've seen nurses and RT go deep and frequently enough that the secretions are pink, which I suspect is blood.

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    Neck during start of shift when I'm assessing, then usually at my computer station, where I can grab it if I need it. I probably wear it around my neck half of the shift. It isn't unprofessional. It makes you look like you are working! When I first started after graduating a year ago, some of us noobs noticed that some of the "seasoned" nurses didn't even appear to have stethoscopes! Kinda hard to assess breath sounds without one.

    I don't like the clips. My unit is an old VERY CRAMPED med-surg floor and as a kinda big guy, I get hung up in cords, lines, chairs, IV poles, etc. every time I try to get to bed 2. I would get snagged on even more stuff if it was hanging from my scrubs.

    And you know what else? We were told in school not to chew gum. Unprofessional. Well, lemme tell ya, when I am leaning in close to a patient at the end of a 12 hour shift, I am sure they appreciate my wintergreen gum a lot more than what my breath would really smell like. It's NO BIG DEAL.

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    I would recommend that in your time off, it really helps to review skills you're likely to use when you start. Just practice and recite the steps of simple things like IV starts, foley placements, assessments, etc. Pretty basic skills that really become a lot easier when you start doing them for real.

    And really review the most common meds. Not that many, really, but if you're gonna be med-surg, then just get real familiar with your BP drugs, insulins (and their onsets, implications, etc.), pain meds, and anti-biotics. Those four classes account for 90% of the actual workload. Well, I take that back...documenting accounts for 90% of the workload, lol.

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    $24.50 to start at my place. I was happy to get it! Texas has no income tax, too. So not bad. I think my place pays a little better, but I think it's around $20-$25 at other hospitals in town.

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    With all due respect to the late Daytonite (who on this site helped MANY students, myself included, get a grasp of care plans) I say this...

    The care plans are a complete waste of time. I graduated in December, and have been out of orientation and on my own on a very busy Med-Surg unit for about 4 months. Care plans do have a place maybe in first semester of school to teach you what you need to be considering while caring for patients, but they are WAY over emphasized and have absolutely no practical application in my practice.

    They are just nonsense. We have them printed on these sheets that get passed from shift to shift, only to be signed and placed on the shelf until you hand them to the next shift.

    I am too busy actually working to use them. I mean seriously, do I have to look at the paper to say this person has knowledge deficit r/t disease process? Potential infection r/t an IV? They are just busy work, and I have enough of that already. I already have to chart about 500 different things a shift (not exaggerating, add up charting IV sites Q2, fall precautions, rounding, meds, nurses notes, assessments, I&Os, etc. x 5-6 patients).

    I like what I do, but sadly we are so busy that it is a struggle to just give meds, do dressing changes, and chart without being an 1-2 hours late every shift.

    Does it make any difference to me if the person has alteration to metabolism r/t DM or alteration to nutrition r/t NPO status? No...I look at the orders the MD wrote, and I carry them out. I understand that they may need teaching regarding some of these issues, and I'll provide it, but not because I looked at the care plan...

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    That would be a separate diagnosis. Such as...

    Risk for aspiration related to impaired swallowing secondary to oral inflammation (or whatever)

    Impaired swallowing...

    Acute pain or chronic pain...

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    My Diagnosis:
    Impaired oral mucosa membrane related to inflammation secondary to infection as evidenced by a small cold sore that started inside the lip, severe swelling on the lower mandible, gums that are beefy red with several open wounds which are draining purulence, superficial skin is erythematous and hot to the touch, choking on the drainage because unable to close mouth and swallow correctly and lose of sensation in the mouth and throat.[/quote]

    I might go with:

    Impaired Oral Mucosa R/T Infection, Secondary to Herpes Simplex (cold sore), A.E.B. severe swelling and purulent drainage.

    I don't have a current NANDA list, so if Impaired Oral Mucosa isn't a current Dx, you could use Impaired Skin Integrity or whatever.

    MAYBE that helps.....

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    Graduated with my ADN RN. NCLEX in a week. I was very lucky to get a job on the General Surgery floor I was precepted on in my last semester. A couple of good patient comments made the difference, I'm sure. I start orientation on the 18th.

    Thanks to all who helped for the last couple of years (Daytonite, among others)!


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    OK. I'm just a student still, but I'm 3 semesters in, so here's where I'd start:

    You always start with ABCs. I am curious though, how the book would list the interventions, as I would consider the O2 sat % to be done with vitals. I guess technically, I would have to say VS, then O2 sat.

    I don't think the wound drainage is significant, as a small amount of drainage would be expected on post op day 1.

    Anytime you see a lab value, you wanna make sure you know if it's normal. The Hgb and HCT are low, which could indicate a bleed. However, I think that many times they are low post op because of bleeding during the procedure, so not necessarily a big deal. They do seem pretty low, though.

    One concern to me would be the diminished pedal pulse (especially on the same side as the surgical procedure). That makes me think possible circulatory problem.

    My biggest concern would be the lung sounds. One of the biggest concerns post op is the risk for blood clots. Post op (especially something like a hip fracture, and anything concerning the lower extremities) you're worried about the pt. thrombosing.

    The shortness of breath, confusion, and crackles in the lungs (think pulmonary edema) are hallmark signs of a pumonary embolism.

    That's probably gonna be your priority.

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    Quote from daytonite
    i came into nursing before nursing diagnoses were used. the difference was instead of putting a nursing diagnosis on a care plan where the "problem" goes we put the signs and symptoms that the patient was having, i.e. nausea, constipation, edema, coughing, etc. all nursing diagnoses have done is allow us to group similar types of symptoms and organize them into specific problems that have now been given names (labels) that include within them a set of signs and symptoms. maybe it was because i came out of another way that care plans were done that i "get" what nanda is doing.

    the fact is that the critical thinking process which is what care planning is hasn't changed. what has changed is what the profession wants us to use (the nanda diagnoses) in creating these care plans. someone else could come up with the xyz system of nursing diagnosis, give nanda a run for their money and it won't change the way we critically think. all that will change is the labels we attach to the different nursing problems which the xyz system would then say are better to use. i don't know how else to say this so you all understand this. if you learn the nursing process you can work with the nanda diagnoses or the xyz system of diagnosing. it won't matter. all that is required is that you follow the rules in using either diagnostic system. what is important is that you know the nursing process and how to use it in getting to the diagnosis.
    i have thought about this quite a bit since my last posting, and i want to refine my position on the issue. it's the nanda diagnoses that i am unhappy with. i always say that i understand the point of the care plans, and what i mean by that is that i know the point is to teach critical thinking. what i wish i had said is that while care plans are a valid tool with which to teach us this concept, the taxonomy is unnecessarily burdensome. i think that care plans are so derided and hated because of this nomenclature that refuses to state the obvious.

    so i guess the issue for me is who are these people that approve that list? it sure doesn't seem to be the people that use it.

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    Daytonite, I am always happy for the help, and I have on more than one occasion thanked you specifically for the VAST amount of help you provide here.

    I knew that my post would bring a response from you. I am very new to the profession (not even actually practicing, yet). I just have an opinion on this subject (which is shared by almost every nurse I've talked to in clinicals).

    I'm sorry that my post might be taken as a slight against you or the help you provide. You have helped me, and countless other students on this forum.

    My point is that in my (inexperienced) opinion, the system of using NANDA Dx just doesn't make common sense. That's all. I might be wrong.


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    Ugh. I turned this semester's major nursing care plan today (which makes it my 3rd major).

    It's such a beat down! Like I've said before, it does help in the beginning, but with only a semester left before graduating, it's just time that would be better spent by students in some other learning activity.

    I just think that the whole NANDA list is ridiculous. I understand the arguments for it, but it just needlessly creates a new language for nursing problems. I mean, is there no better way to word "Environmental Interpretation Syndrome, impaired" or "Spiritual Well-Being, readiness for enhanced?" What does that even mean? Instead of saying "this patient has a stomach ache," at some point there will be a new dx on the list that says something like "ineffective abdominal pain management related to ineffective bowel readiness."

    I exaggerate, but IMHO, I think it's a joke. Anyway, it's almost over. And I'm getting up from the computer. I've got a risk for impaired skin integrity related to my chair's ineffective comfort maintenence.

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    I came within .1 point of failing 2nd semester. I was freaking out. I learned my lesson, too.

    My original class of 50 is down to about 20 by the end of 3rd semester, for various academic and other reasons. There are, however, a number of students that failed a semester and have come back to do well.

    In my school, if you fail a class you have to repeat the whole semester. It's a crushing blow, but you CAN come back from it.

    Honestly, I don't know if I could stand repeating a whole semester. It is a real test of how bad you want this career.

    Good luck!