Content That P B and J Likes

P B and J, ADN 4,178 Views

Joined: Nov 30, '10; Posts: 119 (34% Liked) ; Likes: 127
RN; from US
Specialty: 3+ year(s) of experience in Nursing Supervisor

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  • Dec 12 '16

    Even if the patient is not an alcoholic, a cocktail or a glass of wine isn't necessarily inappropriate. Why do people lose their right to enjoy a favorite beverage simply because they are in assisted living or even a nursing home? Assuming it's not going to harm the patient, what exactly is the problem here? Nowhere is it stated that the nurse has an order to get the patient hammered.

  • Dec 12 '16

    Quote from purplegal
    Apparently, we are to give him whiskey along with his evening medications. This worries me since alcohol interacts with so many medications.
    If you're uncertain why the whiskey was ordered you can always ask the prescriber for clarification. I'd treat it the same way as I would a more traditional order; i.e. get clarification if something is unclear. If you are concerned with medication interactions I think that a pharmacist is a good resource if you have one available to you. Personally I wouldn't be worried about one drink but if you need to have your mind put at ease, definitely reach out. After all, I don't know your patient's history or current status or medications, so I'm just speaking in general terms.

    It doesn't seem right as part of my nursing duties to be giving patients alcohol.
    If it's somehow beneficial for the patient (either by preventing him/her from developing alcohol withdrawal or simply by providing some culinary enjoyment ), do you still feel that it shouldn't be a part of your job?

    A couple of years ago I visited an old classmate who works hospice at her place of work. I noticed that they had an actual wine refrigerator in the kitchen (dual zone for red and white) and she told me that wine was served with dinner for those residents who wanted it. Served in real wine glasses. In my opinion at least half the therapeutic value is lost if you serve wine in a cup, mug or any other kind of wholly inappropriate vessel

  • Nov 12 '16

    We needed a stethoscope (They recommended the Littmann classic IISE, it's what they sold at the bookstore on campus but the VA bought me a Cardiology IV), a pen light, bandage scissors, solid black or white waterproof shoes without mesh, a laptop (we take tests on our computer proctored in class, a lot of the courses are hybrid with an online component, and we chart on our laptops after sims), and like $2,000 in books

  • Nov 12 '16

    Don't you know that sunglasses are so much cooler than boring regular glasses? Are you bigoted against cool kids? Are you taking your memories of being uncool in high school out on this oppressed young man?

  • Nov 12 '16

    Quote from traumaRUs
    Using ONE meter between MULTIPLE patients is a disaster waiting to happen. How are you QC'ing it? They are not meant as multiple pt devices.

    Im an APRN in dialysis units and this is the reason we can't keep glucometers in our units: they are not meant for more than one pt and there is no way to adequately disinfect them.
    This is not the case. I work at an SNF and it is perfectly fine to use the same glucometer on multiple patients. The glucometer needs to be cleaned with a hospital grade disinfectant wipe and allowed at least a full minute to dry between each patient. The glucometer itself should never be in contact with the patient, the blood only touches the strip. This is the process that we follow and has been approved when the state board visits our facility annually.

    It is not reasonable to think that each patient who need BG monitoring in a hospital setting would be issued their own brand new glucometer which would then be disposed of once they were discharged.

  • Nov 12 '16

    You could say you've done additional research and found the local rates are significantly higher than you are being offered and originally said would be satisfactory. You want the opportunity and to learn and grow in this position with commensurate pay and that you need to revisit the wage negotiation

    If they question why the delay in determining competitive rates, you could tell them that you've since learned how to perform better search using the best variables and criteria.

    If you're not asking for above and beyond the current rates, they may be disappointed if not irritated. Just be sure to consider which positions you're making comparions, some clinical staff do make more than entry level mgmt.

  • Nov 12 '16

    Last week I hit a milestone.

    I fit into scrubs. The tops and the bottoms. I paraded around the living room checking if I could bend and turn. I wanted to know if there were bulges showing or some unsightly side effect. Nope.

    I'm no movie star but I'm wearing scrubs. I even had my mom take a picture.

    It was an awesome moment.

    They were Koi size 5x.

    3...2...1...Remove your jaw from the floor. Wiggle it around to see if it works. All good? Alright let's move on.

    The last time I was able to fit into scrub pants and bottoms was nursing school in 2012. They were 4x but I believe a very generous 4x. I had used black yoga pants with scrub tops for years masking the problem when all I wanted was a smaller derriere and pockets.

    I have come to the conclusion that a nurse needs three things to survive a shift.

    1. Pens. Many, many pens.
    2. Coffee. Lots and lots of coffee.
    3. Pockets. You can never get enough pockets.


    I did everything I mentioned in New Grad No More...Continued including entering, getting through and passing nursing school over 300lbs. It never stopped me from achieving my dreams. But it is keeping me from my optimum health.

    At my heaviest I got to 346. If I sneezed I'd be 350. This was also around the time I landed my dream job. I was 320 when I got in and the stress of being the new kid on the block had me packing to 346.

    I woke up one morning and said aloud. I'm going to die. It's may not be today. It may not be tomorrow but I'm smart enough to know...I'm asking for trouble.

    At work, I'm your short as stilts on a potato and round as I am tall RN ready to meet your every need. I'm knowledgeable. I'm quick. I'm willing to learn what I may not know. I work well with my team and I am passionate about my patients. I dance, I sing, I smile. I work my assets off all night and I go home exhausted at least 36 hours a week.

    I get the job done. I love what I do.

    I have perfect blood pressure, A1C's and labs. I have no disabling pains that prevent me from rolling out of bed and doing what I need to do. I am also very aware of the risks and pitfalls that await me if I continue on in this manner and this weight. My body will eventually turn on me and diabetes drive, hypertension way and bypass avenue are all ahead on my journey.

    I've put my foot down. I'm doing something about it.

    I have been fortunate to have coworkers and managers who saw past my size. They saw my capability. They saw my drive, confidence and attitude. They believed I was worth the position and able to carry through. I have won over my patients and proved that I was able to meet their needs without hesitation.

    And I've lost about 40 lbs since August of this year. I've chosen a sugar free and low carb diet. After years of experience in dieting and gaining it back I have learned that my body responds very well to this combination.

    I still have a long way to go, but I'd like you to walk this journey with me.

    As nurses we are educators. We learn twice as much as we teach and this for me is one heck of a learning curve. I'm looking up and researching what makes weight harder to lose, the proper nutrition to adopt, pitfalls in addiction, exploring obesity as a disease process, how to aid your patient and maybe yourself (and more).

    I think my experience may help others have an insight into obesity and the physiological, psychological and pharmacological implications of this condition.

    The truth is....

    Implementing this knowledge is a lot harder than it looks.

    It's going to be just like my career journey...

    One bite at a time.

    Very soon I will not need to Suck it in and I look forward to it...

    Won't you join me?

  • Nov 12 '16

    Quote from Workitinurfava
    I admire her will to want to be a nurse and not really be a nurse. Too bad she didn't do it the right way.

    Admire.....I do not think it means what you think it means.

  • Sep 18 '16

    Quote from Dianna11
    I've assisted the physicians with the culture, and it is indeed a sterile procedure. Otherwise they wouldn't have special kits for it.
    I've been an ED RN for 8 years. Just because there is a kit doesn't mean it's a sterile procedure. We have lots of kits — IV kits, suture removal, etc., that aren't for sterile procedures.

  • Sep 18 '16

    Quote from Orphan RN
    My BFF (also an RN) had a loop recorder implanted to try to capture a pesky arrhythmia that had been dogging her for years. The last one had scared the crap out of her because her vision telescoped down like she was about to have a LOC (or death). She had also been alone. Although severe while happening, the events occur very infrequently - maybe once or twice a year.

    She was awake for the procedure which was performed via a local. She received no empyric Rx antibiotics pre or post-op, and a number of questionable occurred things before/during/afterward breaking the chain of asepsis that I won't go into.

    When she became febrile on post-op day #2 she returned to her cardiologist's office for a wound check - more bungled things happened I again elect to skip over for brevity's sake. It was now at this point he finally Rx'd an antibiotic. He never got a culture of the drainage - he didn't feel it was necessary.

    Less than 24 hrs later: the incision began to pop open, and she woke up with a huge hot, red patch surrounding the dressing on her chest. It felt like a lit cigarette had been stuffed in next to the device, then sewn back up. When she called her cardiologist's office to tell him how sick she felt and to share some of her concerns he dismissed and poo-pooed her. Already feeling like death warmed over, she began to cry because he continued blowing her off - instead of applying empathy to a frightened pt, he unkindly suggested she "do something about her anxiety".

    He also snottily claimed the device would never work it's way out.

    The following morning her PCP referred her to the ER - she was admitted.

    The incision had dehisced, the device nearly extruded itself, and she started oozing yellow purulent drainage from the site. She had a pocket of foul smelling pus surrounding the device after less than a week S/P insertion that smelled like an exhumed coffin. She became septic - her blood cultures were positive for staph. Oh, did I mention the culture of the incision site came back positive for MRSA?

    She just came home yesterday from a 5 day hospital stay with a PICC line and vanco infusions (which look pretty cool - like small balls).

    Now her dance card for the next month or so is occupied with numerous MD appts (cardiology, infectious disease, wound care, et. al).

    Could all this have been avoided had the MD just listened to my BFF's concerns and acted sooner? Or maybe if he had he done a whole lot of things differently before/during/after making that first incision? Dunno, but it certainly couldn't have hurt though.

    This is a slightly different scenario than your average, garden variety I&D, however it makes me believe one can never to "too sterile" while performing any invasive procedures.

    And just for the record: If it were me or my son, I'd prefer sterile gloves - please and thank you.


    The good news? After reading the device an "event" had been captured and recorded in less than a week after insertion!

    Comparing imbedded hardware closed with sutures to an I&D of an encapsulated abscess that is left open to drain is apples and oranges.

  • Apr 26 '14

    Old-school RN here. Studied for Boards (before they were called NCLEX) while traveling West in a wagon train, fighting dinosaurs along the way. Cut my teeth in several ICUs, when Swan-Ganz catheters were becoming all the rage. Have seen trends and treatments come and go, the pendulum of nursing practice swing first one way then the other way.

    Background: I worked in IR (Interventional Radiology, which included staffing the Cardiac Cath Lab) for 21 years. Most recently (past 10 years) I work exclusively in Cardiology: Cath Lab, Stress Lab and Cardiology Case Management.

    Current Issue: Two recent encounters blew dust off a few dendrites, and got me wondering about the practice of transporting cardiac patients from either the ICU or tele unit to various procedure areas.

    Encounter One:

    Patient with NSTEMI (non-ST-elevated MI, the "less" dangerous form of MI) and +chest pain in the past 24 hours arrived via bed to our Cath Lab. He is not on a cardiac monitor. Say what???

    Repeat: He is not on a cardiac monitor. His accompanying nurse reported "the doctor said he could go unmonitored."


    Waiting for my next patient to enter the Stress Lab, I heard a familiar beep-beep-beep and turned toward the door expecting to see a gurney roll through, patient attached to the monitor, RN in attendance.

    What rolled through the door: Nuclear Med tech pushing a wheelchair, on which sits a patient with the transport monitor in his lap. Beep-beep-beep. No RN.

    My question: WHO is monitoring the patient???

    And now I ask you, gentle readers:

    1. Do you know your OFFICIAL hospital policy regarding transporting cardiac patients (or any ICU or telemetry patient, for that matter) off the unit for procedures?
    2. How old is the policy?
    3. Is it reasonable, sensible and sustainable (i.e., is there sufficient trained staff to accompany a monitored patient off the unit for two hours, while other nurses cover the transport nurse's patients)?
    4. Do ALL tele patients and ICU patients require RN attendance and monitoring for transport for procedures?
    5. Is it time for re-evaluation of said policy?

    I offer food for thought in the form of four articles my newly-dusted dendrites found when I did an online search for "monitoring patients going off the unit."

    First is a short thread from our own, in which members describe a wide range of policies and how they are implemented: Transporting Telemetry Patients off the unit - page 2

    Next I found a 2004 article - a statement of practice guidelines! - from the American Heart Association: Practice Standards for Electrocardiographic Monitoring in Hospital Settings

    (make some popcorn and settle down for serious reading with this one)

    Patients are divided into three classifications according to diagnosis and condition, to determine the need for monitoring. Lots to consider and ponder.

    I was pleased the website search revealed a wonderful small article outlining how one facility empowered nurses to formulate an algorithm to use that "enables safe patient transport without an RN or monitoring."

    The article is written by Nancy J. Mayer, MBA, BSN, RN, and published in the AJN Nov 2009. The algorithm is simple to use, takes a lot of guesswork out of the decision-making and requires a second nurse's (usually the charge nurse) approval for the transport plan.

    Look up Transporting Telemetry Patients -Aligning Forces for Quality (pdf)

    And finally, a short article about, well, exactly what the title says:
    Telemetry monitoring during transport of low-risk chest pain patients from the emergency department: is it necessary?

    Targeted mainly for patients being transported from the ED to a tele or ICU unit, this is a thoughtful study. Lots of ideas here.

    Oh, and the encounters I described earlier?

    Encounter One:

    I respectfully requested the nurse re-evaluate each transport situation. Patient with NSTEMI and chest pain within 24 hours who is going to the Cath Lab (which means, we don't yet know for sure the extent of coronary disease but he just had an MI, so it is quite possible he has cardiac disease!), no matter what the MD writes --- I will transport him on a cardiac monitor!

    Encounter Two:

    Think about it: Yes the patient was sent on a monitor. However, is sending the patient on a monitor, without an RN in attendance to watch the monitor, really carrying through with the intent of the policy of monitoring a patient during transport? IMO,either send him on a monitor with an RN or obtain an MD order to transport without monitoring.

    Ah, my old dendrites are tired now. Hopefully your patients who need watching (to paraphrase the Bard, [mis-]quoted in the article title) "must not unwatch'd go."

    Thank you for your attention, and I wish your patients EXCELLENT care!

  • Feb 16 '14

    One of my fellow nurses- let's call her Jane- was overheard complaining loudly this morning. She had received feedback from a physician that one of her chart notes was "unacceptable." She went on to say that she didn't understand why her note was unacceptable. I asked Jane to read aloud the note in question:

    "Patient was inappropriate."

    "What's wrong with that?" she asked, explaining that this particular patient had been rude the day before, yelling that it took too long for Jane to retrieve her narcotic prescription. The patient had, apparently, shouted a few choice words at this nurse while exhibiting some threatening behaviors.

    Jane's documentation, however, did not reflect that.

    As nurses, we need to chart specifics, and we also need to be objective. This is straightforward when we are describing, say, a wound that can be measured with a ruler, or a patient's report of pain as "burning in nature rated at a '6' on a 1-10 scale." But when it comes to behaviors, things get a little more difficult. A patient's wrath can evoke a negative response within the nurse that makes it difficult for him or her to remain impartial. Also, nurses may lack the precise vocabulary to explain the event.

    Jane told me that she had felt threatened by this patient, describing her as angry and inappropriate.

    "Okay, Jane," I said, "what specifically did the patient do or say that made you think she was angry?"

    "She started yelling. She was talking loud and fast."

    "So you could chart that the patient's speech became louder and faster. What did she yell at you?"

    Jane repeated some choice four-letter words that had been addressed to her.

    "Great, I would have charted those verbatim. Use quotes. What about her stance? Did she get closer to you, point, stiffen up? What gestures did she use? Did she threaten you?"

    Remember that the chart is a legal document and, as such, can be considered evidence. An accurate, unambiguous description of behavior, statements, stance, and gestures will stand on its own in a chart review. If you ever need to testify in court, the specific words will speak for themselves.

    The same goes for what patients say over the phone if you are a telephonic nurse: chart specific words in quotes, tone of voice, or change in tone if that occurs. If words are slurred, chart that.

    Don't use subjective words such as agitated, upset, verbally abusive, aggressive, angry, or, as Jane did, inappropriate. These are ill-chosen because they are interpretations of behavior, not precise narrative; being subjective interpretations, they mean different things to different people. Instead, chart specific behavior, actions, and appearance. Some examples are:

    • Pacing
    • Clenching fists or jaw
    • Reddening of the face
    • Trembling of face or body
    • Stiffening of body
    • Sudden movements
    • Changes in vocalizations such as voice becoming louder or faster
    • Approaching or touching the writer or other staff

    Use exact quotes whenever possible, including any obscene or threatening language that was used. One of our allnurses members, Meriwhen- an experienced psych nurse- is clear and unapologetic about this: "I've written out, in unedited and exquisite detail, the most profane things that patients have said...if they're addressing me and/or I hear them being verbally aggressive to others, they will get quoted verbatim. And I never asterisk/ampersand anything out, not even the really bad words.... As they were making threatening statements to us, I documented it all word for word" (Meriwhen, 2013).

    After our discussion, Jane was able to compose the following thorough, specific, professional late entry note about the encounter:
    "Patient stated 'It took you too darn long to bring me this prescription.' Patients voice became louder and faster. Patient stepped within 12 inches of this writer and pointed finger in face. 'Tell Dr. Smith that he's a terrible doctor! I'm never waiting this long again!' Patient declined offer to speak with clinic manager and left building without further incident."
    May your documentation, likewise, always be descriptive, specific, and accurate, and may your patients always be cooperative.


    Buppert, C (2012). Nurses: What Is the Most Important Documentation Advice? Medscape Nurses. Retrieved from Medscape: Medscape Access
    Meriwhen (2013). Retrieved from
    (no author). Chart Smart: Documenting a patient's violent behavior. Retrieved from

  • Feb 16 '14

    When I first started in our emergency department night shift, I noticed that the 2-3 students were largely ignored for the first half hour or so during shift change. They stood nervously by the desks, repeatedly adjusting their coats and book bags with a look of "please tell me what to do!" on their faces.

    I looked around at the day shift staff, busily getting report on the sick, critical, violent, or the repeat pts that they will be taking over on, so busy that having to explain things to students was just not possible at that moment.

    So I took over and made a whole structure for them which was heartily accepted by my coworkers. On student days, I try to wrap things up early and give a quick orientation. I give a few tips on NCLEX, on how to stay cool in crazy situations, and what to expect for the day, and what to do when an ambulance arrives with a pt. Then I pair people up with the most patient, coolest and toughest 20+ year vets and go home. I usually get told how the students did when I get back to work that night. It's almost always great news. The evening students are always paired with me.

    When it hits the fan at the wrong moment, I still have been able to get them in on mega-codes, help ortho MDs reset bones, start CPR, explain the critical nature of XYZ patient, and why that walking/talking pt will be sent to the ICU. Even with varying degrees of receptiveness, students have almost always been amazingly well mannered and willing to dig in. Except once.

    One day last semester, a pair of students came down and I noticed increasing amounts of boredom/irritation as I went through my (now well practiced and tailored) orientation when I was interrupted in my talk about megacodes.

    "I don't want to see that, and I definitely don't want to DO that. Just tell me where to stand while they do whatever they have to do and I'll wait until it's all over," she said dismissively.

    I was floored. I asked her if she had intention to work as a nurse. She answered that she did, but not in any situation where she would have to do anything dirty or see blood. In fact, she planned to get her NP as soon as possible so she could just write orders and walk away. Her friend agreed.

    When I asked her why she was in the E.R. rotation, she said that it was only because she had been assigned to it. I could only think about the other students who would have loved to be there and what a waste of everyone's time it was for her to have even been there at all. I couldn't help but think of what a waste of time it was for me to have just spent the last 20 minutes telling them anything at all since it had clearly been thrown away before I even spoke.

    To tell you the truth, I was completely upset. I remained upset for almost a week. I spoke to my coworkers who said that many times they will avoid having a student because of that very attitude. I ended up going home and thinking that I didn't know if all students secretly felt that way. If so, why was I putting so much effort into them?

    Just before the winter break, I spoke to an instructor and asked her opinion. She gave me great news. It was this, "Just send them back to their instructors and pop an email to the school."

    Huh. So with the semester ending, I dug back into work and stopped thinking about it.

    This semester the students started to arrive again. I watched them stand a fidget for a moment before my instincts took over and I started to cautiously orient them. My fears were immediately dissolved when one asked "Do you think we might get to do CPR?"

    Thank God for the kind of students I look forward to seeing in my department.

  • Feb 16 '14

    Quote from Jackson County EMS to GWER
    We are inbound to your facility with two patients involved in a MVC with multiple injuries...
    The nurses took report on both patients and prepared the trauma bays for a couple in their 80's who had been T-boned when the husband pulled into an intersection. No current life threatening emergencies were reported. Each patient was assessed and stabilized. A recurring theme was each spouse asking about the other spouse.

    After the hustle and bustled settled down we reassured each patient that their spouse was fine. We opened the curtain separating their rooms and informed them that they were right beside each other and they could talk to one another. They could not see one another because they were secured to backboards and unable to turn their heads to the side but they could hear one another. The wife wanted me to know her husband had a blood pressure problem......oh dear she couldn't remember the name of the medicine he was on. The husband told me how they had been married for 60 years and I could see the sparkle of love in his eyes.

    As time went on and test results returned it was decided that the wife had an injury that required her to be shipped to a Level 1 trauma center. The doctor informed the couple of the care decisions he felt were necessary. I began to see fear and worry in the husband's eyes. That is when I jumped into gear of getting the portable heart monitor. I connected the husband to the monitor and moved his IV pole and bed right beside his wife's bed. I put his left bed rail down and her right bed rail down. I told them that if they just reached out they would be able to feel each other's hands. They reached out and found each other's hands and held on tight.

    They talked and reassured each other it would all be okay. They told each other they loved them. The husband told her as soon as he could find someone to drive him to the other hospital he would be there. The doctor told the wife it would be best if her husband stayed all night for just one night to be observed and make sure he was okay. The husband didn't want to but the wife encouraged him that he could see her tomorrow.

    The helicopter crew came and the beds had to be separated after a final hand squeeze and I love you. The Mrs. was loaded and transported to the other hospital while the husband was admitted for overnight observation.

    The next day I came to work I found out the wife had died that night from her injuries. I was heartbroken for this lovely couple. As I reflected, I was so thankful that I had taken the time to connect the portable equipment and rearrange the beds and allow them to hold hands.

    Many times we are too rushed in the ER to make time for the important things in life. And what was more important at this point in time? To hold hands for the very last time...

  • Feb 16 '14

    If the faculty knows who they are they can check their answer sheets to see if they all match, too. I like the "There's a lot of whispering and page rattling in the back row-- it's so distracting. Could you please ask them to stop?" approach.