Latest Comments by patwil73

patwil73 4,287 Views

Joined: Sep 17, '05; Posts: 265 (43% Liked) ; Likes: 254

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  • 1
    fiveofpeep likes this.

    Quote from fiveofpeep
    For someone working nights, how would you recommend I accomplish this. I definitely dont think it prudent to call over inconsequential med holds in the middle of the night, but I wont be seeing them before I leave. Do you just trust that acknowledging it in the chart is enough?
    We have a doctor communication sheet in front of the order section in our charts. Nurses can relay concerns or questions there. For a held med we would document a prog note and then write a communication note if we wanted a change or clarification. Also our medication charting is computerized so if we hold a med it literally says on the screen "Med held" and then gives the reason - so the doctor perusing the charting will know why we held it.

    As long as you somehow document why you held it, and the matter is not urgent (colace at night for example) then that should be sufficient.

    Hope this helps

    Pat

  • 3
    silverbat, kathy313, and fiveofpeep like this.

    Your judgement was exactly right and unfortunately the one who was supposed to be teaching you was wrong. The decision to hold a bp medication should be done based on pt condition and history and "not" because it might make them fall out of normal range.

    For example - if your patient was a liver/renal disease pt who presented with new onset HTN, and was given metoprolol to bring it down - and you noticed a steady decline in the SBP - you could hold the meds and call the doctor with your concerns - namely that you feel the medication is not being cleared fast enough and that it is having a cumulative effect.

    However, if the patient normally suffers from HTN and his BP is 120-130's with his medication - why would we hold it? Unless we want his blood pressure to go up.

    Also never sign any charting that you don't agree with, unless it is something you did - you could sign you held the bp meds (because you did), but don't sign for low bp (since you don't agree with that). As the poster above mentioned - this is a legal document and can be used in court. It is much easier to answer questions about your documentation if you at least agree with what you said.

    Hope this helps

    Pat

  • 0

    A pharmacy that apparently makes injectable version: http://www.sgpharma.com/company/mainexplist.htm

    Also here: http://www.ncbi.nlm.nih.gov/pubmed/17720114

    Which indicates it is used in England but not North America - and comes in 75mg dosage. In my micromedix the oral dose seems to have some nasty side affects, but I am not sure how that would translate to the IV form or what would constitute an overdose - everything I have read so far seems to indicate 75mg as being standard.

    Hope that helps

    Pat

  • 0

    Quote from jistravel
    I am a first semester nursing student and during clinicals was looking at a patients chart. I know my patient had a laparoscopy and one day later was receiving morphine IV. I think it was written in the chart Nacl 0.9% 240 mg + morphine 250 mg IV. On the IV bag, it said 100 ml/hr. Can some help me decipher this? Does this seem right or did I missread? I am just trying to understand this for myself and not going to use this for anything else. I have not started on administering medications or IVs yet. What would be a realistic post surgery Morphine, Nacl, gtt/hour?

    Thanks again
    By chance did it read NaCl 0.9% 240ml + MgSO4 250mg? That would be magnesium added to the IV fluid solution which seems a lot more likely than her receiving 100mg of morphine an hour. Also a good reason why we should not use abbreviations as MgSO4 can look a lot like MSO4.

    You can receive magnesium for a potentially lethal rhythm problem called Torsades de Pointes, or because your level is just low, or if the patient was also pregnant it can be used to help treat pre-eclampsia, although in that case the woman is usually a 1:1 nursing care. In both Torsades and Pre-eclampsia though the dose is often much higher - anywhere from 1-4gm. I don't know if I have ever come across someone receiving only 1/4 gram of Magnesium.

    Of course if you missed a decimal and flipped an abbreviation it could read MgSO4 2.5gm which would equal out to 1.25 gms an hour which is within the guidelines for a continuous dose.

    Hope this helps

    Pat

  • 1
    morte likes this.

    Quote from Reno1978
    I don't think that is correct. When I hung TPN preparations that included lipids in the solution, we used an in-line filter and they made their merry way to the patient.
    Could be a bigger filter. The 2nd source I quoted before said for TPN alone it is a 0.2 micron filter, whereas if you filter both it is a 1.2 micron filter.

    Pat

  • 1
    ellakate likes this.

    Quote from centexRN
    Help! How do we get families to work with us for the best patient outcomes?
    The long answer is you carefully assess your family to determine their skill level, knowledge level, comfort level, and willingness to engage in the practice necessary. You have to determine if they are in a place of enough comfort to be able to understand the directions you are giving and to comprehend the reasoning behind them. We have to understand that they might be scared, overwhelmed with other life problems, angry - and we have to be able to get past all that in order for effective teaching to take place.

    Once we have we need to teach at their level. We need to find alternate ways to teach that get the idea across when our first attempts fail. We have to be willing to let them try and fail and to keep coming back with support and reinforcement.

    Finally we have to understand that they are not professionals and probably will never do it just like we would - and that is ok.


    The short answer is we may not.

    Hope that helps

    Pat

  • 0

    Quote from peachpower
    So, quickly, a history of what has brought this topic about-

    I'm in clinicals, and I made the egregious misake of asking my instructor this question:

    "WHY DO THEY HANG LIPIDS SEPARATELY FROM ELECTROLYTES IN TPN??"

    I was told to look it up, found no satisfactory answer and had nothing to present in post-conference. Due to that bit of insubordination (???), I now have a 2 page paper due TOMORROW, and have yet to nail a black and white answer. I will truly appreciate any help I can get. I am terrified that I will not have this done.... Please share any and all information that you guys have.
    My guess is your instructor did not know, and hence had you do the research. I know they used to hang seperately but now I almost always see them hung in 1 bag. However, in the past it might have been to either more accurately measure how much lipids you are getting or to monitor for adverse reaction to the lipids.

    I found this website:

    http://www.merck.com/mmpe/sec01/ch003/ch003c.html

    which includes a section:

    Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea, headache, back pain, sweating, dizziness) are uncommon but may occur early, particularly if lipids are given at > 1.0 kcal/ kg/h. Temporary hyperlipidemia may occur, particularly in patients with kidney or liver failure; treatment is usually not required. Delayed adverse reactions to lipid emulsions include hepatomegaly, mild elevation of liver enzymes, splenomegaly, thrombocytopenia, leukopenia, and, especially in premature infants with respiratory distress syndrome, pulmonary function abnormalities. Temporarily or permanently slowing or stopping lipid emulsion infusion may prevent or minimize these adverse reactions.
    So when one of those reactions do occur - it can be harder to stop a combined bag that you need for other nutrition than to stop an individual lipid container.


    You might also check out:

    http://www.ceufast.com/courses/viewcourse.asp?id=180


    Not sure how you will get two pages out of that - but good luck.

    Hope this helps

    Pat

  • 0

    Quote from Vtachy1
    I thought I remembered in nursing school that we diurese at night. I know that the fluid moves from your vascular space at night and then in the morning it moves back to your blood vessels and causes increased blood pressure right? OR do I have it all wrong, its been 20 years ago!
    Usually we want to diurese in the morning so the person is awake when they have to keep getting up and going to the bathroom. Doing it at night would keep them from getting any sleep.

    Of course sometimes we have to do both and if they have a foley it can make sleeping easier.

    I have never heard of fluid moving out of your vascular space at night and then back in. Fluid should stay in the vascular space unless you have damaged vessels or an electrolyte imbalance that causes a fluid shift. People usually have a higher blood pressure during the day because they are more active and stressed. During sleep everything tends to relax including the smooth muscles which leads to dilation of the arteries, or lower blood pressure (this is not 100% happens everytime, but more of a general trend).

    Hope this helps

    Pat

  • 0

    Congratulations - I graduated there in 2001, so I might not have the most up to date experiences from there. As I recall class size started at about 20 and we had 5 at the end.

    We did Long Term Care the first 2 quarters then on to St. John's for most of the rest - except 6th quarter which was partially pysch.

    Some of my experiences - 2nd quarter was the toughest as we did diseases - and everything seemed to have the same symptoms. I also had a lot of trouble that quarter with the medications trying to keep it all straight (I had no medical background going in - so if you are like me, get a drug book early and just start reading it a bit each night).

    Take advantage of the skill labs to practice your skills and always volunteer for procedures in the hospital - the more experiences you get the more comfortable you will feel.

    All the clinical areas were nice to work in - they mostly made you feel welcome and helped out as they could. But be prepared when you go in, because you will get grilled on your knowledge. I tried to memorize everything which I don't think was the best plan - instead try to organize your patient knowledge from general to specific (such as airway/breathing to COPD to using oxygen to needing more rest during activity to using medications such as albuterol/atrovent or lasix). Note how yu can take a general area, list their diseasee process, what that means to them, what you need to be aware of, and what they take for it).

    Also try to make a lot of connections between the different pieces of knowledge you have - it will make things easier to remember if you have more than one way to get at it?

    For example a person is in for infection. They have a history of hypertension, congestive heart failure, and atrial fib. They have been vomiting and had diarrhea for the past 4 days. So the infection leads to a high WBC and temp which is the bodies way of making it easier to fight the infection. Vomiting and diarrhea lead to fluid loss or dehydration - to help it we replace it with more fluids usually IV. Too much fluids can overload the heart, especially in CHF so we give lasix to help remove the fluid. If we don't do it quickly enough the person can have breathing difficulties from fluid overload which can stress the heart and cause the afib to increase in rate which leads back to the heart not pumping effectively enough to remove the fluid which makes it more difficult to breathe. So because they are getting sicker we tell them to stay in bed and place a foley to help drain the fluid away. The foley is a prime spot for infection to enter the body and without scrupulous care, they get another infection from the foley which leads to elevated WBC and temp and off we go again.

    So when researching your patient try to make a flow chart and diagram how one thing can lead to another or impact another.

    Finally when you go in to take care of a patient - ask yourself what is everything that I might need when I walk in that room and make sure you bring it - try to anticipate what your patient might want so you are not always running out to grab something you need.

    Hope all this helps - it is a lot of fun to be a nurse. Good luck.

    Pat

  • 0

    This was in ICU where unfortunately we do not have a written policy on having central lines with specific drugs - even though we know we should. No one in the hospital other than ED and Anesthesia is trained in EJ's (although I have asked to be) so I couldn't go there. Anesthesia was in surgery (this at night with only 1 on) and the hospitalist was not comfortable due to training to put in a central line.

    What I would like is a policy that states if you get this drug (dopamine, levophed, etc) you must order a central line and have it placed prior to start (unless an absolute emergency). Also if it requires more than 2 pokes for 2 consecutive blood draws due to poor venous access or you lose an IV in under 24 hours due to poor venous access you get a central line. However, we are not there yet.

    Do you know of any reason why one can't use a surface chest vein? Any literature out there that says they can't be used?

    Thanks for your reply

    Pat

  • 0

    Hello everyone - I posted this in the IV/Infusion group but it doesn't seem to get much traffic so I though I would repost here and see if I could get a few more views.

    Original Post Follows:

    I am looking for some guidelines on acceptable IV insertion spots and the dangers of using subprime areas - such as legs, shoulders, chest. Are their any places that are simply unacceptable to use and why? Finally if someone could point me to some best practice research that would be wonderful.

    This case came up this weekend, where a patient had been poked around 7 times before I was called and I simply could not find an IV spot on her arms due to gross edema and cellulitis. Unfortunately she was dependent on levophed and upon arrival it had infiltrated into her wrist. The only spot I could find was the chest which had a great vein (surface) strong blood return, and flushing had the feel of fluid upstream from the insertion with no sign of infiltration. I wish I had someone who could put in a central line but no one was willing to do so.

    I know it is not a good spot to place an IV, but the situation to me was a bit desperate and I truly could not see another spot (I tried in two others that both blew due to being spider fragile veins - and those were the only two I could see, which normally I would never have put an IV in except for the situation).

    So if I could find some literature, perhaps we could revise our policy to push doctors to place central lines more often in cases where we lose IV's every 6hrs or where the only insertion site is a suboptimal space.

    Thanks for any help you can provide
    __________________________________________________ ________________________________________________

    I did get one response to look at the Infusion Nurses Society - but their website does not provide the guidelines (although you can buy the book from them). I found a copy of Core Curriculum for Infusion Nursing which outlines what veins should be used (and although it provides rationals for their use, it does not talk about the use of chest veins).

    To me it seems a lot like the scalp vein of an infant. It does lie over the bony ribs and sternum. It is not dependent so that should minimize the risk of blood pooling - particularly in a continuous infusion.

    So any answers out there as to why we should never use chest veins?

    Thanks in advance

    Pat

  • 0

    Thank you so much for your reply.

    I found a copy of Core Curriculum for Infusion Nursing at my hospital which does outline the veins that should be used in IV therapy - which are essentially the ones you see used most often. However it doesn't even mention the use of surface chest veins which leads me to ask - is there any research out there on the functionality and acceptability of their use?

    To me it seems a lot like the scalp vein of an infant. It does lie over the bony ribs and sternum. It is not dependent so that should minimize the risk of blood pooling - particularly in a continuous infusion.

    Now I am not arguing that we should jump right to this vein, but I am wondering if there has been any study done showing that it has a greater risk of complications and/or has it even been studied since it use is probably very rare?

    Once again thank you for your time - and please know I am not arguing just to be argumentative, but I have this innate desire to know the reasoning behind things - instead of being told that you simply can't do it.

    Pat

  • 0

    Hello everyone,

    I am looking for some guidelines on acceptable IV insertion spots and the dangers of using subprime areas - such as legs, shoulders, chest. Are their any places that are simply unacceptable to use and why? Finally if someone could point me to some best practice research that would be wonderful.

    This case came up this weekend, where a patient had been poked around 7 times before I was called and I simply could not find an IV spot on her arms due to gross edema and cellulitis. Unfortunately she was dependent on levophed and upon arrival it had infiltrated into her wrist. The only spot I could find was the chest which had a great vein (surface) strong blood return, and flushing had the feel of fluid upstream from the insertion with no sign of infiltration. I wish I had someone who could put in a central line but no one was willing to do so.

    I know it is not a good spot to place an IV, but the situation to me was a bit desperate and I truly could not see another spot (I tried in two others that both blew due to being spider fragile veins - and those were the only two I could see, which normally I would never have put an IV in except for the situation).

    So if I could find some literature, perhaps we could revise our policy to push doctors to place central lines more often in cases where we lose IV's every 6hrs or where the only insertion site is a suboptimal space.

    Thanks for any help you can provide

    Pat

  • 3

    To answer your question, it is helpful to remember that autonomy is almost a fundamental principal of healthcare. People have the right to make their own decisions regarding what care they want and don't want. However, when you lose the capacity to make informed decisions, you also lose your autonomy.

    In this case, the woman when she became delirious, lost her right to make her own decisions regarding care. Now if she had an advance directive written that would take over - since that is the purpose of them. In the absence of an advance directive, it would come down to whoever had the legal right to make decisions for her.

    Without and family involvement, the first person to make decisions would be the doctor. If the patient happened to survive the night and still no family could be found, then the hospital would begin the process of getting her a guardianship that would make those decisions for her - unless she regained the ability to make her own decisions.

    If the doctor knew of her prior wishes he might very well hold off on giving her chemo (he might also just because it could be useless at this stage), but in the absence of an advanced directive most physicians would probably treat her as full care - even knowing her wishes since to do otherwise could be a legal nightmare.

    So yes it can be medically indicated to treat pnuemonia in someone dying of cancer - and it could prolong her life uncomfortably. This is why having an advanced directive available and family who understand and will support your wishes is so important.

    Hope this helps

    Pat

  • 0

    Quote from jadavis
    I have to do a speech on how allergies, health history and current health affect drug administration? I am not sure where to find this info. I hope that someone can help a nursing student out.

    Thanks,
    Jennifer
    In most good drug books you will find all this information.

    For instance is the patient allergic to sulfa drugs - well the drug book will tell you if the medication is in the sulfa class.

    The book will also give you a list of contraindications - or instances not to use the drug and precautions - or instances to be careful of giving the drug. Now take those and look at the health history. For instance dilaudid (extended release) is contraindicated in bronchial asthma.

    Finally the drug book will give you adverse affects. If the drug causes hypotension and their current health is they are hypotensive - you might want to think about holding the medication. Of course you have to determine if the primary reason you are giving the drug is more important than the adverse affect it may cause. Lasix can lower the blood pressure, but many doctors will still want it given if the person is suffering from severe CHF.

    You can also see how the drug is supplied and determine if their current health allows for that administration. A patient with a severe stroke may not be able to swallow a pill - so medication should be changed to IV or IM.

    Hope this helps

    Pat


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