mi_dreamin

I was addressing the sentiment that people who test positive somehow don't care about anyone or anything but themselves.

Most of the people I know who have tested positive did "all the right things" and still got it. You cannot stop a virus.

When I worked the floor I usually looked at my pt's labs/admission note, and any test results once I knew they were coming. It took me 5 minutes and then I knew what questions to ask, e.g. I see ancef was ordered, was it given? I think that would be my concern with no face-to-face or verbal contact. I don't need to know the whole story, but there was almost always something that wasn't documented in the EMR that I needed to know. Otherwise I wouldn't have minded no formal report.

Placing IVs and getting that first set of labs, cervical exams, especially when there is progress ?, placing Foley's (in females) so satisfying to see that urine in the tube ?

As long as we have met our per diem (0.60, 0.90, etc.) we are offered CN1 (critical need 1) which is time and a half plus $10/hour or CN2 which is time and a half plus $20/hour. At our main campus they almost always offer CN2 versus CN1 and usually with a lump sum incentive, for example, CN2+125 would be your base rate x1.5 +20/hour, +$125. If you are in overtime it is time and a half plus time and a half. I would not be incentivised to come in for and additional$2/hour ?

I definitely appreciate all of your feedback. I guess the thing about it for me is that they weren't calling it anything, not a stroke, not encephalopathy, just, "her brain is fried." They provided no treatment beyond some fluids. I guess I just wanted to know if what happened sounds like a reasonable series of events considering the facts as presented. Unfortunately I cannot talk to the providers involved, which is why I wanted some insight into why things may have happened the way they did. Thank you to everyone who replied, you gave me food for thought!

I'm not disagreeing with you, however, based on our protocol they should have at least done a stroke assessment and then modifieds Q4H. I do know for a fact that she had a decline in function. I'm not even saying she was a candidate for tpa at the time of presentation, I'm just saying that it seems like somebody should have done more for her.

No MRI was ordered. We called MD to bedside immediately but no stroke alert was called d/t being outside tpa window. MD ordered aspirin supository and said she needed an MRI in the morning. We did the initial NIHSS as none had been done. Beyond that I don't know what they ordered for her. I assume she just laid in the ED before coming to the floor. I didn't personally speak to the ED nurse but it sounds like basically nothing happened, which is what is so upsetting. It sounds like she had progressive loss of function in addition to positive head CT and they did nothing for ten hours then sent her to the floor. She wasn't assigned as my patient but I did put in an incident report and we called our director (our manager didn't answer).

I encountered a situation on the floor this week that made me angry but I don't want to form a judgement without a better understanding of why and how this happened. So with that being said, let me hear your perspective (especially ED nurses!) 38 year old female with known hx substance abuse presented to ED around 15:00, UDS positive for methamphetamines and cocaine. Functional ability at this time unclear but between 15:00 and 19:00 she pulled out her IV and the physician said okay to not replace it. 17:51 head CT is completed and read, impression acute- sub-acute infarct, MRI recommended. 00:57 ED RN calls report to floor nurse, states they were going to send pt home but she wasn't able to get up and walk. Floor nurse asks about head CT, ED nurse replies something along the lines of, "her brain is fried from drugs." 01:30 pt arrives to floor. Right arm is drawn up, pt lethargic, makes no meaningful vocalizations, minimally responsive. Right eye is unresponsive to visual exam. NIHSS score is 30. Help me understand. How did this happen? We're the nurses just burnt out? Did they miss the symptoms and decline because they weren't looking for it? Help me come to terms with this ?

^What she said. Also, their meeting doesn't necessarily mean your preceptor "threw you under the bus." What you are describing sounds like an error that requires an official report. Where I work an incident report goes to your manager who addresses the incident with the appropriate parties. Since you are still in orientation it makes sense they talked to your preceptor first to get her take on what happened and evaluate your progress. I am not saying she didn't make comments that sparked the concern, however, as someone who has precepted new grads and even seasoned nurses in a new specialty, I can tell you that it is easy to vent about someone who is new and slow(er) and doesn't have the hang of everything yet, even if you think they are doing a great job. All that is to say don't automatically assume that she is out to get you - that attitude will color all your interactions and take your focus off of what it is you are supposed to be doing, learning how to be a labor and delivery nurse. Focus on learning, volunteer to start other people's IVs/draw labs. Be your own cheerleader when you do something right and when you do something wrong ask for feedback, "what can I do differently so that doesn't happen again?" Mostly don't panic, nobody is perfect, do freak out when you're not. You can do this ?

Where I work nightshift can definitely be steady but tends to be much less busy and demanding. I am primarily dayshift but like to pick up nights because it is more money and less work ?‍♀️There are actually several open day shift positions on my unit but none of the nightshift RNs will come to days because it is so much more busy and a lot more work (their words). You have to realize, on day shift you are doing 2, 3, sometimes 4 or more med passes as the docs add orders, coordinating procedures/therapy/meals, talking to family members, planning care with social work/docs, discharge planning/teaching/coordination, in addition to the things that all shifts do - call lights, admissions, patient care, charting, etc. Night shift can be hectic, emergencies harder to deal with, and 04:00 can feel like a nightmare, but overall it is less demanding than dayshift (on my unit anyway). It seems to me that the worst part of nightshift is the toll it takes on your body/circadian rhythm/ social-emotional health. My aunt worked nightshift for 5(?) years and always talked about how it was still busy even though it was night and people don't sleep. Then she came to days and realized what a HUGE difference it is. Just my 0.02¢.

If not in a pain crisis pt can switch to SL meds, oxycodone and morphine are often given sublingually in patients who cannot swallow, unconscious patients included. The provider may also add a fentanyl patch for continuous release of pain medication. SL meds are absorbed through the mucous membranes and usually work faster than PO and last longer than IV. FWIW, this is based on my experience with inpatient hospice care.

Among my favorites: Pt grabbed scissors, held them up and loudly stated, " I want to see the son-of-a-***** who put those orders in!" Dr. Do-Nothing made aware. Pt pushed sitter and ran into hallway, stated loudly, "I'm not ashamed, do you wanna see em!? Do you wanna see my *****!?I'll show you!" Security present. Pt educated that SpO2 was too low to remove BiPAP and eat. Pt stated, "there has to be some compromise, it can't be all **** me, **** me **** me!" Pt then turned to face the window and refused to engage in further communication at this time. Will continue to monitor. (Sorry for the * bomb, I couldn't leave this one out and that's what he said) Staff responded to pt's bed alarm. Pt stated she wanted to know who stole her whole lady parts. Genitalia intact upon assessment, will continue to monitor. Pts heparin gtt turned off and left off by nightshift RN. Dr. Know-it-All made aware, states, "what do you want me to do about it? Ask the pharmacy, just follow the policy." Heparin gtt resumed. And 3 of my favorite admitting diagnoses ever: "Fell ill" "Probably sick" "I got pergernant" (That's not a typo)

In this specific circumstance I would have educated the family regarding the dying process and asked the provider for comfort meds; roxanol, oxycodone SL, atropine SL, scopalamine patch, ativan, haldol, etc. A rapid response is for patient's whose plan of care is not strictly comfort care. That is why communicating with the family first is so important. Maybe they feel something else should be done besides strictly comfort care, maybe they need the provider to come and educate them that the patient is imminent and nothing will change that. We have called a rapid on a patient whose plan of care was hospice but that was only because when the patient was suddenly declining very rapidly (not unexpected) the family panicked and wanted everything done. That patient went to ICU only to come back to our floor and pass the next day. Communicating with and educating the family is one of the most important parts of hospice care.

Oh my! I wouldn't want that! ? ?