psnurse

Well I guess it would depend on who you ask. But since you are asking me, the ER is the only place I want to be. Went to nurse practitioner school to be a ER NP. I worked critical care before coming to the ED but found that the ED is the place that felt the most like "home". If it is ok to call it that. I went on a float the first time and was quite nervous, but everyone was very helpful. I had such a good time that I floated every night until I was eligible to transfer and then I did. I have always found a great team sort of environment. That might have to do with the fact that one doc cannot see the number of patients needing to be seen right away by himself. So there is some reliance on the judgement of the nurses he/she is working with to do what needs to be done. It is not a place for the faint of heart. You will most likely do things and get the order later more than once. But there is one promise I can absolutely make to you...... You will never have exactly the same day twice in a row. Good luck!!

I think it is a great idea. It is already happening. I am sure the AMA is whining about it, but it is happening anyway. I hope to attend one of the programs and have been investigating. What would be wrong with nurse practitioners having increasing autonomy? Many of us practice autonomously anyway and it would eliminate another ball of red tape. I am all for that. Of course, there are then 50 states to be convinced that a completely autonomous practice for NPs is a good idea. That probably would not occur until long after I am too long to run those ED halls.

I have been an ED nurse for awhile and recently started my first NP job in the ED. I don't have great websites, but I did find some really helpful books on the ACEP website. ACLS and PALS is also available these days online. I went to the AANP conference this past summer and they had some good hands on learning sessions such as chest tubes, central lines, arthrocentesis, ect. I love working in the ED and hope you enjoy it as much as I do.

Interesting. I hadn't really thought about this topic until just now. I will finish my MSN for FNP in August 2004. I haven't caught anyone referring to me in any proprietory way. I haven't heard anyone refer to my FNP clinical preceptor in any proprietory way. Her patient's just love her, and a couple apparently think I am ok too because they make their appointments on my days. My second clinical site is in the ED where I am also employed. Everyone is very respectful. My friends tease me about being the doctor today, but that is all that it is. One of the teasers has enrolled in an FNP program and another goes to an info session this month. Perhaps I inspired them in some small way and THAT is truly a compliment.

Should nurses be allowed to strike? Absolutely! This is a personal choice each nurse must make. When the choice is made they must also be prepared to live with the consequences this may cause in their life. You see, I am currently a scab. Not by virtue of working for a company that supplies nurses to hospitals when a nursing strike occurs, but because I continue to cross a picket line where a number of our nurses are on strike. I would do it again. I hear the complaints and I have objectively looked at them. I find the complaints to be invalid. It took almost a year for the complaints to be uniform across all the strikers. Before that it was a collection of personal agendas. The contract proposals are so transparent you can almost tell who suggested them. I listen to the mantra of collective voice and have to chuckle to myself. How in the world is splitting the nursing voice between competing unions a collective nursing voice? It seems almost comical. Besides, the lack of voice is not really the problem I perceive, a lack of knowledge about how to efffectively use the voice nursing has is the root of the problem and not likely to be solved by union tactics. As I said, a nursing strike is in progress where I am employed. From experience, this strike has done more to divide the nursing voice than one could hope to repair in a lifetime. The crux of the matter seems to be union security. Don't laugh they actually admit this. I don't see how this has anything to do with patient care or working conditions or nursing. That issue is purely about the union. The way I see it, the constitution provides for freedom of association, but if the freedom to refrain from association is not also implied, freedom of association itself is a worthless tenet. Good luck as you debate this matter. I have undertaken this as a thesis project.

After 10 years, I still don't do snot. It isn't the trach thing that bothers me, the ET tubes are ok. But let someone actually spit a specimen into a cup and I lose it. This was confirmed the other day in the ED when a patient was coughing on arrival and someone handed him a cup. I looked up and found the snotball sitting there on his lower lip and had to excuse myself gagging all the way. But this is improvement. I used to suction ET tubes and trachs with a trash can at my feet.

Yes diabetic neuropathy causes pain. Sometimes severe pain. Neurontin can be helpful. But if not narcotics are indicated. Research shows that tolerance to narcotics may begin to develop as early as 2 weeks after regular dosing. The sustained release narcotics allow for better pain relief and better functioning during the day. MS Contin 30 mg twice daily isn't an extraordinary dose. The patient will invariably be titrated even higher before it is all said and done. I would suggest a pain clinic if one is available in your area. These practitioners are most helpful to manage chronic pain, such as pain associated with diabetic neuropathy. There seems to be confusion surrounding the ideas of physical dependence (which someone chronically taking narcotics will develop), tolerance (which will also develop with chronic narcotic use), and addiction (which is a physical and psychological phenomenon). This confusion often results in people taking narcs for chronic pain being labeled as addicts. Oops, got up on my soapbox for a minute. I have to add.... How realistic is it to allow tolerance to go this far? Quite realistic.

I am confused about IV push meds and IV certification. Where I live only LPN's are required to have an IV certification. Even after that, they still can't push meds. So if this is the case, the preceptor is requiring something outside the scope of practice which would need to be addressed.

Ok... I have read about writing the reason the provider says you should be off on the excuse. I disagree with this and would require a new note with simply the date I could return and any applicable restrictions. We are bound to uphold confidentiality with regard to our patient's records. Why don't you expect your own medical care to be confidential? The exact nature of interaction with my health care provider is on a need to know basis. Unless I am at the office for a work related reason, my employer doesn't need to know.

The IV Nurses Society is probably where this originated. At least that is where they point when we ask about this policy. And how to tape your IV is a policy where I work. No tape under the transparent dressing. Can chevron outside the transparent dressing. Have no problems with them falling out.

It is worthy to note, we had very few call ins on the weekend. People would come to work half dead to avoid making up the time. Not sure this was the best way to do things, but it was effective.

Where I work now, there is no policy regarding weekend call ins. Sometimes they are a problem. Where I used to work, it was policy that you made up the weekend time. Not necessarily the next weekend, but sometime in the future. The nurse manager kept a list of who called in on what weekend day. She would plug you into the schedule when she needed coverage and mark the weekend call in to be made up off the list. Once I found myself on an extra Saturday night. I asked why. So she showed me the list where I had a Saturday call in 6 months before. Was time to pay the piper.

Yes hoolahan, The points system is a nice thing if you are requesting off. It eliminates all those nasty little conversations about who is who's favorite. The other side of it doesn't make everyone as happy. This same point systmen is used to decide who goes home on adequate staff time if no one is requesting off. Again, the most points wins. So in that way, it might not be ideal. Those who love to pick up extra time don't always want to go home, even if it is their turn. But let's face it.... the above situation almost NEVER happens. There is usually at least one person willing to go home early or take an unplanned day off. But it is all written down. It is systematic. And everyone knows the rules in advance.

Here is another question that has plagued me for quite some time. What about those 11a - 11p people? They are on shift for 2 ordinary people meal periods. Are we saying that they are entitled to only a meal before work and one during their shift?? I guess the same is true for 7a - 7p, but the period they are on after the normal dinner hour is shorter. Are we saying you should have breakfast, come in at eleven, take a late lunch, and then not be hungry again until midnight when you get home. I think this is ridiculous. I have occassionally worked this shift, but attempt to avoid it on a regular basis because it seems that this is the expectation. One of the charge nurse where I work recently proposed, as a measure to be sure everyone gets a lunch break, that food be delivered to the unit and people eat in the break room where they were immediately accessible. I blew my stack. My break time is MY time to do with as I please. Covering my breaks is an institutional responsibility. Instead of trying to make things easier for the institution, why are we not demanding the same consideration other workers enjoy?? I will take my break, and I will cover for others to take a break. Do whatever you want on your break... stand on your head in the corner, grab some local fast food, pick up a prescription, or dance the hula... I don't care. It is YOUR time!!!

I will attempt to explain how we do holidays, but it gets complex. So if I stop making sense....... well you will have to ask questions. We maintain a holiday rotation list. Everyone is required to work every other holiday (our facility recognizes 6). So usually what happens are the holidays are overstaffed BIG TIME. So the scheduler can go by seniority and start asking who wants to shift their holiday to another day during the week. Usually there is enough takers, these people work another day during the week for holiday pay (2 1/2 times). If you are not one of the ones who has been there since the cornerstone was laid, you can request off. This is handled on a points system. The points are maintained by the staffing office. If you come in extra you get points, if you stay late you get points, if you go home because of overstaffing you get points. Get the picture. The one requesting off with the most points wins the prized day off. But you never know until the day and the unit needs are evaluated. The regular charge nurses work every other holiday but....... Our relief charge nurses get this perk.... they only have to work 2 holidays per year to everyone else's 3. And they ask me why I do it!! The relief charge nurses also get to choose which holidays they wish to work. Last year I was to work July 4th and Labor Day. However, since the facility pays 2 1/2 times for holidays, someone usually wants the money more than me, so I traded off July 4th, and requested off Labor Day. I had to work 8 of the 12 hours on Labor Day, so I worked 8 total holiday hours all year. I was off Thanksgiving, and will be off Christmas. Was to work New Years, but am going per diem, and our per diems have no holiday requirement or weekend requirement. This discrepancy between the regular charge nurses and the relief charge nurses may seem unfair, but our regular charge nurse traded holiday deal to keep from working any weekends. Also Christmas Eve and New Years Eve, and the Friday after Thanksgiving are not considered holidays and no one is required to work them are part of any holiday rotation.

One more thing... the night shift can snooze on their 30 minutes. They just have to do it away from the patient care area and have a designated wake up person.

According to my interpretation of the law regarding breaks, you are entitled to 15 paid minutes for every 4 hours that you work and at least a half hour unpaid lunch. So for a 12 hour shift, you should be leaving the floor 4 times. And it isn't a break if you are interrupted. The time starts over from the beginning. Covering for a break doesn't mean that I am to do your routine tasks. You should have those completed to the point that a break is possible. But I should handle whatever urgent situation may arise while you are away, answer your lights, get things for patients that could not be anticipated (i.e. water, coffee, ect) I take my breaks and encourage (with varying degrees of success) others to take theirs. Re-charge those batteries for a couple of minutes. It will be good for you.

I don't find that I often have the time to critique the work of others when I am on shift. But if I were to observe such breaking of sterile technique a friend of mine who works in the OR offered her solution. As a circulator, evidently part of her job is to keep a watchful eye on the sterile field and report if it was broken. If she is told she is crazy that sterility was not compromised, then she is supposed to walk up and place her non sterile gloved hands on things, making the break in sterility obvious. I can only imagine the cursing that would ensue following such an act. But the argument that sterility was not compromised would be rendered silent. As for more than 3 venipunctures... I find I am often the court of last resort for IV starts. The patient has usually had more than 3 attempts by more than one nurse before I am called. I have a personal limit of two attempts before I start looking for a central line inserter. Unless there is a hospital policy limiting the number of attempts, or the patient kicks all the nurses out of his/her room, you could technically stick as many times as necessary. I don't think this would be the best example of good judgement or good personal ethics, but technically I am not sure there is anything you can do about it.

Of course I take verbal orders. I don't work in a teaching hospital, so I don't have anyone in house most of the time. I have to take verbal orders. I have never run into someone not owning their own order. I can only imagine that I would confront them, then and there. Probably not too nicely either. If the person supervising these residents was required to take all calls for verbal orders, I wonder if that person couldn't invoke some sort of procedural change. Bottom line, in my opinion.... this is their problem... they just haven't been faced with the proper impetus to get them moving in the direction of a solution. In the meantime, I wonder if verbal orders should be required to be signed by 2 nurses. (A waste of at least one nurse's time) Or if a recording device could be placed on one phone and all calls for orders could be made from that phone. We have a recorder on one of our phones. But it is to keep physician abuse under wraps, not for failure to back up one's orders.

I work in a similar unit. Up to 36 beds. We do post PCI, post PPM, 24 hour post OHS, r/o MI, CHF, cardioversion and whatever else they think is not sick enough for ICU but too sick for the floor. We sometimes do TEE's at the bedside. We do our own sedation for procedures (i.e. chest tubes, cardioversion, TEE, ect.) We use and may titrate as needed NTG, Nipride, Dopamine. We use dobutamine, amiodarone, primacor, lasix gtts, cardizem, corvert, ... well the only thing we dont' take is levophed. How about that. All levophed has to go to ICU. We have patients with and without lines, with and without closure devices. We use integrilin, and reopro. Radial and femoral approaches to PCI. We monitor by tele, no hardwires. We often get AMI and don't send to ICU because of physician preference for our unit. Go figure. Our ratio is 3:1. And as the person making the assignments I can tell you that this is often an overwhelming load. My manager is also looking for information on staffing ratios because admin thinks we should be able to do more. Would love to hear whatever you come up with.

Bedrest.... Standard 6 hours after intervention if no closure device is employed. 1 -3 hours for Angioseal. We also trialed Perclose. The rep said they could be up in one hour but we had a lot of venous bleeds that prevented them from getting up for a while (approx 3 hours) We also use a radial artery approach where I work. No flat time is necessary, but we do keep them in bed a couple of hours. Mostly to keep them from using their right hand to get around (i.e. pulling on rails, pushing self off bed, opening bathroom door, ect) The radial approach is a HUGE hit with the patients and the staff.

I am working in my first non- "decentralized" unit. I long for the "decentralized" days. We didn't often work short. It was pure teamwork in action. Loved it!

I have heard this type unit called step down, tele, or pcu. We have three levels, ICU, CVU (stepdown), and general med/surg. So I am talking about the one in between. Let me tell you a little about why I asked. Currently this unit enjoys a 3:1 staffing ratio, however, there is a plan afoot to change it to 5:1. That I think would work out well with redesign of the things done in the stepdown area. But I am not sure how it will work out without a population change. In this step down unit, the patient type varies. There are new strokes without thrombolytics,12 - 24 hours post CABG and valve surg. Thorocotomies, post percutaneous coronary intervention, and chest pains that sometimes work their way into having an MI but don't transfer out. They take chronic vents, trached or still with ETT waiting to be trached. There are those requiring airway observation and respiratory failure. Various arryhythmias, and some rather severe CHF/pulm edema. From time to time the fresh MI is admitted to this unit due to lack of space anywhere else. Also they get new seizures, observation chest trauma, and anyone in the entire place that goes into afib. The only vasoactive drip I haven't worked with on that unit is Levophed. But Dopamine for B/P support is ok. Nipride for B/P control is ok. Also Primacor, Dobutamine, Cardizem, Amiodarone, NTG, Lido, Pronestyl, Corvert, and just about any other little thing goes. It is acceptable to keep patients on these drips in our step down unit and the drips can be titrated every 15 minutes if required and still meet written admission criteria. Occasionally there is need to monitor CVP, the old fashioned way. But no other hemodynamic monitoring. All cardiac monitoring is done with telemetry, and watched at a central station by two people doubling as unit clerks. They do elective cardioversions, complete with conscious sedation. They also have occasion to do bedside bronchs and TEE's with sedation. They often receive patients with arterial sheaths in place. These are not connected to any monitoring source so that makes me a little bit nervous, but so far no one has bled to death. Most of those patients also have anti-platelet drugs on board. They do not remove the sheaths themselves, I am often the one that does it for them, but the addition of this task has also been proposed. Those patients with q1h fingersticks and insulin drip titration? Right in that unit as long as they are not exhibiting neuro changes. But they keep the place smelling nice. Let's not forget DT's, and OD's. They seem to come often to this unit. LPN's are utilized as primary nurses, but according to state law, they are required to be directed by an RN. There are usually a couple of techs in the unit. The plan is to increase the nurse:patient ratio and use more techs. Which would be fine on some of the walkie talkie rule outs. But I don't see how it is going to work on lots of the other patients. So this is a survey that I have been asked to put together. It will be presented to the powers that be, in an effort to keep things running smoothly. Thanks for any help.

While I am not Canadian, I have lived and worked a few years in Florida, as well as 25 miles from the southern border of middle Tenessee and investigated job opportunities within the state of Tenessee. Perhaps I could be of some assistance. I would go with Tennessee. There are asthetic reasons as well as work reasons. In Florida, the bugs are huge and many. Tenessee has bugs, but on a smaller scale. In Florida, the major landscape attraction is the beach. As a side note I like the gulf beaches better than the Atlantic beaches. Beyond the beach it is basically flat. The change of seasons is not dramatic and colorful. Many flowering plants find it difficult to survive the heat, however many tropical plants thrive. Oh and if you plan to have pets, prepare for the invasion of the fleas. Holy cow!! If you enjoy sitting on the porch, prepare to screen it in. However, the climate is temperate when it isn't downright HOT, the thunderstorms can lull you to sleep on almost any given day, and there is always something to do in the water. Depending on which part of Florida you choose, the housing costs may be difficult to manage on what you will be paid. On the economic scale, there is no state income tax in Florida. I couldn't afford a house on my wage alone. Property taxes and utilities were high. Car insurance and other fees associated with owning a car were high. My health insurance benefits left a lot to be desired and a lot of out of pocket expenses. However, Florida, being a community that survives in part due to a large tourism base, always has some form on entertainment available, from pro sports, to outdoorsy stuff, to any variety of indoor stuff. Tennessee, is a beautiful place. There are mountains and streams and lots of outdoorsy stuff to do as well. It is not that long a drive for a beach vacation, and when it is over, you get to leave the sand and a lot of the bugs behind. The pay was just ever so slightly less, but I could afford the average home on my income alone. They also have no state income tax. They boast several large cities with lots and lots to do. The health benes leftmore money in my pocket from the premiuns, to the out of pocket expenses. The retirement investment options were comparble to Florida. The change of seasons is usually breathtaking, espeically in the mountains. Most flowering plants and trees to very well, enabling you to beautify your personal environment, if you like that sort of thing. Both Tenessee and Florida boast a couple of major university medical centeres, so they are technologically comparable. The cost of licensure in Tenessee is far less than Florida. 8 years ago it cost about $175, compared to $65 in Tenessee for initial licensure. Renewals were not $175, about $50 or so. But for the money, my choice would be Tenessee. I am sure there are many in Florida that would argue, but that is my story and I am sticking to it. If I were to ever return to Florida, which isn't likely, I would look into the area surrounding Gainesville or Ocala. Maybe not the and glitz capital, but reasonable housing costs, and sometimes the sand is mixed with actual dirt, the grass grows better, they have a few rolling hills, but the fire ant population is still alive and well. If I were to return to the Tenessee area, which I hope to do sometime soon, I would check out Chattanooga and Knoxville. I don't think Memphis is the best representation of Tenessee. So I guess it all boils down to this being my opinion of the whole thing. Florida is a nice place to vacation, but I don't ever want to live there.

I have been assigned to root out information on Progressive Care Units to hopefully head off redesign efforts that will upset the apple cart of the nurses working fulltime in one of the units I float to on a regular basis. Answers to the following questions will be greatly appreciated. What types of patients are admitted to your PCU? Medical cardiac? Interventional cardiac? Cardiac surgical? Respiratory distress? Vascular surgical? Other types? Do you titrate vasoactive drips? Any that you aren't allowed to keep on your unit? Just tele or is some hardwire monitoring available? Do you take the chronic vent patients? What is the nurse:patient ratio? Do you use assistive personnel? What kinds? Do you utilize LPN's? Do you utilize them in an assistive capacity or as primaries? Do you do conscious sedation in PCU? Do you have standing admission orders? Do you have standing ACLS orders? Do you mix your own drips or are they mixed in the pharmacy? Do you have written admission criteria? Have copies? Are elective cardioversions performed in PCU? Do you pull arterial sheaths in PCU? Who does the actual pulling? What educational requirements must be met? Any additional information you would like to share about your PCU would be appreciated. For informational purposes, if you are comfortable doing so, please list the name and general location of your facility. Thanks for your help.