rnwaller

Hi Everybody, We need to distinguish here between an LTAC (Long Term Acute Care HOSPITAL) and LTC ie. long term care or a SNF - Skilled Nursing Facility/Nursing Home LTAC is a hospital (and licensed as one) some even have ICU level of care. Per Medicare guidelines (thats what everybody uses as their standard) the goal length of stay is 20-30 days (you do not keep patients in an LTAC long term - although some stay a few months). Patients are seen by physicians daily and respiratory therapists are an integral part of the system. An LTAC is designated for "medically complex" patients requiring extended recovery times from an ACUTE illness. The most common LTAC patient is a complicated ventilator wean or complicated wound patients. What is mentioned as a 1 to 5 nursing ratio is common although ICU does remain at 1:2. SNF - Skilled nursing facility What is commonly know as a nursing home. Both short term medically stable recovery patients and chronic conditions. Licensed as a SNF not as a hospital. Nursing ratio's can range from 1:20 to 1:26 and I agree they are a challenge to work in. They are accepting sicker and sicker patients (some that meet the criteria to go to the LTAC hospital.) God bless the SNF nurses! FYI Acute Rehab - Patients with acute medical condition, stabilized, that can tolerate 3 hours of rehab per day. Most common stroke and trauma ie. Senator Gabrial Gifford. Hope this helps!

I continue to monitor the patient (which would include transfusion reaction) just as if I hung any other medication. That is, in essence, a nurses job. Keep up the great work everbody.

I am hopeful that you have enough repore with your manager that this discussion should not be a big deal. In my opinion, no need to tell your personal story, just express an interest in moving to day shift. Is there a day shift position posted? Is it your hospitals policy to post in house positions to employees first? Where are these postings? Day shift usually has a different 'flavor' than evenings or nights - be sure you want to make the move, and remember you may also loose evening differential.

Thanks for choosing ER Nursing (although this could change) 1. Ask your guidance counseler to 'shadow' and ER nurse. 2. Sign up to get your nursing degree - I highly recommend a BSN program while you're young!! 3. Graduate and taking the nursing boards, preferable in a compact state, find us what this is before you take the boards. 4. Spend one year in med/surg/telemetry and one year in ICU 5. Get a great job in any ER (with this background they will love you!) 6. See you in six years, we'll be waiting with bells on!

I am concerned with the posts I see here. I seem to be reading a lot of one person 'against' another. I agree there are some bullish/bossy people out there - but my guess is they are fewer in nursing. Most nursing enviornments require teamwork, so being bossy doesn't work. Recently, I was perceived as being "bossy". It is a new job and lots of personalities in the mix - as well as recent management changes. The end of the matter was - I was folllowing direction from the charge nurse and my colleagues thought I was being "bossy". I was doing what I was told - my colleagues perceived it as "bossy" because it was creating more work for the team. My thoughts to this group, when someone is being "bossy" take a moment to step back and ask, is it possible they are just doing what they have been told to do (and you don't like what their telling you) or does this person function differently than you? I am an assertive person (I admit it) and I have a 'get 'r done' philosophy. So, I want to do what has to be done and get it done. Others have a more layed back approach. I'm not bossy and their not lazy. We work differently. I try me best to recognize the strengths and weaknesses of my self and my colleagues every day. I hope you all will, too. In the end we are all nurses.

I am agreeing with Liverpool Jane, as an RN and a JW I try to avoid hanging blood. In the US it is always two nurses who hang blood (so I am never doing it 'solo'), and after the blood is hanging it is my job to monitor the patient (as nurses do all the time.) The Bible also states that free will is a choice (not always the right choice) so if the patient with his/her physician has consented to have blood, it is not my place to impose my religious beliefs on them. I hope this helps. - Michelle

Hello again, You mention this patient had chronic anemia. Is she getting the full follow up? Does she have a hematologist, is she getting Epogen? Iron? May be this is all true but I do sometimes find that a patient will refuse a transfusion, then no aggressive follow up is made. She is in my prayers. Michelle

I have been working ED for 9 years now. Lately, I am feeling like a taskmaster - I start the IV, give the meds, dip the urine, give the contrast etc .... What I don't seem to have is any input/interaction with the diagnosis process. The best example of this is I walked out of a patients room the other day and the clerk says - OR is on the phone for report on Mr. 'A', I didn't even know Mr. 'A' was a positive appy (the doc never bothered to tell me.) In my opinion its a severe lack of respect for the nurse as a part of the team. I feel professionally stifled. Anyone else experiencing this?

My hospital is just looking at uniforms and I expect a decision this year about a single scrub color. I too have been at a facility that went all white. I agree with several posts - looks good but is impractical at times (I work ER). I can say that with 17 years of experience including travel to six states, white gets two thumbs up because it makes you immediately identified as a nurse and seems to come with respect from patients and families - I can live with this. So get out the bleach and be proud to be identified as a nurse!!!

Your already on the right track. The system we used was two (or three) triage nurses. One continued traige and one started workups, including sending labs, ekg etc. (an ED tech can also be helpful) We had a chart rack and a specimen holder and this nurse followed results for these patients (had to show EKG to someone watch for critical labs etc.) For that busy an ED you need a doc/mid-level assigned as the "go to" person for triage. If I felt an IV was necessary I used the hallway near triage - I did not let IVs go to waiting room. We used Zofran ODT for quick relief. The charge nurse (or whoever assigns beds) would work with the triage team to know who needed the bed next. I have had a normal EKG with positive cardiac enzymes results sitting in the waiting room so the mention of follow through for results is important. Some people will still leave, even though you are getting thi ngs done for them, so a call back system has to be developed if you get abnormal results requiring follow up. We did urine dips/upreg etc.. but I never told patients results if they were going back to the waiting room - if they have the answer they were more likely to leave. Motivated as we all are, sometimes there is just plain waiting.

You sound very stressed at your current position. I hope you can clear up these change of shift procedures or you may need to move on. Think about suggesting some solutions, get a group involved in making it better, hopefully you can gain some administrative support.

re: pregnancy test Answer - Please call your PCP on Monday for your test results. The result is not an Emergency! I have actually been able to do this once!

Maisy, You did not say how busy an ER you where in or if its a one or two nurse triage system. I spent a year on committee of this very question. Some quick answers. We initiate standing orders in triage including Xrays and bloodwork - IV starts are held off as who is responsible to monitor an IV in the waiting room and what if the patient leaves? It is imperative to have the medical director behind this. It does progress to some more aggressive ordering for experienced staff with established relationships with the doc (ie. head CT, U/S for DVT etc..). I hope this helps - feel free to ask me more.

ED and Breaks, tough words in the same sentence. Scheduling - not a part of the ED language. I have just returned to a regular ED job after a few years of traveling. My experience is a system where you have a 'buddy' assigned is best. You and your buddy schedule breaks with each other based on census and acuity in your zone (your buddy should have an assignment physically close to yours). I try not to leave urgent undone tasks for my buddy. Charge and Triage are usually buddies. When my buddy is at lunch I do my best to follow through on whatever happens with all of our patients, if I need help I try to get it. If its falling apart or somebody goes downhill and I feel patients are at risk I let Charge know and I call my buddy back from lunch. Sometimes, a stable patient has to wait for something because we are people and we do need an occasional break. The ED is far from a scheduled world, but its the only way for me!

If your relief has not arrived, report off to oncoming charge RN, if he/she cannot accept report then have your OT sheet in hand and let him/her know gently but firmly that you expect to be paid if you cannot report off in a timely manner. On the flip side I worked for two years with a nurse who hardly charted anything during her shift and spent 40-90 minutes OT on a DAILY basis charting after giving report (tough to follow her as she took all the charts for the first hour of your shift). This was addressed with her on several occasions but only after she was finally told no overtime did it stop.

I too am an RN, who is also one of Jehovah's Witnessess. I have tried to read the thread so I would not repeat anything. I have had the privilidge of doing a lecture on transfusion free medicine. I consulted the Watchtower's Hospital Liason Committee as previously mentioned. To help those RNs trying to decide if a specific procedure (such as the surfactant) is acceptable, I will review the principle from my lecture. The Bible states once blood is removed from the body it is to be poured on the groundg, therefore accepting a transfusion from a bag of blood which has been stored is against the writing of the Bible and not accepted by Jehovah's Witnesses. One post mentioned a witness doing a pre-surgery blood bank donation, this is not within the Bible principle. The other matters such as, hemodialysis and bypass is (as already mentioned) are "matters of conscious" for each witness. No specific Bible text refers to this issue so one must make a personal decision about such things as a continuous circut, hemodilution or blood fractions ie. Epogen (as proteins pass from mother to fetus). Some facts I discovered preparing for my lecture may surprise some of you. The anethesia "standard" of needing a Hgb 10.0 for surgery has no documentation or research behind it. I have known several patients with Hgb Post-op infection rates increase 25% for patients receiving blood transfusions. At least for prostate and breast cancers, relapse rates increase as much as 80% for patients who receive blood transfusions as part of their treatment in comparison for those who do not get blood (we all realize their are MANY other factors in this mix.) I hope you all will realize that we are all people, just as you would not serve a pork roast to a devout Jewish person, please educate your Witness patient so they don't end up in the same position. Thanks to all those nurses out their who take the time to be true patient advocates. Michelle

Working in nursing for the last 16 years in six states I have had a variety of experiences but none so frustrating as the recent assignment in Houston, TX. Apparently, it has been commonplace for YEARS that Mexican residents drive (illegally)across the border to get dialysis. The Houston area health district spends an average of 100,000+ PER PATIENT/PER YEAR on illegals getting dialysis. By the way, since they are illegal, they come through the ER, to an ICU or telemetry admission for dialysis EACH WEEK!!!!! I am not a mean person and do not have a problem as previously mentioned to do preventive programs such as vaccinations, but where does this stop?Is the US suppose to support health care for everyone who physically gets across our borders? And for those who support providing the care I only ask, where does the funding come from?

I am a traveler and I have found most hospitals smoke free. Some have nurses who will allow patients to take a "smoke break." Sorry I can't go there, too much liability letting a patient (with an IV most likely) go outside the building - and how am I suppose to track when they go and when they return. Professionally (and I apologize now to all smokers) I think it is inexcusable. The public no longer tolerates a doctor that smokes, so why does anyone think they have any respect for a nurse who smokes? Recently, my friend went with her daughter to the ER. She calls me to say she was taken in a little screening room by a nurse (I'm guessing it was triage) and the nurse reeked of cigarettes - and this was at a Childrens Hospital. She was disgusted and thought about leaving!!! She progressed to another nurse and it ended up an ok experience. But she kept asking me how it was possbile for this nurse to be smoking.

I wish you all the best in your decisions. You complied with the nurse practice act but you have discovered that bad politics of HMO medicine. I have to agree with other posts, IF you want to take this on you need to go to the insurance companies. But, you certainly run the risk of being blackballed in a rural community. You can also ride the charting redirect road,"Per Ms Boss Lady pt has regular labwork, labs drawn at her request, to follow up with Dr. So-So." In the end, maybe ask to work FOR the insurance company? Remember, the rest of us love you......

I am a travel nurse whose home state is CT. Cost of living in CT is very high due to taxes - nice house 275-350k but then you pay 3-5k a year in property taxes!!! Plus property tax on your cars. Gas currently 3.19 (second only to California I believe). As a staff RN I would be about $30/hr with 16 years of experinece. I think this is low since we work weekends and holidays and a refuse collector makes $18/hr. As a travel nurse without benefits (my choice) I make between $35-45/hr depending on the location. So, for those of you thinking travelers make so much more than staff - think again. One of the biggest problems in nursing is you top off in your salary too quickly - after about 10 years your at staff RN top pay, and there is no where to go from there if you don't go in to management. Financially, the health care industry is already strained so I do not see this pattern changing any time soon. One of my scrub shirts says how I feel most days "Nursing is a work of heart." We are not in it for the money.

Terra, I just read your reply saying you are renewing, I'll bet your agency is calling you back about the renewal!!! When you finally get them on the phone for that, get the recruiting manager on the phone, INSIST ON THE MANAGER/SUPERVISOR ONLY, get your housing issue resolved in that phone call. In the future you may have to be willing to say NO to get what you need, NO new housing, NO renewal - they don't make money if you are not working and its probably too late to cancel your housing. Sounds like you have a lot of lessons learned, I wish you the best.

Thanks for the input, especially the phrase about having a phrase in your contract about what happens if the hospital cancels. I also found out it depends what state your in and the state law about contracts - both ways if you breach or if they cancel. One person suggested I just go after a weeks pay in small claims court. Still thinking.

I also work for American Mobile, I don't know who your recruiter is but this sounds WRONG to me. Stick to your guns, say No I want the bonus or a little extra hourly. Remember what others have just said a higher housing is better (its tax free). Be careful with American Mobile recruiters they tend to rush you into lower pay. Say maybe (the first time unless its a great offer) make them wait a little, slow down and you will probably get both the housing and the bonus.

Recently, I was on a travel assignment and after three weeks I got a call from my agency saying they did not want me to return. (I had a 10 week contract.) Be assured I have 15 years of clinical experience and it was absolutely not over a clinical issue. My agency put me back to work in three days. I am seriously considering legally pursuing the hospital for breach of contract. Does anyone have any experience pursuing anything this serious?

When I first read your title, I was surprised. If you haven't heard of American Mobile then you haven't done your homework in travel nursing. They are in the top three of the largest travel agencies. They have both ups and downs. There pay isn't always the best but they do have a huge variety of assignments. You have to be willing to stick to your plan and get what you need, don't be intimidated by the recruiter who I believe tries to rush you sometimes. Say no, and say I want more. My experience with them has been good but I insist on certain standards and did say no on more than one occasion.