Fairlythere

I agree drug seekers are difficult to deal with, however at a recent conference on Pain Management, Nancy Pasero, who wrote the Pain Management manual, reminded us that addicts have pain also. They ask for frequent meds because they generally take more when they are not hospitalized. It is not our job to detox them. It is not for us to worry they are going to be "addicted", they already are. Some "seekers" are actually experiencing "pseudo addiction" which if their pain was adequately managed, they would not be "seeking". Also, on the subject of the pain scale, the tool needs to be properly explained to the patient. Many of my RNs walk into a room, ask for a "number" and leave. The patient may never report his number is less because he is afraid that his pain gets under control, he will be given less meds or not be monitored as well and his pain will return. Good trust between patient and RN working together will help. EVERY patient deserves pain control treatment, EVEN the "addicts". I do believe the docs do them a disservice sometimes by writing orders for standard PRN medications for them, like "dilaudid 1-3 mg q 4hrs iv". Of course the addict will ask for that on the dot every four hours. Scheduled meds, around the clock, using less opiates and more multi-modal approaches will treat them much better. Read Pasero's book, it is a real eye opener and helped me understand how I have poorly treated "repeat offenders" on my unit because I didnt want to deal with their "supposed pain". Who are WE to judge? We are supposed to advocate for our patients. By the way, I am NOT saying we should willy-nilly give any old med to anyone. Of course monitoring for adverse effects, over sedation, and trying the least invasive or least narcotic med combinations possible are always front line in treatment. Im just saying we should work WITH the patients. I cannot tell you how often in a short period of time since that conference the trust and explaination of the pain scale approach has made a difference for my patients. :heartbeat

Okay, so two weeks ago I came down with a right red eye with watery discharge. I woke up after a night shift and found my eye stuck together. After gently washing it, I looked in the mirror, and it was red. :eek:Acckk. I called in and went to the clinic. They said I had probably viral pink eye, which is contagious. Just in case, they gave me some gentamyacin eye drops which didn't seem to help, because it was not bacterial. In three days it was mildly improved. Occ. Health said I could return to work when it wasn't draining. I went to my doc and she said,no, it lasts five to seven days and she wanted me off work the rest of the week. I was better by the end. The following week was my week off. It was all good, but I was off almost three weeks all told. I was so ready to go back Sunday. I worked four nights. Today, I get up and BLAMO The eye is red, draining, sand papery. I want to cry. I called in and will go to the doc in the am. But I have no more sick leave. I can't keep doing this. I am not even sure I have a contagious type..none of the grandkids I have been around have it, my husband doesn't have it. Should I go to work anyway and gel and wash like mad???? I really don't want to put people at risk, but on the other hand, how much risk is it. :thankya: How do you know if it is????

Here it depends on the unit. Right now there are a few in the ED and PACU in Bellingham, ED seems to always be looking and also the ICU...A half hour away I hear they are laying off non-nursing staff. Funny we are having a shortage and over worked ....

Just saw this post, in the Whatcom County area, Bellingham, there is a hospital here that hires LPNs for ED, Mother Baby Post Partum and one med/surg floor. At this time there are a couple openings in the ED I think. Check out http://www.peacehealth.org Good Luck.

Are you thinking of vistaril??That is no longer given IV.

Well, I have been reflecting that I have been clean since June 28, 1983. I am coming up on 25 years, mostly in NA. I sponsor 8 women, I got clean at the age of 24 and am pushing 50. Its amazing. Two years ago I got to awaken a lost dream and became an RN at 47 yrs old. This is the first job I have ever had where they don't know I am in recovery. I have seen a few people I know at meetings of course but we are all quiet about it. Im having a big bbq in June to celebrate. Id love to invite a couple people I work with but they wouldn't get it. I am afraid I will be judged and monitored at work. Most of em know I don't imbibe, but that is as far as I have gone. It's weird to me not to tell, but this profession seems to be rather black or white. I would think MD's would be more understanding but they seem instead to be very intolerant.

I work on a med-surg floor and we mostly do gynecological surgeries, though we have others too. It seems most people coming back have nausea/vomiting within a couple hours. Most of our post op standing orders call for Phenergren IV, PO, or PR , Onadestron or Reglan. Reglan is useless if they are not eating. Zofran has little effect it seems and Phenergren zonks them out so bad I HATE giving it. They are already drowsy, on PCA's of some sort and had spinals. What do you all do? What can we suggest to the MD's? Vistaril is seldom if ever used. One older RN told me once of some drug they gave that worked wonders and was very inexpensive, but I can't think of it. (maybe droperidol? or Tigan? ) She did not know why they don't give it anymore, but said they still have it in the pharmacy. I have never used either of them. When I had surgery the anesthesists always gave me something and I never had post op nausea. So, whats your opinion?

Leslie, yes the general consensus is that the surgery itself and meds including the ativan and opiates threw her off. She cannot take ibu because of allergy nor can she take toradol. See my next post for an update.

I love the thought of tele and ekg but the docs are all saying its the opiates. Weird thing is she was lucid again all day, just a little confused. And she had nothing all day but tylenol at noon as the docs dc'd everything opiate. Yet at 5 after her dressing change she started going off again, hyperventilating, screaming for help, etc. We called the family in and in 20 minutes she was calm. She is still seeing floating things in the room and stuff, but was able to tell us how and why she fell and broke her hip and endured another dressing change. The ONLY other thing is she is anemic and got two more units of blood tonight. PT actually got her out of bed in a chair today also. Cant wait to see her tomorrow....

She actually did have a UA previously but is on abx of course and that has been treated. Hmmm..

She has a foley. She WAS on a heparin drip but that had to be stopped she was bruising so much. Now she is on PO coumadin. But thanks for the thoughts...

Yup, pain and ativan were my first thoughts. Getting the pain controlled in an elderly with her tendency to snow is the tough part.

UPDATE 7/28 I have had a few days off. Day after this post, I go in to find my pt. up in a chair, talking to friends, lucid and cheerful; helped back to bed, a lot of pain, but only tylenol. Still, her wound is still weeping serous and dressing soaks out in 2 hrs. Still has a foley but UOP good. Anyway I go back tomorrow. First I spoke with a nurse friend and was suprised to learn she is still there. SHE HAD TO GO BACK TO THE OR FOR AND I&D OF HIP, NO ANESTHETIC CEPT A SPINAL AND HAD HEMOVAC PLACED. So, the upshot is she is not draining more than 5 ccs in the drain a shift, cultures of the hip are pending again, and she was SO MUCH pain that night the MD was called and because she is on coumadin tx and has allergies to IBU, the only thing they could come up with was neurontin. Guess it worked well for her. Cant wait to see what tomorrow brings. Okay everyone is stumped on this lady. Lets try and figure it out without me breaking any HIPPA's Elderly Hx. CHF, aneurism (which left her very slightly off) broke R hip, came in and had ORIF oriented and talkative at admit and up to day after Meds: pca dilaudid, removed day two Heparin GTT removed day three, on Coumadin. Multiple bruises even on her pubic area. Has had three or four units of PRBC's. Percocet, removed day four, Onadestron schedule twice daily, PRN Vicodin .5-1 Q6, Lorazepam po or iv .25 Q4 only. Daily meds include Potassium and antibiotics, prevacid, doc, senna and Lasix. Now, the pca, percs, some phenergren were all d/c'd because the pt began to have altered loc. She also panics and has a sense of doom and hyperventilates, thus the lorazepam. Often the pt is diaphoretic and states she is hot. She is a COMPLETELY different woman then when I first saw her. The wound is stapled and well approximated but weeps so much serous fluid that the dressing must be changed Q2H. She obviously has much pain when turning. During the day she becomes a bit more lucid but is unable to get up with PT more than sitting up. When she is "sundowning" or whatever is happening at the eve/noc period, she is practically having to be restrained as she is so confused she doesnt even realize she has a broken hip. Yesterday when I took her over she had had only lorazepam X2 and TYLENOL for pain. UGGGH. This is because she denies pain when you ask her and because her son did not want her to be so loopy as it scared him. She was becoming more and more disoriented and anxious. I and the NTL consulted everything and did vitals.. O2 sats normal, temp normal, bp normal WBC normal, blood cultures and wound culture growing NOTHING. Gave her lorazepam X1 and her vicodin, .5 X2. She only got worse. LUO on shift (250) Our thoughts - Pain, sundowning and ARF?? Other theories were sepis but the signs are not pointing that way. Small stroke, but grips equal, no noted drooping. She had to have Narcan X2 for sedation and guess what, she snapped out of it a lot, but that was after 10 doses of percocet the day and night before. However yesterday she had had no meds all day and still became very agitated and disoriented. SO, what more can we do? If its been tried I will let you know. If we find out what happened, I will let you know.

Yeah, we have 3 ml. Its just that my brain couldnt figure out how to get it into a prefilled 10 cc syringe without losing some of it cause I was too thick headed to think of using a REAL needle rather than a blunt plastic one. DOY! Its interesting to see how many people do things differently though.

I agree that if there is an iv running and the drug is compatable it may not have to be diluted, but we are supposed to always dilute toradol and phenergren. My problem is not that I cant figure out how much to draw, its that if I want to dilute with 10ccs and the dose is .5, I cannot accurately measure .5 with a 10 cc syringe, they dont have markings that small. My problem was how to get the .5 I draw up in a small syringe into a 10 cc syringe. Tazzi's solution works perfectly for me. Oh, by the way, I like the idea of hanging phenergren as a drip in saline rather than diluting it and injecting it IVP, it zonks pts out and is so torturous to the vein. Im sure its going to end up being outdated as far as iv use just like vistaril is now.

I know how much I NEED, problem is I cannot accurately measure .5 of a 1 cc vial in a 10 cc syringe, as another poster pointed out, the measurements are in increments of 2, 4, 6, etc. Could do 1 cc because there is a mark. Anyway, I like Tazzi's suggestion, I forget about using a sharps needle to inject into a larger syringe hole. Always using those plastic things, you forget about sharps LOL.

The threads about diluting phenergren and nexium reminded me. I want some tips. For instance, if you give 12.5 of phenergren, the vial is 1 ml = 25 so you have to pull 1/2 a ml. We use syringes with the sharp tip plastic "needles". If I pull 1.2 cc to be accurate I would have to use either a TB 1 ml or a 3 cc syringe to get the right amt. of phenergren. Then I need to add 10 cc of saline. I cant transfer the drug to a larger syringe without loosing some. I cant start with a 10 cc saline filled syringe and squirt out 1/2 cc of saline accurately and fill it accurately with the phenergren. I cant accurately pul 1/2 cc in a 10 cc empty syringe and fill it with saline. What do you do?? If the whole amt (25CC or whatever) of the vial is to be used then of course there is no problem, I load the vial in an empty syringe and then draw up the saline to dilute it. So far I have had to draw out 1/2 cc in a small syringe and waste it thus having the correct amt. left in the bottle to draw into a larger syringe. Is this the only way??? Help. Same if I get an order for toradol 15 and all we have is 30 ml vials, etc. I cant imagine if the order is going to be 6.25 of that 25 cc vial. Signed, Missing it somehow!!!

The other day I had a patient who's prn order was Vistaril 25mg IV. It was given diluted in the IV tubing and shortly after was followed with a bolus of NS (for low urine output) so Im sure it was cleaned out of the vein rather quickly. Later research shows this drug is only to be given IM as it is torturous to veins. I was horrified and will call the pharmacy to see if they need to change this. Aside from that, I have read the main concern is that it causes most problems if accidently arterial or if the vein is punctured and thus can cause hemolysis or necrosis. Used to be it was given IV regularly from what I read but due to the risks, it is usually given IM now. Should I write myself up for not catching this and do you think the patient is at risk for the side effects if it was flushed so well through a patent IV line? Thanks for your help. I realize it is not the pharmacy or even the doc responsible as I should have researched the suggested route, but I had no clue as most of our drugs in this class (antihistamine/anti-emetic) are delivered IV. Ready for my thrashing-suggestions. Go easy on me, Im already beating myself up severely as a relatively new nurse. :trout:

bklynborn, Im sorry you wont be returning to the hosp. I hope you find something that is satisfying and pays well too. I know the local Option Care is less pay but I did a couple days preceptorship with them and they are nice folks. Take care, Col

Oh I wasnt talking about the OR and PACU vitals which are hooked up to monitors and I am sure are VERY accurate! I was indicating the rolling "robo nurse" that the CNAs wheel from pt. to pt on the floors. Thanks everyone, I will definately bring up the contamination factor and the idea of indiviual cuffs per pt. that could be cleaned by CS in between. I cant count the number of times an aid has come to me with a low pulse ox reading and they didnt realize the machine needs certain perameters to read correctly, like a good pulse. :)

At our hospital the CNA's use "robo nurses" to take vitals. It is relatively fast for them, taking BP and pulse and o2 sats at the same time. However the more I work, the less I trust them. It seems like one night the CNA reports all my pts. BP's are up, another night they are low. Or they can't get the machine to work. I take them manually to check. Sometimes I agree with the machine, sometimes not. Also the pulse ox seems weird. It will often show lower sats then the hand held machine. When I was in RN school we were told to not use these machines, but the BP cuffs in the rooms are not always in good shape either. I do prefer to check my pts. pulses on both sides during an assessment if I can and at the same time I can accurately check respirations. What do you all think about these machines? Does your facility use them???

I have been an RN for about 9 months. Last week the students came to our unit. They are assigned two patients and must have the same RN for both. This means I have to watch them do every med pass, get the meds out of the pyxis room for them, review their charting and teach new procedures. Is this normal for where you work to start doing this so soon?? Also we are orienting an experienced LPN to our unit, she also was assigned to me for several hours. While she was able to get her own meds and take on four patients and I had little to do with her, it still took supervision and time. I never said anything at the time, but started to wonder later. Just curious how your facility handles this. I will definately check out our policies today and report back to ya.

[EVIL]Cooper can say that because she's only been an RN for less than a year. You just wait!. [/EVIL] THAT WAS DOWNRIGHT MEAN! :lol_hitti To the OP: Remember, as in all forums, people will more often come to board to vent than to tell what is right. When all is well, we forget about complaints and problems. All in all, I doubt many of us would have forged through the rigors of nursing school and boards if we didn't TRULY want to be nurses, for more than the money. To the people working for "years" and who think it is totally not worth it, Im sorry. My two cents: I took the view that this career gives me the opportunity to work in whichever area I was drawn to. When in my first THREE months, I KNEW graveyard shifts on med surg was not for me, I applied elsewhere in the hospital. People were shocked that as a new nurse I was granted a transfer to an evening position on another unit. I wasn't. I truly wanted to work there. I heard it was the best floor to work on because it was the most supportive and had a mix of patients I was attracted to. I believe my attitude got me through the interview and though I had to stay in med surg for three more months, I am now working on my favored unit and I LOVE IT. In my humble opinion, I will love it in 12 years If, after being cross trained to peds and mother baby units I find I am not happy or cut out for this area, which so far I highly doubt, I will move on to another area. I floated to observation unit a lot and I wouldn't mind trying that either. OP, This is what I love:redpinkhe about nursing, the patients are for the most part thankful and wonderful to get to know. :smiletea: They each have unique stories and I rarely find ones I cannot get along with. I am a people person and I feel that is what makes me a good nurse. I try to fit in with them, not make them like me. I get lots of kudos, but even if I didn't, I go home knowing I did my best most days and I am satisfied. If I ever feel this second career, which by the way I started in my mid forties, is not working out, I WILL move on. I learned a long time ago, Stuck is a rut in your mind, not a reality. If nursing is your passion, you will be fine. You will also have days when you vent, and this is a better place for venting than it is for happiness. LOL :smilecoffeecup:

Today I had a student RN in year two. I myself only graduated in March last yr and have only been on this floor for two months. Its a mostly surgical floor, some medical. She took two pts., but was not allowed to hang IV meds, give po meds or do any nursing activity unsupervised by me. Her slip stated if she could not give the med because of time constraints, she was to observe me instead. OMG! When I was a student our instructor would not let us go with a nurse and take two pts unless SHE had checked us off giving PO and IV meds. The instructor had to observe them, not the nurses. It took so much time to wait for her to look up meds, prepare them and administer them. I got out an hour late because of my own sick pts and not being able to chart on time. Anyone got any tips? I know they will be back.... PS, I am NOT dissing students, I love students, I just never had to time manage with a student yet...my co worker had the same problem...

My head was spinning. I had two simultaneously important tasks. One guy needed constantly monitored, he had a gallon of golightly coming out his little colostomy about every 10-20 minutes. The aid was helping but I also needed to keep an eye on things and run when he called. (it filled up quickly) Another pt recieved an order for insulin drip and Q2hr checks while NPO for a procedure that night. Pts sugars had been in the 300's for days and the target was to get them to 120-150. Drip first, so I went in to prepare her for the drip and give a pain med. Murphy's law : Of course at that time the IV was failing. I got the equip but was unable to start one. I immediately told the RN in charge. She said she would come and try it. I said the pt. needed a drip. I kept running between the other guy and her and my other pts. The NTL tried and failed to get an IV. We called the resource RN. She couldnt do it. Again I said, well she is ordered a drip, needs pain meds and needs antibiotics, is NPO, and its now awhile since the order and almost an hour past her 1st time for her BS check. Suddenly it registered with the NTL the doc had written these orders now almost an hr ago. Though I had told her then,when I asked for her to try the IV, I guess she didn't hear me. Immediately she called the doc, got a picc order, got an interim insulin order (her BS was still 300+ and the picc RN was unable to get up there for a bit.) They were unable to start the Picc at this time, so he got an IV in finally. The NTL then stated she was taking over care of the pt. :uhoh21: Later she said I should have said something sooner, I should have called the doc and gotten an order to get insulin via shot while we were waiting, etc. I should have asked for help sooner, I should have moved faster on this, been more proactive, etc. Okay I am in my first year, I didn't do it right and constructive criticism is good and she was kind, and later gave me the pt. back. But meantime I was in tears and six years old for about 20 minutes. ARRRGGG. I was late with all my charting and had to stay over two hours. I felt incompetent and frightened as Im on a new unit for my third week and am afraid they will send me away. How do you handle this kind of criticism. I had never even done an insulin drip, no one up there was able to start the IV. I just cried and went on break as the NTL told me to and started back.