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pebbles

pebbles

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  1. pebbles

    Help resolve a question on GCS...

    You are. Localizing would be a pt reaching to his ETT when suctioned or reaching toward your hand to stop you when you apply painful stimuli. Withdrawal is just simply pulling the limb away from the pain.
  2. pebbles

    Critical Pt and More stable Pt

    I always try to remind myself that being extremely self-absorbed can be a huge aspect of the sick role - for a pt and their family. I remember one guy I had while I worked on a surgery ward, took it so personally that I wasn't cheerful and waitressy. "You could at least smile!" He snarled. When I told him I just wasn't smiling because I was concentrating on not making an error with his IV pum programming and that I was also worried about another pt of mine who was "very sick", he knew not to take it personally, and we got along much better. I don't think "There is someone else who is very sick" violates privacy, it just gently lets them know that they aren't the centre of your world, without hitting them over the head with it. My father in law still, several years later, takes issue with a nurse he had who was not cheeful and didn't offer him a basin or a warm blanket.... I remember visiting him the next morning after this, and he asked "what does code blue mean?" - It means your nurse was too busy to worry about a warm blanket and you should just have asked and not begrudge her the fact that you had to ask! Geez!!!
  3. pebbles

    Blind Nursing Student?

    Amazon.com: The Doctor Will Not See You Now (9782895072430): Jane Poulson, John I read this book a year or so ago and found it very interesting and enjoyable. Yes, this doctor must have some help from others to assess her patients. But she is absolutely the one doing the doctoring!
  4. pebbles

    Night shift: let residents sleep?

    How many nights have you slept in a bed soaked with your own urine lately? It's not only bad for their skin, but if they have any cognition at all, it's embarrasing and humiliating and misery-provoking. Better to do proper care and change them. Most people will sleep better quality if they are warm and dry, if you have a hard time getting them to sleep after a turn or change, that's a different problem to address.
  5. pebbles

    Patients Making Up Lies

    Oh yes. It was years ago, and it actually still haunts me, so I feel your pain. The family hovered over me all night. for three weekend nights in a row. They snapped and snarled at me when I asked the pt basic assessment questions. ("Are you having any pain?" - "SHE HASN"T HAD THE SURGERY YET followed by a glare"). Yeah, some people have pain even before they get thier tumor removed, sue me for asking. They made unreasonable demands. I basically got zero breaks for 3 nights in a row because they were so demanding, and I could not get adequate time to work with my other pts. It was awful. Then they went to my manager on monday and said that I had ignored their mother's pain, that there had been no nurse in the room for hours at a time and that they were given no information. I was lucky. My manager was a good one, and I had good documentation. This pt had an epidural, so I had been documenting my frequent assessments, plus comments on the vital signs records about all the care assessments and interventions, explanations, etc. Complete with times to the minute, showing how often I was in that room and all that I did for her. My manager showed this to the family and asked them if they were saying that all this was a lie - and they had no response. My boss actually phoned me at home to talk about this and ask where all their anger was coming from. Probably poor coping and needing to lash out, we figured. The pt had symptoms for months and had been sent away by numerous doctors before actually getting some tests done and finding out she had stomach ca. After that she was moved to a different ward and I hard the family were terrorizing staff there too. But to me this is no excuse. We are not figurative punching bags for people to manipulate or take things out on. If I get a sense that a pt or family are getting "angry" in their coping, I do some CYA charting and make sure my general documentation is detailed and specific.
  6. pebbles

    two people for hoyer lift-why?

    I took care of a pt who died in our trauma step-down as a result of severe fractures she got from falling out of a hoyer at a nursing home. Turned out the sling hadn't been pushed properly into the slots on the lift arm. The CNA who had taken the short cut that day and lifted her alone to get it done faster was absolutely devastated. I have no knowledge of what (if any) disciplinary action the CNA faced, but in this case the family were understanding about it being an accident - they were the ones who wanted to hurry as they were taking their mom out for a family outing - and also she was elderly and in very poor health. But still.
  7. pebbles

    What has happened to nursing?

    Florence Nightingale faced some pretty stiff opposition to some of the changes that she tried to bring about to cleanliness and lifestyle in improving the outcomes of soldiers. And that's just what's known and documented about her life. Never mind the fact that she tried to bring about change and she was a women with little or no power! There was a LOT of politics and rules that had to be done and gotten around so nurses could do their jobs back then - and in any age. It's life. I think the disillusionment hits us all sooner or later. It does suck that all this politics affects the patient care. But you know what, it always did. People who are good nurses will be able to see through all that, deal with the politics in time and still be able to reach patients and take care of them. It's hard in the first year or so. But don't lose heart. Once you find better ways of dealing with "the politics", you'll find your groove again with the patients. :) Don't romanticize the past - the past was way worse than you imagine.
  8. pebbles

    New Grad in ICU?

    This is a VERY common thread topic if you go back a few pages. You might want to look at some of the other "new grad ion ICU" threads as well.... It's a mixed bag and it really depends on the supports in place and the expectation of your employment. In *my* hospital, a new grad out of school would never be a safe consideration for ICU because we aren't set up to preceptor and educate them. Others are different. We are a tertiary care centre, but the smaller community hospitals in my area have always hired and trained new grads. Therefore, opinions will vary. You should not go by what people from other places and the internet tell you, you should look into what programs there are in your location and whether other new grads have been successful in ICU's there. Tips for getting into ICU as a new grad? - Nursing for Nurses Does a Med-Surg preceptorship placement hinder an ICU position after grad? - Nursing for Nurses i want to start off my career in icu once i graduate - Nursing for Nurses New Grad BSN to start in MICU - Nursing for Nurses New Grad starting off in ICU - Nursing for Nurses Good luck!
  9. pebbles

    Where are all of the "experienced nurses hiding?"

    I'm an experienced nurse. The reason I don't post too much on this forum is that I have worked in the field of nursing for 11 years and reading all these threads on here is sometimes like reading work stuff. I'm on a couple other online communities for nurses that aren't as active as this one too. The sheer volume of what's posted on here and the small amount of threads I find interesting, stimulating or relevant to my own working life means I can see however many pages of threads and still feel like there is not much I want to say in them. YOu've also seen how some of the same topics come up repeatedly, that has an impact as well. My time off and my break time, I just prefer to do other stuff. I'm more choosy about which threads I want to post in now. It could be that the majority of posters are people who just haven't gotten to that point yet. The world of nursing is so new to them, it's all interesting, it's all worth hashing out in discussions. So they are more active.
  10. pebbles

    Quality Improvement Issues

    I work in an SICU and our biggest problem is VAP....
  11. pebbles

    Leveling art line to tragus for cpp???

    Wow, am I glad to see this being discussed! I work in an SICU that has many neuro patients. About a year ago, one of our attending doctors who is an anesthesiologist, did a whole bunch of "teaching" on Rounds about leveling art lines at the tragus for neuro pts. This was based on one article he had and the fact that this was the practice on the OR. Before that, we always leveled at phleboststic axis, nobody ever questioned it. It had never been the practice in our unit before. Because our hospital policy states to level art line at phlebostatic axis, if the docs want us to level the art line at the tragus, we have to get the doctor to write a specific order for that. (and then d/c that order once the ICP monitor is out - we had an instance where a pt was sent to a non-neuro step-down unit and the nurses were still following the order to level at tragus, with no understanding of what it was all about). It "went viral". The neuro docs went to the neuro step-down and said "the nurses in ICU are leveling at the tragus for their art lines, why don't you do that?" - all with NO real basis for this practice change. It's all been very upsetting. We haven't been able to find any concrete evidence as to why the practice of leveling an art line at the tragus would be a good thing. All the "norms" and safe pressures in texts (CPP, etc) are calculated using the central pressure at the aortic root. We are taught to shoot for MAP of a certain level because this has been shown to generally perfuse all organs. Are the proponents of leveling art lines at tragus suggesting that we my be under-perfusing the brains of our non-neuro patients? If you move your transducer up, really all you are doing is manipulating your zero point. Yes, it may give you different CPP values, etc. But as we say "treat the patient, not the numbers".... The danger is (as stated in the pdf presentation linked on the first page of this thread) of when you do start to treat the numbers and use fluids inotropes, etc. I haven't been able to find any real clinical research as to the exact pressures found the the COW, how this relates to artline readings at either level point, and how much of a difference this makes. I agree, it is potentially huge. There are many centers practicing leveling at tragus on the assumption that it reflects cerebral perfusion pressure - but what if their assumption is not actually correct. My centre is one of those places, and it's gone to all sorts of practice committees and physician committees because to make a practice change unless you have decent evident makes no sense at all.
  12. pebbles

    anyone else having low unit census?

    Nope, we're the trauma center. Drinking and driving is the flavor of the season so far. Ironically, a lot of them seem to be men in their forties and fifties, not just the youngsters who think they are invincible when they go out.
  13. pebbles

    Need some helmet product info from ya'll

    Where I live, hockey is a big deal. Our ortho engineering dept just buys whatever hockey helmets they can get on sale at the time!! @Mike: Helmet is to protect the brain, dura, etc when the bone flap has been removed. They are supposed to wear the helmet any time they are ambulating or turned on that side, etc. Otherwise you are limited as to what position you can place the pt in, limited as to what physio can be done, etc.
  14. pebbles

    Experience of ultiva (remifentanil).

    It is extremely potent. It's used in the OR's only at my hospital, and the nurses in labour and delivery sometimes use it in PCA form. The hospital policy/monograph specifically states administration is restricted to physicians only, with the exception of the labour floor. We used it this past month on a patient in profound liver failure, because of its short half-life (the monograph says it should clear the body within 10 minutes), and not wanting to overload this liver failure patient with longer-lasting drugs that wouldn't clear his system for days or weeks. Our attending physician had to write all the orders for it, and had to specifically write orders in the chart covering us to administer this drug. We had a continuous infusion at really low doses (0.01-0.05 mcg/kg/min) and it worked well for this patient. After seeing the effect that even tiny titrations had on this patient's LOC, I do agree that the use of this drug should be restricted to OR's with very rare exceptions.
  15. pebbles

    CRRT Priming Volume?

    We are taught to try and take the priming volume off within the first few hours as long as the pt tolerates. We divide the volume between about three or four hours so you aren't taking it all off at once. I don't think there is official policy at my hospital on this though. I personally don''t do so unless the goal of CRRT is fluid removal in general, then I can just add it in. But I agree with your rationale of yes, we instilled that volume of saline into the pt, but that volume worth of blood is now also outside of the pt. Our CRRT educator does discuss both theories with us and is comfortable to let us do what we feel is best for the specific patient.
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