magicman

I currently provide a podcast that can be used for CE. While many listen, few take advantage of the CE option (as yet). I think this is due, in part, to a few things. first, the general age of the nursing population is a bit older than those who regularly use iPods, etc. Second, the culture of nursing is one of more "brick and mortar" type courses (even with home study, many I think still want a "book" to study from). The culture IS changing though. It's interesting to note that physicians have been using recordings for CE for well over 25+ years and it has done well as an option for them. It's quick, it's time effective (you can listen any time you want), it's timely (it takes less time to put out an audio than to write and publish a new text), and it's inexpensive. If you'd like to know more of what I'm doing, drop me a line and I'll share it with you. Paul

You most CERTAINLY may disagree! That's the beauty of the forums. :) As for bending, I've never, in 28 years, seen a 20 guage bend upon intorduction into a vein. The type of patients your ED sees has to be taken into account also. We see a LOT of elderly patients, so 18 guage's wouldn't fly as easily (smaller, less straight veins, etc.). As for CT's, our radiology dept. doesn't have a problem with 20's for any CT. They seem to work just fine for all of them. Now, hemolysis is another story. But I've had just as many draws hemolyze (per lab) with 16's and 18's as with 20's. It's all in the technique I guess. :) I DO know from firsthand experience that a 20 guage is MUCH less painful (traumatic) than an 18 guage (and I have great veins.....called ropes!). I looked for flow rates before and couldn't find specific volumes, but again, it would depend on the size of the catheter (18 guage double lumen vs. triple lumen, etc.). But they're finding more and more that there are fewer trauma patients who actually need large volume replacement (i.e. not in open thoracic of head injuries unless profoundly hypotensive....... One other thing to consider is the amount of time you have to spend starting the IV. Now, I know much of this is repitition, but still.........you have a better chance of starting a 20 guage on the first shot than an 18 (again, depending on the size of the veins, age of the pt., etc.). I'm thinking much of it comes down to personal preference. I've used 20 guage's for years with little problems and have heard all of these arguements over and over again. And in the end, the 20 guage cath has continued to work (policies have changed, restrictions loosened, etc.). Just my

I didn't think the ENA had that many credit hours available! I'll have to take a look. I usually get 30 - 40/year.....Florida requires 28 now (I think. They keep increasing it). But I need 100 in 4 years for my CEN, so I always have extra. I'm not sure about "all" states, but I know of many that require a minimum number for recertification. And although you don't have to tell them how many you have, they have the option to audit you and THEN you have to prove it.

Way to go Mare!!!! Welcome to the club! Again congrats and good luck!!

While I can understand wanting to use larger bors catheters for trauma and surgical patients, in practical application, it's much less traumatic to the patient, quicker, and you have a higher success rate with 20 guage than with 16 or even 18 guage caths. They (20 guage) work just as well and can take the higher pressures for IV contrast, plus you can give blood through them essentially as well as 18 guages. If the pt. needs large bore, a central line might be a better choice. Now, this is all predicated on the size of the pt's veins to begin with. If they have large veins, then a larger catheter can be placed easily (although if their veins are that engorged with blood, do they really need a large bore angio?). In practice, I use 20 guage catheters on alomst everyone with no problems.....trauma patients excluded. TRUE trauma patients should have large bore, but depending on the type of trauma, they may or may not need large volumes of fluids. But as previously stated, a central line would be preferable. Just my

The answers to this are numerous. First, there's the lack of true preparation in nursing school to perform the job of a nurse in real life (i.e. managing multiple patients, time management, skills you may not have gotten much practice on, etc.). Second, there's the orientation, or maybe the lack there of. In the E..D. (I'm an E.D. nurse), the recommended orientation is at LEAST six months (that's from our national specialty organization). I would say ANY orientation should be at least that long. It takes some time to get your feet under you as a nurse and feel like you're actually doing the job well. Look at physicians...........they do three years in a residency! Now, I know that's apples and oranges, but even still............3 years to, say 6 weeks!?!?!? The heavy load for newbies is bad too. If it doesn't make someone turn tail and run, it makes them anxious and skiddish and puts them in a position to make mistakes that can ruin many lives. And should they make it through this gauntlet, they become the same way as the other nurses. They turn on newbies, dump on each other, and generally stab their coworkers in the back. Great line of work huh? With all that said, my suggestion would be to find someone to be a mentor to you. Someone who can be a sounding board for your frustrations and that you can turn to for help and guidance. It doesn't need to be someone you work with necessarily, but someone with experience and who is willing to spend some time with you. I wish you all the best!

I too think the ICN nurse was WAY out of line. Everything the other two responders said is how I feel also. You're a team as a nursing department in the hospital and should work together. With that said, taking an NRP course (or similar) would be a good idea. Also, trying to get your hospital to sponosr one, based on this incident, would be better. As an ED nurse for 17 years and a paramedic for 12 before that, I can tell you that unless you work on peds all the time, it scares ALL of us. But, in doing it (working on peds) more, you become less anxious and more willing to do things. While 2 years in the ED is a good base, the longer you do it, the more comfortable you become (as with ANY line of work). But don't think you were wrong for requesting help. You were right in knowing your limitations and that you needed backup. I commend you for that. Now take that knowledge and make it a positive. Get some pediatric training (PALS, NRP, etc.), and talk with your department director about getting the same for the entire department and maybe even joint education with the NICU.

Not only taking report, but even getting a bed assignment can be worse than pulling teeth! It can take upwards of an hour or more to even get an assignment when there are beds available! And yes, there are almost ALWAYS attitudes from the floor toward the ED. They also try to nit pick and find reasons to write us up on almost every pt. Been like that for years now.

I started as a medic also and hadn't done any other nursing before starting in the ED also. Your background in pre hospital care gives you some of the skillsets that are needed to be a good, quality ED nurse. I say go for it!

Are there no other Florida E.D. nurses here? I'd really like to get some input on this.

I have a request from my fellow Florida nurses. We were told at our last staff meeting that our staffing ratio was one of the best in the state at 5:1, and that the average in the state was more like 7:1 or worse. We were "dared" by our department director to find a better ratio in the state for an ED. I KNOW there have GOT to be better ratios than 5:1 (I mean being EXPECTED to start out with that ratio, not what ends up happening with holds, etc.). Please help me show this. I need the hospital name and the scheduled ratio, nurse to patient and/or nurse to bed amount. Or, if anyone knows of where I can find this information already posted, either here or another site, please let me know. Thanks in advance!

I was an EMT and a paramedic for 12 years before going to nursing school. That 12 years was invaluable then as it is now. I would highly recommend not only finishing your EMT, but putting it to use in the field for a while. THAT'S where the REAL learning happens. You get to understand how to look at patients, how to assess better and quicker, make decisions faster, etc. That all comes with working in the streets and isn't something that can be taught. It's definitely NOT taught in nursing schools. Just my 2 cents. Best wishes

First, I feel I must correct something here. The correct terminology is mute, not dumb. That's (dumb) an antiquated way of saying things. AFA the GCS itself, it might need to be up to policy. Im my facility, the GCS is always based on a max score of 15, but specified to be to the PATIENT'S normal ability. Thus, in this case, the score would be 15, but with the stipulation that the patient is mute , but responds and interacts correctly.

Could we please get away from the statement that the ANA is a "union". It is not, nor does it act as one. It is a PAC and a loose association just as the ENA or any other "association" is. It (the ANA) has no legal right to bargain for ANY nurses working anywhere in this country (that I know of), nor does it make any contracts with any hospital to bargain for their nursing employees. AFA joining, dues is prohibitively high for the people working the front line of nursing to be given so little back for it. The powers that be in the ANA have their own political agenda that has very little to do with the nursing profession, and they (IMHO) are truly out of touch with what nursing is and does from a practical standpont. They deal more with the "theoretical framework" of nursing. And (again IMHO) they have made some poor choices in what they have spoken out in favor of. Just my 2 cents.

AFA your question, the minimum 30 day time frame sounds pretty good overall (although longer might be better depending on your daily census). The certs you want nurses to have are good, but requiring them before being hired will diminsh the pool of available nurses to choose from. you might want to make it that they obtain those certs within a certain time frame once hired (i.e. one year, 6 months, etc.). Although a minimum of ACLS wouldn't be too stringent IMHO. I Do however have a few questions. First, why is a PA pulling a nurse from anywhere to do orientation? Is that not the nursing departments function? Second, if the PA pulls a nurse in to do orientation, does that not count against the nursing departments budget? How can someone outside of the nursing department do this without any consequence? It sounds as though either the department manager (I'm guessing that's not you) and/or the DON of the facility need to do something official (i.e. incident report, disciplinary action, official discussion with the medical director, etc.) based on your facility's policies. The PA should have NO control over nursing staffing or scheduling whatsoever. Again, IMHO. :) Good luck and I hope you get this sticky problem solved soon! :)

I'd be most interested in the sample letter! I'll print it and give it to everyone I work with to send too! :) AFA the "problems" noted with the levels, I too wonder how many nurses will return to the bedside if this type of bill gets passed into law. I personally know of at least a half dozen nurses who have left my facility and hosital nursing altogether because of staffing issues (I work in an 81 bed facility). I would like to think that most of them would return if mandatory ratios were enacted.

First, I think the resentment comes more from the fact that CP's, while serving a VERY useful purpose in school, serve no REAL purpose in the "real world" as they are structured today. As an example, have you ever used "Energy Field Disturbance" in a CP? It could, realistically, cover EVERY possible thing that could be wrong with a patient if you think about it. Second, ND's and CP's were developed to give nursing a "separate body of knowlege" and "a language all our own". Now, while I agree nursing DOES have a specific realm of influence and specific body of knowlege, was this truly the BEST way of proving it? I liken it to doing proofs and theorems in Algebra. They aren't fun, but they do make you think about the steps involved in an equation and teach you logical thinking, etc. BUT, you don't USE them in the real world unless you're in a field of research. CP's might very well work great in a teaching environment so the student can learn critical thinking and what he/she needs to be aware of with certain medical diagnoses, but what purpose do they serve in the "real world"? Again, I challenge anyone to prove they are a better picture of the patient than the rest of the medical record. They are written in such archane language with so many long winded medical deifnitions that NO ONE reads them except nursing. Is that the point? To make them so cryptic to anyone else that ONLY nursing uses them? Is that not a waste of resources and time? You speak of them being tiring and cumbersome.......why should they need to be? And while I agree we are the "guardians of our patients health and welfare", and that we "must have the basic knowledge of knowing what should be done because of what is happening to him/her", what does writing the long definition of a medical diagnosis have to do with that? In school, yes, it is imperative we learn what the medical diagnosis means and what the possibilities are for our plan of care. Once you HAVE that knowlege, as a professional, what is the purpose of writing it all out again? Who are we trying to impress or prove that we have the knowlege? As a licensed professional and a graduate of an accredited school of nursing, does THAT not prove we have the knowlege in and of itself (medico-legal, law suits, etc. asside). Last but not least, you state "Every facility or organization that hires nurses have different forms and requirements for us.". Since when does a profession NEED a facility or organization to make their paperwork for them? We are licensed to practice nursing jsut as a physician is licensed to practice medicine. That means we can work independently and not FOR anyone but the patient. That would mean the profession should set up our own requirements for documentation, not the company who hires us. Once again, we (nursing) becomes subservient to another for our existence. We aquiess and give away what others worked so hard to achieve -- the independence and acknlowlegement of nursing as a profession.

Very well stated and I must agree 100%!!! That might have been a better way to state my thoughts. Thank you!! :)

I didn't miss it, I actually stated it! That's the only place we (nursing in general) are on our own (in general). My point is about CP's though. More emphasis is placed on them from a medical aspect (i.e. "airway clearance, ineffective" -- what's psycho social about THAT?) and more obscure wording used to clarify the MEDICAL diagnosis than anything else. As I originally stated, that is not my point in bringing this up. I only did it as a background on where I came from (again, the digression v. to the point of the female v. male - NOT BAD, just different perspectives/ways of interacting). Which has been and still IS my point about CP's!! They are a GREAT TOOL in school to give you a better perspective on patient care!! They give you different ways of looking at a medical diagnosis and what you, as a nurse, can do to help the patient cope with it (without going into the medical aspects of the care). But if we are all supposed to have this basic footing when we enter the workforce, then why why why why why must we continue to write it??? We're only writing it for ourselves (other nurses) and we already know it! You can know what ND's the patient has by reading the physician and nursing notes (the psycho social issues should be documented in the nursing notes), so you already know what's going on. Why RE write these again in the CP? And why write out all the interventions you MAY do for the medical care of the patient? You know you're going to document I and O's, limit fluid intake, limit activity, keep the HOB elevated, etc. for patients with CHF (oops, I should say fluid volume, excessive, R/T altered cardiac output). Why are we writing it out? This SHOULD be a given (unless of course, we don't feel nursing is a profession but more a task oriented job).

Just HAD to respond to this one. Notice I added an "etc." in there. I didn't feel the need to go into ALL the details of what we all do. I thought we already knew that part. But I would be interested in what you feel IS truly only in the realm of nursing to perfrom? And what science is nursing based on that is not driven by the medical model? Unit specifics asside, nursing HAS delegated much of the nursing care traditionally performed by nurses away. Today's nursing students are taught that bed baths, ambulation, ADL's, etc. are not their duties to perfrom. Now, some schools may still teach this to nurses, but many newer nurses I speak with tell me they are taught these are jobs for the PCT's, CNA's, etc. AFA using CP's to get a picture of the patient, it may be one more tool for nursing, but what other discipline even reads it? Physicians certainly don't, and I don't know one other that does. As I said, even WE (nursing in general) don't use them properly. And we continue to push it as "our" language. Just one more way nursing (again in GENERAL) isolates itself from the rest of the healthcare team in an attempt to justify the position. First, who said I hate the things that are our beginning? (and please keep in mind that Ms. Nightingale felt nursing WAS subservient to medicine and should stand when the doctor entered, give up their chair to the doctor, etc.) Second (and maybe more importantly), what "corporate measures" do you speak of and which management do you mean? Remember, each and every hospital has a DON (CNO, or whatever set of initials your facility uses these days). Ths DON is a nurse, and is supposed to be a nurse FIRST. That would mean being the advocate for nursing within the facility/corporation, etc. If nursing management chooses to aquiesce to the "business" of health care, how does that benefit anyone? (and TRUST ME, I understand that healthcare IS a business today. The only difference between it and the "traditional" business world is the amount of money/incentive available to the workforce) AFA the paperwork, if yours hasn't changed, then what corporate measures are you speaking of and how are they carried out? Are you telling me/us that the amount of paperwork (or computer work) that is related to your care HASN'T increased over the last 20 years? I know MINE sure has. We document more care on more paperwork in more ways now than EVER before in my 20+ years. Separate pieces of paper for all KINDS of different things that have come about for HMO's and the lawyers (please don't digress to THAT problem in health care here. That is for a thread all by itself). Now as to the CP's/ND's, as cited before (and I looked it up and it really IS a ND), when is the last time YOU used "energy field disturbance" in a CP? And I certainly hope you're using "coping skills, ineffective, potential for" in EVERY CP written/updated. EVERY patient has this, and we should be prepared to deal with it. My point is there are SO many ND's that fit ALL patients that to do a true total CP (which, at least in the beginning IS the point) can and does take more time than it's worth since no one other than nurses read it (and WE {said nursing in general} use generic CP's with computer generated statements, etc. to save time). If a CP is to be COMPLETE for a patient, it normally should be 10+ or more pages (especially in a critical care area). And for who? Other nurses to be able to read "our language"? No one else even LOOKS at it for anything dealing with the care of the patient. RT, PT, OT, etc. don't even GO to that part of the chart to get a picture of the patient. THEY read the physician's notes, labs, etc. and then talk to the nurse (maybe) and then go talk to the patient. What in the CP gives one a better picture of where the patient is in his/her continuum of illness that isn't in the rest of the chart (except the psych social issues which is where NURSING is the ONLY discipline in healthcare that documents and manages it -- NOT A BAD THING, only stating a point. Someone NEEDS to manage it for the patient, and why NOT nursing? It is a NEEDED part of the care). As for nursing not being able to get anywhere, I agree totally!! We (said nursing IN GENERAL) spends more time infighting about useless issues (RN v. LPN, ADN v. BSN, advanced practice, ND's {energy field disturbance -- how much time, effort and money was waste on THIS one!?!?!?!}, etc.). In the end (IMHO) CP's can be a great tool if used properly. Unfortunately, nursing (again on the whole) chooses to use it as a tool to isolate itself from the rest of the team, for the "advancement of the profession".

One point I gotta bring up with your post is that medication delivery is NOT within the scope of independent nursing practice. It is done only on the express order of a physician, thus nursing can not do it independently and therefore is not part of the nursing process/care. It is medical care. The evaluation of it before and after is part of the nursing process, but also is part of the medical model of care (evaluating the medical care given). As for why you are giving a specific medicine, that again is within the medical care of the patient (remember that nurses can NOT independently TREAT the patient with medications.) Also, contraindications, side effects, etc. are all medically based as well as within the realm of nursing. Therefore they are not exclusive to nursing. My point? Nursing perports to say that ND's and what they do accomplish are exclusive to the profession of nursing, and they are not. True nursing ONLY care is comfort, positioning, EDUCATION (probably the biggest thing we as nurses can do with and for our patients), etc. We (nursing) have delegated MANY skills (said hands on care) to non licensed support personnel (foley placement, bed baths, splinting, morning ADL's, etc. have and ARE all done routinely by CNA's, techs, etc.) so we can "focus" more on the "nursing process (said PAPERWORK). We spend less time at the bedside now than ever before in the name of better patient care and advancement of the nursing profession, yet we forget WHY we are nurses..............the patient. Without that person lying in the bed (or any other place we interact with patients), we have no profession (as it relates to direct patient care in the hospital, ECF, etc.).

Hahahaha.........yeah, I'm a male nurse also. Strangely, I've observed the same thing, even in the E.D. (where I currently work). I GOTTA get a copy of the current NANDA list and see this one!! I can just imagine telling this to one of the docs I work with. Any one of them would look at me as if I had been into the Pyxis for personal satisfaction!! Hahahahahaha

Many interesting posts on this thread. Thought I'd toss my 2 cents into the mix here too. :) As a nurse who started as a paramedic, I have a differnt outlook on nursing as a whole as compared to many I have spoken with who came thru only nursing school. The largest difference is that paramedics are accepted easily by physicians and nurses are not (no flames or discussion of doctor/nurse relations please). With that said, let me put a thought out to all of you. Nursing "diagnoses" are just a long handed way of writing a medical diagnosis. It's the SAME thing people!! "Inadequate airway exchange r/t fluid volume overload" is a LONG way of saying CHF. It's the definition of it!! I thought nurses were supposed to have their own "unique" body of knowlege? This "body of knowlege" is NOT unique, it's a round about way of saying the same thing as a medical diagnosis without actually saying those words (because they're sacred???). As many have said, ND are a great tool in school to get you thinking along a certain line with patients. In the real world, is there REALLY a point to them? A few have mentioned they are useful when you don't know anything about the patient. Well, I pose this answer to them. Read the progress notes, MAR, I/O sheet and labs, and I'll bet 10:1 you have a GREAT picture of the patient without even GETTING to the CP. AFA nursing as a profession, I agree whole heartedly that we are. But why must we, as a profession, have to PROVE our knowlege and abilities through so mush truly useless paperwork? The paper doesn't make the profession. Our ACTIONS do. Our abilities to care for and treat our patients appropriately. To make accurate assessments of them and impart this information to the physician in a timely, accurate, and succint way. That is professionalism. To call the physician at 3 AM and say "Mr. Jones is getting short of breath." with no set of v/s, intake and output, description of how he looks, an SaO2 (maybe even a blood gass if the area you're working in is appropriate for that), maybe an EKG, etc. and telling him (the physician) you placed Mr. Jones on O2 @ 2lmp (or whatever may be appropriate) and how it helped, and what else you'd like to do (either as a suggestion or directly asking for it depeneding on the physician), is only ASKING the physician to look down on you (and in turn other nurses) and NOT think of us as professionals. Basically, if you ACT like a fool, you'll damn sure be treated as one by the medical community. You want to be treated as a professional? Then ACT like one. Nursing is no longer subservient to medicine. We are a part of the team. Patients don't come to the hospital to see a physician, they come to see nurses. We are given an education in nursing school, USE it for heaven's sake. Sorry for the rambling. Guess I got carried away there. As to ND's being research based and helpful in developing evidnce based practice, I agree in theory. Research is great in teaching hospitals, and multi center studies, but in daily practice, with the current state of healthcare (short staffing, high patient loads, etc.) they (ND's) take more time than they're worth. As to having a "language" for our profession and setting us apart as a profession, why? Why make it SO obscure that even physicians don't (and won't) read it? Hell, even WE don't understand and use them how they were meant!! We fill in the blanks and change them as we need because it's a requirement. The medical community uses their education (which is basically taken for granted they KNOW what they're doing) to write out what they see and plan for us to do (yes, THEY plan what will be done for the patient in a broad sense), then we carry it out. Why can't WE do the same? Why MUST we write out in LONG HAND what we're going to do, and THEN go do it? Why not just go DO it and write what you did? I mean, if someone is dyspneic lying supine, do we not put them in a fowlers position (if that's appropriate for the patient's condition)? We don't write "will maitain HOB at 45 degrees to facilitate better oxygenation", we write HOB placed in fowlers with decrease in SOB (or something similar). And if we don't, won't the physician either do it himself or TELL us to (reposition the pt.)? What in that is nursing specific (other than nurse are the ones who DO it)? C'mon y'all. Stop deluding yourselves and your fellow nurses into believing we have a separate language and "specific body of knowlege". Our "body of knowlege" is based in MEDICAL evidence (prove me wrong here). Yes, it is considered nursing care, but it's said to be "medically appropriate", not "nursingly appropriate".

What about them? Help them get out of the vehicle and into a w/c or onto a stretcher (depeneding on the need) and into the ED. The pt in your example could be taken by w/c to triage and then to where appropriate by the same. :)

I've called EMS more times than I care to remember to remove someone from a vehicle with neck/back/trauma complaints. I've placed a c-collar and done vitals and waited with the pt. until EMS could arrive and extricate them. I used to be a medic before I became a nurse, so I understand the need for scene safety first and then to protect the patient's spinal cord, and have tried to instill this in my fellow nurses. The best and easiest way to think about trauma and spinal cords is this: ANY trauma above the shoulders, the person has a broken neck until x-rays prove otherwise. ANY trauma above the hips and the person has a borken back until x-rays prove otherwise. ESPECIALLY when you're talking about extricating the person from any type of vehicle.