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I'm confused. Are you guys saying you don't want to use critical thinking skills to try and come to an answer? Critical thinking is so very important as a nurse and a hard skill to master. I deal with orientees almost daily and use this same approach on them. For instance: Patient has a Dx of CHF. Orientee tells me that the patient is doing good but his blood pressure was low (80's/40's) so he held the am B/P medication. B/P up to 90's/50's by noon. I start asking more questions. Urine output has been low all day and the family was complaining because they think The patient was sedated...He's been sleeping all day. I asked how the skin was and orientee says, "intact". I said is the skin dry/warm? How is the turgor? What does the urine look like? How do the lungs sound? Is the patient still taking a diuretic? Yes and the diuretic was not held this morning. Although this orientee did many of the right tasks, he was not critically thinking. It took lots of questions / guidance for him to realize that this patient had been over diuresed and was in the beginning stages of hypovolemic shock. Nursing students must learn to critically think...their patient's lives will depend on it. If anyone has any ideas on how to teach critically thinking without asking questions, I'd love to know those techniques. (And I'm not being sarcastic...I'd really love to know).

I think the majority of med errors happen because someone failed to follow policy and procedure. Sure, you didn't follow P&P because you were busy, over-worked, sleepy, stressed...etc. But the bottom line is, someone took a short-cut and made an error. Something that I have been guilty of as well.

It is probably in your hospital P&P to fill out an incident report for medications missed and notify the MD. I would fill out an incident report describing exactly what happened. The day shift nurse is at fault. Medications should only be charted when they are actually given. There is a reason for the process of signing off medications given...Safe patient care!

I've only had one person attempt to bully me. I was a traveler at the time and had been at this facility for a few months. This nurse was in charge and always gave me the sickest patients...usualy DNR's circling the drain. I was on a first name basis with the coronor and the organ donation lady. I had much more experience than her and I think she was intimidated by that. Anyway, she liked to try and ridicule me and pretend she was joking. Once in a patient's room she tried it and I interrupted and said, "Hey can you do me a favor and leave your attitude at home?" She was in shock and never pulled that kind of thing on me again. In fact, I think she was a little scared of me after that.

I'm sorry your daughter is having to go through this...you too. The whole area probably had deep tissue damage that you just couldn't see until everything opened up. The good news is now that it's open, it can be treated. Make sure you ask for home health to take over once D/C'd from the hospital. They can come a few times a week to do wound care and the PCA's can do it in the interim. I have seem great results from wound vac therapy. Also don't forget nutrition. Make sure she gets a dietary consult while in the hospital. She will need good protein to aid in wound healing. I'm sure you know that, but when you're the mama, it's hard to think sometimes. Wishing you and your dd the best. Keep us updated.

Speaking of defibing babies... I got a request from the newborn nursery a few weeks ago requesting an inservice on how to work the defibrilator. It seems they had to cardiovert and had quite a time figuring things out. Since my own child will be delivered in this hospital in about 5 weeks, I was MORE than happy to privide this education!! The problem with using the defibrillator, as well as ACLS, is that you get recertified every two years and then might not have to use this skill in the interim. I encourage nurses to play with the defibrillator on a regular basis. We crack the cart and have mock codes or just refresh our memory on where things are and how things work when defibing, cardioverting, pacing...etc. At first, the nurses are reluctant to participate because they are either busy or uncomfortable with the equipment. When we are finished they are glad they had the review and without fail, request more frequent inservices like that.

I would also take that order to mean 1000ml should be infused over 125 cc/hr. If it were continuous, it would have just said NS @ 125 cc/hr. Maybe it is a regional thing. Better be careful with travelers, because they are going to read the order as written and not know how things are normally done in different areas. I also wonder if insurance will pay for the additional bags when the order says 1000cc to infuse. It's scary to me that things can be so different, depending on where you are located.

I use the CURE approach when teaching time management / prioritization. C = Critical U = Urgent R = Routine E = Extras Of course the key is to constantly re-evaluate. Often times, new graduates are very task oriented and their stress level rises when something happens to throw off their schedule of tasks. Ask yourself, "What can wait 30 minutes?" What can wait and hour? What can be delegated? When should I ask for help? It's a skill in itself to be able to prioritize and it takes practice.

The thing about menial tasks is, they do require tons of critical thinking. You're not just cleaning poop. This patient has been hospitalized. Do they have diarrhea. Did they contract C - diff in the hospital. Are they constipated? Could they be developing an illeus? What is skin integrity like? Any breakdown? Are they are risk? How is their nutritional status? What about their foley caths? Any signs of a UTI? Is intake = output? Any signs of sepsis? How about pulses? Any signs of DVT's? I'm sure any nurse could go on an on about the opportunities for critical thinking, even in a rehab facility. Patients have complications anywhere...not just in ICU or ER. As a student and a new graduate, it's common to be task oriented and if you are able to complete tasks in a timely manner, you think you're doing great. Well you are doing great, but you've got a lot more to learn and you can start now on building those critical thinking skills. Good luck!!

OK, so I'm the only wierdo. I don't play with people's hair, but I'd let (almost) anyone play with mine. I love it! If I could only get them to rub my feet!!

This is a great learning experience! It's also a great opportunity for patient teaching. Many diabetics do not understand sick day management for their diabetes. If they are sick and not eating, they hold their diabetic meds. The stress/illness causes their BG rise regardless of oral intake. Many, if not all of the DKA admits to the hospital are caused by some sort of infection to begin with. As for holding insulin (or any medication). Check your hospital policy and procedures. Most will state that the MD must be notified if no previous parameters were given.

What a hard position to be in. My instinct is to hold fluids and give lasix. Patient probably needed pressors instead of more fluid. Could the increased intrathoraxic pressure be causing the low b/p or was the sepsis causing the low b/p. It's hard to tell which to treat...septic shock or hypoxic shock? I'm interested in everyone elses responses.

I thought the purpose of the una boot was to decrease edema in order for the wounds to heal. If it is wrapped on two separate portions of the leg, the edema will be trapped between the wrapped areas. I have used dressings directly to the wound sites before (under the una boot), usually polymem just for the absorbency and cleansing properties.

I don't think this doc is just a jerk. I think he has some big mental health issues that will only get worse.

Ouch! On the bright side, I am very pregnant (almost 8 months). When people touch my stomach and ask when the baby is due, I act offended and tell them I'm not pregnant. The horrified look on their face is priceless. Then I just die laughing. Ok, so I've got a sick sense of humor...but it brightens my day. hahahaha.

When I worked home health, all of the RN's were chemo certified and we did hang chemo in the home. We did lots of IV's. Most of the time the caregiver was taught to hang the IV's and the RN would only have to come weekly for PICC line maintenance. Of course, the family could not hang chemo.

Why in the world would any hospital think that 4 weeks is enough orientation? You need time to adjust and 4 weeks is not enough. In my experience, Nurses who are returning to acute care usually need longer orientation. Especially those who have been out of nursing all together. I have finally convinced my supervisors that this investment of time is worth it. The returning nurses I've worked with have turned out to be fantastic practicioners. Once the time managment is mastered, there is a wealth of critical thinking skills that the new graduates haven't developed yet. Please be patient with yourself. Talk frequently with your preceptors, supervisor, and educators. If you like Med-Surg, stick with it and I'm confident you will be successful.

In my opinion many of the JCAHO directives are very useful to patient care. The problem is that most of the directives / deficits are "Physician problems". Since administration couldn't possibly make the physicians accountable, they try to make the nurses fix the problem by filling out a new form. Example: signing orders, Medication reconciliation, Core Measures. These are all things that Physicians need to do, but the responsibility is given to the nurses. The problems will never be fixed by doing this...and patient care continues to suffer.

Our hospital will soon be moving the hall patients up to the floor halls in order to decongest the ER. This is supposed to be in emergencies only. My guess is that it will be the norm.

Man, this is a great thread. I just thought I knew all about this subject. Thanks CoreO!

I want the ability to tell patients exactly what time they will go to surgery/procedure in the morning. Until then, I just tell them 7:30am....when my shift is over. hehehehe. I know that's evil, but I only do it when they won't accept, "I don't know" as an answer.

The only time I've ever gagged or thrown up at work was when I was pregnant. At that time, anything would make me puke. Normally, that only thing that I can't handle is cat or dog vomit. Everyone in my house knows I can't clean it up and they give me grief over it. It's just so......fuzzy. bwuuuuuck!!!

I don't know about your agency, but many agencies have rules against transporting patients. You and the agency could be held liable if there were an accident.

I pull up one patient's meds at a time. It's the way I was taught and it seems safer. Other than safety, My concern is how other nurses feel about waiting for the Pyxix when you're monopolizing it to pull all of your patient's meds at one time? Just a thought.

Chloe, I'm sorry you had such a poor orientation. Slamming new grads on the floor to sink or swim is one of the reasons we have such high turnover of nurses. I am the clinical educator for 4 very busy Med-Surg units (@ 200 nurses). We have completely over-hauled our orientation process with great results. One week of hospital wide/classroom education. then one week of shadowing a preceptor. After that the orientee starts with one patient, adding a patient each week or when ready. Usually time management is a problem going from 3 patients to 4, so they can have a few weeks with 4 patients to get comfortable. Once the orientee is independent with 5 patients, we give them a couple of weeks for team-leading experience. Finally we have the orientee "float" to the other Med-Surg units for a few shifts for orientation. The Supervisors and I meet regularly with the preceptor and the orientee to see how things are going, if goals are being met, Any problems needing addressed. In the two years that I've been in this position, we've only had one orientee not make it and that was a language barrier issue. We offered to send and pay for english classes, but the orientee refused. Every single orientee is still working with our hospital system, most in the same unit. I know our system is probably unique, but I think the investment is really worth it. My goal is to make every orientee successful.