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ED, ICU, Progressive Care, Informatics

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  1. SpEdtacular

    Written Up

    The OP's "double dosing" is just a symptom of a bad system and stems from multiple issues. Here's what comes to mind for me: Benzodiazepines are not the best treatment for insomnia and if used regularly they can cause rebound insomnia and make the patient dependent on the medication in order to fall asleep. Now granted sleeping in a hospital is way different than sleeping at home so some extra help might be needed, but many of the folks in the hospital that need benzos for sleep were already taking them for sleep when they got there. Technically, the patient saying the doctor prescribed 1mg of Xanax is true and there's a good chance the OP isn't the first (or last) person who did this. The doctor wrote the duplicative orders for Xanax which were then reviewed by a pharmacist before being profiled on the patient's MAR. Ideally this should have been caught by the doctor or pharmacist and one of the orders should have been canceled. The hospital should have a policy regarding duplicative orders and educate nurses on how to address them. It's not clear if that's the case here, but orders like the ones referenced by the OP and orders where there are multiple meds prescribed with the same or similar indications get a lot of well meaning nurses in trouble. For example, there's an order for 2mg of morphine for PAIN and 4mg of morphine for CHEST PAIN greater than 5/10. The nurse decides to give the 4mg of morphine because while the chest pain is only 2/10 the patient's leg pain is 10/10. It seems okay on the surface, but it could get a nurse in big trouble. Or maybe a patient has orders for both Tylenol and Motrin for pain and fever q4 hours. How should you give them? How do you know which you should you try first? Do you give both at the same time or rotate between them every 4 hours? What if Tylenol is for both pain and fever but Motrin is only for pain? If I give Tylenol for fever and shorlty after taking it, the patient wants something for pain, can I give Motrin or do I have to wait since the Tylenol has pain as an indication too? Having a clear policy about these types of orders can prevent this confusion and nurses who are aware of the issue are less likely to second guess themselves when deciding whether or not to give a med and/or get clarification from the provider. When the OP scanned the medications, the EHR should have warned her that it was too soon to give the additional Xanax (it may or may not have done this). Unfortunately, technology bias can lead to an overreliance on the computer to catch mistakes and some nurses (and doctors and pharmacists) assume all is well if the EHR "lets" them do something. Reporting this as a med error or near miss is appropriate, but I sincerely hope the OP isn't being punished for her actions. That helps no one and negatively impacts safety.
  2. SpEdtacular

    New RN needing advice

    I did an RN to MSN in Informatics through Excelsior College and was very happy with my degree program. I'm not sure why you think you'd be "stuck" and unable to work in other disciplines because you specialized in informatics. Most MSN programs have the same core curriculum and then additional courses for whatever you are specializing in. If you decided you really wanted to do NP school and got accepted into a program, you'd already have a master's degree and would just need to take the NP specific courses and do clinicals. The same is true for becoming a nurse educator or clinical nurse specialist. As far as employment is concerned, it depends on a lot of factors like your background, your experience, the job market, and the type of job you want to do. When I graduated, I had worked as an acute care nurse in ED/ICU for 6 years, but the only informatics experience I had was my Capstone and using an EHR as a nurse. When it came down to it, my knowledge of ED workflows was as much a factor in me getting hired as my degree. Some of my coworkers did get a foot in the door by becoming super users and/or trainers, so if you have the opportunity, it's worth looking into. Saying that being an NP and being an informatics nurse are different is an understatement. First and foremost, I'd think about whether or not you want to provide direct patient care. If you love being at the bedside and spending time with patients, informatics nursing may not be the career path you want to take. If you like working with end-users, collecting and analyzing data, and designing and building workflows you'll love informatics.
  3. SpEdtacular

    Young, Thin, and Cute New Hires

    Ever read The Jungle by Upton Sinclair? Young and hopeful guy applying for a job at the meat packing plant looking down on the older industry veterans who couldn't get work thinking they just had a poor attitude, were lazy, or whatever... and that he was better than them. This thread totally reminds me of that.
  4. SpEdtacular

    Position difference between RN vs. BSN

    Interesting information. I haven't had the opportunity to read all the studies at this point but it seems they show a definite correlation. I'm curious about whether or not they found causation and what factors might be responsible for the difference. I guess I've got some reading to do
  5. SpEdtacular

    Position difference between RN vs. BSN

    I've never heard that BSNs have better patient outcomes. Where did you hear this? (I'm not being sarcastic. I know my post might come off that way). I know many hospitals prefer BSN over ADN because higher/continuing education is one of the "Forces of Magnetism" criteria used when a hospital goes for a Magnet Certification and as a previous poster said the BSN courses go more in depth into things like management.
  6. Whilst EMSing I picked up an "unresponsive" gentleman that was seen lying in the street by passersby. I said sir what's the matter today and he said I'm cold and I drink like fish. I said sir I appreciate your honesty, and I respect you for that. If only everyone were so honest...
  7. Old ladies are sneaky like that
  8. SpEdtacular

    Where did you hear that?

    What are some strange/illogical/bizarre/false things you've heard while working in healthcare? For example: I had a patient with sciatica who was having a flare up. She was prescribed a muscle relaxant. I asked if she took it and she said no. So I asked if there was any reason why she didn't want to take her medication and she said that she wasn't going to take muscle relaxants because her heart was a muscle, she was 65 years old, and she didn't want it to relax. I had a young woman experiencing angioedema and she asked if she was going to get a tetanus shot. I said I didn't think so but if she needed one to mention it to the doctor and she might be able to get it while in the ED. She then proceeded to explain that she wanted a tetanus shot because tetanus shots cure EVERYTHING.
  9. SpEdtacular

    Funny Sign in slips

    This was a "medical emergency" I responded to while working as a paramedic. Chief complaint of: "I wanted fried fish for dinner but my wife wouldn't make it for me. She said the doctor said I'm not supposed to eat fried food but she would bake the fish. I don't want baked fish I want it fried! She makes me so mad and I got the pressure and the sugar" (this is no quite verbatim but you get the idea) Another good one: "I tied my boot too tight yesterday and my foot hurts"
  10. SpEdtacular

    How does your ED handle "walk-in" MIs?

    The biggest thing for walk in STEMIs is getting the 12 lead EKG within x minutes of arrival and identifying Acute STEMI. That gets the cath lab rolling and reduces door to balloon time (which is the number the EDs are concerned with). Great job!
  11. SpEdtacular

    I just have to say this....

    Sign me up!
  12. OP Great topic! I find it very interesting that different programs have such different requirements. I was a paramedic prior to becoming an RN and there was tons of clinical. We were required to do 500 hours in the ED, 500 hours on the truck, rotations in the cath lab (observing), OR, ICU, med/surg floors, etc., we had to do skills a certain amount of times e.g. 100 IVs, 20 intubations in order to finish the program, and then we took the national registry test which consists of a written and practical exam. When I started working I did three orientation shifts and was on my own. I went to Excelsior for my RN and they have practical exam you must pass to graduate. For the most part I felt very comfortable when I started nursing although I know I've still got a long way to go. It seems like teaching to pass exams has become the norm in America which is really too bad.
  13. SpEdtacular

    The Top Three AN Red Herrings

    How about when someone asks a relatively benign question looking for opinions and inevitably someone responds as if it were directed personally at them because they have zero reading comprehension and everything is about them anyway isn't it? :icon_roll
  14. SpEdtacular

    An open letter to the ER triage nurse

    The OP's story pretty much disproves that theory because the triage nurse, while not attending to her bathroom needs, got her where she needed to be in spite of her poor attitude (the nurse not the OP). All healthcare workers should do their best to be polite, attentive, empathetic, nice, professional whatevers but crucifying someone for once incidence of being rude is a bit extreme (and yes maybe the triage nurse is chronically rude but we don't know that). "There's a bathroom over there, you can walk there." was the triage nurse's initial response which I can see as coming off as rude even if it wasn't meant to be and maybe the response given rubbed her the wrong way and she thought she'd respond in kind (even though she should have been more professional). I don't pretend to know what other people are thinking because I don't know what other people are thinking unless they tell me. I know I've been screamed at because someone perceived me as belittling them or being rude. I'll never forget I was taking a medical history on a lady with MS and replied with a few okays or uh huhs to acknowledge I was listening and out of no where she started screaming, "HOW DARE YOU TALK TO ME THAT WAY! HOW DARE YOU BELITTLE ME! DON'T YOU SPEAK TO ME LIKE I'M A CHILD!" something to that effect. Everyone's jaw dropped because I was being nice and nothing about my manner was rude, although for whatever reason that's how the patient took it. I took a breath and without missing a beat I said "Ma'am it was not my intention to belittle or insult you and I apologize" Then she calmed down and said "Thank you, Now you're speaking to me like I'm an adult." Was I thinking lady I don't know what the f*** you're talking about but you need to calm the f*** down because you're acting CRAZY! Probably. My point being that had she not told me that she felt this way I'd never have known. I understand being sick is typically not when people are at their most assertive but by not addressing the behavior with the individual you're not giving her the chance to apologize (because most people don't want to be rude) and/or change her behavior because she might not even be aware that she upset you.
  15. SpEdtacular

    professional organizations

    I came across this site which I really love. They have all kinds of great resources and you can earn CEUs online. You can actually read the CEU articles for free but you have to pay if you want to get credit. Enjoy and Welcome! http://www.nursingcenter.com/mync/index.asp You can also join the American Nurses Association (ANA) or your individual state's nursing organization or both. Plus most nursing specialties (critical care, emergency, wound, etc.,) have their own organizations and credentialing centers as well.