IngyRN

So after many years outside of bedside, I have returned and its been 7 LONG months. Its not any easier. I feel more anxious and self doubt than ever. It's quite humbling to have new grads teach me..& I have been a nurse for 10yrs. I feel like such an idiot. I am under contract for x amt of hrs vs 1 year whatever occurs first. However, as much as I want to work overtime to complete the hours prior to the year it makes me super anxious..........any advice on reducing my anxiety?

Is there some kind of formula to determine or estimate how many units required to meet a certain level. for example how many units of prbc will bring up h/h 1 gram. how many units of ffp will lower inr by how many numbers?

When I was in NS-my favorite rotation was L&D. Sometimes I would even stay hours after my clinical was over to stay with the pt ( of course w/the permission of the pt, instructor and RN). Unfortunately, following the advise of my nursing advisor I went into med/surg instead of a job I was offered in post-partum. Now years into my career I am so unhappy. I wonder is it med/surg or nursing. I dont want to give up my career in nursing without attempting L&D. But how can I get into L&D-nobody will even give me a chance.

I never have pt w/PCA. Can somebody please explain settings/terms. IE lockout, basal, etc. thanks so much

Have you contacted your RD (dietician)? They usually have these resources.

I worked as an insurance nurse in the past. Most insurance companies require bedside experience (usually 2-3 yrs). However, it is best to got to their website. Let me know if you have other questions.

This may be a stupid question but I am assuming MONA is for Morphine, O2, Nitro, ASA. Are these the top 4 prioroities or should these be done in this order?

How important is it for the patient w/CP to get ASA stat if pt is on heparin gtt. The patient was nauseous and could only tolerate taking 2 baby asa instead of 2 ( as per protocol)??

I would not say anything until your plans are definite. You don't want to burn bridges. However, be prepared, although your NM may seem nice, she may not like the idea of training and hiring you for only 6months.

I know the usual needle length for IM is 1-1 1/2 inch needle. I was taught in NS to hold skin taut ( ?sp), inject at 90 degree angle, withrdraw to assure no blood return, if no blood return>inject medication. 2 questions> what if you inject and the needle is long enough that part of it is still outside the skin-obviously it is deep in the muscle, but can it be too deep or too close to bone??? When injecting into deltoid, specifically flu vaccine, I see that some actually pinch the skin instead of holding taut-is this a new technique? Thanks

Thanks for the replies. The pt was actually just on Novolog ( apparently I was sleepy when I started the thread-sorry). The patient initially had very high BS despite being on a high dose algorithm (250 to 370's), so they added the prandial dose. After this, the BS were improved ranging 140's to low 200's. I realize Novolog is fast acting- I was afraid he would bottom out with 8 units. For my own knowledge, how do I know when it;s too much insulin and should question the order-are there any resources you can offer. I feel pretty clueless about it all.

For all you diabetes pro;s I had a pt with a fasting BS 123. He was on 6u prandial humalog , along w/novolog algorithym which indicated an additonal 2u of novolog. Novolog is new to me ( I just returned to bedside after 7years) , it seems like 8units is alot for bs 123. However, my preceptor insisted this was the norm and ok to give as long as pt was eating. Could someone enlighten me??

I too worked for an insurance company as a DCP. Although the insurance DCP has the final say re: authorizing rehab LOC and payment, the first line of communication with the patient is the hospital DCP. They are the ones who meet w/pt, discuss dc options based on par facilities, location and appropriate setting. The patients always have a choice where they want to be referred to based on the above. Many times they ask for the hospital DCP for their opinions and make their decsion based on that.

just a thought. is your survey taking account demographics. i only ask because the pay scale varies so differently depending on area of the country. should this be one of your questions?? i am in oh. 1. how long (years) have you been a nurse? 10 years 2. what is your annual gross income? 60-70k 3. have a bsn. 4. how long have you worked for your present employer (seniority)? 1 month 5. on average how many hours do you work weekly? 36 6. do you work during the week, over the weekend, both? both (every 3rd) 7. what is your gender?female

Why is it that PIV's clot off when a running IV completes infusion and is left connected. Like when an IV abx (Vanco in particular) completely infuses but the line is not detached and line line flushed immediately??

more questions 1) If you flush w/20cc is it ok to waste only 10cc? 2) I was taught to use the same prefilled NS syringe used for flush for the waste. In other words, a prefilled syringe is attached and NS flushed thru the catheter. That syring is left attached and blood is drawn back for waste. Is this w/in protocol?

Sorry if I wasnt clear. The Y-connected NS had not completely cleared the blood, hence the line was still "pink"-would you still push thru this running IV even if it wasnt completely clear. I didnt push the lasix directly because she was getting a 2nd unit and preceptor said it was a waste of time to disconnect just to reconnect.

I have been taught how to draw blood from PICCS in several different ways. Some RN's tell me t flush prior to, others say no need. Some flush w/10cc then waste 5cc. Some flush w/20cc then waste 10cc. Some stop fluids for 1 hr other stop for 1minute. What is the correct way?

Post PRBC, you run the NS to flush the line-how clear is the line prior to pushing lasix thru the port. My preceptor states that as long as the line is "pink". However, arent you still techically mixing the blood w/ med or is this reasonable??

Good point. But the answer is no. This is according to hospital policy & procedure. At my hospital the RN gets consent.

Being nice, donuts, cards...helps to put your name out there but if your facility's reputation is questionable its not going to get you anywhere. How long have you worked for them? Get a feeling from your hospital case managers what their experience has been in the past -if it is questionable, you will have to work hard to prove otherwise. Look at what their problems , if any have been in the past & try to adress them. As a case manager, I look for: 1)past pt outcome- are my pt's returning to the hospital worse or with things that could have been treated earlier at the facility. Remeber, 1st & foremost our primary responsibilyt is not just get the pt out but to get them out to place that CAN provide the care they need. 2)what are the pt's opinon re: care if they do return-word of mouth is important. 3)how does your facility rate with the Dept of health score ( if they do that in Florida-in RI the DOH rates the facilities , gives them a score & posts this online). 4)Is your facility known as "cherry pickers" ( as we call them in RI)- do you only take the "easy" pt with good rehab potential or are you willing to help a case manager with one of those "train wrecks". This may help establish a relationship between you and the case managers as apparently there isnt one. What is your response time when you get a referral in regards to evaluating the pt & accepting them-long response time and giving false hope (ie, after reviewing the WHOLE chart & saying you have a bed at last minute responding with " we cant accomodate their needs is NEVER seen in a positive light!) 5) Offer to give your case managers an inservice to provide some CEU's as well as to tell them what you have to offer at your faciilty. Please do not complain about the case managers to their boss- you will get more with honey than with vinegar. The case manger has to give pt choices-however, there isnt anything to prove that they aren;t giving their opinion about one facility over another (pt's will ask and rely on their opinion). Complaining WILL be worse. 6) You may want to market to MD offices- I have seen this with the orthopeadic groups who know their pt will need rehab postop- the office offers the choices in the pre-op appt. Essentially, make sure that what you are representing is worth it. If case managers have not seen good outcomes for their pt's, you will not see an increase in referrals if you cannot prove to them otherwise. Good Luck!!

I am not quite sure I am understanding. Is this a nurse reviewer for an insurance who you are referring to? Why do you feel there is "false documentation"? Are you privy to their documentation or are you referring to what they are communicating to you? If the health plan uses Interqual as their criteria-you certainly have grounds for making the appeal that this indeed meets inpt criteria. If this is seen as a "trend" re: false documentation, it needs to be taken up by the reviewer's supervisor. As far as I know, Interqual just provides the criteria-it is the facility or insurance's job to make sure that those agents using Interqual are using it correctly. Although, a breast reduction is one of those inpt procedures that have an "*" so it can be obs as well ( I am referring to the 2007). Perhaps that is why it was denied?

Thanks for all your help. You are a great resource. I am sure I will have more questions in the future. Thanks again!

Is it ok to change a dressing while pt has running fluids??

Thank you all for your words of support. It makes me feel so much better that I was not the only one experiencing this. I think it is especially frustrating for me because in my previous role as a case maanger, I was very organzed and proficient. I hate feeling like the new kid again! Thanks again everybody. Of course if anybody else has suggestions, please keep them coming!