2rntish

There are also major changes to ACLS so it is not just for the lay rescuer.

Do you have a standard concentration for your post code drips?? We are in the middle JCAHO and one of our hospitals got a ding for the old Broselow tape and rule of 6... Is there a reason we can't use a premix dopamine gtt at 1600mcg/ml (800mg/500ml)? Is it the volume that might be wasted and that is the reason pharmacy wants to mix a 800mcg/ml infusion in a 250ml bag (200mg/250ml)?? It seems like this could cause more confusion... Thanks for any comments...

During menstruation one has to lessen physical exertion including walking, dancing or heavy house-hold work. The body demands rest and relaxation and one needs to provide that. That would be after all the a** chewing you did during the 1-3 weeks of PMS

Look forward to it. I am looking at 21 computer generated "prevented med errors" right now. 3 are actual prevented errors. The rest are "noise" like the PRN time issue. I am more than happy to wade thru all of these if we can prevent even 1 error. We are still in the learning phase of what is an error and what is not. That is the reason for my question to the group. It is very obvious that it has prevented errors from reaching our patients. Before you implement your system, visit with as many users as possible and learn from their trials and errors. There are growing pains with any change but this one has been worth it.

I,m sorry, I should have explained. Bridge is the Bardode scanning system that is supposed to help varify the 5 basic rights of med admin. Scan your badge, scan the pt armband, scan the med...It does a cross check for allergies, order in system, wrong dose, wrong time... With routine meds we have an hour before to an hour after the "scheduled" time. a 2 hour window. With PRNs it can not be prior to the exact time stated in the order: q 3 hr, if you give a dose at 0700 it had better be 1000 or later before you scan another dose...If you scan 15 sec early it generates a warning which does 2 things: 1. It desensitizes the nurse to warnings. After several of these type warnings, I am afraid they will disregard the really important ones. 2. Every warning that is generated, I get a report and have to justify who, what, where, why...It is about to wear me out. We have the ability to set parameters but most administrators think that q 3hr means exactly q 3hr. I would like to see a ......15 min window....or something along those lines. Bridge has been wonderful so far. Without a doubt, it has prevented MAJOR MED ERRORS. We just need to fine tune the system. P.S. NurseRatched, Love your post about JCAHO. We are 2 months out and the usual BS has started...nothing to do with improving patient care.

If you have a PRN dose q 4hr. Give a dose at 0700. Is the next dose due at exactly at 1100? Or do you have a window at you facility. We use Bridge and if you are 15 seconds early, it will generate a warning. I think there should be a "window" prior to the exact time...

Our guidelines state what the assessment is, the scope of the RN, scope of the LPN but says nothing about times. JCAHO leaves it up to the hospital to define times. I have not sorted through all of the CMS regs yet. I think that in our case it is one of those" it has always been done that way" things that no one can remember why.

Can anyone help with guidelines for reassessment by an RN? Our current policy states q 24hrs. Our sister facilities say it should be every shift...It would be hard to have an RN do the shift assessment every shift in our facility. We have a great group of LPNs that will not heitate to ask if they are not sure what they see or hear... I can not find anything that "states" the time frame. JCAHO leaves it up to the facility. Most say it is based on acuity more than a clock. What say ye... thanks

V Tach with a pulse is fairly common. Some patients are stable...good BP, no SOB...just a little fluttering in the chest. Some are unstable: chest pain, SOB, diaphoretic, hypotensive... Some are pulseless. You never have a pulse with V Fib...

Orientation is important if it is directed towards your position on the floor. We do 3 days of history and tradition of our system. By the time we get the nurses, they are brain dead and ready to quit. Most orienttes want to be assured they will not be thrown to the wolves and that the real orientation is to their unit, to their job and will not be completed until they are comfortable with the processes on that particular floor.

I started in nursing for all the wrong reasons. I grew to love it, advanced to a position that is more rewarding than any I could imagine. Please let him do it.

Last post (I almost spelled pist :chuckle ) for the day. Not all of the state boards of nursing agree with you and your BON. I know of atleast one that leaves it up to the facility and the MD at the bedside. I also wonder if all the extra training is to push that little syringe. If the MD is directing the procedure...what in the hell or you going to do that requires extra training outside of ACLS, PALS, advanced airway. Last time I checked most MDs studied a little pharmacology. Probably know ASA I, II, III....how much to give....or is that the extra training you are talking about. Do you have a code team at your hospital? How long does it take them to respond??? Can you not still bag THE OCCASIONAL pt that needs vent support from FENTANYL, DEMEROL, VERSED, DIPRIVAN. Get your head out of the sand and look at ALL DRUGS. Look at the ACTUAL COMPLICATION RATE not what a drug company influenced by money from certain groups who are trying to hang on to a little autonomy and willing to put up big bucks. LOOK AT THE NUMBERS. 10,000 cases and the DOCOMENTED need for resp support is a hell of a lot less than those complications seen in recovery or OR where all the gifted gas passers work. How do you propose to staff all the cath labs and endo suites??? I don't know about your neck of the woods but we don't have a CRNA or better for every case. We do have an MD... I've got a good idea ...let's not use a wonderful drug like Diprivan that has fewer complications than the good ole John Wayne drugs like Demerol. Keep pushing the old stuff, I'll take the good stuff. Research the nurse practice acts and if you can't find atleast one that allows the facility to decide. Pretty aggresive for our little podunk state. Maybe you can call our BON and give them your facts. Maybe our BON will change their mind "just for you". I am sure they DID NOT read any drug information before they made their decision.

Reminds me of an old saying. You are just like an ostrich, you can bury your head in the sand but your *** still shows. Too many miles between us. I will go my way, you go yours. There are happier threads to follow. You stand on legalaties, I will stand beside pt care. You side with the board, I will work with the Drs who are comforting and caring for pts. You make sure all the i's are dotted, I will try to make sure the meds are available to pass. I work in the real world where nurses do what they have to do. We no longer have time for back rubs and foot soaks. Nursing has changed, some of us have as well. I don't like computer documentation, I think it is unsafe. What about barcoding...times are a changing. Us, good ol boys, unethical, cowboy, practicing outside the board guidelines, and whatever else I have been called will continue to take care of pts the best we can. I just saw John Wayne aggressive ICU nurse...I used to work with a passive ICU nurse that was scared to do anything including defib a pt without a DR there. Get a grip. And read the Dip literature very closely and see if it is your interpretation or what the manuf actually states. Think like a lawyer since you seem to be drooling over my subpeona. Does it say a nurse CANNOT do it in a monitored situation???

Whoa there sister, take my meager attempts at humor in stride. Did not intend for you to take the "idiot" thing serious. And I don't remember any inservice on Dream Cream. I have learned a lot from the posts on this subject. Nothing to sway the numbers that we have accumulated over the years. Kerry says Bush is unsafe My day in court will probably be like the last Seinfeld episode with people, you included, coming out of the woodwork to testify for the prosecution about my impotence (sp)??? When the day comes I will stick by my guns. We have all made mistakes, some admit to it, some don't. I have had my share. Hope to have learned from them all. Never remember making the same one twice. Don't put too much stock in the Board of Nursing. We stood our ground from the BON point of view against a physician. He went to the board and had them change their ruling. Guess what it involved: conscious sedation and LPNs. Left us looking like idiots "for real". I would do it again in a heart beat if I thought pt care was being jeopradized. My only point is and you can read my previous post to stevierae, things that were really new and scary years ago, like a swan ganz, are now "routine" .Not to be taken lightly but proven to be safe. All of a sudden space travel comes to mind. Not even news worthy anymore until tragedy strikes. I still remember the Apollo missions when we got to get out of class and go wath the liftoff in grade school. It just bothers me a tad when I hear people say that it is beyond comprehension that an RN can push a certain drug in certain situations. By the way, i am not an endo nurse. Probably closer to education/quality/JCAHO compliance. We have not had any problems with state or JCAHO surveys. Our records indicate as I have said before, complications are nil. The real risk is to be on a med/surg floor with routime med admin. That is where the work on competency and risk assessment should be focused. I will take your bet on legislation being enacted to prevent it. It is too common place. The physicians will not stand for it. And if it does get through the 1st time it won't take long for it to be changed...How about lunch on it??? Damn, someone just walked in, back to work...

I will try to stay civil because I do choose to repond. You are an idiot...I AM TEASING>>>LIGHTEN UP Every scenario I have discussed involves an MD being at the bedside. Not some lowly CRNA. AGAIN TEASING...I respect these guys and gals as much as anybody on this board. I am just sick and tired of people quoting 47 pages of crap that, if you read the PDR, a lowly RN would never be able to do anything. I teach ACLS, PALS, NRP,TNCC. I know what is involved in these courses. I also I have several close friends who are CRNAs. I have a pretty good understanding of what is involved with their training. No one,including CRNAs, are guaranteed to be able to handle an emergency as a new grad. It takes years of "under the gun" training. Hell, we are traing med aides in nursing homes and in the VA centers. Why do these pts rate such poor care. The proof is in the pudding, we have given over 10,000 doses of Diprivan in Endo and Cath labs with fewer complications than given aspirin on the floor...with RN pushing and MD present. If you choose to respond and can keep it shorter that most of my nursing textbooks, feel free. Nice credentials by the way. I could add Regional Faculty behind most of mind but since I know what it means in the grand scheme of things. I won't. This is an interesting topic. I enjoy it.

I will try to stay civil because I do choose to repond. You are an idiot...I AM TEASING>>>LIGHTEN UP Every scenario I have discussed involves an MD being at the bedside. Not some lowly CRNA. AGAIN TEASING...I respect these guys and gals as much as anybody on this board. I am just sick and tired of people quoting 47 pages of crap that, if you read the PDR, a lowly RN would never be able to do anything. I teach ACLS, PALS, NRP,TNCC. I know what is involved in these courses. I also I have several close friends who are CRNAs. I have a pretty good understanding of what is involved with their training. No one,including CRNAs, are guaranteed to be able to handle an emergency as a new grad. It takes years of "under the gun" training. Hell, we are traing med aides in nursing homes and in the VA centers. Why do these pts rate such poor care. The proof is in the pudding, we have given over 10,000 doses of Diprivan in Endo and Cath labs with fewer complications than given aspirin on the floor...with RN pushing and MD present. If you choose to respond and can keep it shorter that most of my nursing textbooks, feel free. Nice credentials by the way. I could add Regional Faculty behind most of mind but since I know what it means in the grand scheme of things. I won't. This is an interesting topic. I enjoy it.

My point with Diprivan Stevierae. Nothing could be more critical than having a catheter inserted through 2 chambers of the heart and into the pulmonary circulation system. Leave it wedged...major problems. Have it pulled back into the RA...major problems. It did take us a while to gain the Dr trust. They were the dinosaurs that thought nurses did bedpans and baths. Once some of the newer docs started letting us do these and saw that it was rather simple...things changed. Is Diprivan more dangerous than a manipulating a swan??? Are the complications harder to deal with??? DO NOT misunderstand me please. I realize that Diprivan, like many other drugs, must be used in a closely monitored situation with competent staff but to say that a anesthetist MUST do it is a little old fashioned in my books. DO understand that my view pertains to Cathlab, Endo, ER where the physician is on the scene.

My point with Diprivan Stevierae. Nothing could be more critical than having a catheter inserted through 2 chambers of the heart and into the pulmonary circulation system. Leave it wedged...major problems. Have it pulled back into the RA...major problems. It did take us a while to gain the Dr trust. They were the dinosaurs that thought nurses did bedpans and baths. Once some of the newer docs started letting us do these and saw that it was rather simple...things changed. Is Diprivan more dangerous than a manipulating a swan??? Are the complications harder to deal with??? DO NOT misunderstand me please. I realize that Diprivan, like many other drugs, must be used in a closely monitored situation with competent staff but to say that a anesthetist MUST do it is a little old fashioned in my books. DO understand that my view pertains to Cathlab, Endo, ER where the physician is on the scene.

The last care plan I did in school was 24 pages. My best friend and I choose our patients. They were identical, same diagnosis (CHF), same Dr, same meds...I suggested he do the first half, I would do the last half...we would swap and have a complete Care Plan. We did it and turned them in. Identical Care Plans to two different instructors. He got a 96, I got a 74. The worst part of it was I couldn't complain because they would know we cheated. And the last JCAHO nurse surveyor I talked to agreed that nursing diagnosis/Care Plans made no sense to him.

No hostility here (I don't think). I have seen situations in ER where we have several RN,CCEMT-P working. A patient comes, difficult intubation, facial trauma...anesthesia is called, can't get the tube in. Critical care paramedic is mentioned. People who have lived and breathed this sort of thing and told they were not "qualified" and if a Dr couldn't do it, what made them think they could. I have been in the same ER with a different DR in charge that would allow help. Things went very well. I saw an LPN under a DR direct supervision make an incision for a PEG tube. I hit the roof. Stupidest thing I had ever seen, certainly not in her scope of practice. The DR told her exactly where, when, how... she had seen it done hundreds of times. Dr was holding the scope...Guess what, the patient did fine. No I don't want an LPN cutting on me but if the DR is there, guiding every move, much like they are when the RN pushes Diprivan, it will be OK. Do I want the RN in a rural clinic with a PA pushing Diprivan. No. I just hate to see people with such a closed view. When I started in ICU the only person to even touch a Swan Ganz was the DR. He did COs, wedges...never dreamed a nurse would be able to DC one. After a couple of years...call a DR to do one of thise procedures and see the *** chewing...

Kudos to you Yoga for being the only person in the medical profession intelligent enough to do anything. I also work with RNs who think the LPN should only do bedbaths and bedpans. I think it has something to do with job security.

It never ceases to amaze me what 2 more years of education does for some people. Yoga needs to realize setting in class is not the only way to learn good pt care. I know some MDs that spent more than 2 years in class that I wouldn't take my neighbors dog to. Sometimes it is the "cowboys" that are out there saving lives while others discuss who has the best education.

I think it is a great tool as well. Still don't know how to deal with students.

remember kiss, keep it simple...don't rewrite the pdr on a drug card. most drug books have the critical, life threating ses, containdications...in bold. i also think it helps to write the information (helped me) toimplant the information in your mind. what do the students ahead of you say. they have been through this. what do you need to safely administer meds and answer the patients questions?? most instructors want to see what you feel is critical for that med. things change from pt to pt. how do you use the info on your card to critically think about your pt. they would let you use the book if they wanted everything listed...

That's the way it was here before the "new, latest and greatest technology" was implmented. IT is a nightmare for our staff and the students. The school has already told us that they will have to go to a small, rural hospital to get medication administration clinicals if we can't do something different. Being able to co sign one time after all the meds were scanned would be acceptable, but to scan and co sign after every single med is not functional. :angryfire