chocolateheals

Great questions. What I know about insulin gtts does not defy logic, so I hope I can help you understand. For our DKA'ers and HHS'ers, we have extremely detailed protocols and "decision trees" for titrating the insulin drips. This is so that we can take care of these poor patients with the highest standard of care- the whole protocol is based on a lot of research, and took our awesome diabetes team years to write. These are very complicated cases.. and the DKA or HHS diagnosis is on top of other medical or surgical problems that you and the doctors are trying to work on... even more to think about. Our protocol details when to draw labs (ABG, lactate, chemistries), and what fluids to use and when (once glucose is below a certain point, we add KCl to the fluids). It's also designed so that we don't bring the glucose down too quickly. I'll spare you all the details of it- it's pages long, back and front. After I post this, I'll rummage around to see if I can send you a copy. A great thing about our protocol is that the doctors in the ED take an empty order form off the shelf, and check boxes that are appropriate for the patient, but most of the boxes are already checked (like lab frequencies, etc). So that at 3am, the exhausted new intern is less likely to make a mistake or overlook something vitally important. Maybe one of the best things about having a strict protocol is that doctors cannot arbitrarily pick times, fluids, doses and types of insulin to give, and let a patient eat without it making sense. If you take one situation, and ask 15 different doctors to give you and order, I bet you'd get 15 different orders. You don't understand? Neither do the doctors. Not to cut them down, but they have to know a lot about a lot. And they're not going to keep it all in their heads. Unless they're an endocrinologist, they're bound to miss something. As far as eating... if they are in DKA or HHS, they MUST BE NPO while on the insulin gtt. (As someone else mentioned, if they are on a continuous enteral feeding, it's fine to be on an insulin gtt for tight control.) Once someone is alert enough and aspiration is not a concern, they can ONLY have water and ice chips. They may beg and plead. Too bad. If we do it right, it really reduces the time they spend in the hospital. Plus, a lot of these folks have gastroparesis from their diabetes, and are likely to throw up once they eat anything, so I encourage them to go slooooow. Our patients cannot eat on an insulin gtt until they've been at a goal glucose level for a set number of hours. The steady amount of insulin they are receiving = their BASAL insulin needs. In other words, the amount of insulin their body needs to carry out its metabolism, all the time, day and night, regardless of food intake (which is prandial and correctional). Then I call the doctor and ask for a diet. Then I proceed to tell the doctor that I will not let the patient eat any food until I have a sub Q insulin order IN THE CHART. Sometimes they say "yeah, good" on the phone but then it takes hours for them to get to the acute care to write that order. If I haven't let the patient eat yet, I carry on merrily with my now stable insulin gtt, with my patient still NPO. The doctors use a calculator that they access online, plug in the amount of insulin the patient has been getting on the gtt, and are able to convert that into an appropriate subcutaneous dose and type of insulin. Once I've got my subQ and diet orders, I give the patient the first sub Q insulin injection, and leave the drip on for 2 more hours, and let the patient eat. I hope my answer helps you. I like **LaurelRN's answer a lot, too, and didn't want to be repetitive. It's really good that you care enough to ask these questions. I think you could be very instrumental at your community hospital and could be a part of a diabetes team, or help institute a protocol to manage these patients better. It will save your hospital money if these patients are managed correctly and could be great for your resume. A big idea, especially if you are getting used to your first year in the ICU. Perhaps you could just suggest the idea to your manager. What do you think?

Thanks for the encouragement BonewaxRN. That was very helpful at the time. It's been almost 6 months now, and all my tests have been negative. I'm just putting it out there in case other people are reading this who are scared about a recent stick. Keep your chin up!

Hmm. Maybe I missed the point of the "admission unit." Are the patients physically moved from the ED to you, then to the floor or ICU? The hospital I work at has an ED, but patients who are admitted go directly to floor/ICU. We do have something called "ED observation" which is opened if the ED is especially busy. Patients go here if: 1. The ED is full, and they are not sure if the patient will be admitted at all, so some additional workup/ observation is done there. Or 2. If the ED is full, and there are no acute care or ICU beds open. I will say that there is some delay in our admit labs and treatment if the floor is busy... but a new patient will obviously get priority over someone present and stable. But, it sounds like th is is happening in your admit floor too. Interesting. I'd love all the hx and paperwork to be done by the time they get to me, though!

That is great news for you. I see this thread is fairly recent, too. I just came home after starting my morning with a needlestick. This patient is already known to have hep C. Mine was after I gave the pt. SQ insulin. I immediately washed, bled, bled some more. Somehow I got 2 stix on my finger, I don't know what the heck I was doing! Not sure if it was a thru and thru. I went to our ER right away, and so far I know the source is HIV neg. Like you, I'll be calling employee health on Monday. After I got back to my floor from the ER, I re-grouped, and my life flashed before my eyes. I told myself I won't worry until I hear results. Have heard about multiple stix on my floor, all of them with + source infections, and NONE of the nurses contracted diseases. Still, I am so worried right now. That's why I came here to see what others had to say! Glad to hear that you are safe and sound. Here's to us trying to be safe with the rest of our needles!

I'm wondering if you have had an opportunity to talk with your father's doctors- is the cough new maybe from a HAP? Or is it merely still due to fluid overload? Or with a constant cough like that I wonder if it could be from an ACE inhibitor? I hope your father mends up nicely and starts to feel better

Sounds like a plan. Good for you for being willing to move to get a job. If you are a new grad, it should be much easier to get a job in a location you like better, once you have a couple years of experience. Anyway, yes I'd call the HR of each hospital you applied to before you leave for your trip, to see if it's possible to set up a meeting. Dunno though, they may just refer you back to the nurse recruiter? Best of luck!

Based on the info you gave us, I think it could go either way. She could be normal, or she could be kukoo! The "staffing changes" could have only one positive interpretation, if a couple nurses are going through life changes and need to move or psych was never really for them and now they get to change units. So not 100% guaranteed to be a negative thing, but it is not DEFINITELY a red flag. In the end, go with your instincts. I had interviews with 2 of the nurse unit managers at one hospital, back to back. The first one (we'll call her Manager 1) seemed to have trouble articulating what she was thinking. Her office was more cluttered than I even knew was possible. I walked to the next interview vowing that there was no way I'd work at the first place. I've been working 2 stories above Manager 1's floor for a couple years now, and am always SO glad I went with my instincts about that interview. I've heard that the floor staff are great, but the management makes working there a bit miserable. Best of luck with your interviews and decision making!!

I worked with this pt for a couple weeks. He had been a trucker, but had just quit his job for rehab, because he had an MI a couple weeks ago. He was sitting on his couch at home when a truck went through 2 walls of his house and HIT HIM. (When you think you're safe...) The driver had a seizure and lost control at a high speed. Anyway my pt had tons of fractures and quite a bit of hardware put in, but remained amazingly optimistic! My hero! This was just after I had a patient (straight laced, no IVDA) with bilateral shoulder necrotizing fasciitis. I've worked at this hospital for exactly 6 months now, and suddenly ridiculous Grey's Anatomy cases don't seem as ridiculous... And I had a pt with RABIES, that's right, rabies!! No one has rabies! I could NOT believe what I was hearing when I got report! I tried not to laugh all shift, as I kept remembering "The Office" episode where Michael makes them do a rabies fun run. This poor pt was bitten by a bat 3 times on her neck, and did not seek medical attention for two months when the site was numb/tingling . Maybe she was embarrassed? My heart goes out to her because she seemed like a wonderful person. If you are bitten by a rabid animal, please wash and go to the ER.

This is a funny thread. On the giving end: I don't mind using needles at all. I try to never get so casual that I let myself set down a used needle. I always try to make myself go to the sharps ASAP as good practice. And I'm convinced that the first day I wear sneakers like everyone else, a bobbled syringe will result in the needle going straight through the mesh into my foot. This is why I still wear my unattractive thick leather nursing shoes. On the receiving end.... I like to watch IV starts (they're kinda gnarly), blood draws, the intradermal "skin bleb," and I've never had a sub-Q but would probably watch. But the idea of getting an IM makes me sweat. I think it's the idea of that much fluid being pushed between my muscle fibers, it kinda freaks me out. Anyway, to answer your original question, I don't think my attitude has changed at all since becoming a nurse. I'll always be fascinated/scared of the same stuff, tho hopefully getting IMs will become easier as the years go by!

Hello Blaze~ I just made it through nursing school. I was a tutor for for 5 semesters at our school's "Learning Center." That being said, I saw that there are lot of reasons why people have a tough time making the grade. My best advice is: Network, network, network. Make friends with people in classes/semesters above you. Get to know people in your skills lab. Ask them the best teachers to take. When you find out your schedule, ask them tips on that teacher. Let's face it, not all teachers go by the book, sometimes they test more on lecture. Without cheating, you can find out A LOT about your professor's teaching style, test-writing style, and paper grading style. Insider tips can make or break your grade. It could even bump your B to an A in the end. People learn differently... some learn better in study groups where you talk about what you're learning, some do best by burying themselves in books. Don't be shy!!!! Ask your classmates to meet for a study group. Chances are, they would like to but A) are also being shy, B) Aren't motivated enough and need a little push, or C) are already in a group and can invite you. Study groups can save you from HOURS of extra studying. Be organized. By the time it is midterms or finals roll around you are BUSY!! If before/after every single class you spend a couple of minutes organizing your powerpoints in a 3 ring binder, this will save you significant time and stress by test time. Staple whole powerpoint lectures together so that you don't lose pages. Arrange papers in order of class. If you take notes on separate pages, put them next to the powerpoint for that lecture. Use something cheap like a sticky note to mark each week, the topic, and book chapters covered. This way, when you want to study a topic, or a friend asks you a specific question, you can turn quickly to it... stress free. This seems simple, but when I told this to students, their eyes lit up and they later gave me feedback that it really helped them. Talk to your professors. Sucking up is not required. But if you come up with a question during class and do not raise your hand, see them after class and they will have more time to clear up your confusion. Go to office hours. People always have questions about papers... a lot of professors told me that if students would have simply visited their office hours to review a paper before it was turned in, they would have gotten a much better grade. Again, this is not sucking up... it is just a part of going to school! An added bonus to this is if you get to know your professors, they can potentially be a great reference to you later for a job. Most professors love investing in people's success. Go to a tutor. All schools have academic support, so check out that office. Check it out even if you don't feel like you need help. Get the name of the tutors for your class. If they have office hours, go to them. If they hold study groups, go to them. DO NOT FEEL "STUPID" FOR GOING TO A TUTOR!! As a tutor, I worked with students who had learning disabilities, people with ADD, students who failed tests, and fantastic, organized A+ students, and everything inbetween. People won't judge you for going to a tutor- chances are, they will admire your for working so hard and being dedicated to your studies. Tutors have the job because they WANT the job. They love to help people. The best part is, they can direct you towards what you need to be studying more, and tell you the information that you don't need to worry as much about. :wink2: They can also work with you on test-taking skills. Well, I could go on and on, but I feel that's some of the best advice I have that would apply to any school. If you follow all of these, the next thing to do is to make sure you make yourself take some time to HAVE FUN!! Best of luck

Hello all! I am hoping to get advice or at least people's . I graduated with my BSN in May 2008, and did a military move with my husband away from my school state. Took and passed my boards... Next month he will be deployed for a year, so I am moving again and interviewing in the state I grew up in, with family around. Right after he comes back from his deployment, my DH will be done with his active duty time, so we can pick where we want to be. We'll most likely stay where I've been, putting down roots while he was gone. I am thinking about starting with med/surg, since that seems to be most people's advice. But then again, I did a preceptorship in a cardiovascular ICU for my last semester in nursing school. There ARE new grad ICU positions out there, but I keep pulling back on my own reigns, try to tell myself how horribly stressful it would be, and make myself look into the med surg jobs again. After that ICU experience, med/surg seems so boring!! I am very aware that a med/surg job would still be very challenging for me at first, because there is so much to learn, and who doesn't need to work on their time management? But the things I'll be busy with will be different... in med surg I'll be waiting for patients to use the commode, bringing them tea, and helping them with their knee bend exercises after a knee replacement. In the ICU, I am trying to put an IV in someone who is really sick, titrating multiple meds at once, and watching doctors place art lines. So much cooler! In the end, does it REALLY matter where I start?? Shouldn't I just do what I love, if there is an opportunity to do it? I am thinking of going back to school in about two years... I'd like to be an NP. I love cardio stuff, ICU stuff, want to be an adult nurse practitioner some day, would LOVE to work overseas (medical mission type stuff) for at least a year of my life, am now 23 and would like to start a family just before or at 30. Which means having a pregnant body, then maternity leave. Am I a crazy person?? Can I do all this?? Should I try to plan it now?? I realize that I'll probably end up adding to my list of passions as I learn about new things I like. Basically... I've said what I'd love to do in the future, is there any way I could screw that up NOW and pick the "wrong" job? Would a grad school be more or less likely to accept me based on what type of nursing I have done in the past? I believe I should stop asking questions now. All my fellow graduates in my class seemed to be so smooth about their first job pick. How can I be that confident? Thanks for listening, and thanks for comments/advice.

This is a very timely thread for me, because I had my first interview yesterday, and another tomorrow. I think it is a safe guess that, after I'm done with all my interviews, I will have to decide between several offers. (There are a lot of hospitals in an area about 60 miles North/South, and I haven't moved here yet, so I can move close to whatever hospital I end up working at). My older, wiser sister recently sat me down and wanted me to know that a lot of women have a hard time asking for a raise or salary negotiation. She wanted to know if I felt that it would be hard for me to talk with management/HR about money. My reply to her was that we learned in our last nursing class that you just take the job you want, and don't get to pick your salary/ $ per hour as a new grad. I appreciate everyone's feedback, as I'm still not sure. At this point, though, I am encouraged that it really wouldn't hurt to ask for a few more dollars per hour. They could always say no, but it's not like they would take back the offer altogether.

Well... I am also a poop dreader. This advise comes from the heart, because I have the same struggle. I have just finished nursing school (My graduation was yesterday, YAY!!!) and here is the advice I have for you as a pre-seasoned nurse. Don't put off cleaning up poop. Sure, there's always a chance that they will go again right after you have cleaned them, but it's better for everyone if you just tackle the beast and get on with your day. If you hate poop that much, chances are you will just feel dread starting when you find out your patient has gone until it's all cleaned up. Why not just cut to the chase, spend less time dreading, and get it over with? This really took me a long time to come to terms with, but it really makes my shifts a lot better since I realized this. Sometimes it makes me gag. I can look at poop, talk about it, whatever. I have no problems with it mentally or visually... but the smell makes me gag despite any reasoning I try. There is no mind over matter when it comes to me and the smell of fecal matter. Maybe in time I will just happen to get over it. The worst thing is that I don't want other nurses to think I'm being silly, dramatic, and unprofessional if I gag, and I don't want the patient to feel worse than they already do. Carry Burt's Bees chapstick in your scrubs pocket, and if you know that you will have to clean someone up, put some on your upper lip and maybe a little bit in your nose before you enter the pt's room. It helps. My favorite advise is from another student. As funny and gross at it sounds, it really helps. As you are reaching out to turn the patient, wipe them, or whatever, you will be looking down and extending your arms. Discreetly sniff your armpits if the smell is really bad. Sooo stupid, but it works, and you can laugh about it in your head. Humor always helps. (Just don't smile, keep your nurse face on) Double gloving is also nice when you are going to be doing something dirty. Hope this helps