RedERRN

Provigil's generic name is Modafinil. According to the prescribing information found at provigil.com, "PROVIGIL (modafinil) is a wakefulness-promoting agent for oral administration." and "The precise mechanism(s) through which modafinil promotes wakefulness is unknown. Modafinil has wake-promoting actions like sympathomimetic agents including amphetamine and methylphenidate, although the pharmacologic profile is not identical to that of sympathomimetic amines. At pharmacologically relevant concentrations, modafinil does not bind to most potentially relevant receptors for sleep/wake regulation, including those for norepinephrine, serotonin, dopamine, GABA, adenosine, histamine-3, melatonin, or benzodiazepines. Modafinil also does not inhibit the activities of MAO-B or phosphodiesterases II-V." What makes it even more suprising to me that Provigil is being prescribed post-cath is what the website has to say about cardiovascular side-effects: "In clinical studies of PROVIGIL, signs and symptoms including chest pain, palpitations, dyspnea and transient ischemic T-wave changes on ECG were observed in three subjects in association with mitral valve prolapse or left ventricular hypertrophy. It is recommended that PROVIGIL tablets not be used in patients with a history of left ventricular hypertrophy or in patients with mitral valve prolapse who have experienced the mitral valve prolapse syndrome when previously receiving CNS stimulants. Such signs may include but are not limited to ischemic ECG changes, chest pain, or arrhythmia. Modafinil has not been evaluated or used to any appreciable extent in patients with a recent history of myocardial infarction or unstable angina, and such patients should be treated with caution. Blood pressure monitoring in short-term ( larger when only studies in OSAHS were included, with 3.4% of patients on PROVIGIL and 1.1% of patients on placebo requiring such alterations in the use of antihypertensive medication. Increased monitoring of blood pressure may be appropriate in patients on PROVIGIL." Of course, I have yet to ask one of the cardiologists who is prescribing this WHY they are prescribing it - I also haven't had to give it since my original post :)

I have recently run across patients who are post-cath that have an order for PO Provigil 200mg BID. I have yet to ask a cardiologist the reasoning behind this, but I have researched the uses of Provigil. All I can find is that Provigil is used for narcolepsy and correction of circadian rhythms in those who do shift work (labeled uses) and in post-traumatic brain injury patients to help restore neurologic function. I have asked and asked other nurses (including the director of our CVU) and pharmacists and no one else know the reasoning either. Have any of you run across this? Why is Provigil being used in select post heart cath patients? Thanks for any input.

Highest BP: 277/224 (My mother in law during adrenal crisis) Lowest BP: 20 systolic (pt fresh in from EMS - came in "nonemergent" ) Highest blood sugar: 1900 (my case-study for nursing school - Dx HHNK) Lowest blood sugar: 8 (and the patient lived!) How about highest potassium? For me it was a 50-something-year-old lady with no Hx of dialysis that suddenly became "paralyzed." Her potassium was 9.9 - nonhemolyzed!!!! She was cured by immediate insertion of a quinton cath and dialysis!

What about the coroner? Could he/she convey this information to the family without negative retribution?

Always take into consideration what the nurses have going on in their rooms. For example, if Nurse Smiley has an STEMI in one room in prep for stat cath lab and a patient with ARDS in prep for RSI in another room, then she is not the nurse to send the 101y.o. full code from EMS who is now apenic and unresponsive. Never, never, never enter the room and just stand there watching your staff work their butts off (I had a charge nurse who would just come and stand at the door during codes...she never offered help or anything)! Do whatever it takes! If the patient needs poop cleaned off of them so they are presentable enough to go to the floor then clean them up! While being chums with the other members of administration can make you feel more powerful and may help you climb the proverbial ladder, making friends and having fun with your staff is waaaaaayyyy more important - after all, we see ourselves as your coworkers. Oh, and CONGRATULATIONS!!!!! :yelclap: ~*~Sally~*~

I am sorry that you are going through this with your staff. It sounds very frustrating; however, I am sure the nurses are not intentionally leaving the labels off of the lab draws. After all, that only creates more work for the RN by having to recollect the specimen... Sounds to me like your perspective is not from the staff nurses' perspective - not that that's a bad thing...but in this instance you should really seek out the staff nurses' advice. Pick their brains. Maybe you could even set up a "Task Force" of staff RNs to nit-pick and address this issue thoroughly. This would not only address the problem at it's root, but it would make any necessary changes more acceptable by the staff since they wouldn't be changes "forced" on them by management. [banana]Just my $0.02.[/banana]

This sounds to me like a classic case of MI-induced heart failure. Possibly these changes were due to an infarction she experienced prior to the CABG? That would explain the "wet" lungs and dry bladder... If this is the case, you cannot prevent the A-fib in her. You just have to do exactly what you did: monitor her and treat as necessary.

The ER I work in has a policy where all patients meeting triage levels of 4 or 5 (we use the 5-tiered ESI) are sent to "Quick Care" where they receive a MSE (Medical Screening Exam) by a physician. If their chief complaint is then deemed to be non-emergent, the patient is instructed by the physician (by scripted dialogue) that their condition is not an emergency. The patient is then given the option of #1) staying at our facility to receive treatment after paying either $150 cash or their entire non-emergent co-pay or #2) leaving our facility to seek care at one of the many urgent care facilities across town or with their private MD. The reasoning for this policy is that soooo many patients present to the ER with non-emergent complaints. These patients contribute to the overcrowding and sluggish throughput. Unfortunately, we nurses can't legally tell them that they are not having an emergency and need to leave. According to EMTALA, all patients must receive a Medical Screening Exam by a physician. By following our policy we cover all the bases. It seems to work WONDERS...and word has spread pretty quick around town, too!

Hmm, it's kinda funny that you posted this because I am going through the exact same thing - except my area of 3 years experience is the ER. I've deliberated about making a change from the ER to the ICU for about a year now and I have finally decided to make the leap. The hospital that I work in is VERY bad about holding resentments against those who do departmental transfers within the hospital (ie ER to ICU) so I am going to a different hospital to do work in the ICU there. Maybe you could use a good break from the same thing too. I've talked to almost all the 15+ years experienced nurses that work in my ER and every single one of them says they experienced the same type of thing early on in their careers and switched to a different specialty for a while. That is the best benefit of being a nurse - we get to choose where we work and what we specialize in...might as well close your eyes and jump - as long as no bridges are burned, what can it hurt? Sally

NS here

I have been feeling really, really burnt out lately. I used to love my job and look forward to going to work everyday. Now it seems like every new patient is a new stress that I will leave feeling "incomplete" about. I find myself wishing I had critical care holds so I could spend the time with them that is enough to leave me feeling satisfied about the care I've given. I don't know if I'm going through a temporary burn-out or if this is forever... Are any of you going through this, or have you experienced this before? Just out of curiosity, I was also wondering if anyone knows any statistics on the average number of years spent as an ER RN before moving on to other departments/careers... Thanks Sally

I'm like gonzo1, I've had only 2 patients in situations where they needed it IV...and it was a very slow IVP...I give it IM fairly routinely.

That is toooooooooo funny!!!!!!!!! :rotfl: :rotfl: :rotfl:

Wow. This is a perfect example of "eating your young." Great job, digidog!

In my ER these things are not optional...they are mandatory. We spend 90% of the time with no available adult ICU beds...NONE. Our ER becomes the ICU overflow area. If a patient needs CVP monitoring, we do it. Central lines are inserted by the surgery residents. A-lines are commonplace for the Level I area of our ER and all those rooms are stocked with A-line setups. There are a few things that we do not do: most enemas epidurals PCA pumps

Sounds like its time for a d-dimer and spiral CT of the chest to rule out PE (fat embolism). This is VERY common after ORIF of long bone Fxs.

Gosh...you must work at The Med in the ER with me.... :trout:

Hi all! I work as a staff nurse at a major hospital - I've worked in the ER there as a RN for 3 years and I worked there for 1&1/2yrs while in nursing school. Recently I've become really, really frustrated with the way the hospital treats staff nurses. I only make $0.75/hr more than I made when I had just graduated nursing school - before I took the NCLEX! On top of that, our benefits really, REALLY stink. Honestly, I could go on and on and on about why I am so frustrated with this place where I used to be proud to work. I'm starting back to school in June to complete my RN-BSN and I won't be able to put in any overtime...that means I won't be able to make ends meet financially. So, I'm thinking that I should resign from my frustrating staff job and sign on agency for local ER assignments. I have talked with 2 local agencies, MSN and AAS. I talked to the folks at my local MSN office today and the lady I spoke with quoted me anywhere from $35-$39/hr with no assignments more than 30 miles from my home - that's about $10-15/hr more than I make now. She also said that MSN offers benefits and 401K. I don't know about AAS. I have a meeting with the folks in our local AAS office on Tuesday so I don't have many details about what my options are there as far as benefits and pay. So, what would you do in this situation? Are you almost always able to get shifts when you want them? Are there any reasons you regret being agency? Thanks ahead of time for your input! :)

Hi all you southern belles and gents! I'm Sally. I live in Macon and work at The Medical Center of Central Georgia in the ER. I am currently in school to complete RN-BSN and should be done in August 2008.

I'll go first... What functions do the nursing assistants provide in your ER? stocking rooms, transporting patients, drawing blood, helping place patients in gowns, entering lab orders...the problem is that there is no real way to hold them accountable to actually doing these duties and MOST of the time all of these duties fall back on the RNs Does your ER have good RN/Assistant relationships? No. The assistants (we call them "techs") don't like to be asked to do anything but when nothing is being done the RNs ask the techs to do something and the techs usually come up with some reason why they can't do what is asked of them...although, this is not true for all of our techs, some are really, really helpful What requirements does your ER place on new-hire assistants? no previous experience required but must pass EKG class (for telemetry monitoring), phlebotomy class, and BCLS What is your ER's nursing assistant to patient ratio? on a good day (which are rare) it is about 1:6. Usually it is about 1:20 and sometimes it is 1:52 !

Quick Poll: What functions do the nursing assistants provide in your ER? Does your ER have good RN/Assistant relationships? What requirements does your ER place on new-hire assistants? What is your ER's nursing assistant to patient ratio?

I don't remember the exact words he used, but one of our genuine medical frequent flyers presented one night because he had slept with a prostitute and then proceeded to wash his privates with bleach "so I wouldn't get an STD." Ummmm.....yeah. He was airlifted to the nearest burn center!

I'm sorry you had the experience of a gum-smacking country-music-listening gal working in triage :uhoh21: . I'm sure that had to make you question the professionalism of the employees there straight from the start. I can completely understand that this triage nurse, who also seems to have been less than polite, would make you skeptical as to the professionalism of the care you were receiving. Its funny how we, as ER nurses, don't always realize the impact of that first impression - the triage nurse - on the patient's perception of care given. You mentioned that this hospital is a Magnet designated facility. Magnet hospitals strive to follow Best Practices. In the ER it is Best Practice to divide patients based on Chief Complaint into different zones of the ER. In my ER you would have been triaged to Fast Track - the decision of which zone a patient is placed in is made by the triage nurse. The management of the ER must trust the triaging skills of your triage nurse to have her assigned to be in triage. Anyway, patients are assigned to zones based on Chief Complaint. In this instance, your Chief Complaint of n/v/d :barf01: does indeed sound to be more gastroenteritis (stomach bug) than pancreatitis or colitis. The doc probably read your chart, noted what zone you were in, made sure you weren't actively dying (laid eyes on you) or in danger of dying (labs). I would be upset if I had been in your place last night. You're probably thinking something like "what the heck am I paying all this money for if the doctor isn't even going to listen to me with his stethoscope." As comforting as it may be, a stethoscope is not a diagnostic tool. It is used to help decide differential diagnoses - differential diagnoses determine what tests, xrays, and labs need to be preformed. In your case the doctor was correct to form his differential diagnoses by knowing your Chief Complaint and talking to you. He was completely correct to go ahead and order diagnostic studies (labs and xrays). I know that it is hard to change the way of thinking that a doctor should listen with a stethoscope etc; but, with today's technological innovations, that is no longer necessary. Maybe the doc was thinking, "Hey, she's a smart gal! I don't want to listen to her with my stethoscope and have her think I'm some old-fashioned, uneducated doc." You never know. I'm sure that your negative feelings of the doc not listening with his stethoscope were compounded by that first impression given by the triage nurse. I am an ER nurse. I work in triage very frequently. I plan to share your experience with some of my coworkers because it helps to prove the point that the triage nurse should remain the epitome of professionalism at all times (and NEVER chew gum)! I'm sorry you felt you had a bad experience. I hope this clears up some of your frustrations. But most of all I hope you are feeling well!!!!! :icon_hug: Sally RN

What is a day usually like in the ER? I work 7a-7p in a Level 1 trauma center at a 700+ bed hospital. Our EC has 52 beds that are divided into Quick Care (Urgent Care), Pediatrics, Fast Track, Level 2 (main EC beds), Level 1 (ICU/critical pts), Trauma, and Chest Pain Center. Upon arriving to work we are given our assignment which consists of 3-4 rooms in chronological order in a specific zone. Ideally the nurses in Level 1 and Trauma only have 2 pts but we are so short staffed that this rarely happens. Each nurse sees an average of 6 new patients a day. This is in addition to the 3 or 4 patients that are already in the rooms when coming onto shift. Each patient is in different phases of care. Some are just in from EMS, some are waiting on disposition, some are admitted and waiting on hospital room assignment (which can literally take days). In our EC, the nurses do most everything because our techs are not held accountable for any of their assignments - :angryfire: this is a really big issue contributing to our high turnover of RNs. What all diagnoses do you see? If it is a diagnosis, or even a symptom, we see it. Our hospital is also a Neuro Center, a Heart Hospital, a Childrens' Hospital, and a Trauma Center in addition to being a teaching hospital and the only indigent care facility in our area. How many patients do you see? Each nurse usually has 3-4 patients (most of the time 4 pts since staffing is sooo bad). The nurses in Level 1 should have only 2 patients based on the hospital's Critical Care standards of practice...yeah, right. Sometimes the nurses in Level 1 will have 4 patients - but rarely more than 3 are actually critically ill. In one day each nurse sees a total of 9-13 patients each day on average. How long was your orientation? 12 weeks - it included 3 12 hour shifts per week in addition to 3-6hours lecture per week on Emergency Critical Care and ACLS, PALS, and TNCC certification. What qualities/skills do you feel are important? Honestly, the most important quality/skill I possess is the ability to compartmentalize. Quick thinking, excellent rapid assessment, very good communication, and patience are the most important nursing qualities/skills.

What steps do I need to take to move myself, my career, and my family to the UK? I have considered a temporary work visa but I think I would be more likely to go for citizenship - not entirely sure though. I have a husband who is currently in college for a Bachelors degree in Business Management...we would wait until he graduates in 2009 before moving to the UK. We also have 2 children - a 6-year-old and a 2-year-old. I know there are different grades for nurses in the UK. Would that be an issue? I live in the USA and work as an RN at a large hospital (700+ beds). I work there in the Level 1 Trauma Center designated EC. I am going on 5 years experience there with 3 of those years as an RN. I also have ICU experience. Any input is greatly appreciated!