indynurse

Whenever I am precepting a new nurse who doesn't have any OB experience, I try to find out from the previous shift which moms have the best fundus. Some of the really small women have a fundus you can practically see before you even palpate for it. For the harder to find fundus, I will palpate first and then tell the newbie where to find it. After a few of these, I will make her assess the fundus first and then have her tell me where to find it. If you are ever in doubt about a fundus, get a second opinion. Maybe the fundus really is boggy. Maybe her bladder is full and her fundus is displaced to the side. And then again, maybe she is just "extra fluffy" and it is difficult to find. Don't be afraid of causing a little discomfort when you are checking. Explain to the pt why it is important for you to do what you do. Have the patient lying completely flat in the bed. I find it easiest to palpate the fundus that way. If the fundus is boggy, do not be afraid to massage it. I have never massaged a uterus from boggy to firm to atoney. Whenever you are in doubt, get a second opinion. It is hard to trust yourself and your judgement on day two. Where is your clinical instructor? If he or she is unavailable, find out who the nurse is who is ultimately responsible for that pt on that shift. If the student thinks one of my pts is boggy or bleeding heavy or doing anything "worrisome" I want to know about it and if the instructor can't go check on it with them right away, I want to do it. Whenever a student is caring for one of my pts, I try to sneak into the room before the student, introduce myself to the pt, let them know that a student will be taking care of them and if they have any problems or concerns to let me know. Sometimes, if I hear something in report about the pt that worries me, I will do a quick assessment. The clinical instructor takes her students around each morning and introduces the student to her patient's nurse. I make sure they know that if their (my) pt needs anything and the instructor is tied up with another student, the student can come and find me and I will help. I remember plenty of rude nurses from when I did my clinicals and did not appreciate the way they treated nursing students. I enjoy having students on the unit and find that they can be very willing volunteers when you need help with something like transferring a pt from the cart to the bed. We had a day a couple of years ago when things were going to down the tubes for two of our pts at the same time and the nursing students and their instructor pitched right in and kept things from getting even uglier.

I've worked as a "tech" twice since I became an RN. The first time I was a fairly new RN and got pulled from my med-surg unit to a gero-psych unit to be used as a tech. When a tech they had missed seeing on the schedule showed up, they decided to still keep me as a tech anyways. I quickly figured out why they weren't using me as an RN. The RNs on that particular unit sat on their rears and let the techs do all of the patient care. One nurse left the nurses station one time in the eight hours I was there. (the bathrooms and breakroom was in a locked area behind the nurses station, so they didn't even have to go onto the floor for a potty break. After that evening, the only time I had ever set foot on that unit was to respond to a code. Where I work now, I was on-call one day and was called in to replace a tech (on my own unit) who was too ill to finish her shift. It was fun. Much less charting. If the nurse I was teamed up with was busy, I was able to give PRN's to her patients so they would not have to wait. The other nurse thought it was great to have a nurse tech with "super powers". We tried to talk our manager into staffing like that more often, but for some reason she would not go for it.

Been there, done that, received the e-mails and it didn't work so well. While we were free to e-mail our comments or concerns, most of us felt like our concerns weren't being addressed as well. Now, we are back to the monthly "live" meetings.

I have a co-worker who returned a pair of work shoes after she had worn them for three months because they squeaked. The store clerk told her that there had been many complaints about her particular kind of shoes so they replaced them. It wouldn't hurt for you to check with the store where you bought them or even contact the manufacturer. If they know of a problem, they may replace them for you.

I was taught in Nursing school to push the needle through the skin quickly and then push the plunger slowly to give the med time to start disipating into the surrounding tissue. I rarely have anyone complain and the ones that do are the ones who jump when I am swabbing the site before the injection. Of course, the best pts to give injections to are the ones still numb from their epidural. :-)

Be upfront about the prescription med use. If you have proof it is prescribed for you by your physician you will be fine. My mother was in a MVA a few days before she had to take a drug test. She was given Vicodin and Flexiril for a strained back and neck. A few days later she was called and offered a position dependent upon results of a drug screen. She explained the meds on the form she had to fill out prior to the drug screen and she got the job. As others have said, you need to be honest about your meds and why you are taking them. At my hospital, all applicants who are being considered for a position are screened. We are also subject to random drug screens and breathalyzer tests and if we are injured on the job, we also must submit to these tests. If we are ordered to take a drug screen, we must submit to it within three hours or we are subject to termination.

A lot of our prn pain meds are ordered Q3-4hr prn. Sometimes a physician will order Tylenol gr10 or gr 15 "now" if the pt has a HA or elevated temp. I always make sure the physician knows if it is less than 3 hrs since the last dose of a pain med that had acetaminophen as an ingredient. This is usally a one time order and our patients (post-partum) are usually only in the hospital for 2-4 days after delivery. When I review discharge meds with a pt I always point out the fact that their prescrition pain med contains Tylenol and that they should not be taking Tylenol at home unless they are substituting Tylenol for a script pain med dose unless they discuss it with their OB first. When I was in nursing school, one of my pts was a very young women who took more than double the labeled dose of Extra Strength Tylenol for several days for stress-related HA's prior to a big event in her life. She went into liver failure and had already had two liver transplants by the time I cared for her. She was in her mid-twenties. She spent over a year in ICU and was a frequent re-admit after that. I have taken Tylenol very seriously ever since then.

What does peds think about having an infectious pt on the same floor as newborns. If everyone is using proper precautions, technically, the only problem would be if it was an airborne infectious agent. Of course, we do not live in a perfect world and Suzy visitor who just contaminated herself by touching Uncle Joe may not be able to resist the urge to reach out and touch a baby she sees a Mom wheeling down the hall. If your nurse mgr doesn't seem helpful, talk to your risk mgr. It probably won't get you out of taking care of med-surg pts, but he or she may see the need for better education for the nurses without any med-surg experience.

One morning, on post-partum, I got in report that Mrs "Jones" wanted to leave ASAP. I had been off for a few days and had not taken care of her before. Her doc was there and just starting rounds. Peds had already been in and discharged the baby and nursery was done with their part. When report was over, her OB was at the desk writing her d/c order & scripts. Mrs Jones was 18 and married to baby's father. I went into her room and she was sitting on the couch with a young man who was holding the baby. I go into my d/c teaching which includes lochia (how long, how much, what colors to expect), peri-care review, breastfeeding and engorgement, and, given her young age, special emphasis on birth control and how long to abstain from intercourse and how she can ovulate and become pregnant within 6 weeks or while she is breastfeeding even if her period hasn't come back yet. After I finish with her discharge instructions, I am telling her about what else needed to be done before she could leave. At that point I turned to the young man as I said "Dad" needs to load up the car. Mrs Jones tells me that isn't Dad, but it is her 16 year old brother who stopped by to see her and baby before he went to high school football practice that morning. Dad had to run home because he forgot to bring the corificeat to the hospital. That explained why the young man was so quiet and looked a little embarassed. Now, if there is a man in the room when I do d/c teaching, I make sure he is Mom's sig other/hubby. BTW, I asked Mrs Jones why she didn't stop me and she said she thought it would be good for him to hear what women go though when they have babies.

I like the idea about the L&D nurse checking the fundus with the post-partum nurse when the patient arrives in her room. I can't tell you how many times I have received a pt still numb from epidural whose fundus is up 4 when the report I received was that she was 2 below. Usually, it is a scrub tech or CNA who brings the pt to the PP unit so I can't verify my findings with the L&D nurse in person. Not all of the L&D nurses send their pts to me like that and if I get a pt who needs cathed and I am getting 1000cc's of urine within 5 minutes of her arriving on the unit, I write it up. When I started working in L&D last year, I hoped that I could change a few attitudes there and educate them about why the PP unit does what it does. I found that the nurses who always sent there pts to PP in good shape already understood and the ones who sent pts to PP with full bladders, bloody gowns, dry IV's or not medicated for pain (your PP nurse will get that for you when you get to your room) still don't have a clue. Unfortunately, L&D nurses are in high demand around here and the clueless ones don't get so much as a talking to about how they do things. Our hospital is not set-up for ldrp's and would require MASSIVE renovation to make it possible. I think I would like ldrp. The reason I work L&D and PP is because I like taking care of both kinds of pts.

We don't really have that kind of hostility from NICU at my hospital. Most of the NICU nurses are pretty knowledgeable about why Mag isn't just for PTL. We all (L&D/PP/WBN/&NICU) all whine about the DOCTORS inducing 36 weekers for "discomfort of pregnancy" or LGA and the baby comes out at 5lbs. Not all of the docs are like that, but there are a few that if you see one of their 36 weekers coming in for a labor check, you just know, regardless of the assessment, that that lady is not going home undelivered. And, these women are not given a clear picture of what delivering a 36 weeker could be like.

Right now, we only have the moms. We will be switching to couplet care and I have been hearing them mention giving us 6 couplets plus an admit. With the amouint of staff we have and the number of inductions we do, it will be interesting to see how this is all going to work. Last week we had a day where we had 10 deliveries between 0800 and 1200. Some of my co-workers have worked couplet care and said it is great until you start getting a bunch of admits, then it can get very chaotic. We do have CNA's, but how much help they are depends on who it is. Some of our CNA's are excellent but a few of them are really scary and I can't trust them to notify me of something as simple as an abnormal temp. I really like taking care of PP pts, but if things on this unit don't change for the better soon I think I will just transfer to L&D full-time or start looking into other hospitals around here. I like most of my co-workers on PP and would hate to leave, but a lot of changes that have been implemented lately are taking more time away from the RN providing pt care at the bedside.

Our standards of care for In House Transfers say that the L&D nurse calls report to the receiving unit prior to transfer. I was working PP and when the L&D nurse called to give report, I was with another patient and the Unit Sec told her I would call her back in a couple of minutes. On PP we usually have 8-10 pts plus admissions and getting report prior to transfer helps me to prioritize my workload for the time when the new pt arrives. Having worked both sides of the transfer, when I am on PP and not available to take report as soon as the L&D nurse calls, I ALWAYS call back as soon as I finish what I was doing at that time. I called L&D back for report less than 5 minutes after the initial call and guess what, the patient was already on my unit and in bed. I went to the pt's room and found the pt., but could not find the L&D nurse to get report. I think it presents a poor image when I have to ask the patient things that I should already know. Also, this patient was left unattended and, if I were getting another pt out of bed for the first time after a c-section or helping with a breastfeeding, it could have been a very long time before I found out she was there. In my opinion, it is not my patient until I have report if the pt is transferred from one unit to another. BTW, it was not like they were short on beds or staff in L&D that day. IMHO, it was just poor form on the part of the transferring nurse who, BTW, came back five minutes after I went into the pt room to give me report. Prior to this job, I worked on a Med-Surg unit and always got report from PACU on a post-op pt prior to transfer to my floor. I have always thought of post-partum admissions as similar to a fresh post-op pt. For those first few hours, they are at increased risk for complications and bear closer observation. While most PP pts are stable from start to finish, I have seen enough patients "go South" unexpectedly after delivery to be extra vigilant about all of my new patients.

One of our Lactation Consultants told me about the book a few months ago. She said she cannot tell me how many times she has taken calls from distraught mothers about how their baby would cry constantly and how they could not keep the baby on the schedule outlined in the Babywise plan. Our LC tells these moms that the baby did not read the book. She also tries to explain to them that Mom probably does not eat the same amounts at the same intervals each and every day. Sometimes we just snack and sometimes we go for the whole Thanksgiving meal with all of the trimmings. Our appetites differ day to day and hour to hour so why shouldn't a baby's appetite be similar. Also, the baby may not really be hungry, but is just looking for some additional oral/sucking stimulation. When a baby seems to be wanting to eat sooner that expected, I will encourage Mom or Dad to try putting there finger (clean, of course) into baby's mouth and letting her suck on the finger for a couple of minutes. Sometimes that settles the baby. If that doesn't help and they have checked for other causes of crying, then maybe the baby really is hungry. I had some parents following the plan a few weeks ago who would only feed/attempt to feed the baby for 10 minutes on each side every three hours. As soon as they were done with the allotted feeding time, they would bring the baby back to the nursery and tell us to keep the baby until the next three hour time to feed. They became angry with us if we brought the baby out to the room before the next SCHEDULED feeding time because we thought the baby was hungry. I have since wondered how this baby was doing. Now, when I see the BW book on the patient's nightstand, I do not comment on the book. I will point out how each baby is different and has different feeding demands. I try to educate these mothers to be flexible with the baby's schedule. Getting a baby into a routine is important, I feel, and does provide the baby with a sense of security. I just don't think there is a one size fits all feeding/sleeping/playing schedule for babies.

Do you have to give report to the PP nurse prior to the transfer?