castens

Yup. That's the point of something like ACLS - you're covered in an emergency (if you're doing the correct things, mind you), but as soon as a physician is around to take over, they do. How often I would wake up docs would depend on our working relationship and the extent of the need. It was not uncommon for me as a staff nurse to meet the MD in the AM and say, "this is what I did over night... sign here." Now, in order to do that, you need a very special relationship and you need to know what you are ABLE to do and what they really need to know. You have to be careful with this, because if you screw up, it's completely on your head. 99% of the time, I would start something if needed as I am making the call to discuss. Now, I'm talking medical management here. Labs/tests are a completely different story. No doc wants to be called for chest pain and actually have to order the 12-lead and troponins; they would much rather hear, "He's having chest pain and this is what the 12-lead shows."

This is a great point - much better than I said previously. A great misconception is that academia exists to teach. Rather, academia exists to store knowledge. While teaching and professional training are a part of that, they are not the biggest parts.

It IS difficult making tests, as I'm sure you've discovered when you've had a bad test. Questions have to be valid. Actually it's not necessarily the "ABCD" questions that are hard but when you have a good essay question or case study or critical thinking question, it's question death if that gets out. Not only that, but from a nursing education standpoint, the instructors have a lot to do besides think of test questions. There are care plans and papers to read, current research and literature that needs to be reviewed (or written/conducted), and clinicals that have to be proctored. Once you have a good and valid test, a lot of free time is cleared up if you don't have to recreate it every semester.

It's not that they don't want you to have the information on the exam... it's that there's a lot of money that can be made by selling exam copies online. A lot of money -- like hundreds of thousands of dollars. For that matter a lot of money has been made by frats and soroities by keeping many years worth of exams on file and using them to cheat in later years. It ain't you... it's the idiots before you.

Rather... she doesn't get paid if they changed nurse characters. She gets beer money if she designs scrubs.

It sounds like her unit (as are many) is covered by a slough of standing, or preprinted, orders. That is, the doc will write, "Admit to ICU using Intensive Care Unit orders." That order set then has things along the lines of: "RN may order XXX at his/her discretion under YYY circumstances." OR "To maintain blood pressure parameters of X, RN may start and titrate dopamine. If dopamine ineffective, nurse may start Y." Things along those lines. Those orders may also include the necessary authority to order central line placement if central drugs are to be given. It's not uncommon for these order sets to have EKGs, x-rays, CT scans, and various lab work listed for RN discretion.

I advise newer nurses to watch themselves when they have a nurse or MD as a patient. If you find yourself double checking meds and namebands or examining skin or doing a more thorough assessment with nurses and doctors -- ask yourself why! Your standard of care should be just as high for all the normal folks. In that case, it's not that you're giving better care to nurses and docs, but you're giving sub-standard care to others. Ask yourself why you feel the need to be "more careful" with collegues... could it be because you need to be more careful in general? (I'm not saying that this applies to the OP, but something for all of us to remember.)

While this is not even close to an issue in my hospital, I just want to say that this is a fastastically coherant and well-written argument. And spot on, too!

Always 1:1 - no exceptions.

The best way? Flowers and a brown nose. Seriously, though, I think the best way is to think out loud. Hands down. If you think out loud (even the obvious) they will automatically know what you know and what you don't know. Example: "His lungs sound a bit crackly, his CVP is now 18 - up from 12 - and his urine output has slowed to 25 mL/hr. It sounds to me like I should give the PRN 40 mg of Lasix, which I would give IV push over 4 minutes. What do you think?" Eventually, your preceptor will know how you think and what you know, and the thinking out loud will be able to decrease. This also allows the preceptor an easy way to say something along the lines of, "I can see why you would think that, but..." Thinking out loud is something I still do to this day, though in a different way. You should never get out of the habit of running stuff by your coworkers if you just need to reinforce your brain. It may be something that would be obvious to you on Monday, but when it's Friday and you're doing a double, two brains are better than one.

I'm wondering if anyone has a good, fairly succinct, learning packet about pacemakers - focusing on sensing/pacing problems. I'm looking for something that is more concentrated on permanent pacers, rather than TC or TV pacers. I've noticed that quite a few of my new hires - even experienced critical care nurses - really aren't up to snuff when it comes to interpreting paced rhythms. Anyone have something they're willing to share? Thanks!

...and when you get the "double bird" you know that they are definitely following commands (and probably ready to extubate, for that matter).

Which did(do) you like better--school or the real world? Why? I much prefer the real world, because I know I'm making a difference. Of course, school is important so that you can learn HOW to make a difference, but there's nothing like the feeling of real life. Which do you find harder? Specifically, the transition from school to real world. I'll never forget my first couple weeks of real life and feeling that whole weight of pressure and responsibility. Otherwise, I think they are equally as hard, just in different ways. What are some of the specific hurdles you faced in school? On the job? Forcing myself to be humble (both IRL and in school). I came into nursing with huge motivation and quite a lot of medical understanding. I still have to force myself to admit when I don't know, or force myself to be patient with those who don't know. After 10 years, though, I'm much better at it. Maybe I should put it a different way... I've never had a problem with saying "I don't know", but forgiving myself for not knowing. Good luck!

We have staff educators at our hospital, of which I am one. Our educators aren't unit-based per se but have extensive clinical experience. Most have Master's degrees or are Master's-prepared. I am actually the exception (I have a post-bacc ADN), but since my career goal is actually DNP (starting school up again in the fall) I was hired in light of my experience. Using myself as an example: I report to the manager of Staff and Patient education who reports to the Director of Education and Clinical Practice. Since we're all in the same office, we all work together and I chat and receive guidance a lot from the director as well. (She is also the head of our CNS program - very busy). I am the educator for Critical Care (Trauma-Neuro ICU, Cardiac-Medical Critical Care) and for our neurosurgery step-down unit. I meet with the nurse managers of my units on a regular basis (weekly or so) and do unit rounds every day to resource my staff and find education needs (new equipment, procedures, etc). I work very closely with my CNSs and many time our roles get blurred - except in tasks clearly defined by the MN Nurse Practice Act, of course. I would say this is one-third of my duties. Another third is the teaching of classes. I teach our hospital's EKG and rhythm interpretation classes and I also design/teach our critical care entry courses. I frequently help out with our new grad entry classes. The final third is very much Human Resources support. I meet with all new RNs hired into my three units, do their initial hire assessments and guide their orientation with preceptors. I also do follow-up assessments if needed for performance improvement. Hope this helps!

All of this from UpToDate: [All emphasis mine.]

This is from UpToDate Online: Now... I don't know if the vials are specified IM only/IV only/IV or IM use so I can't comment specifically on your case, however it is documented that it can be used IM. There are accepted off-label administrations for medications if prescribed. For example, Haldol, which still says IM injection only, can be given IV and has been for decades. Frankly, I would have looked into the situation in more detail. If, like Haldol, the vials say one thing but there is established (key word is established... not just now and then, for convenience) practice for another, I would have administered IM. (Now, if the physician wrote IV, it would not be acceptable to change to IM without contacting him for a correction first.) I'm curious how this is dealt with in your hospital. How does the medication get delivered to the nurses? Does pharmacy simply deliver the vials for the nurses to administer? If so, and if IM and IV doses come from the same vials, why hasn't anyone caught this yet? Surely SOMEONE would have seen "For IV Only" on the vials at some point, wouldn't you think?

I would also like to ammend my previous post. I definitely don't think that a nursing student should be discussing end-of-life issues like continuing/withdrawing support with a family - at least not without their instructor/preceptor heavily guiding the conversation. Important convesations to sit in on, yes... not yet ready to participate.

Whoa! Just be careful how you do this... and I would NOT advise a nursing student to do this. There is a very realistic possibility - I've seen it happen too many times myself - that the family might behave like Jim Carry in "Dumb and Dumber" "Do you think there's a one in a thousand chance you could love me? "I'd say more like one in a million." "So you're telling me there's a chance!" One in a billion is still a chance - and it's that chance that a lot of families pick up on... especially when they're trying to decide on continuing support. Also keep in mind that the one in a billion chance, if it exists, probably wouldn't materialize for YEARS. A more realistic course of action is to understand for yourself (by inquiry, or reading the chart) what the physician's take on this is. Have there been blood flow studies, EEGs, MRIs? What is the medical prognosis - which is not the same as "a chance"? If in fact this is determined to be a permenant vegitative state, I would discuss the patient's wishes with the family. Would "Steve" want to live this way permanently? At this point, the patient's wishes are the only thing that the family, physicans, and nurses as patient advocates should consider. Having said all that... 1. Good job in doing your research! Evidence-based practice is what I wish 90% of my staff looked at! 2. Miracles do happen, I've seen numerous myself. But even as a devout Christian, when I'm dealing with tragic patient cases, I make my rule: Believe in miracles, hope for miracles, but don't count on miracles. 3. There ARE fates worse than death. 4. Everybody dies sometime, the only differences are how soon and how well. It may be that at this point, the best death is all that can be done. By the way... if Steve's family (or other document) indicates that Steve would want to be kept alive by all heroic measures possible, the staff will have to accept that as well - and sometimes that can be harder for nurses than withdrawing support.

SpO2 monitors work by sending a laser through tissue and vasculature and sensing how much infared light passes through. I'm not sure if higher light concentration, that is less absorption, or lower light concentration (higher absorption) gives you higher sats, but the point is that unless your patient has enough gravity to warp light (and the U.S. isn't that bariatric... yet) you can't send a laser through the forehead vasculature and bend it to hit a non-linear sensor. If you try, you get a piss-poor guestimate from a non-critical thinking computer.