lmc512

I have been a nurse for 7 years now and still feel like I have not found the right words to tell a new mom that breastfeeding is not her baby/babies best option right now (after multiple attempts and initiating pumping of course). I have been presented with this situation numerous times over the past few weeks and am hoping you all have some suggestions. The most recent situation was new mom G1 of 35 week triplets ranged from 4lb 6oz- 4lb 11oz. It goes pretty much like this...mom declares she wants to solely breastfeed her little 35 weekers, blood sugars are decent in the 50's, but they are only 4 hours old and you know that if these kiddos don't get formula the sugars don't take long to plummet. Doesn't seem to matter how much I explain to them about preemies, blood sugar, brown fat, the brain needing glucose, dehydration, jaundice, multiples, etc, etc. They just don't get it! I know that 9 times out of 10 they do allow formula once the sugars do drop (a few refuse and prefer baby goes to NICU for IV fluids rather than have a drop of formula hit their baby's mouth), but I feel like it is my nursing responsibility to prevent it from getting to that!!!!!!!!! I mean we know from doing this every day that with the little ones (and the big ones once they are a few days older) a little formula can go a long way. Suggestions :-(

Just wondering if anyone else uses the TC bilimeter, BiliCheck, with the disposable tips you calibrate each time? If so, when you do your test, do you lift the meter in between each of the 5 readings or do you just press softly enough to get the green light to stay on and pull the trigger 5 times without lifting it off the skin? I was taught to do it either way at one hospital and to lift it off at another. Just wonder if it makes any diff.........if this question makes any sense at all!!!

Once our patients get to the postpartum floor we do Vag. deliveries on admit then again in 4 hours then it is once a shift (so basially Q12), the same goes for assessments. For C/S they get vitals on admit, then Q4hr X24hrs with resp rate Q2hr if they had a spinal morph and assessment is once a shift. Of course everything is more frequent if issues.

We do about 12,000 deliveries a year. Both Vag and CS babies stay with the mom the entire time unless they need to go to NICU. There is a nurse in the PACU that is a NICU nurse and is assigned to the role of NRN (neonatal resource nurse) for that particular day. If the PACU nurse thinks something is wrong with the baby then the NRN is right there to look at the baby. They are also there to initiate blood sugars or CBC's on the babies based on risk factors they may have. I also agree though, that if the PACU nurse is 1:1 with the couplet that is adequate observation.

I am just wondering if anyone else despises the Alaris IV pump...specifically PCA...as much as I do. What a totally obnoxious invention. Today I was trying to start a PCA on my pt....so I get the PCA channel and attach it to the "brain" and I'm good to go....or NOT. I attached it to the left side of the brain (and it attached with no problem) then when I turned it on to program it informed me that it must be attached to the "right hand" side of the pump. No problem.....except that no amount of strength can detach the PCA channel from the left side to put it on the right. ok, no problem, so we will just get a second PCa channel and attach to the proper side. So we do. Turn it on and the screen says we can only have ONE PCA attached (even though it will not work on the wrong side anyways) so we cannot use it...again!!!!!!!!! AHHHHHHH. So then we start over completely and still didn't get it right because the PCA must b e directly attached to the brain and then the main channel attached to that. I CANNOT STAND ALARIS PUMPS. They are so "smart" they are going to make me crazy. Way too many functions and safegaurds to overcome whIle pt is crying in pain. So ridiculous. Has anyone else had similar issues with Alaris? And don't even get me started on the pointless drug libraries. BRING BACK THE BAXTER PUMP!

At my hospital recently a lot of staff in all departments, not just OB, have been getting canceled or floated due to low census. One unit last week had an estimated 60 cancellation/floats in one week. The hospital says this is due to the "downturn in the entire economy." They are also not just canceling staff but increasing the nurse to pt ratios and the charge nurses are having to take full assignments despite the fact there are no techs or sec's on. Admin tells us there is a drop in census in hospitals all over the country now. Have you all found this to be true at your hospitals? I feel like there are so many salaried administration types (excluding nurse managers) that are not on the "front lines" that continue to work their worthless 9-5 positions (maybe that was too harsh) while nurses get stretched dangerously thin and they cut staff in other vital depts such as laundry so you can't even get any linens delivered for over 24 hours because there literally isn't anyone to bring it so your patients lay there on dirty, bloody sheets and you try your best to cover the blood with chux and apologize over and over. And how does admin explain babies having no shirts or blankets after they are just born because there are none! It's getting absurd! That was a little ranting...sorry. What have been your experiences?

But I have general questions about various PIV's and central lines and who puts them in and takes them out and where exactly are they going etc... What is the diff in an EJ, IJ, triple lumen, central line, PICC and what are the most important things to know abaout them...I know they get heparin flushes and flush with positive pressure, but what else should I know

I am curious to know what everyones nurse to patient staffing ratios are on the postpartum floor. Does your unit consider mom and baby seperate patients when counting patients or do you consider a "couplet" to be one patient for staffing purposes. Where I work now we count them seperately, so typically one RN will have 5-6 pts total. Where I used to work we counted couplets and usually had 6 or 7 couplets (so technically 12-14 pts total despite what administration thought) What about where you work? (this is only postpartum not antepartm/ L&D as well)

this is not from the ER, but i work in OB and i have had a pt take the hospital breast pump home (the kind that is on a tall rolling poll), and also someone took the mattress out of a newborn crib. Also a few clock takers i think. Oh yeah, and several people have taken their sheets home.

I am interested in your thoughts on this... Pt. is a G5P5, has stat section for fetal distress under spinal, spinal stops working when they are closing and pt is intubated and put under general. Pt desats soon after intubation and drs think PE, AFE, or air embolus. CT is neg for embolus, chart states something to the effect of "pt has episode of hypoxia/resp failure for 10 minutes" Pt was given epi and some other code drugs i'm not familiar with and is stable enough to move to ICU. Turns out when pt was intubated ET went too far and went down into rt. bronchus so left got no oxygen I am guessing. So...ET was pulled back to correct position and pt improved dramatically. So she was extubated approx 12 hrs later and brought out to our regular ol' postpartum floor. She is doing decent other than she looks like she has been to hell and back, excellent urine output (turns out only due to the lasix she received prior to transfer), so after about 3-4 hrs with me she starts having a crummy 12cc or so an hour...dr had me fluid bolus her 500cc despite that her lungs are crackling and wheezing (she can barely budge her incentive spiro), and she is so edematous her hands look like sausages, so i gave her the bolus over 2 hrs and it had zero effect on output, i think she had about 15 cc out. So then we do some labs and sent some urine for sodium and creat. According to dr her problem was "prerenal" due to some fena ratio they do which i have never heard of so therefore their conclusion is she is "DRY" So lets give her a LITER bolus now. I mean will they not be happy until she is dead! Luckily I do not have to deal with these issues with postpartum moms often but I am thinking this lady has more than enough fluid on board her body just isn't getting rid of it. Her BP is a tad low, 90's/40's, pulse 70, sats 95 on 2L. So basically in 6 hours she had 112 cc of urine out that was mildly concentrated. No lasix ordered. So basically I am just wondering your take on all this, especially the fluid boluses.

if she is already 1 month PP then there is nothing really "OB" in my opinion that you would need an LDR nurse to do. her fundus would already be contracted down too far to palpate and her vag bleeding would be basically done. now imagine the tables turned and a postpartum/nursery nurse gets a general surg, hem/onc, cardiac service, etc patients from the ER because the rest of the hospital is full! it's outrageous!

for me personally, I have found that not "overanalyzing" working night shift has helped a lot. At my first job I work majority day shift with a few weeks of nights thrown in there and of course I was really ticked about doing nights. I would put a black sheet over my window so I could sleep better and I would do all the trying to stay up late the night before and sleeping late. And I got into a pattern where on my days off I could not fall asleep until 3 or 4 am. But now that I changed jobs, I have done all nights for going on 9 months now and since I had no choice to do days I just suck it up and it hasn't been so bad. I did away with the black sheet because I found it tricked my body into sleeping too much which will also make you tired, so even on my days off I wasn't waking up until 5 or 6 pm. Now if I am not working the next night I will set my alarm to get up at 1 and then I MAKE myself do somthing, exercise, grocery shop, whatever as long as I'm not sitting on the sofa. Then I can go to sleep with the rest of my family at 11 or so and sleep no problem. My advice is dont let night shift take over your life. I think most of it is mental. good luck!

So what do you do when it is the postpartum pt that has the MRSA? Heck we get off service with MRSA, VRE etc on our mom/baby unit and one nurse can have thosee isolation pts and healthy mom/babies at the same time. I used to work at another hospital for 4 years and never once had a MRSA or isolation pt at all on the mom/baby unit then I change hospitals and MRSA is like a common cold here!

For postpartum we mostly are looking at CBC's specifically WBC, H&H, and Platelets. WBC's are generally elevated from the trauma of delivery, i would not worry about them unless they are over 20 and the pt has a fever, not concerned about H&H until it is below 8 and 20 but you still have to look at what their predelivery was to see how much they dropped and are they symptomatic and platelets i am not really concerrned until they are below 140 but then again 140 could be great if they had HELLP. it all depends on their situation.

I might have missed something, but just tonight I have given several doses of IV Phenergan 25mg to various patients. As for using a needle to inject into the port, there is nothing wrong with it other than needleless systems are safer. You diluted it and you pushed it slow, nothing much else to it. i have only had one pt in several years have any reaction to it. It made her very anxious and basically mean, but then it wore off and she was normal again.

Our postaprtum unit is also free game for any pt. in the hospital. I hate that. The non-postpartum pts geneally take up the majority of your time on a shift and the postpartum pts that are supposed to be there get "ignored" We also gets MRSA, VRE and whatever other gross thing comes in the door. I have had pts on Trauma service, oncology (the nurses that should have had the pt had to come down and do their chemo on the PP unit for us), general medicine of course and any other service really. The other PP units I have worked on did not accept admits from outside the hospital because NICU docs would not let them on the basis that the pts are "dirty" I thought that was the norm. Wow was I wrong. Now that I changed hospitals, like I said it is a free for all. Then again we get plenty of pts that are PP and are MRSA+. Then I love how when our unit is full LDR has to hold the pts rather than sending them to another adult floor but if med surg is full and PP has beds then sure go ahead and send this to PP. It's enraging!

The temp policy at one hospital I have worked at was 96.5 or less then baby goes under the warmer and you do a sugar. Otherwise just wrap the baby well and have parents hold. I went by this policy for 5 years and seriously probably only had to put a babies under the warmer a total of 5 times. The place I am working now, any baby less than 98 goes under the warmer and then you have to do sugars until you get 3 greater than 45. I have always felt that a baby dropping their temp is an important clue that something is wrong with the kid if they aren't maintaining their temp. But now if you never let the kid get below 98 how do you really know if they are dropping their temp. I mean their normal temp may be around 97.6 which seems totlly reasonable to me. the two hospitals seem to go by such drastically different policies. which one seems more reasonable to you?

The first hospital I worked at, the policy was babies >42 wk, 4200 gms, and Now the hospital I work at now does blood sugars out the WAZOO (spelling?) they do so many sugars i'm not even totally sure what the policy states. i think for diabetics they do ac time 24 hours! then they measure all babies and plot them on this chart to decide if they are lga, sga, aga. for the past 10 years i thought a baby that was 40 weeks and 8-4 is an avergae baby, but oh no, not at this fine institution. we had better check sugars AC, PC, and whenever else until the kid is approximately 5 years old! then they do the sugars on this great machine called an ISTAT that takes about 25 minutes to actually give you a result after giving 12 error readings so that you have to start over. anyways....thats another rant. but i too wish this hospital that is supposed to be one of the best teaching hospitals would jump into 2008 with their policys!

I definitely know that "totally lost" feeling you have. I agree with the other people that you should maybe try to ease back into the hospital setting as opposed to going straight to the ED. I just switched hospitals recently and am also have difficulty getting used to the basically non-existant orientation program they offer. Where I came from regardless of the experience you had, you must go through the same orientation program as the new grads so that you learn how things are done at the particualr hospital. It was also great because you got to meet the other new people starting at the same time so you didn't feel so alone. The program consisted of classes and of course precepting on the unit. When i switched hospitals I also opted to go to a unit with higher pt acuity and after a few weeks of feeling totally dissapointed in their teaching skills and realizing they had no plan as to how to orient people I transferred within the hospital to the same type of unit I was on. If you don't feel like you are providing safe care to your pts and it is driving you nuts then take yourself our of that situation. I think there is an expectation in nursing that one must work with the sickest pts and the most complicated equipment in order to be successful. I am 800% happier taking care of my pts on my "piece of cake" unit as some call it than driving myself and my family nuts on the other unit. It is all abut what makes you happy, and after having been in this same situation 4 weeks ago I can pretty confidently say if you need to post this at all then you need to get the heck out of there!!! GOOD LUCK!

I feel your pain. What drives me nuts is when you have experience and you change hospitals and the nurses on your new unit act like you are a total idiot if you don't know how to do something. It really makes you feel like ****, but you have to resist the urge to run. They forget that if the tables were turned and they were new they would be just as confused in the hospital you came from.

why not! because I do not take care of those types of pts daily and haven't since nursing school years ago.

Call HR from the hospital you are interested in and find out the status of your interview. The offer has to come through HR because that is who gives the salary quote. It has been my experience that HR is slack about getting back to people so just call and let them know you are still very interested but need to let other offers know your decision. They understand you need to be employed and should not miss out on those opportunities if they are not interested in you. GOOD LUCK! Oh and by the way, it is hard to get them to contact you even when you have experience in the dept. you are applying for. HR is slow as christmas!

If a mother/baby nurse gets floated to the antepartum/gyn unit what type of pt is an appropriate assignment? Would a pt there for hyperemesis who is on continuous tube feeding, has a PICC line and is described as drug seeking who happens to be one of those pts no nurse wants twice and appropriate choice?

maybe it just wasn't contracted or the pt was too "plump" for it to be very obvious.

i think we need to get rid of this idea that we owe our pts something. we owe them nothing but safe, competent care for them and their babies! ob pts these days need to stop worrying so much about their free steak dinner and start worrying more about taking care of their babies instead of sending them off the the nursery. the nurses already know what to do, it's the parents that need to learn. it drives me nuts that nurses are being treated more and more like a stewardess or personal assistant. give them a few extra diapers and send them on their way! their "perk" is a happy healthy baby and a mom that is alive and well!