litlamp

Where I work LPN's can do alot. The scope of practice in TN for LPN's is very minimal and mainly covers medication administration (push meds). We do everything but hang blood and there is a short list of meds we cannot administer (sedation, oxytocics, chemo, and titrated meds to name a few). Per our scope we cannot push meds anywhere but in a peripheral line and only to pts over 80lbs (never to peds or pregnant pts). I work on a telemetry unit and take my own patient load (up to 4 pts), do the initial and daily assessments (a RN does one initial assessment too but it's very short) deliver patient care, IV meds etc. If certified (IV cert course 40hrs) we can also push most meds.

I forgot to add.. always check the policy where you work :)

Where I work they go into the sharps boxes. Never into the trash.

Thank you all very much for the replies. I'm still learning that all cases may be different for post op dressings, initially I thought how I learned... that you initially just observe the dressing and change when ordered and it's is usually after the Dr. performs the first change. I need to go with the -when in doubt, ask/call - from now on, and get it in an order. Am I wrong to think that some dressings wouldn't be changed, just observed and if there were to be drainage that would be reinforced or circled and monitored? If so, could you tell me which this may apply to? Thanks again!! You all are always so helpful.

When would you change the dressing on a *new* PEG tube if there were no written or standing orders besides "remove sutures 7 days postop"? Would you change the dressing with or without an order or would you assess the dressing and if being clean, dry and intact wait until the 7th day to change it? For my question, keep in mind there is no order written for a dressing change and there is no facility policy written for new PEG tube dressings. The only facility protocol is written for existing PEG sites and daily dressing changes. Any input is appreciated.

Our facility has been faced with unusually low census the past few months. This has lead to staffing changes and many nurses getting "called off" or put "on call" for the shift. The problem with this is there is no policy or procedure to do this fairly, no rotation schedule in place. I inquired how they decided who to call off and I received different answers. For the most part they call off per diem first, then part timers, then they go by how many hours the full timers have. That may sound ok but they only go by the two weeks viewable on the schedule and don't take into consideration that the previous two weeks you may have been called off 2-3 times and others 1-2 times, you can see the issue. My question is, how do your facilities keep track of called off low census days, and how far back is the time examined? Do you use a calendar? Spreadsheet? Can you offer any ideas to better track these days visually and for a longer period of time? I'd appreciate any input!!

I just wanted to post an update in case anyone was looking for the same information: I called the TN BON today and asked for clarification of the scope of practice with administering push medications. I asked if administering medications through a syringe on a pump was considered a push medication. She stated that in fact it was not and what they consider a push med is holding the syringe in your hand and infusing a medication directily into an IV line. As long as it's not a medication/serum listed in the scope of practice that we cannot administer, it is within an LPN's scope of practice in TN. I believed I had interpreted it correctly but it is such a relief to know for sure. Thanks for all your replies and advice too, this site is invaluable!

Nope, but it is similar in set up. It's unlike excel in that there are check boxes with pop up choices and small areas for type in comments.

The IV was KVO 30ml/h only for a q 24h antibiotic that the charge nurse changed to PO, and only required the doctor to sign off on it in the am.

I think I'm a bit perplexed being that we don't use meditech, however, when the information is entered the previous three entries are already visible to me at that time in the electronic charting system our facility uses. I documented in the flow sheet directly before and after her last entry, factually as required as of that timed entry. I guess what I'm questioning is because this is where both of my entries were made..... or it could be that it's just too darn early and my neurons need a jump start this morning..

We use a different application. Entries are made with your personal login. After your digital signature upon completion, the entry is locked and uneditable. I couldn't change another nurses electronic charting just as I couldn't change their handwritten charting. I'm still new to the system myself so perhaps there is a way to do a "late entry" but again, that would be something she would need to do.

Yes it is sad and disheartening to see this happen. I've learned mostly through this forum and on my own that no matter what others may do, my actions as a nurse must stand alone. I know I am my patients advocate and as long as I do what I know is right than I can sleep at night, even if it may get a peer into trouble.

Thank you!! (((sigh of relief))) :)

Let me know if you would have done this differently please... I had a patient whose IV was not infiltrated but at the point of access was showing irritation. I reported to my charge nurse and she assisted me with removal and assessent of the area herself. She said to leave the IV out until the doctor assessed her in the AM. (it was KVO 30ml/h) I charted everything accurately in my nurses notes. I reported this to the next shift, in detail. The following day I had the same patient. (doctor had not been in yet)While entering my flow sheet which is basically a head to toe assessment and in a different window from nurses notes (computerized charting) I noticed that the night shift stated the patient still had her IV and it was infusing at 30ml/h!! When you enter your assessment you can see the previous three entries at the same time, I "assume" she may have just copied what the previous entry was? My assessment was in the morning and prior to IV removal. We only do 1 of those flow sheets per shift, all other info is in the nurses notes. So, I entered on the flow sheet that she had no IV, it was removed at ___ as stated in report on ____. I also let my preceptor know. I know it may send trouble that nurses way, but I didn't see to do it any other way. What would you have done?

I completely understand and I am a new nurse myself. Working on time management, as I have found out personally can have a huge effect on how your shift may go. For instance, when you receive your assignments and report, look at your patients and their diagnosis and current condition, which patients need to be seen first, set a priority list and try to go by it. Take a few minutes after report to set a list in order. Although we use electronic charting and flow sheets I always carry a notebook with me along with my patient list and a copy of their paper kardex. I use a multi colored pen and for instance use red to make notations to check blood pressure if I received in report that they were running low, or for accuchecks if they are q2 .... whatever the case may be. Granted, I'm still working out my own way but thats what it takes, trying different ways in order to find out what works for you and your patients. I don't know your patient load but for vitals I get my vitals first thing at the beginning of the shift when making my initial assessment that way I know myself what they are. If your NA get the vitals maybe try talking to them? Give them the heads up based on what you receive in report.. ex.) "Sally, room __ or Mr. ___ has had a high blood pressure, could you let me know what his next blood pressure is?" or "Sally, could you please let me know when you get vitals on ____ or if it's at this range ______? I'd really appreciate it, Thank you". Or, when in doubt, get them yourself when doing your rounds, it may add a few minutes but it would save you the anxiety and you would have your patients information for yourself. Keep in mind, and remind yourself often that there is a learning curve. It takes time, allow yourself that. Always ask questions. Do you have a preceptor or someone you could ask at work? Look at how your senior nurses prioritize and take a que from someone you admire as a nurse. As to charting, chart what you see, be accurate, detailed, and confident. Be aware that it is a legal document but don't let that overwhelm or paralyze you. If you do a complete assessment, you have all the information needed to chart accurately. If in doubt, find that 'mentor' and have them read over a few entries to get feedback. It takes time, let yourself breathe, hold your chin up. You never stop learning, and thats a good thing!! You can do it.

The Lasix is screwed onto the pump and infused by the pump as a secondary infusion and at a slower rate, so is this considered "pushed" by me? Just making sure you understood it was on the pump and not "physically" pushed into a line. (essentially as a piggyback setup) Just trying to clarify what you are saying about the Rocephin too; you call a piggyback not a push medicine. Is this because of the amount of fluid being 100mls or how the tubing is set up? or is it the rate at which it is infused at? What our facility uses is 50mls, run as a secondary infusion at 50ml/hr or 100ml/hr, so I am unsure if that changes what it's labeled as. Gah, I'm so frustrated. I ask the same question to my preceptors, charge nurses, our DON, and my past instructors. I get different answers from everyone and what their interpretation is and what they "think". This is just making me sick to my stomach to think I may be putting my licence in jeopardy.

No, I'm very sorry, I didn't mean for that to sound like an accusation. I meant it as how I'm being preceptored.. which has included all the short cuts but not anything as you just mentioned.... that it does not replace a full assessment. I observed my preceptor not do a full assessment (I didn't leave her side from the patient to the computer for charting) She charted as if she did complete a full assessment. Thank you... you don't know how much this means to me right now! On my last roundings, so far, I've had such kind complements from both families and patients and no matter what has happened throughout the day it's that moment that means the most to me. If they are comfortable and I've been a good nurse for them it can turn a bad day into a good one. It's becoming my favorite part of the day. Thank you for understanding how I feel, and thank you for all the insight I've been looking for.

I'm having an issue with my states scope of practice, how to interpret it compared to how our facility operates. First off, I'm practicing in Tennessee, I am not IV certified, and I do not have more than 6 months of experience as a licenced nurse. We did have IV training at the school I attended (limited to inserting and discontinuing) This is the first line in our scope of practice: ~~Intravenous (IV) Push Medications - The administration of intravenous push medications refers to medications administered from a syringe directly into an ongoing intravenous infusion or into a saline or heparin lock. Intravenous push does not include saline or heparin flushes. ~~ OK, so given that, my question is, is the following considered a practice of pushing a medication and exactly what is the definition of a push medication? (amount/time/ect) When we receive an order for a medicine, say Rocehpin reconstituted (by vial not hand mixed) to equal a mini bag of 50ml's and it's hung as a secondary infusion at 50ml/h is this a push med? Would you say it's out of my scope of practice. How about lasix if it is drawn up into a 5ml syringe then put on the pump to infuse as a secondary line... is this considered a push medication and out of my scope of practice if I am not IV certified? Are these considered "directly into an ongoing IV infusion" as per my scope of practice? I just want to know I understand it clearly it seems our facility may be skirting our scope of practice... I do not want to do anything to put my patients in danger or put my licence at jeopardy. Please, any input would be very appreciated.

That is a valid point, thank you for making me look at it a bit differently. I don't want to jump to conclusions or misinterpret anything and I know being a new nurse I may be over critical which will change as I learn. I guess I just want to learn the book way (facility policy way) first then the shortcuts just in case that person with normal respirations for 10 seconds doesnt have apnea until 15 seconds. I know my instincts will pick up with time and experience. I see now how much I need to work on time management and prioritizing skills and how important they are. I do understand how you would handle the pills in bed situation, I wouldn't think of giving them at that time I guess my main concern was what if it was a critical medicine? But, not knowing the details I guess just assess the patient from there on for any changes. Would you include something like this in report? I can understand what you are saying about the one new nurse wanting a very detailed report. Being new, I'm not exactly sure what to give in report. I asked my preceptor last night and she said to tell the on coming nurse "everything".... eek well, that really narrows it down for me. I noticed when I started telling her the critical lab values that her eyes started to roll.... but I thought it was important? In a few instances I received report and the off going nurse knew the patient had an IV but couldn't tell me where or what was running. I just want to be the best nurse I can possible be, I want to be good with all aspects of care and keeping my patients comfortable and safe. I'm giving it more time before I say anything to my supervisor, and if I continue to see something I'm questionable about I'll bring it up as unjudgmental as possible. Thank you for responding, I don't know what I'd do without this forum.

A little backstory: I recently began orientation to our local hospitals med/surg floor. It's my first position since graduation and passing boards two months ago. I love nursing, I love providing care for and being my patients advocate. I want to provide care for my patients, to be instrumental at a point in a persons life when they need it the most. I understand it's not all sunshine and rainbows, I truely do, but I know if I can start every day with a purpose of being a good and true nurse to my patients that I'd be doing as I had always wanted to do. Currently: I am orienting to the floor that I was on during my clinicals in school. I am somewhat familiar with the floor and some of the staff. However, it seems like a completely different world than what I witnessed during our clinicals. So far I've had three days on the floor with a preceptor, and every time it's a different preceptor. I am having a hard time with how all of the three are practicing as nurses. I try extremely hard not to be judgmental, after all I am a new nurse, but not new to nursing. I've observed pulse being counted by just looking at a patient, respirations being entered in a chart at the nurses station after not being counted, lung sounds being charted for without checking (she didn't even have her stethescope with her). These are just the top of my list... bare with me. We received in report that a patient had 4 staples posterior occipital, thats what my preceptor also charted. However when I went in for vitals, I wanted to observe them and noticed there were 5 not 4 staples. This leads me to question if they were ever even looked at, at all. All three of the nurses walked into patients rooms unannounced, didn't address patients before getting vitals and as one did, throw the sheets off of a patients lower extremities to assess edema without even looking at the patient. I found two pills in two separate patients beds, gave them to the nurse and she shrugged and threw them into the sharps container. Pneumothorax patient with a chest tube had nothing at the bedside incase the tube came out, not so much as even a 4x4. Oh, and lungs were not assessed after removal of said tube. Hearing in the med room, "we're not supposed to do this... but I'm going to anyway" when mixing medications, and charting meds are given before they are. I happened to question a paticular medication that was being pulled from the pyxis, she was pulling the incorrect dosage... I just asked if I read the MAR correctly and she said to shhh I was confusing her, she finally realized it was wrong when she looked up at the screen and said, "oh, I've never noticed that before, hmmm." Not counting pulse before administering dig. Stating to a patient, "I'm gonna put you in a vest if you keep trying to get up!" Sitting at the nurses station talking, gossiping about each other and their patients... how so and so's a pain, telling personal information.. etc. This is just a short list, sadly I could go on. What do I do? I'm supposed to learn the ropes, but I don't want to be this kind of nurse. These nurses (3) have been at the facility for 6-12 years. I'm at a loss and all I get is, "welcome to the reality of nursing". Please tell me this is not it. How do I stay professional and practice safely in this type of situation? How do I not become jaded? Am I being too judgmental? Am I looking at this wrong? Please help me. I want to be a good nurse. How do I continue? I refuse to put my licence in jeopardy, I refuse to not provide the level of care I know I'm capable of. But how do I learn in this type of situation?

Thank you for clearing that up. I was certain if that was the case it would have been in the literature.

I've been talking with classmates who are currently taking their NCLEX-PN this week. I know before taking mine last week I read as much as I could about the test itself. A question came up about some exams automatically going to 205 no matter what, and that sometimes they have a random candidate take the whole complete exam. Is this true? I didn't remember reading anything like that. Thanks in advance!!!

I read this awhile back, hope it helps. Link will direct you to the full article. It's directed more towards staging but the article is very informative. http://www.medscape.com/viewarticle/563159?src=mp National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System The National Pressure Ulcer Advisory Panel has updated the definition of a pressure ulcer and the stages of pressure ulcers based on current research and expert opinion solicited from hundreds of clinicians, educators, and researchers across the country. The amount of anatomical tissue loss described with each stage has not changed. New definitions were drafted to achieve accuracy, clarity, succinctness, clinical utility, and discrimination between and among the definitions of other pressure ulcer stages and other types of wounds. Deep tissue injury was also added as a distinct pressure ulcer in this updated system.

Well put and one of the best pieces of advice ever.

Thanks Daytonite I overlooked the actual patho r/t inflammation and was thinking how pain is transmitted. Thanks for pointing that out, it's even more obvious looking at it that way.