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Perpetual Student

Perpetual Student

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Perpetual Student has 4+ years experience and specializes in PACU.

I'm running out of time!

Perpetual Student's Latest Activity

  1. Perpetual Student

    Medicating PONV vs. watchful waiting

    I prefer to be very aggressive re: PONV. I personally absolutely hate feeling that way, and figure most patients share that view.You also lose style points if your patient is puking all over the place post discharge from the PACU.I will give one antiemetic and see how the patient does, but if the nausea is severe I will typically give two very close together. If a patient gets nauseated just chilling in the bed, odds are it will recur if you don't give an antiemetic. Barring significant contraindication, I have a very low threshold for medicating for nausea. If the patient gives even the slightest indication of being nauseated I will medicate. Even if there is a contraindication for some antiemetics it's usually OK to give a different class. It is generally better to over-treat some than to under-treat. Particularly in patients that should not vomit due to risk for complication or exacerbated pain (e.g. neck surgery patients).I don't know if you ever do outpatients, but it is also important to be aggressive with that population. They need to be able to get up and move around some when it's time to go, hopefully without puking all over.
  2. Perpetual Student

    V-fib refractory to an initial/second shock

    Refractory to means not fixed by in that context. So if shocking your v-fib isn't working, what other intervention might you want to try? You're on the right track when you mention that it's a pharmacology question.
  3. Perpetual Student

    What makes nursing stressful for you?

    The possibility of forgetting to document something that will bite me on the butt makes me a bit uneasy. This job would be so much easier if there wasn't such a huge focus on CYA/make-some-regulatory-organization-happy documentation. Having to have an order for every stupid little anything that common sense should dictate. Having to not say what I really want to when dealing with stupid, lazy, and rude people.
  4. Perpetual Student

    IV narcotics?

    I would do it as above posters described in the situation at hand. Another way to do it is to draw up some NS from the flush into another 10 cc syringe, then draw up the appropriate amount of drug. That would be the correct way if you needed a precise concentration of drug in your syringe, for instance if you were going to titrate a medication to effect. Also, if the patient has a running IV I will open it wide open and just use a 3 cc syringe for the drug, drawing back from the bag to dilute it. That's a little more cost effective (and less work), plus when you're done you can just pull back again and push it in to flush it.
  5. Perpetual Student

    what are you going to do with this order?

    I'd fold it into an awesome paper airplane and then do my own homework. All kidding aside, what information would you like to have that you don't have? Is that information necessary to safely give the drug? Does your P&P manual provide the missing information? We can help you, but your learning experience will be more helpful if you work it out yourself. edited because the smiley didn't work. Also, compare the dosing information provided for the patient's weight. Do they match?
  6. Perpetual Student

    As a nurse, what does it mean to be in medicine?

    It annoys the heck out of me when someone calls nursing "medicine" or worse yet uses the phrase "medical field." It is misleading and disrespectful of nursing as its own discipline.
  7. Perpetual Student

    First Code Blue

    Call for help while assessing and start BLS, and other interventions once adequate assistance is on hand. Start CPR as promptly as possible. Don't be afraid to direct others in what to do to assist you. You need to be AGGRESSIVE. Learn to harness that adrenaline rather than letting it freeze you. Under extreme stress fine motor skills deteriorate. Try to use big, simple movements Most codes at work don't bother me all that much. If it's a younger person, or someone otherwise pretty healthy it sometimes makes me pretty sad. There's only one I've been involved in that still gives me chills every time I think about it. That's not to say I don't respect the value of life, just that I've grown to accept that everybody dies. And honestly, I wish the pain and suffering would end for some of the folks who're still kicking. Here's an excerpt from a post I made in response to a somewhat similar thread in January:
  8. Perpetual Student

    When is it too late to intiate CPR?

    The only real problem in the post I see is where the above was used as part of the rationale for not starting CPR. Those are indications to perform CPR, not withhold it! That said, you've received some good advice here.
  9. Perpetual Student

    Pulled to other floors?

    The ICU nurses in our hospital are floated all over the place frequently. A buddy who now works in the PACU with me left the ICU mostly because he was tired of working on the floors. He said if he actually got to work in the ICU most of the time he'd have stayed. What exactly do they have you do in the PACU when you're there? Help out? Cover hold patients? Recover phase I patients fresh out of the OR? If the latter, that's pretty dicey from a safety and liability standpoint without adequate orientation. At least be sure that you've got an experienced PACU nurse backing you up at all times who you're not afraid to ask for advice.
  10. Perpetual Student

    Preceptorship in the PACU

    Get dressed and wander in with a grin. Whoever is the first in should check that the bays are all set up. Take a look at the schedule for the day to get a feel for what's gonna go down, but expect everything to change. Be sure to say hello to everyone and see if anybody needs help (assuming you're not the 1st one in, not quite as applicable to a student who should be hanging close to the preceptor). As a student, study up on your drugs (opiods, pressors, benzos, ABX of choice, etc.) during down time and at home. Be familiar with the different anesthetic approaches and their implications--regional, neuraxial, general (TIVA vs. gas). Try reading up a little bit on the cases being performed that day if you're not familiar with them. Ideally, spend some time reading Drain's Perianesthesia text if you can get your hands on it. Don't be afraid to ask questions, as it is impossible to anticipate and study everything that will come up in a day. One thing I want to add: if your preceptor tells you to be quiet or get out of the way, please do it and observe closely. Some situations take the experience and finesse of an experienced PACU nurse. I'll talk my preceptees through just about anything, but when the patient's comfort or safety is at significant risk I may need to step in. Never put off what you can do now. When you receive your first patient do as much as possible as quickly as possible (while still doing it correctly) before you get your second patient. Don't delay your documentation unless clinically necessary. If you're giving chin support your other hand can be documenting assuming your patient is stable. Without freaking out over it, always expect that in 2 minutes you'll have another patient. That way when the OR forgets to call out and goes "SURPRISE!" as they come into the PACU you're not overwhelmed. Think about patient disposition the moment the patient hits the PACU, or better yet once you know you're taking him. Is the current bed assignment appropriate? Will this patient require a higher level of care than planned? The sooner you can get issues like that addressed and let the house sup know the sooner you can get the patient moved. Your job is not merely to care for the patient, it is to stabilize him and transfer him to his destination unit in an expeditious manner. Anticipate possible complications and how you would identify them and respond. Be proactive in preventing issues that you can. Part of getting him ready is to optimize his comfort, of course. Do not wait too long to start working in the opiods if appropriate. It'll take you way longer to get your patient's pain under control if you let it get insanely horrible. If the patient's arousable and showing signs of pain or complains of it, go ahead and give some meds. If X-rays are ordered arrange for them to be done as soon as you're aware--you don't want to be delaying transfer while you wait for radiology to show up. Same goes for labs. Review your orders as soon as they're available and you have a moment.
  11. Perpetual Student

    Very little witnessing going on with drug wastes on my floor!

    All they gotta do to get around that is put some clear fluid in the vials. Shy of taste-testing or sending it to a lab, there's no way to really be sure.
  12. Perpetual Student

    What are you really good at?

    Reassuring and comforting fearful patients, especially those in severe pain. Riding that fine line between agony and apnea is my specialty. I am the BEST at making a mess. If you want wrappers and such all around the garbage can instead of in it, I'm your man. Need something spilled? Can do!
  13. Perpetual Student

    Average recovery times?

    I work both phase I and phase II in a mixed inpatient and outpatient department. We typically use the gurney from the time the patient changes into the clothes until the time he goes home/to the floor. So furniture isn't really a factor in our practice. Typical phase I time is about 45 minutes for most outpatient general anesthesia cases. We hold onto everyone for at least 30 minutes, in part due to the amount of time it takes to get the post-op orders from the surgeon and get our paperwork done. Ideally, the patient will be awake, have his pain under control, and not be particularly nauseated by the time he's transferred to phase II or the floor. I've kept inpatients for a few hours even when a bed is available in order to get their pain under control and then make sure they keep breathing. I'll take however long I need to, though I do try to move people as soon as they're ready for the next step. Phase II time is typically about 40 minutes, though both can vary considerably based upon patient needs. I've occasionally received a patient out of the OR, recovered 'em, and discharged 'em to home in about an hour. One little boy who was very eager to go to a BBQ comes to mind. If only the men were always as manly as that boy! Treat opiod tolerant patients aggressively, taking into account their usual routine, their level of sedation, and degree of pain. It is unrealistic to expect to not hurt, but pain should be minimized. If they're inpatients, don't hesitate to throw in some benzodiazepines, esp. in drug abusers. If they're outpatients, consider small doses of midazolam (sometimes even .5mg of midaz can do wonders). I don't mess around with nausea, either. Complain to me and you're going to be getting an antiemetic every 5-10 minutes until I run out of ordered drugs (and I'll seek further drugs to cover other receptors as needed) as well as an appropriate volume of fluid. While it is indeed true that often time does a lot to help with nausea, the drugs do work and it's only humane to use them. Granted, if you've given ondansetron, metoclopramide, droperidol, a scopolamine patch, and fluid to a patient who still feels nauseated, he may need to go home that way. I wouldn't rush him, though. I've had some folks who do indeed want to get a move on once you've thrown the kitchen sink at 'em. They're gonna be nauseated wherever they are, might as well get home where they can be more cozy. Also, don't forget other measures such as a wet, cool cloth.
  14. Perpetual Student

    What is the hardest subject in the nursing curriculum, in your opinion?

    All of that pregnancy and birthing related stuff was incredibly challenging for me. It was (and still is) totally alien to me. Don't get me wrong, I kind of liked learning some of it as it's an important part of life, but talk about complicated.
  15. Perpetual Student

    Depressed-Need Your Positive Thoughts/Prayers

    If you accept that prayer works why wouldn't you accept that God exists and elect to worship him? I don't mean to troll. I'm actually what you could call an agnostic. I WANT to believe. But I don't believe in anything anymore. Even that which I can touch is met with a high level of skepticism. I'm just a mite logical and such. I know what it's like to feel like a failure. I feel like an absolute failure for ostensibly being a critical care nurse and not recognizing certain signs and symptoms in my mother for what they were and forcing her to seek out help from her cardiologist and PCP, instead ascribing them to effects of obesity and smoking. Best wishes and I hope you're able to find a workable solution.
  16. Perpetual Student

    How much pain medicine is too much?

    It's too much when the patient stops breathing sufficiently or becomes totally snowed. If a patient is awake and with it enough to realize it's been two hours it's obviously not too much.