Perpetual Student

As stated, they could terminate you if they so desired. It sounds like honestly they need nurses, and you sound like a motivated employee who happened to get really sick, so I doubt they will terminate you. By the time they terminated you and trained somebody else you would probably be ready to return, so it'd defeat the purpose assuming you're an otherwise good employee. I hope you get well soon and are able to jump back into your new job once you're healthy.

As a patient, I try to be extra accommodating and non-demanding. I will quietly voice any requests, but make it clear that I think it's a kindness for someone to do anything other than keep me from dying and that I have no problem waiting until it's a decent time. I make it clear that I value input and thank people. That's not to say that I don't ask questions or want anything, but I try to be super respectful just as I'd want someone to treat me or my colleagues. Fortunately I've yet to encounter a nurse or provider in my own care whose competence I was concerned about. If I did . . . well, I'd still try to be polite about it. One thing I've learned from doing this job (and my mommy may she RIP), is that a smile and a thank you are a lot more effective than being rude or obnoxious. Honestly, I'd rather be the patient who's stable enough to have to entertain himself surfing the net on his phone than the one everybody's huddled around trying to stabilize. Sadly, many people, regardless of profession or lack thereof, are so self-centered that they can't comprehend the realities of the world whether it be in terms of health care, economics, or anything else. I have no problem taking care of other health care personnel and their family members in the PACU. Esp. people I know, as I believe I am able to do an excellent job of tailoring their care to their needs. Granted, this setting affords such a close ratio that it's easy to be perceived as caring and on-top-of-things if you're moderately competent or better. The patients/family members who're not any fun are people way out of their element who won't listen and don't realize how ignorant they are of perioperative patient management. This is worse in lesser trained assistive staff, and also some doctors who practice in totally irrelevant disciplines who probably have bad attitudes as a baseline. For example, I'll get the CNA/MA family member who is freaking out about one vital sign parameter that is consistent with the patient's status who won't listen when I explain why it's acceptable.

A student has no business taking an independent patient load in an ED nor any other sort of critical care area. While it's incredibly stupid that the facility does not provide access to the EMR to students, that shouldn't be the determinant of whether you take an independent patient load. It sounds like you're collaborating with your preceptor to pretty much do the entire job, which is what you should be doing as a student. Anything else would be doing you, and the patients, a disservice. It sounds like your preceptor respects you and is giving you a wonderful learning experience, which is what you're supposed to have. Would you really want to go to an ED and not have an RN be actively involved in your care, even if it's just to say behind the scenes "good work, I agree with your assessment and plan" to the student?

Specialized units with mandatory call often provide opportunity for OT (OR, PACU, IR, cath lab, and so on).

If the fluid is compatible with the drug I always just let it keep running (often turning up the rate if it's on gravity tubing to provide further dilution). When I am done pushing the drug I draw in some fluid from the bag to use to flush it. I definitely advise not unhooking the tubing. It wastes time and every time you do it you risk contamination. If the fluid and drug aren't compatible pause the fluid, flush, give the drug, and flush before resuming the fluid.

From staff perspective: the money can be nice; it's also better to have to work some OT occasionally than be so over-staffed that you have to take a ton of low census hours. For example, as a full time person I'd rather work 60 hours per week than 20. I prefer to not have to eat top ramen and drink cheap beer. From management perspective: ideally you would be able to staff properly to not need excessive OT, but there will always be circumstances in which you need someone (sick calls, vacations, and so on) when you would love to have as many options open to you as possible. Ideally you would find a volunteer rather than insisting someone work OT.

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.

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.

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.

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?

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.

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:

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.

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.

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.

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.

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!

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.

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.

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.

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.

A bikini is totally the way to go. The skimpier the better.

Vicodin with 500 mg of acetaminophen is still out there--I got a bottle myself very recently. It has indeed been banished from the inpatient end of our system, however. As to the posters questioning why oxycodone would be ordered along with Vicodin or Percocet, it's obvious that the intent of the provider is to adequately manage the pain. For a lot of folks 2 Percocet or 2 Vicodin q4 or 6h will not be sufficient to control pain, but add in a dose of 5-10 mg of oxycodone in the middle that interval and the patient may remain quite comfortable.

The difference between oxycodone and Percocet is the acetaminophen in the Percocet. Most patients seem to understand that when I explain it. The pertinent difference between hydrocodone and oxycodone is that mg for mg the oxycodone is more potent. Some patients experience different side effects with one or the other, or express a preference. I'd just let the patient choose. One thing I'd like to point out is if it's the Vicodin with 500 mg of acetaminophen I'd go with Percocet instead when possible to avoid excessive acetaminophen over the course of the day. I recommend giving one of the acetaminophen containing meds (e.g. Percocet or Vicodin) first assuming the patient hasn't already had too much acetaminophen for the day. Then reassess after an hour or so and give some oxycodone if the patient's still in significant pain and not overly sedated. Also, whenever possible try to use other interventions along with the opiods. An NSAID such as ketorolac (Toradol) or ibuprofen (Motrin) can be very helpful. Using ice where appropriate can make a huge difference, as can appropriate positioning (e.g. elevating an affected extremity, raising the knees a bit in an abdominal case).

What other professions allow you to play guess "what rectal foreign body will be removed tonight?" Or try to convince a normally a&ox4 dude that he's really in the hospital, not at Lowe's.