eyknough

I think I'm thinking too far into it myself. :) Just being cautious. It's interesting how important they made medication order noting and medications in general sound in school. I've never had to question an order yet besides perhaps informing the doc of a patient's extremely large size when a 0.1 mg clonidine was ordered. Boy they sure scare the heck out of you about these things when we're being taught. Still, though. There's just something about unlicensed people noting orders that gives me the heeby jeebies. I know I'm the last possible chance to catch a potential mistake when I'm passing meds, but having the question in the back of my mind whether or not people who knew what to look for were involved in at least noting the orders will give me even more cause to pause and think. Good brain exercise, I suppose. Psu, I agree that to verify it is safe and compatible requires a nurse, doc or pharmacist. I thought that's why it was required that a nurse note the orders even though a pharmacist is in the loop. Nursing instructors made it seem like we nurses are responsible for catching any possible mistake that can be made by any healthcare professional and ancillary staff. Perhaps it was overkill to keep people questioning things... such as me. :) Thank you for your input. I'll ease up on the notion of an MA noting orders, especially since they're requiring 2 people to note the orders.

I agree that MAs are performing many functions that used to be more nursing-oriented. With proper training, blood draws and medication administration can still be safe as long as there are more knowledgeable personnel in the loop to make sure everything is safe. If the med is ordered and noted properly, then I feel it is safer for somebody who knows how to safely administer a medication to administer it, such as an MA. But there are also RN's around to apply their knowledge and keep an eye on the patient's condition and step in and take action should something start to look wrong.

I haven't heard of any mistakes that have been made per se. Is noting orders something more than just entering them in to the system so they can be implemented? If that's all that was necessary (especially for fully computerized systems) then the order could just go straight into the computerized mar after the physician orders them without needing to be noted at all. I thought a more in-depth knowledge of the medication's function was necessary to note orders. Those steps are necessary to check the physician to help keep the treatment safe for the patient. Does the MA know which labs to check to ensure the medication is safe? Interactions? Which body systems will be affected and whether adding (or changing) the medication would be safe? Which assessments will be necessary after the new order is implemented to ensure the change in medications is not having a negative effect? Moreover, if an order is unsafe and is implemented with damaging effects to the patient are the RN's still liable for administering it after they were noted and verified by unlicensed providers? When I see an order on the MAR during med pass I assume it has gone through all the checks and balances to be indicated on the mar. This particular system I'm working with does not use computerized MARs, so during med pass I don't necessarily have handy access to labs, recent vital signs, etc. But even if I did, what about the LPN who passes meds without necessarily having the broader knowledge base to know which assessments would be necessary during med pass. I don't know... My gut tells me "red flag". But it IS a "second" noting signature, and there is only one MA. So in effect someone with a broader knowledge base is still checking the orders for safety. And I'm not dissing on anyone in the field, but LPN's are carrying out the full functions that are usually only delegated to the RN as well. Nursing diagnoses, treatment plans, phone orders.... I haven't been an RN for a long time, and I have learned a great deal from everybody I work with. But if I'm sitting on the court stand (or in front of the nursing board), is company policy going to cover my butt? The differences in scopes of practice were made very clear in nursing school. Perhaps nursing school should be made more "real world" if it is ok, then. Makes me uneasy....

Hi all, I have a question about physician's orders and I figured this is a good place to go! :) I started a new position today, and a person who I was introduced to as a medical record's organizer plopped a stack of physician's orders in front of me for me to "second sign". Their policy is that two people are to verify physician's orders and two people are to initial each order in the MAR to verify the order is correct and safe. I couldn't read the signature on the orders, so I asked one of the other nurses whose signature I was "second verifying". They told me it was the MA who noted the orders and that this MA also sometimes fills out the MAR for you to second verify as well. I was further informed that this person is not even certified as a medical assistant, and that this person's highest education level is high school. This person also happens to be the nursing director's offspring. I figure it's not really my duty to necessarily verify this person's credentials, but if this person is on the schedule as an MA then I figure I am safe to treat this person like an MA, which does not include seconding this person's noted physician's orders. Is it even legal for an MA to note physician's orders or to transcribe them to the MAR? Anywhere? I thought this was the exclusive domain of the RN, nationwide. I didn't notice that any of the orders were verbal orders; they were all hand-written by the doc. So that takes some of the danger out of the equation, but I am a little confused as to how to deal with this. Perhaps I am mistaken and with the proper inservicing and training the MA can note orders? I sure know that in the N-Clex world it is only the RN who may note orders, period. It really gets under the skin of the nurses I worked with, and even though this person has been nothing but pleasant to me it really irked me as well. I worked my little tail off in school for years to be licensed to note and transcribe physician's orders! What do you think? I did not second the MA's noted physician's orders.

That's awful! The restraints that must have been necessary were to prevent involuntary muscle twitching, must be? Wow... Although babies are still circumcised without anesthesia to this day.

I have been working in the Jackson area for a couple of years. The interview isn't too tough. They'll give you a couple "what would you do if...." questions. Just remember infection control and patient safety and you'll do well. It's a good place to work for me. I guess it's different for each facility, but it pays the bills. The pay is better than the equivalent position in a hospital. Be aware and be safe, it's a prison.

What a great thread! I've had a couple moments when I ask myself what school these people go to. lol My favorite one to pick on is when a nurse reports that a patient has a "UA".... Uh, you mean UTI, which was diagnosed using a UA? I had a nurse tell me that a patient was on the BM watch list because they hadn't had a BM in 3 days. I said "But she's not eating!" To which she responded, well she's on TPN so she should be pooping something. Really, people? Really?! We are hooking that TPN to a PICC line, not a feeding tube... Sontimeters really gets under my skin, too.

I think it's the staffing to client ratio. I started out in a LTC facility where I was assigned about 15 patients, and I thought it was just too much for me. I like to feel like I'm meeting all of the patients' needs, but there's just no realistic way to do so with such a ratio. I was told it is worse elsewhere. Boy, they were not kidding. I started at another facility where I have 48 patients. Like the nurses above have said, I spend probably more than an hour initialing on the lines and signing my license away in a place where I can not feasibly provide adequate nursing care for all the patients I am assigned to. And when I check regulations for nursing home staffing, I find that I could, by law, have more than double that patient load. My head is spinning. The answer, in my opinion, is more help. Fewer patients to take care of so their needs can be met; so the nurse isn't driving home every day wondering what they were not able to get to... wondering how they will ever get to everybody with an inkling of compassion. The nurses who are successful in this setting, I find, have become assembly line workers. They just don't care anymore if the patients are happy; they don't care if needs are not met. I hear "time management" over and over at work. What that boils down to, in my opinion, is prioritizing, and then telling all of the patients who are not high on the priority list that you don't have time to just hold a conversation with them. Priorities are priorities, but I think everybody's needs are important and deserve some attention. I can not honestly tell them "I have to take care of someone else right now, but I will be back".... because I know that as I take care of priorities, other priorities will arise that will supersede many clients' needs. I am a new nurse with less than a year's experience (but with 18 years of aide experience). I long for the day when a hospital will call me up and offer me a position.

Be careful with assuming preterm labor. The way I see the situation, she's only having uterine irritability and contractions controlled by the brethine. There are criteria for labor, and I didn't think I saw enough information to assume preterm labor. No contraction duration or frequency information is given. There are no hard core attempts to stop labor. We all know twins are going to be preterm, but ya have to be careful about adding information that is not there. There is a reason for the amount of information given, because there is enough to get plenty of nursing diagnoses without needing to assume information. It may even be specially designed to try and catch people if they add information to the situation. Is this for an OB class? Could be a psych question with some OB and med surge thrown in there depending on what you want make of it. I'm starting to think more about the cryosurgery to her cervix. Your risk for infection dx may be right on the money!

I like dx number one. Number 2 seems inappropriate because there has been no mention of PROM (unless I missed it). Same thing for number 3. We don't want to seem predictive. Of course we're going to be watching for infection, appropriate coping with anxiety and we're going to be trying to reduce risk for injury to mother and fetus. So far, she's doing fine, except that she needs terbutaline to try and delay labor. There has been no rupture of membranes, and no signs that she is in actual labor. I think you'd be wise to focus on some of the concerning side effects of terbutaline, as well as possibly a "readiness for enhanced learning" dx. It says she is nervous, but doesn't mention any maladaptive or palliative coping mechanisms. She's ready to learn about how to care for newborn twins. I think you nailed one possible diagnosis in your interventions, fetal oxygenation. I think you should address s/s of fetal hypoxia as a nursing diagnosis, especially since she is cramping (which may lead the mom to not breathe appropriately... pulmonary edema is a possible SE of terbutaline), and may lead her to position herself in ways that hampers oxygenation of her placenta. So, risk for fetal hypoxia, risk for injury r/t possible preterm labor, anxiety, and readiness for enhanced learning. You want to be careful with risk for preterm labor, because as nurses we can't really treat it. In school they're picky about that stuff. If you start writing medical diagnoses, as my fundamentals teacher pounded in our heads, you are practicing medicine without a license, and you go directly to jail. lol Of course, I grasp for straws sometimes... Once I included impaired dentition in a psych care plan.... well it was hard to come up with something! And yes I had to rewrite that dx, goals, interventions and evaluations. Ugh!

I, too was hung up on cultural sensitivity questions. Here's one that I have used as a template to answer all of my future cultural questions: 1. An Arabic woman has returned to her room after having had a breast tumor biopsy, and she is waiting for her husband. The nurse has client teaching to perform regarding post-op care. Understanding that in Arabic culture, it is appropriate for the husband to be present during such information exchanges, the nurse will: A. Perform client teaching. B. Ask the client if she wishes to wait for her husband. C. Wait for her husband to be present to begin client teaching. D. Give the client pillow therapy. (Had to throw one ridiculous one in) I chose B.... EEEEEEEHHH! Wrong answer. Correct answer: C! I specifically asked the instructor if we were to adhere to the client's cultural practices even if they seem derogatory or sometimes even potentially harmful to us. Her answer, straightforwardly: Yes! Now, keep in mind, this is N-Clex world, where everything is perfect and nothing is to be assumed. But now I know just how important that cultural awareness is when it comes to getting the correct answer on these type of questions. Just remember, unless it's illegal, adhere to the cultural practice in N-Clex world. Also, remember fundamentals students. You are learning another way of thinking, and I found that one of the things I'm used to by now (I graduate in May) is screwing up, and not believing I screwed up. As in, I believe the teachers are false sometimes. Just remember they are trying to get you able to bass your boards, and it's supposed to be challenging and difficult. You're being prepared for a challenging and difficult profession! Hang in there, the light at the end of the tunnel eventually gets brighter and brighter.

Yeah, this sounds like a HIPAA violation. Even if the nurse's intentions were good, if it is not in his or her job description to investigate using client records, then their records are private. It sounds like the nurse in question was trying to stir up BS, which is a great reason to report the incident. However, taking your time will get you in trouble. After all, it is not even your duty to determine whether a violation was committed. If you have a question, you are supposed to report it. If you wait a week, then expect reprisal for waiting. If you report, then watch your back. People are nasty and seem to like exacting revenge. Good luck!

I hear ya. I remember check-offs for nursing procedures, and they were tough to pass. It's amazingly easy to break sterile technique! But anyway, I just wanted to mention something that one of my clinical instructors told our group on more than one occasion. She said that we nurses are not paid for our technical skills, we are paid to use our brains. So following that logic, if someone's having trouble with inserting an NG tube or foley, there's always someone else who can help out and get 'er done. I think she was noticing how much we were focusing on procedures, and being able to 'do' nursing things, which was taking a lot of time away from learning the enormous amount of information we need to know to be a nurse. But of course I also notice the eye-rolling when ever we students try to dive in to our knowledge of medicine and physiology while at clinical. After all, don't the blood sugars need to be checked, oh and mrs. jones needs to be in the shower, too. Just remember, while we are students it's a different game. We spend so much time writing every lab value down and trying to gain insight as to the best way to care for a certain patient. After all, we students will be writing numerous care plans and drawing up tons of concept maps. So we're there for a little different purpose than to do the crap work so the staff nurses don't have to deal with it. We're learning. Also, we've been lead to expect a certain amount of orientation and training at each specific site. Perhaps we're just burnt out from more than 2 years of full-on mind-steaming theory work. But if we made it through nursing school (at least in Michigan), then we're probably worthy of your time and effort. We ain't no dummies. lol CNA's can insert foleys? The way we're taught in Michigan is that a task can not be delegated to a UAP if it in invasive. Although we can delegate other nursing takss based on inservicing and trusting that the UAP can do it adequately. After all, if we delegate a nursing task, and the UAP botches it and gives the patient a mean UTI, it's not going to be the UAP who gets in trouble..... Because inserting a foley in a hospital or institutional setting is a nursing task.

Wow! I'm surprised by what I'm reading in here. I'm due to get my associates in nursing in May, and my experience in clinicals has left me feeling like most nurses love their jobs. (Which is, I guess, what pretty much everyone's already saying.) I wonder if the nurses put up a front because they have a little pity on us poor nursing students. I have noticed a surprising amount of bickering and proverbial chest pounding by pretty much everyone but the doctors. But wow, it sounds like they're really pounding critical thinking skills into our heads in school for a good reason. One day I may have to defend my judgement call in court, and probably even more often at work. I'm ready.

great thread! shaving cream works wonders for helping to remove bm from hairy body parts. (i like the lotion idea for the same purpose, as well as a moisturizing body wash!) don't breathe through your nose while cleaning up anything stinky. toothpaste can work to clean the odor of bm off of hands (generally the residents'... i hope!) i learned that one from my granny who used to work at the old state home. if you are planning a road trip and have residents who are incontinent, double layering the brief works great, but you have to remember to make a tear in the crotch of the inside brief so it has somewhere to leak through to the outer one. otherwise the inside one will just overflow through the legs, and likely miss the outer one entirely. during clinical i saw a trick that may have already been described above as a burrito wrap. except the burrito is wrapping the private parts only (for males of course). they'd actually tear a hole in a small brief and (using amazing dexterity) push it over the private parts to make them pop through the hole. (i was told by a lady that to pull them through would hurt. funny since i have the same parts!) wrap up the 'package' and contain it in the normal brief. at first i thought this was overkill, but if you think about it this would expose a lot less skin to chronic wetness from urine.