enigmaticorange

Thanks! Ive been in there a few weeks now and the advice given is spot on! I really, really get now why critical care/ER experience is usually required. Ive been in codes before, but what Ive seen and treated now? Whoa. What an amazing job, and I have SO much to learn.

After working nights in tele, I finally got my dream job in the cath lab! I am a person who always wants to know as much as possible about any new environment. I bought a text book and have been studying the Wiggers diagram and hemodynamics- things i know they will teach me but want a good base to begin with. What other things should I know going in? what drugs are standard in your lab? What non-obvious topics do you deal with on a daily basis in an interventional lab? Sedation, other drugs, labs, etc. Any tips for me?? We have separate EP/Cath labs, so I don't have to worry about EP (yet). TIA!

My behind would be is big trouble if i told a family we had staffing issues. It is a hospital, not Denny's. You tell someone there is not an adequate number of people to care for patients....they don't take it well. Even if they have no idea what we put up with on a daily basis with unsafe staffing issues.

When i told my pediatrician that I would not have my son circumcised, (and this was before i was a nurse) He said to me: "Well at least we have ONE informed parent in the world!" This surprised me quite a bit, especially since this doc tends to be condescending. I originally left the choice to my husband, and i believe it should always be the father's choice. If the father isn't around or if there are questions, I would try to give basic info about it, giving three reasons for and three reasons against. I would refrain from giving an outright opinion. This is too easy to label as medical advice from a doctor.

No, med/surg is general medical problems while a post surgical unit is specifically for recovering surgical patients unless they are Ortho. (We have a separate ortho floor, you might not) The surgical floor takes lots of bowel resections, amputations, general surgery stuff. They come there after leaving PACU- which is more focused on immediate and short term reviving/monitoring of patients from anesthesia and determining pain control. You will see a variety of ages on a surgical floor and many, many PCA's.

I am on a 33 bed tele unit, and we are expected to give bedside report always. It is always a PIA to change, but really, bedside reporting can be great when 1: staff is properly trained in reporting off, and 2: Staff is scheduled to match groups as closely as possible. Night/day take diff # of patients on my floor so I have at least 2 people to report to, but hopefully if a nurse is coming back I only need to give updates! A bedside report should be by exception and goes something like this: "Hello Mrs Jones, This is Anne and she will be your nurse this (evening/morning). I am just going to give her some information to let her know how to best care for you." (Situation/Background:) Mrs Jones is a 81 yo pt of Dr. Smith. She arrived in the ED after experiencing CP at home. Pain was relieved by 2 nitro and 2mg morphine. enzymes were positive on arrival and is set for a cath today. she has been NPO since midnight and the cath sheet is in her chart. She has a HX of CAD, arthritis, and Diabetes, and is ACHS finger sticks. (assessment:) As you can see, Mrs. Jones is A/O x4 and is able to walk with 1 assist. Lungs clear upper lobes with crackles in bases. O2 2L sats WNL, CXR showed mild bilat infiltrates. Pressure fine, Sinus Rhythm, mild edema to pedals pitting +1. Cath is today. No CP since arrival. LBM yesterday, voids in BR Skin WNL No pain IV #20 L A/C INT (exit:) Thank you for allowing me to care for you, Mrs. Jones. I hope you have a great day today, and Anne will return shortly for your assessment." It takes 5 minutes, and if patient has fluids, foley, skin issues, etc., these can be looked at while giving report. Only report what is NOT WNL. I still have nurses I report to asking about random labs and asking, "Positive pulses?" No. The have no pulses and I forgot to tell you that their feet and hands fell off during the night. No, I cant tell you the exact last blood sugar, look it up if it is important to you. I told you they are a finger stick/diabetic. If the sugar was >300, I would find it noteworthy. Just remember, it is not the time to chit chat with the patient about sports or take care of non-essential requests by the patient. If the patient suddenly needs a new water pitcher or use the BR, etc., I let them know we are rounding and we will have an assistant come right in and care for their needs. If the issue is pain, we grab it quickly while still talking or ask the charge to assist. I am rarely not finished by 7:30. The longest I have ever taken was the day I gave report to 3 nurses, one of which who was both talking sports with patients and does not know how to take a hint. In a completely separate issue- Why are glucose checks being done at 0600?? Do your patients eat at 0630? Why can a CNA not take blood pressures on a tele floor? I have all vitals taken at beginning of shift so when I give my first round of meds they are already in the computer for me to check.

Altra- That is a very good point you make. The push for 100% patient satisfaction has turned patients in to monsters sometimes. I think a ginger ale should do the trick once in a while instead of pushing zofran. Once a patient has had a clear cath, clear enzymes, normal EKG, Im ok backing off of morphine. Until then, it is my butt if I don't follow chest pain protocol or at least address it with a doc (and document!!) If I have prior notice that the doc is aware and doesn't want them to have meds, no problem- and i can push check that magical "doc aware" button in my pain charting.

Assuming that I am the nurse actually admitting the patient, our ED nurses dont handle admitting orders. Their job is to stabilize then ship them up or out. Our ED docs don't write orders for admitted patients. All ED orders are null and void once the patient is admitted. (God, I would LOVE to keep the ED orders...they understand the proper dose of Haldol and pain meds when needed...) The admitting docs often write orders from all over the hospital or even at home. The ED nurse often doesnt know if a patient is capable of walking or not- it isnt a priority. Our ED reports often go something like this- Did you read the ED report? Ok. we will send them up.

I work nights on a cardiac floor that of course includes lots of admits for chest pain. I often get this scenario: Patient admitted at 1am from ED, chest pain was 10/10 on admit to ED, recieved MONA, etc, pain relieved by the time patient is admitted. So, around 3am patient experiences chest pain and what orders do we have? Tylenol. Xanax. wow. really? No nitro, no morphine, nothing?? Then I have to call the doc and get one of two scenarios: 1. Call Doc, Doc doesnt call back unless we page 3 times because they are asleep. I would be too if i were them. They proceed to order the morpine/nitro/whatever we need or ask for, no problem. 2. Call doc, doc proceeds to yell about the fact that of course he knew the patient is having chest pain, he/she admitted them and sent them up with Tylenol because it isnt cardiac pain and/or they are drug seeking. Ugh. so here is my wish list to docs: 1. If a patient is admitted for chest pain; address it. Send a note or a message if you are unwilling to give anything for pain. 2. If you are willing to give pain meds and you have a patient admitted with pain, ORDER PAIN MEDS!!! You took the effort to order basic PRN's like tylenol, just add one more on. You know people dont come to the ER for "pain" if tylenol is going to do the trick. 3. I realize that the patient is most likely not experiencing true "chest pain" after enzymes are negative and they have a clear cath. This does not mean the patient does not have pain that needs to be addressed. No, this pain wont kill them, but you dont have to ignore it, either. 4. I can spot a drug seeking patient also. I see them all the time, and the generally arent shy about what they want. ("Give me Phenergan at the same time, and fast!!") ok, rant over.

The first time I gave birth; I was 17. My boyfriend at the time (now my husband) was also there. I was treated HORRIBLY by both nurses. It was an uncomplicated delivery and im not even sure why two nurses needed to be there, allowing my entire family in the room while I asked repeatedly for privacy. They let my grandmother, MIL, father, and sister in the room while my grandmother was repeatedly telling me I was "too young to have a baby". Pain control seemed to be removed as an option for me. Fast forward 4 years and my boyfriend was then my husband, and I was an apparently acceptable age of 21. One nurse, only husband and I in the room, nice dark room, epidural offered right away. It was an amazing experience. I decided to become a nurse after this experience, seeing how much difference the attitude of a a nurse can make in patient care and attitude. The first nurses had decided I was some scrubby white trash who was knocked up. Today, I am preggo with #3, a cardiac nurse, and still with my husband. Something tells me that epidural will come just as quick (if not more quickly) this time.

if the issue was tachycardia and the patient was able to tolerate a systolic in the 80's (and many are) then I would not see the problem with this. The opposite is true as well- Ive notified docs about BP's that are 180/100 and in a CVA, this is OK.

Aside from the FB stuff- do you feel comfortable actually working in this setting? When I am orienting a new nurse, there are limited opportunities in orientation for he/she to practice as many skills as possible. That being said; if my orient was uncomfortable performing something as simple as a PICC dressing change; I would be concerned. It is generally not a good idea to turn down opportunities to practice skills. Instead you ask for an experienced nurse/preceptor to watch or even talk you through. The nurse (like many non-confrontational people) was most likely not forward enough to tell you this at the time. Were you able to practice other skills in this time?

lol. mmmmm. Dopamine pie.

The other day another nurse and I are on the way out of the hospital in the parking garage. The smell of rotting eggs is suddenly hanging in the air. The other nurse says "Ewwww, what the heck smells like Mucomyst?!?" LOL. Us nurses are changed forever the day we step into a facility. Do you have any other "Only a nurse would say...." stories?

I flush a foley anytime I am concerned with output -along with a bladder scan, repositioning, and deflation/reinflation of the balloon. Ive only seen a doctor have a fit about a foley once. A pt with Hx of prostate/bladder CA had his foley removed and reinserted by a nurse who saw clots and removed/reinserted a foley instead of flushing. This caused a large amount of urethral trauma and bleeding/clots. I ended up flushing that pt Q4H just to keep the line patent.

How about you stick to troll.com for your obscure advice giving and us nurses take care of each other. k?

As an ACOA- I know that I am probably a great nurse because of my life experience. My mother struggled her entire life with Alcoholism/depression/psychosis which led to an accident causing her paraplegia. She later overdosed while drunk on medication, it is unclear if it was accidental or not. It took me years to trust my husband enough to commit to my marriage or give myself real value. While I still (and will always have) issues with my past, I realize some of my best traits also stem from this. I have more empathy for my patients because of my experiences. I am a strong person and I know how to be independent when I need to. I began to trust myself and OWN the decisions that I make. The diverse and wonderful people I work with help me realize that I am not alone in the world and I don't have to always have to rely solely on myself.

Get a belly belt right now. A full support elastic back brace from motherhood maternity or babies r us. Best thirty bucks I ever spent after running around my tele floor. (I am due 03/05!)

If doctors are around, we welcome them to join us and have a chat for our holiday potluck gatherings. Some do, some don't, some seem uncomfortable taking from the nurses. Why would a doctor ever owe me a gift?? Do you buy gifts for you CNA's? They both deal with and clean up the crap we don't want to-and for way less pay. (Sound familiar?)

I am a cardiac nurse, so I give BP meds to nearly all of my patients. It always depends on the patient, and you have to learn what this means through experience. I have patients who maintain a BP of 90/65 and the doc still wants beta blockers given. Why? The doc is more concerned with the HR at 100, and the pt is known not to bottom out. (Afib/tachy) Other pts can be extremely hypertensive (220/110) all the time... so the doc wants to hold bp meds for systolic

Compressions should be occurring at first sign of code blue. These should continue until a defib is indicated. (v-fib/tach) Asystole should never be shocked. The point of a shock is to slow a V-tach and possibly convert to a perfusing rhythm. If you shock asystole -chances of regaining a beat is even more distant.

You may want to look up more information on the disease process of a burn. This alone should explain a lot, including infection and differentials as well as hemoconcentration/dilution.

Burns cause a very dangerous fluid shift from the vascular space into tissues. A person may sustain a burn that may even appear mild, yet have deadly effects on the body. The Parkland formula is the fluid resuscitation formula I was taught in nursing school. There is an enormous amount of even basic info in regard to burns- here is a great website I found that gives some basics. http://www.remm.nlm.gov/burns.htm

That sounds like my tele floor.. It is usually no problem because we all work really, really well together at night. One night I started with a combo amiodarone/cardizem drip, another cardizem drip on TPN with an NG tube and just about every other line you can stick in, a total care trach pt who was tachy 150's and an unexplainable fever.... and a demanding walky/talky w/ acute CP. We had many admissions that night...but my fellow workers were kind enough to take six patients instead of giving me another. I expect to get 6 patients when I work, but ive had as few as three all night. Keep in mind that i've been an RN only since June. As long as I DONT PANIC and think everything through, I have been fine. (And asked for advice from my fellow nurses!)

My huge pet peeve: Watching any trained medical professional walk out of a C. diff isolation room...., take off the gown, gloves....then stroll right past the sink sitting right in front of them. Please people. Wash your hands.