accessqueen

I think the population you serve really determines the sizes. We use primarily DL 4's because our adult population tend to be of smaller stature (native americans from mexico, central america, etc). When we used all 5's we definitely had more thrombus formation. We customize per patient and situation.

There is a wide variation in how VA dept are run in different hospitals. In smaller hospitals, (such as mine), we combine outpatient infusion with inserting PICC lines, and being the go to nurses for all things IV as needed. We work 8-5 Mon-Fri, except for our infusions which is 7 days a week. There are two of us, so we switch weekends. We do our infusions in the mornings. And respond to PICC requests throughout the day, as well as hard PIV starts. Because we are not available after hours, the hospital nurses are in charge of assessing their lines and doing all line care, dsg changes etc, In large hospitals they have dedicated PICc teams with 24 hour coverage that take care of the PICCs from start to finish. Some hospitals place PICCs at the bedside, some in dedicated procedure rooms. PICC teams usu do not generate profit therefore many hospitals try to squeeze as much work out of as few nurses as possible. That means some hospitals have nurses on call nights and weekends for PICCs. All depends on your facility.

I make the nurses I precept take a tray home and practice setting up for the PICC insertion. I tell them to memorize the tray and repeat setting up until they can do it automatically. I tell them to even use a pretend arm so they get a feel for the insertion porocedure. The set up is the most time consuming, and the most confusing, because if you forget a step, you may have to break sterile technique, unglove, reglove, and increase chance of infection. Also, the more proficient you are at set up and knowing yor tray and equipment, the more confident and efficient you will appear to the patient. THen you can concentrate on learning how to access the vein.

Duriing vanco tx trough levels must be drawn. They used to be before the third dose, our pharm is now doing before 4th dose. Therapeutic levels have changed as well. If the pt is MRSA the recommendations have become 15-20. Other infections the level can be 10-15. If the levels aren't therapeutic the dosage may need to change. We are doing more and more vancos q12 hours, or switching to daptomycin (esp for outpatients).

My favorite thing to do when people start being verbally abusive is to just stop what i'm doing and quietly stand there, calmly, and NOT SAY A WORD. The people rant and rant. And if they pause to breathe, I still don't say anything, so they continue ranting, pretty soon, all they hear is their own voice going on and on nonstop, and a lot of times they actually start to get embarrassed becasue they realize how they are sounding. Most of the time they even start ot apologize. They trick is to just STAY SILENT. If you try to explain anything, you give them amunition to argue about.

DO NOT cut down a PICC. Someone is going to think it's a picc, because it looks like a picc and they will hook up TPN or something equally innappropriate. Seen it happen too many times. BARD for one makes midline kits. I know other companies do too.

One thing that hurts a lot of people is the old advice to "go in at a 20-30 degree angle, and once you get flash to lower the angle". Forget the angle. Go in at as flat as an angle as you can. As a previous person noted, go for a vein that you can really "feel", as opposed to one that just looks good. And if you can feel it but can't really see it, find a land mark, a freckle, a scar, a mole, anything to x marks the spot. Then go for it. Pull the skin back to stabilize the vein, and approach a little from behind the vein. The most painful part is the skin puncture so thats when most people jump. So, go through the skin, then stop for a second and let the patient calm down, then advance. You'll get it.

Wearing a head covering is a religious issue. For you to wear a head covereing would be hypocritical. Living in this country they encounter scarfless women every day, I think if you wore one it would be disconcerting. That is different than making every male wear a yarmulke while in a Jewish temple. You are not in a religious environment. I think it's great that you want ot respect their culture, however, they have to respect yours as well.

The place to get started would be to call the reps from whichever company would be supplying the PICCs. As an example, BARD which is who we use, has an on-line PICC insertion course. That is the starting point. When you complete the course they send out representatives who will train you. HOWEVER. I strongly suggest that you recruit an experienced PICC nurse. In order to gain the confidence of the ordering physicians, you have to be good. You can't be good until you've had adequate experience. If you start out with a bad track record, you will not build up volume, and you will not become proficient. In our 90-100 bed hospital we place between 70-100 PICc's a month. In patient and out patient. But we didn't start out that way. The team we replaced were NOT very good and the docs did not want to order PICC lines. We had to prove ourselves, and I was able to do that because I came in with years of experience and then trained the team. The company reps are usu flying in from some place to dedicate a weekend or a few days to do training. However, if you don't have the volume, they can't train you. Which goes back to having a trained person on the team. Also don't train a whole bunch of people who are not ever going to be very good. Focus on a designated one or two nurses and get good!! Using ICU nurses to put in PICC's prn is a recipe for disaster. Good luck!

I live in Las Cruces, New Mexico. They are ALWAYS looking for nurses. I make 31.00/hr but that's with 30 years exp. However, the housing is ridiculously cheap, and the cost of living overall is way lower than just about any warm climate areas. There are two hospitals and the bigger one just expanded their cardiac cath program with brand new suites and technology and they are also expanding their ICU. I work in the smaller hospital, and they pay 5000 toward the purchase of a home. You could ask for the 5 grand to be paid towards your loan. Worth a try.

You have to remember that you are dealing with a '70's female who just lost her husband'. The same thing may have happened even if you h ad spent all day in her room. You can take all your meds and still have a stroke. May be she lost her will to live after her husband died. I totally appreciate your compassion. But you can't beat yourself up for things that are just not in your control.

Bottom line, when you're in a professional environment don't say anything about anybody that you wouldn't want repeated in front of that person. A huge percentage of the posts on this site are related to issues where people are saying things, repeating things, gossipping about things, etc etc. If you have a legitimate issue, document everything and take it to the proper superior. If you're not willing to document, keep it to yourself. People have to realize that when you work in an institutional environment with a lot of employees, you will ALWAYS have poeple issues. People are poeple, they are not perfect, some are moody, some are angry, many have issues. Just do your job. Also, if people challenge you when you give report, do they have a valid point? One of my biggest pet peeves in the institution that I work in is no one holds anyone accountable for anything. When I used to work in ICU the oncoming nurse would inspect your patinet head to toe and eveything better be right. Nowdays, when I'm doing QA, I find undated IV's, unlabeled tubing, unchanged dressings, etc etc, and I hear, well, that's the way it was when I started my shift. Well, why did you not hold the person accountable that gave you report? I don't know what kind of environment you work in, but maybe this crabby nurse gets tired of things being left undone. I always personally chanllenged myself to try to make sure that the oncoming nurses could not find ANYTHING that I had left undone. It made me a much better nurse.

I don't know as I'd call it hierarchy, it just seems that you tend to socialize in the groups that you have the most in common with. I've worked in places where people were very standoffish all the way around, and other places where everyone is friendly. But even in the friendliest places if you look at who's eating with who, people stick togeteher along their professions, respiraroty with respiratory, lab with lab, RN with RN etc. Or the other grouping is along cultural lines, latins with latins, asians with asians etc etc. I'm not saying this in a prejudicial, or judgemental manner, this is 30 years nursing observation adn experience.

Your describing a different situation, with different legal ramifications. Reporting something about a fellow emplyee, without proof can be labeled slander. The person who supposedly saw the picture taking should have been the one to report it. The fact that they didn't, makes me wonder if it really happened. It's a pretty bizarre story.

The original post states "I was told of another nurse taking pictures. . . .etc". You were told???? and then reported this 'hearsay' to a supervisor??? Did you have any proof?? I'm not surprised people are out to get you.

Yes, I think they were referring to PIV's. I agree with both points of view on this topic. Usu you don't want to use a stroke affected limb, for the previous mentioned reasons. However, in the real world, y ou gotta do what you gottta do. Typically, you end up using the good arm until its worn out, then you have no choice. Understand that repeated multiple IV sticks in any vein will cause scarring, phlebitis and potential thrombus formation. Repeated infusions of caustic meds will cause veins to sclerose and potentiate thrombus.

In my experience the PICC class is just a small part of PICC training. You can get PICC certified on line. The real dilemma is getting precepted. The majority of companies that give PICC classes, do not precept. Don't bother getting PICC certified unless you set up a way to get precepted. There's a bazillion nurses out there who have their PICC certs, but have never put in a line.

I wouldn't call venous thrombosis in arms "common", but they certainly are not rare. I've seen plenty of patients with multi-vessel occlusions in the upper extremities. re:previous post that said that they noted an increase in clots in edematous arms. I've come to the conclusion that a fair amount of time the edema is because of the thrombus, esp if the edematous arm is bigger than the other. If I'm suspicious, I'll make them doppler the arm to r/o occlusion, and lo and behold, most of the time I'm right.

The factor to consider: are the CNA's private or from an agency. The agency should have parameters on what the CNA's are and not allowed to do. If they are private, they can do whatever.

I go into patients' rooms to put in PICC lines. I get told about the patients' pain all the time. I then take this info to the nurse. The nurse may or may not want to hear it, but it is my duty to report it. And I have had many situations where the nurse said she would do something, but I am at the bedside for an hour and nothing gets done. When I get back to the nurse I hear "oops, I got busy and forgot!' If I, or the CNA, or whoever is told about pain, we cannot very well say to the patient, gee sorry about your pain but I can't tell the nurse because she may get irritated." I'm glad those annoying CNA's are patient advocates, better than the apathetic ones who don't care enough about the patient to go hunt down the nurse. The CNA is coming to you cause she's hearing it from the patinet.

Thank you, you are brilliant. I thought I was brilliant, but I racked my brains and wasn't really coming up with any good solutions. Not only easy but FREE!! Some suggested securement devices to eliminate the need for tape, but my facility is NOT going there. Thanks again.

Anyone got a good solution for where to place the tape when preparing for a PIV insertion?? Sticking tape on siderails, bedframes etc is a no-no, except we all do it. But I would like to find an alternative.

The other important question is which do you want to DO the most?? Are you an adrenaline junkie and will never be happy until your in the thick of things?? Or are you intimidated by the acuity of the level II and would feel safe and comfortable in leverl IV?? that counts for more than the money.

Yes if the bag runs out the line could clot. Are you using a pump? Set the alarm for less than the bag, i.e. if you hang a liter, set the volume for 950, then you'll be safe.

One of the best ways to learn things when you are new is to understand that wherever there is one thing that you missed, (i.e. pre op checklist), that's the time you go to someone and say "ok, now I know about pre-op checklists. What are the other areas that pt's go to that I need to know what papers to send or what actions to take? " Examples: what tests/procedures do patients need to be NPO for? hold certain meds for? get special preps for? need specific checklists? need specific IV access for? Find out what are "typical" orders for the most common things you see in your area. (i.e. CPM settings). Obviously you don't want to go around making up your own orders for patients, but knowing what is typical and routine will help you recongize an unclear order when you see one, also will hep you recognize an erroneus order. PT should have checked the patients orders so don't beat yourself up over that one. You'll have enough to beat yourself up over, don't take the blame for others. There's no question, nursing is hard work, and unfortunately nursing school does not teach organizational skills real well (or at all). Besides learning specific nursing skills and care, go to the best nurses in your area and pick their brains about how they get organized, set their priorities, etc. They all have different tips that can help you. THe biggest thing to remember is be PATIENT oriented, not TASK oriented. If you are patient oriented you will always have some sense of satisfaction because you can go home feeling like you helped someone. If you are task oriented you will always feel flustered because it will feel like you can never get caught up or accomplish everything you need to in a perfect manner.