SweetTeaRN

Update...at work today, my supervisor approached me to thank me for "doing the right thing" by hanging the IVPB. Apparently the new policy per our pharmacy is to give PO when the pt. is stable, but give IVPB (diluted in at least 50ml NS and given no faster than 1 mg/min) when the pt. is actively bleeding or unstable. I was told that the SQ route is no longer to be used since the bioavailability is unpredictable. Thanks for all the replies. My manager is going to be doing an inservice since so many people in my department were unaware of the new policies.

I had an instance at work where a pt. came by ambulance from the nursing home with a lower GI bleed about an hour before the end of my shift. The PT was approx. 40, H/H were about 9 and 27. Pt. has stable VS, good pressure and is responsive and at baseline orientation, but skin is pale and has slightly dry membranes. ED doc ordered Vitamin K 10mg IV. I placed the order to pharmacy, and 20 min. later received bag mixed by pharmacy of 10mg Vitamin K in 100ml NS with instructions to deliver IVPB over 30 min. I was hanging the bag as the nurse taking over for me came to get report. When I told her I had hung the IVPB, her eyes got really wide and said, "You're giving it IV?" We asked another ED doc (first one's shift ended when mine was supposed to), who gave me a verbal order to change it to 10mg SQ. When I called pharmacy to change and verify the new order, they stated that "we have just started giving it IV. We had an inservice, and they said you can give it IV now." Although, same pharmacist told me that giving it PO or SQ is just as effective as the IV route. I also had orders for 2 units FFP, which were being prepped by the blood bank as this was going on. Has anyone had any experience giving it IVPB before? Is SQ as effective? I know if the pt. isn't actively bleeding, then IV isn't necessary, but what if the pt. is massively bleeding and is heading towards unstable?

How many hours or days s/p surgery is the patient?

I assume this was used in a case of hypervolemic hyponatremia? Taken from an eMedicine.com article: Lasix (furosemide) High-ceiling diuretic with a prompt onset of action that acts upon ascending limb of loop of Henle to inhibit sodium/potassium/chloride cotransport system, thereby increasing solute delivery to distal renal tubules, which acts to increase free water excretion. This can lead to increased aldosterone production, resulting in increased sodium absorption. Absorbed readily from the GI tract and also available in parenteral preparations. Diuresis begins 30-60 min with oral vs 5 min with IV administration. Potassium excretion also is increased. Elderly patients may have greater sensitivity to effects of furosemide.

These are all great answers. I just want to remind you that ther terms hypertonic or hypotonic does not always refer to the concentration of particles in the cells. The terms can also be used to apply to the solution. (ie, you can have a cell in a hypotonic solution vs. the cell is hypotonic). Try not to concentrate so much on memorizing what the terms mean. It is more helpful to think about where the majority of the fluid is and where the majority of the particles are. WHY with hypotonic dehydration with plasma volume deficits do you get hemoconcentration?? It says 'only water is lost and other substances remain.' Think...the pt. is dehydrated (or hypovolemic...). PLASMA VOLUME DEFICIT...there is not enough plasma outside of the cells, in the interstitial space (plasma=fluid). There are the same number of RBC (hemoconcentration) no matter where the fluid is, so the pt. is therefore hemoconcentrated.

As a new grad, I interviewed in both the OR and the ER, ended up choosing ER because I thought if I did OR I might get "stuck" there. I know our ER manager likes getting new grads as opposed to people who transfer from med-surg because then she can "mold" us from the start. If you work at a facility that hires new grads, I would think it wouldn't be much different than that getting a job with OR experience. I would assume that coming from OR you are at least ACLS certified, if not PALS? Those are things you'll need that might make you more appetizing to the ER. Good luck.

I'm just thinking...what was her pressure before you gave the meds? Did you have an order to hold the Lopressor for a certain BP? Or to contact the MD if her pressure dropped below a certain level? I'm thinking you did the right things otherwise. I hope everything turns out ok for you.

Here's a website that explains the answer very thoroughly... http://adam.about.com/reports/Shingles-and-chickenpox-Varicella-zoster-virus.htm But the short answer is, yes, because the two illnesses are both caused by the same virus (Varicella-zoster virus.) As Ivanna mentioned, shingles is caused by a reactivation of the virus which remains dormant in the nerves of people who contracted chickenpox at a previous time in their life. Anything that causes immunosuppression will put a person at risk for developing shingles if they are exposed to someone with active chickenpox. The link I posted mentions that in a healthy person, exposure to chickenpox (in a previously infected individual) may actually provide increased protection against getting shingles. (Because a second exposure to the virus causes increased production of antibodies.) Those with AIDS, the elderly, and chemo-induced immunosuppressed individuals are obviously a few of the population where this booster effect doesn't apply, and actually increases their susceptibility. Hope that helps.

I agree with almost everything said in the above posts. As a recent new grad, and a second degree nurse, these were all things I considered when coming into the field and choosing to go to the ER first. However, while I respect your opinions about how burnout is occurring more rapidly and how choosing to go into a specialty at first rather than med-surg is creating a problem, I urge you to look at the healthcare system. Compare the healthcare system from when you first went into nursing and then now. I guarantee you the atmosphere has changed a great deal. In today's system, it is much more difficult to be a caring individual within an unfeeling bureaucratic system. With the advent of HMOs, huge liabilities and legal issues, "Doc in a box," Medicare restrictions, and a growing aged population, it is very difficult to be the same kind of nurse that maybe once all of you were. As a new grad, I am saying that it is somewhat unfair to expect the same ideals that were once upheld. While I strive to be the best nurse I can be, and that includes caring, compassion, and a commitment to my chosen field, there is a lot more adversity for me coming into the nursing profession than there was even 10 or 15 years ago. I think the burnout comes from the healthcare system and upper management. And you're completely right, the focus should be on training good nurses, then retaining them. And in most places, that emphasis just isn't there. And until it is, there will always be a "shortage."

The location where I lived when I went to school was very similar to where TheCommuter described. All the same reasons why there wasn't a "shortage" existed. They were very picky about new grads and made you feel lucky if you got *any* job there after graduation. Forget it if you wanted to go into a specialty. Where I live now, the shortage is slightly higher although still pretty nonexistent. I work in an ER that the manager claims is fully-staffed. There are not enough hours for everyone to go around. Some of the FT staff even get 4 hours cut off of a shift per 2 weeks here and there because of this. It is a great place to work and most of the nurses (about 2/3) have worked in this ER for 5-10 years or more. So where I am in the south, I do not think there is much of a shortage at all.

As a student, I would have agreed with your post 100%. I always felt like the care plans were mostly a waste of time. I knew in my chosen specialty, ER, that I would never even see another care plan anyway. With that said, I think care plans are important even though RNs in the real world do not really use them. Why? Because they teach you to think like a nurse. They teach you to think about a pt. with a certain diagnosis, and look at the pt. holistically and think of the different body systems and their integrated role in the patient's illness. This is something that is learned through repetition and critical thinking skills. It is not easily acquired, which is why nursing school exists. I agree that it sucks that many people do not learn procedural skills in school. However, they are easily learned on the job. They are learned only by rote, and the same can't be said for the critical thinking aspect of nursing. With that said, I can't believe you are having to spend only 2 of 12 hours doing patient care. My school wouldn't have allowed us to spend so little of our clinical time caring for patients. We had to do our care plans at home. So I agree with you that the way your school has it set up is unfair and is truly detrimental to the learning process.

The length requirement will probably depend on the individual schools where you are applying- sometimes, the school will specify a page limit, others will give you the limit at a number of words (like "in 500 words or less.") However, a good personal statement can be tailored for each school by changing a few things around. As far as format, I don't know exactly what you mean, but again would look to instructions for applicants on the school's website. You can never go wrong when writing anything formal for a school if you use Times New Roman size 10 or 12 font. I had a BA in Biology prior to nursing school and I think that a degree can only help you. Lots of people are now choosing nursing as a second career. I do not think your background will hurt you at all. Lastly, I would recommend thinking about what inspired you to pursue nursing for your personal statement. When I wrote mine, I knew I couldn't say something like, "I have always wanted to be a nurse" because I obviously wouldn't have majored in biology if that were the case. So instead, I recalled a specific instance where I knew I wanted to take care of people, which for me, happened when I was in elementary school. I said something like, "I knew at a very young age that I wanted to take care of others. When I was in elementary school, a classmate fell off the swing set and I immediately went to help him(...blah blah blah.) Even at such a precocious time in my life, I was aware of the need to take care of others, and committed myself to a career in the medical profession." Something like that (it has been awhile and I don't actually remember what I wrote). So just figure out what it was that inspired you to become a nurse, even if you don't remember the exact moment. Then just come up with more similar examples. Then just talk about why you are pursuing nursing right now, and how being a nurse will change your life or allow you to meet your ultimate dream of being compassionate towards others, or something like that. Good luck! Just make sure that it is true and heartfelt and you shouldn't have a problem.

Since being a new grad RN, I always draw labs with the initial IV start and have never had a specimen hemolyze at my new facility. Where I used to work as a tech, I did all the blood draws using a butterfly (if the pt. didn't need an IV start or for repeat labs) and had many incidences of hemolysis.

I agree, this sounds like it could really help out families in those extreme cases of lack of care. However, my fear would be that this system will just turn the use of the MET/RRT into something ignored or cheapened by its overuse or misuse. In the instance you gave above, where someone did not answer a call light, this is the result of people who abuse the call light so that we as nurses may think about the patient in the room, "he can wait two more seconds for a Coke." Granted, it could truly be a patient's family member calling for help as their loved one goes into distress, but the number of times the call light is used to ask for an extra pillow far outweighs the number of times I've seen it used for a true emergency. The same result may happen here. Instead of hearing an overhead page for "Rapid Response Team, third floor hallway" and thinking that there is always going to be a credible possible emergency when you arrive, it may end up being a family member who is getting impatient since the surgeon hasn't come up yet to round on the patient. Don't get me wrong, the intention here is great, I just fear that those who tend to abuse the system no matter what precautions are put in place will ultimately reduce the worth that this implication would provide to a hospital system. I hope I'm wrong. With that said, I have also never waited 5 minutes to respond to a call bell, much less 20.

I carry my Palm in my pocket, and I am not ashamed to take it out and consult my Merck Manual or PEPID if I don't know an answer. I can't count how many times I have been to the doctor's office and have seen a physician do it...

Hi, I have only worked in a Level 2 Trauma Center, but it is really busy and fast-paced. I love the ER, I can't imagine being anywhere else now. I think the hardest thing for me was that I am a control freak and in the ER you have no control over what walks in the door. If you are used to planning out your entire day first thing it's definitely a struggle in change and time management. Tele experience will definitely help you. I have taken a basic arrythmia class but I still struggle with rhythms. I can tell you when a strip doesn't look right but I may not know what it is. Out of my 3 patient room assignment, usually 2 of them are monitored. If the ER you want to work in sees peds patients, you might want to get PALS certified too.

I'm going to go a little against the grain here. I think that a suit is always a perfectly acceptable ensemble for any interview. However, keep in mind that the best thing you can wear is something that is well-made and well-fitting. After my first bachelor's degree, I was planning on going into pharmaceutical sales, for which I had to buy my first suit. I spent a decent amount on mine and I have only worn it a few times, but I think it was worth it. It fits me well, it is conservative, and I know it looks professional. If you can't afford a nice suit, though, something that fits you well is going to look better than a friend's borrowed suit which is the wrong size. Also, I have been told by career counselors that women should avoid a black suit with a white shirt. A solid color suit, grey, navy, or black, should be worn with a lightly colored or faintly pinstriped shirt. You definitely want to remain looking professional, but you also want to not look frumpy. Also, if you wear the suit to an interview and you seem to be "overdressed" then it is much easier to remove your jacket than it is to sit through an interview uncomfortable because you know you underdressed.

I was interested in ER primarily when I graduated last December, but (oddly) my second choice area was L&D. I applied to both ER and L&D units. At every hospital I applied to, L&D units were the first to pick their new hires and the first to fill up their units. I began applying in September and most places were still hiring for all units except maternal. If you haven't already started applying, I would do it now if you can. I was offered my current position in the ER in mid-October, after interviewing the first week of October. I don't know about most places, but the hospital I work at offers 6 month orientation for all new grads, regardless whether you work in ER, OR, floor, units, L&D, etc.

How to solve the nursing crisis? By sorely misleading the public...

I had this problem when I had lost 20 lbs. after surgery. Radiance is a brand of scrubs sold at my local scrub shop that come in XXS. Their bottoms were the only ones that wouldn't fall off my hips when I was really tiny. They are pretty cheap at the store here, about $16. I think they come in petite and tall, too...the man at my store said he could special order the size and colors I wanted. Urbane makes an XXS that can be special ordered too but I didn't try them.

I just want to point out that this problem is unique to the Medflex I fabric. The newer editions, Medflex II and Medflex III, do not need ironing. I think that IguanaMed are the most comfortable fabric, but I no longer buy the original Medflex I fabric for this reason. Personally, I like Landau the best though because the tops have 4 pockets!

Landau tops...they have 4 pockets. I have many other cuter scrubs but I find myself wearing only the Landau ones. IguanaMed are probably the most comfortable but the pockets are too shallow, so my scissors and hemostats keep falling out. Urbane scrubs are really cute and comfy but NOT enough pockets!

The PEPID suite was originally created to be an ER companion. I have had Skyscape's Nursing Central for over a year and thought it was the greatest thing since sliced bread. My subscription just expired so I thought I'd try PEPID RN suite to see the differences. I LOVE PEPID. My trial has expired but I can still access the content (I just don't get updates when I sync my Palm). Try the free PEPID trial- you won't be disappointed. The database (accessed by clicking the far right link in the program that looks like a house with an "i" for info in it) is so comprehensive. It's amazing. Blows my Nursing Central with Taber's and Davis in it right out of the water.

I agree with the above posters. Duke's pay is notoriously lower than everywhere else in the area, probably because they can get by with it in exchange for the prestige of the name. I would look into WakeMed and Rex, both are great hospitals. WakeMed is the state's newest Level 1 Trauma Center and they are very busy and have a high acuity. Rex is smaller and non-trauma but an easy commute from North Raleigh. UNC is a great place too (Level 1) but depending on where you live may be a farther commute. Also, lack of employee parking there (as with Duke) is a problem. WakeMed and Rex also have the better shift diffs.

I think Charlotte area hospitals pay approximately 20-21 dollars an hour for new grads. (Presby and CMC) I think CMC also will pay about $3000 relocation assistance too. Hope that helps.