CharmedJ7

It's frustrating. Wet-to-dry dressings at best will do little real harm to otherwise clean and normal post-op wound. It's totally inappropriate for more complicated high-risk wounds. Non-healing wounds deserve a wound consult. Wet-to-dry orders are lazy and acting under the basic assumption the wound will heal itself (clearly not the case above). Just my . Mine and.... the literature's

That's strange. Most of the patients on my floor are on PCA and the docs don't write a 4-hr lockout at all. We calculate it as a back-up to what we put in, ie, Dilaudid 0.2/0.2/10, 4-hr lockout is 5.6mg. The vast majority of patients do not zonk themselves out on PCA, for the most part I prefer my patients being on a PCA.

We get a fair amount of bariatric patients on my floor. Generally I find them to be reasonably pleasant - a little wary maybe, I see a lot more super positive family members then patients themselves. What I will say though is that I see a LOT of readmissions - dehydration, malnutrition, obstructions, leaks, etc. The first two are most common, the last is less common although of course this population tends to be rife with co-morbidities that impede healing (DM, HTN, Obesity itself, Vascular issues...). They do go home quickly but I've seen a lot return just as quickly - education is super important. At first when I saw your post title I was thinking a bariatric general med/surg floor and my reaction was 'heck no'. But bariatric surgery itself isn't as bad because as has been said above, these aren't total care patients and the length of stay is expected to be short.

It really depends on the chemo agent in question. I work in oncology and the general rule is that for 48 hrs after someone received chemo they are considered to be on "chemo precautions." Exactly what that means is somewhat debatable, but gloves are important and extra care is taken when handling fluids (mostly urine and drain output for us) and pregnant or nursing mothers defer care. The half-life of agents different so how long a body fluid may be holding onto a cytotoxic agent varies along with it. I'm actually more worried about chemo exposure from the bag than the patient, there are some nasty agents out there that can burn your skin or are toxic to breathe in. But generally I don't worry too much about it to be honest unless there's a spill or other large exposure.

We just moved over to uniforms. We tried the ID band thing, but they still flip around a lot which is maybe why they decided they weren't working (I suppose this is a solvable problem though if they just make them double-sided). The funny thing though, is that with the current state of things, now PTs wears NAVY blue, PCTs wear ROYAL blue, and RNs wear CIEL blue. Less confusing? Surgeons usually wear lt. green though sometimes they wear ciel too. I will say.... much as I utterly hate the uniforms and I DO think it smacks at robotization/all nurses are interchangeable... it does make it a lot easier for staff to ID each other quickly. I think it does next to nothing for the patients, but I've heard from the docs it makes it a lot easier and it's easier for me too when I float to another unit or someone floats to us. What confuses me is that our tele techs can wear whatever they want which is often a white coat - kind of confusing when you come in the room and they're in with your patient and then turn out to be just changing the battery...

This definitely seems like a policy and/or order thing. Pre-OR, the order set has a space for docs to specify which meds, if any, they want given prior to OR. All other PO meds are held, IV usually given. If I'm unsure I'll talk to the team. For HD, they just changed our policy. We used to send meds with the pt to HD, but now they tell us to go ahead and give them before except for once a day abx which should wait. With both it depends on WHEN they are going. I'd say look at your policy and when in doubt, double check with the MD.

As others have said, it really depends. I received report on a pt, didn't like the sound of it, went it with the off-going night nurse and we ended up having to rapid response here and send to ICU. The night nurse stayed the entire time, as was appropriate since she knew the patient well and me not at all. That said, I've also had people call and the offgoing shift get up to go and I'll tell them not to worry about it, just finish up and go home and I'll do it. I think the key is how emergent it is. If a pt called to be cleaned up at 7.25 and report was given it would be a courtesy if the offgoing nurse would help, but certainly not required. If someone starts crashing though, absolutely they have a responsibility. In my final rounds with my patients I ask them if there's anything they need and warn them it can be hard to get things between 7 and 8 due to change of shift. Most people get this. You do not have to feel bad about wanting to finish up and go home, you can keep getting pulled back in and back in and it's a good way to get burned out fast. The martyr mentality that to be a nurse you must always be willing to sacrifice your time and self in a variety of ways to ensure optimal care of your patients drives me a little nuts - if it's a safety matter, YES, if it's a comfort matter, well, maybe. In the specific situation you noted, if the pt had zofran in and a basin and this is just standard vomiting (ie, they're not throwing up blood or anything else to make it seem more emergent), then there's not much that needs to be done at that exact second. A tech could go in to help the pt clean up, maybe the doc could be called for stronger nausea medicine, maybe if this has been happening all day the pt needs an NGT... I work on a GI floor so I see this a lot, usually what people do is maybe page the dr for the next shift (if needed) and head out, would give anti-emetic if it was due and ask the tech to go in, but probably nothing further.

I find in general new nurses have a far easier time talking to residents than attendings on my floor, partly because they're who we have the most contact with. And for the most part, the residents are receptive and easy to work with. I think a lot of nurses enjoy the power dynamic of the new docs who still need a large degree of guidance (think: what's the dose for zofran? what would you give? what's standard here?). The biggest hurdle is the residents who walk in with a poor attitude and superiority complex. That said, the superiority complex can go both ways and I've definitely heard complaints from the residents about nurses being unnecessarily rude and overly smug about little things that come down to familiarity and how the hospital works (think: standard dosing, phrasing of orders, etc). Can't we all just get along?? :). I love the idea of nurse presentations mentioned above. The most loved attendings and docs in general are the ones that will turn to the nurse and ask about their concerns, "anything from a nursing perspective? What are you watching?" I also love when the MDs come to tell me the plan and why they're ordering certain tests or drugs, although I do know nurses who hate this because they find it overbearing. It's basic, but I think both ways it comes down to the degree to which the other person feels listened to. And maybe that's easier with residents because on bulk, they are more willing to accept help and thus are more receptive. If it makes a difference, I work in a very large teaching hospital in a bigger city on a surgical floor. It definitely seems that here, surgical floor nurses have far better relationships with the docs then medical floor nurses, and of course ICU nurses seem to have the best relationship of all because they are a required part of rounds.

I don't know what the purpose of going slow is. Most of my patients prefer it as fast as possible. I've never had any issues.

Thanks for all the responses, I appreciate it! Getting the bed lower for pulling is an interesting thought, I usually bring it up high so I'm not bending down, but potentially it is better lower. As for the too fast/rough thing, usually that complaint comes in more with the lift equipment which in my experience most people hate. I don't ostensibly have an issue with the time it takes, but the reality is, for example, the edema that's making the legs tender isn't going to get better by waiting 30 sec and it'll be worse to continue having to start over than just move the leg once and be done with it. I work on a surg onc unit, so, a lot of abd surgery which is one of the worst for people helping themselves since every motion really does hurt a lot and could even be potentially risky. Also, love the bed pan comment - so true! Random side thought, does anyone have a bariatric bed pan at their hospital?

Not the pt, one of the residents (docs) I'm friends with. I love the PTs and they're great when they're there, but they can't be there all the time and they often put the pt in the chair and then we have to get them back to bed. I like trapezes too unfortunately I don't think they're not an option for most of my patients d/t upper extremity weakness, though I confess I'm not all that familiar with their indications.

I'm going to try to avoid this being a rant, but my apologies if I fail. I find patient positioning and mobilization to be the worst part of my job. We have lift equipment, and I will say it is helpful with getting patients out of bed more safely, but it doesn't help much in the moment to moment repositioning requests. Any words of wisdom for dealing with the following complaints/issues? 1) Pt: I'm uncomfortable Nurse: Ok, how can I help you? Pt: I don't know, just do something. I'm uncomfortable! I just don't know where to start. If they've slid down low in the bed I may help boost them up, but really, I can't read minds and I'm not going to play goldilocks with them until I hit 'just right,' it's not feasible. 2) Pt: Just pull me over! No pushing that hurts! My understanding is pulling=back injury. Using my entire body helps a bit, but it's not sustainable and none of the equipment is made to help with that. 3) Pt: You're being too rough/going too fast! I've tried explaining to people that going slowly is often not possible and/or will not make anything better/easier, and sometimes they get it sometimes they don't. Stopping midway through though and/or letting them retract and then starting over is too much strain on staff both physically and time-wise. Also, lift equipment and friction reducers still require a lot of side-to-side turning. 4) Large pt who requires at least 2-4 people to move them who is probably also incontinent and/or on contact isolation but rounding up people to help is a constant struggle. I just get so frustrated with it. People on my floor are generally helpful but it's draining to have a heavy patient who you constantly need to be recruiting people to come in because even if they will come it's always "in a couple minutes" which is maybe ok if you only need one but god forbid you need >1 and need to coordinate all those "in a couple minutes". I sort of feel bad because I imagine it must suck to be unable to reposition yourself and be uncomfortable and/or sitting in your own excrement, but it's not worth a back injury and I'm not able to regularly spend large amounts of time in any given room to deal with it. I've had little old ladies threaten to hit me because I'm "too rough" (who subsequently forgave me) and I've had 400lb women yell at me for making them uncomfortable and demanding I "put them back how they were" after all the help has already left (who I walked out on after telling them yelling at me wasn't helping anything). I've walked out of rooms and when the resident asked what's wrong said "I don't think I like caring for people." I just don't know if it's a lack of training or technique or it's just one of the realities of the job and either you care so much you don't mind or you just get hard and tell patients they're fine and just to suck it up.

I dilute narcotics because it's pretty hard/impossible to push 0.5ml slowly. I dilute benadryl because it's irritating to the vein. I dilute ativan sometimes for the same reason as narcotics, plus it's kind of thick. Mostly I dilute, usually in 10ml NS, if: 1) It needs to be pushed very slowly and it's a very small amount 2) It's irritating to the vein 3) It specifically requires it.

Pharmacologically it is safe to give 1 then the second at 3 hrs vs 2 together. The only risk I see potentially is if at 6 hrs from the first you give another 2 more than the patient has 3 in their system for a time. It's a little scary that anyone would give a high dose of narcotic vs. a smaller one simply because they feel the need to follow the order to the letter. I can't imagine telling a patient, "no sorry, the doc ordered 2 percocet, it's 2 or nothing". Of course we can call the docs and get sliding orders put in or alter the order, which is maybe fine if responsiveness is good, but it's kind of a waste of time as a general policy. I had a patient worried that 2mg dilaudid would be too much for her since she's often sensitive to narcotics - I said "let's try one" and when she said that worked I approached the doc to change up the order. Changing it before would have limited me if it had ended up 2 was better for her in the end, and it would have involved several more phone calls. What's the point? One of our new nurses had an anxious patient and asked the new resident for ativan. The doc ordered 2mg ativan IVP for an itty bitty old lady (!). The nurse was skeptical and chose to give 0.75mg instead to see how she tolerated it, and even with that the woman was zonked and difficult to arouse for the next 12 hrs. Docs, esp new ones, are not infallible, and it's safer to add more of a potentially sedating agent then to try to reverse an overdose. I often give 1 instead of 2 percocet, any prn I think can always be titrated down and if you need an official 'excuse' "pt refused full dose". It's sort of a tricky topic. I'm in favor of more sliding and standing orders for pain management since seeing how a patient responds to and tolerates pain medicine is the duty of the nurse already, and it seems safer to leave some control in their hands vs. the voice on the other end of the phone who's not able to keep a close eye and isn't familiar with the patients hourly fluctuations. Just my

I actually think this is a great idea. When one of our techs is injured they are designated to "light duty" that means only VS and BS but they did it for all the patients. I actually thought it was a good system because when all the techs are responsible for everything they get caught up in rooms bathing or what not and other stuff falls through the cracks. I think having someone designated to answer call bells combined with a pager system for the nurses would work well. As long as that someone was qualified to deal with positioning, getting patients to the bathroom, etc. There's no reason that has to be the nurse in most cases. In my facility we have a unit secretary who answers the call bells and can ask what they need then decide who to send in. Of course, this is hampered by the frequent inability to FIND the nurse or tech in question, and the whole unit goes into mild disarray when their is no unit secretary (which is frequent at night, because of course, everyone is just sleeping :)). I like the idea of a central operator or secretary sending me text messages of what my patients need (room 4 - SOB, room 6 - water) so I can prioritize, and maybe the other nurses could send to each other too (caught up, silence IV in room 7 please?). I think the things standing in the way of answering call bells is: 1) Problems getting the message to the right staff member 2) Staff members too overloaded with tasks to be able to answer call bells 3) Overuse of call bell "crying wolf" burnout etc If you want to fix the problem, tackle those.

So I had an interesting case today where I got called from lab with a critical PTT (>200) but the anti-xa, which we use to monitor heparin gtts, was therapeutic. My understanding is anti-xa measures more the levels of heparin in the blood and PTT is a marker of anticoagulation levels of the blood, and some institutions use PTT and some use anti-xa. PTT, or preferably aPTT, makes more sense to me, but some of what I'm reading suggests the results can be misleading. I guess my questions are these: 1) What lab test is used at your facility? 2) Would you feel comfortable continuing a heparin gtt on a pt with a critical PTT? Assume no major signs of bleeding and VSS otherwise.

First off, I want to say that WFR and FR are not the same - wilderness training assumes you are farther from aid and thus you learn a lot more techniques and skills (tourniquets for example). Also note there are organizations (like NOLS) that offer wilderness courses specifically for medical professionals which would probably be more appropriate. In the end though I agree with most of the above - it's unlikely to help your resume unless it spurs the interest of the person reading it who is also into wilderness med. Exception potentially if you want to go work with doctors without borders or something like that in really remote areas. I think it's absolutely worth doing, but not as a resume pad.

I feel bad, but I really don't like having non-English speaking patients because it slows things down so much. The translator phones can be good when you can find them (ours have all gone MIA in the past weeks) but realistically I can only use them for admissions, discharges, and consents, which leaves a whole lot of basic interactions in the zone of frantic gesturing. I try to learn the basics of whatever language they speak (Pain? Medicine? Breathe, etc) but god forbid they want something more complicated... My facility is actually fantastic about deaf interpreters, but terrible for other languages. Lots of people do speak Spanish, but rarely at the level required to explain changes in plan of care, rationale for interventions, etc. It's not a good situation but I really don't think it will/can change, because 24/7 translators are too expensive and sporadic translation via language line is too time-consuming. For the most important things I think it's doable, but the reality is the bulk of other things (education primarily) is going to slip through the cracks.

This is a really interesting thread - I'm an RN at the moment (first degree biochem) and I'm heavily debating if I want to go back for NP, PA or medical school. The quality of life issue worries me a bit for the MD route, but I am concerned if I go NP or PA that I will have put in those 2 years and at the end of the day still want more. It's a tough call so it's good to hear other people in similar boats.

Anyone know how CEU requirements are checked? I've taken more than enough already but I'm not sure if it's automatically sent to the local BON or if I'm expected to tell them and/or keep proof of hours. I'm in DC if it makes a difference.

My first thought when I saw this was that I would love it if in ICU nurse floated down to my unit. But I guess we are more step-down than med-surg, and we get a lot of borderline-ICU patients as it is, and we take into account where a nurse is floated from when making the assignment for them. My hospital doesn't really have official "stepdown" units, it's all just med-surg but surgical floors tend to be 4:1 and medical floors 5-6:1 from what I can tell. I feel like an ICU could handle 4-5 somewhat less acute patients, but NO ONE should ever have 7+, I don't care how walky-talky they are, the idea that nothing goes wrong at right and everyone just sleeps is ludicrous. There is so much specific technology and devices these days that it is flat-out unsafe to put a nurse too far out of her 'comfort zone.' Docs complain all the time about nurses not knowing what to do with CBI, PEGs, J-tubes, chest tubes, mediports, vents, etc etc etc but honestly the only way to know these things is to have familiarity and experience with them. Anyway. Floating is a funny thing. I got floated to a medical unit once and found the conditions on the floor to be super unsafe and unimpressive and rapid responsed one of the patients they gave me @ midnight (who had clearly been going bad since the early afternoon) within 2 hours. In that case I was sort of glad they floated me to a "less acute" unit because I was able to recognize the person was really sick and get them out of there. I think there is a place for an ICU nurse float on med-surg, sure some of the BS stuff might slip through the cracks, but they offer a set of expertise and recognition that I think could be really helpful. And realistically, even with 5+ patients, if you have 1 that's super acute the others kind of meld together and less acute tasks might get delayed or pawned off because you do sometimes need to focus in. Just my two cents.

I am ACLS certified. As an RN, that only gives me the ability and certification to recognize, suggest and execute orders from a provider, not to independently initiate it. I wouldn't personally mess with those drugs even if I had the formula card in front of me unless someone else was running the code. Although maybe that would be different if I was experienced with codes and was sure I would be covered, I'd be interested to know if in an emergency an RN would be ok to act that far outside their legal scope of practice.

Someone being a patient doesn't gross me out particularly. I certainly have some patients I find to be gross and/or old and/or crazy, but every once in awhile there are the young, basically healthy ones. When I was in nursing school I had a gorgeous EMT as a patient who I got along with great - had I seen run into him outside the hospital I would not have been closed off to any sort of relationship platonic or otherwise because he had been my patient once. It's been said, but "never say never." Same as with dating docs, CNAs, etc.

Really far away, but the hospital I'm at in DC is new-grad friendly in onc (we just 4 new ones, and med onc always has openings too it seems)

It is NOT outside the PCT scope of practice to ask someone if they're in pain. Part of how PCTs are a help to the nurses is they are an extra set of eyes and ears and gather data to report back. I was actually taught pain was considered to be the sixth vital sign, so if you are doing vitals it's doubly ok. I expect my techs to report back any abnormalities, be it an off vital, pain issues, resp issues, distress of any kind, etc. Sorry, that piece just boggled me. You will be fine, just take the time you need to get more efficient and don't let anyone (yourself included) beat you up over it.