vicarious

Does your facility require a physician order to double concentrate an IV drip? In my facility, we mix some of our own drips, e.g. 40 mg Neo in 1000 ml NSS (or 20 mg in 500 ml). We have no hard and fast policy on mixing drips or double concentrating them (or even quadruple concentrating them if we are really trying to limit fluid intake). I did not think we needed an order to double concentrate a drip. Another nurse told me that we had to get an order before we did so. When I asked her why, she said "just because that's the way we've always done it." When I said, ok, putting that aside, why do I need an order to double concentrate a drip, she replied, "You are altering the dose of medication." I disagree. I feel like it's 6 of one and half a dozen of the other..I feel as though I can compare it to this, even though the situations aren't exactly the same...if a 1 L bolus is ordered and I use 2 500 ml bags versus 1 1L bag, what is the difference? If 0.5 mg Ativan is ordered and I split a 1 mg tab in half rather than use a 0.5 mg tablet, what is the difference? Thoughts?

If you do a finger stick correctly, if the patient never comes into direct contact with the glucometer itself, and if you aren't placing the glucometer on the patient's bed or sheets, I see no reason to clean the glucometer after every patient use. The last thing I am thinking about is how clean a glucometer (esp. one my patient is never going to touch) is. I'm more worried about my hands and the things I have with/on me, like my scrubs. The people that think the glucometers on the typical med/surg unit are getting cleaned after every patient live in a fantasy land. I'm starting to wonder if maybe they think we just haphazardly prick fingers and wipe the blood all over the machines until it spits a number out at us.

It has been my experience that the policy is to clean the glucometer between every patient use. In reality, I have never, ever seen this done. Just curious--how many of us sanitize our pens/ penlights/ watches between every patient? I cannot rationalize that, nor can I rationalize sanitizing a glucometer between EVERY patient use. I understand if the glucometer is dirty. I understand q24h. Further, I understand sanitizing stethoscopes--they come into contact with the pt. but I don't understand why nobody makes a big deal about why we do NOT sanitize blood pressure cuffs between every use. Think about it. What makes any of these things different? But I digress. I don't see a point in sanitizing glucometers unless they come into direct contact with the patient (which they do not). I don't wash my scrubs between patients.. Can somebody enlighten me on why it is recommended that the glucometers are sanitized between every patient use? Are there any randomized control trials not sponsored by the Clorox Wipe corporation :lol2:to show that there are any effects??

Update- PA does require background checks in the state in which you reside if you reside out-of-state. I haven't been able to get a hold of anybody at the PA BON, but I've decided to apply for original licensure in Ohio, apply for Graduate Nurse TPP in PA, take NCLEX for Ohio, and apply for licensure by endorsement in PA. For anybody wondering what the cost differences are, it isn't much of a difference either way..my decision was based primarily on the fact that I reside in Ohio, my school is in ohio and is sort of guiding us through Ohio's application process, and it seems it will be less difficult if my original licensure is in Ohio. Original licensure in OH, PA TPP, NCLEX, and endorsement in PA came out to $440. GN TPP in PA, Original licensure in PA, NCLEX, and endorsement in OH came out to $485.

But I am not licensed in Ohio and will not be when I apply to be a graduate nurse in PA. Thanks all. I am calling the PA BON about this one. I'll let you know what happens

Thanks elk. http://www.dos.state.pa.us/bpoa/lib/bpoa/nurseboard/tpp-exam.pdf It states, "You may apply for a Graduate TPP if you have completed an approved nursing education program in Pennsylvania or any other state of the U.S. less than one year ago and you have not taken the licensure exam. The TPP fee is the same for both PA and Out-of-State Graduates." It goes on to say.."A Pennsylvania TPP holder who takes the licensure exam in another state and wants to obtain PA licensure, must complete an Endorsement Application for Pennsylvania and submit it upon notification of licensure in the other state." It's my personal opinion that it seems a bit easier to get an initial license in PA just from looking at how both states handle application for licensure. For example, I do not think that PA requires fingerprint or background checks whereas Ohio requires BCI and FBI as well as passport photos and a notarized signature. I am not entirely sure, but I'm guessing that getting endorsed for licensure in Ohio with an existing PA license may require all of the above. Also, I have heard that Ohio is one of the more difficult states to get licensed in from a few different people. I guess that is why I wanted to get licensed in OH, which is questionably more difficult when it comes to handing out licenses. At this point, since I plan to get licensed in both states, I don't think it matters that PA charges $100 for out-of-state inital licensure applicants to take the NCLEX, because I'm sure there are fees for endorsement from OH to PA and vice versa. The bottom line is that it is going to cost some money regardless. I see that this is definitely something I will need to call the PA and maybe OH BONs about. Now who thinks that either will answer their phones and be able to answer me? :)

Thanks for your response! It is my understanding that PA issues temporary practice permits to graduates of nursing programs before they take their boards as well. I have seen them refer to them as Graduate TPP or Graduate RN permit.

Hi all, I am graduating this spring from a nursing program (RN) in Ohio. However, I plan to work in Pennsylvania. I am weighing my options and I would appreciate if anyone can give me any information I might not already know! I do plan to get BOTH Ohio and PA nursing licenses at some point. I am currently debating which one I should get first. I have heard that some people find it difficult to obtain licensure by endorsement in Ohio, so I am thinking about just getting Ohio's first and get that out of the way. I am not too upset about doing that because in PA, you can work as a graduate nurse with a temporary practice permit. So to sum up my conundrum...I am thinking about applying for Ohio licensure, and then applying for ONLY a temp. practice permit for PA (NOT licensure by exam). So then I will be a graduate nurse and able to work in PA. Then I will take the boards in Ohio. Hopefully I will pass the boards, so I will be an RN in ohio. I will apply for endorsement (or is it reciprocity?) in PA, and while I wait for the PA board to endorse, I will be permitted to work as a graduate nurse in PA. Is that allowed??? Any suggestions?? :yeah:I applaud anybody who read that whole message and understands it!

In Ohio, there has been some confusion on whether or not a CRNA can prescribe medications for patients..awhile ago I remember reading that in the nurse practice act, there was no mention of a CRNA being able to prescribe any medications, even intraoperatively, even if the prescribing CRNA was the administering CRNA. I believe that has since been clarified, and I believe it goes on further to say that the CRNA may prescribe pre, intra, and post operatively for a patient so long as he or she is the one administering the medication. However, there appears to be a bill (forgive me, I am not familiar with legislative terms) that proposes the CRNAs be allowed to prescribe medications for patients in the pre, intra, and post operative setting and allow for RNs, RTs, and other health care team members to administer per their practice acts. I'm not sure how this bill has been received. If anybody has any input I'd be glad to hear it http://osana.org/osana-highlights/senator-morano-introduces-sb200

Hello, I'm looking for a few simple--albeit good--ideas for a baccalaureate level research proposal. It has to be clinically significant (e.g. not whether or not nursing students are more stressed than other students). It also has to be quantitative in nature. I am interested in the critical care setting, but I would have no problems with med surg or even perioperative proposal suggestions. Medical rehab (hips, knees, etc.) would be okay but more as a last resort. I'd like to stay way from ideas regarding skilled nursing, OB nursing, and pediatrics. My original idea was a study comparing the effectiveness of foot pumps and knee-high SCDs in preventing DVTs, but there were too many variables to control for (different patients on different anticoagulants--too much for BSN level). What I'm thinking now is more along the lines of a study that compares the healing rate of patients in private rooms, or a study that compares healing on a unit with strict visiting hours versus a unit with more flexible visiting hours. Or does a Foley anchoring device contribute to UTI. I would really appreciate some ideas--I have been trying to brainstorm but with little to no success. Please help!

Also, don't talk about your patients. It is so tempting when you are with your clinical group to start talking about your patient and all the things you did for him. But what if the woman taking the elevator with you, even if she is hospital staff, just happens to be his sister? Of course you weren't gossiping about him, but that information really is confidential. Even if you aren't saying his name, how would you feel if you got onto an elevator full of giddy students hearing about how you did this and that and then when you get to your brother's room you find that he was the subject of discussion in the elevator? Another tip-do NOT write down your patient's last name down, and if you are going to print something out, make ABSOLUTELY sure you are cutting his name off. There was a story about a nursing student at my school who lost a full report sheet--name, dx, and everything--on campus from a patient she had. A good samaritan, figuring it was property of a nursing student, found it and turned it into the nursing office. Yeah, I would be lying if I said that I knew what the ending to this story is, but I could just see this happening to me--bottom line, cut the names off and use initials if necessary. Lastly, maybe others will agree with me on this one, but you will find that most of the "cooool" things that you learn in skills labs or whatever (e.g. injections, blood draws, IVs, NG insertions, Foleys, fingersticks, etc.) are really NOT that big of a deal once you get to the meat of your program. I remember being so excited to give a SQ shot or an accucheck at first. Ha. Fine tune your assessment skills. Keep your old assessments for fun (SANS patient identifiers, of course) and look back every year at how much you have grown.

Remember that you will get out of the experience what you put into it. DON'T be a know-it-all (nobody likes a know-it-all, especially one who isn't licensed) DO ask questions (when appropriate) and 2 good rules of thumb: 1. treat the patient as you would treat your mother/grandmother/loved one 2. if you aren't sure, ASK. (e.g., Don't just act like you know how to pull a Foley because you want to do it. I appreciate your eagerness, but the patient won't.) and some more advice.. you are no doubt going to encounter RNs who are not a good example. it will be EASY to emulate their practices. challenge yourself to be the best. sure the right way is sometimes the hard way. but remember, it is the right way. take pride in your work and the care that you are providing--even as a student. I have found nursing to be both a rewarding and at the same time a frustrating field..on a related note, nursing can be stressful, please forgive any bad attitudes you may encounter as a student nurse. Just grin and bear it, and thank God you don't work there :lghmky:

I am PRO CNA's/assistants taking the blood sugars of their assigned patients. We are not asking CNAs to interpret or treat a high or low blood sugar or to teach patients, so I see nothing wrong with delegation of that task. I am thankful to be assisted in this way. I do believe that there should be a standardized rule that if a blood sugar is reported as greater than 210 or something or lower than 60 that the RN should re-take the blood sugar if pt is asymptomatic, obviously treat if emergent or symptomatic. If my patient is talking to me and seems fine and I was just told his blood sugar was 11, you bet I am calling for that glucometer and doing it myself. And if you are AGAINST CNA's taking blood sugars and say that youre too busy to recheck the blood sugar if it falls above or below a certain point--what makes you think taking all of your patients' blood sugars will take you less time? What next, do we analyze our own CBCs too because we are anal and the lab tech may not be? Requiring a nurse to take a blood sugar may be an issue of patient safety, but what a simple task it is.. how many things could I be doing that we cannot delegate to a CNA in the time that it takes me to do 4 or 5 blood sugars?? Could I do my assessments a bit more thoroughly? Could I be doubly sure to adminster the right meds, right dose, right patient, etc? Might I actually make a med pass on time? the list goes on! Thank you CNAs!

I am just wondering if anybody has any information on the typical traffic conditions in and around Pittsburgh, PA, specifically when driving to Allegheny General from 279N to make the 7AM shift. It sounds like it is going to be a bear of a drive for me. Of course nobody I know has to be at work before 8:30 and has no idea. But traffic? And then parking in that far-away garage and taking a shuttle? (I loathe shuttles--I feel as though they hate me too.) Just wondering if anybody here has any experience with AGH and the Pittsburgh traffic. HR makes it sound like it is not a big deal, whereas I am thinking, hmm sure hope I make it to the kronos on time! Also, what about when there are games at Heinz/PNC and you are working night shift? Is there any solution? I appreciate it!

Just remember to breathe through your mouth, always wear gloves, and always ALWAYS wash your hands when you are done (not just the alcohol rub!). Oh and for the patient's sake, watch your facial expressions. Although this was no doubt a "life-changing" event for you (haha, in many ways, it actually was), what you did for that patient was very honorable. I am not sure if you said if he was A&Ox3 or what his mentation was like, but you provided a very basic yet very appreciated service today to this person. Nursing may not be a very glamourous job, but I have found it to be extremely rewarding, poop and all. You just have to look at every disgusting situation (and there will be more) as an opportunity. Look at this as the opening of the portion of your nursing carreer that allows you to show off your clinical skills..now poop, but soon foleys, SQs, IMs, IVs, etc. It does not stop! (And lucky for all of us, there is always going to be the poop.) Nursing is a skill and sometimes it takes a colleague to remind you of that! Thank you for being invested in your own development into a skilled nurse! I think we would all be surprised to hear how many students shy away from these kinds of opportunities and I would be VERY interested to know how many nursing students get out of school without ever having wiped a butt (because even ONE would be too many).

Thanks guys, I have to admit that I am new at this and I am very randomly pressing a "Thanks" button on some posts, although I am not too sure what it does! I hope it sends all of you some money or something (fat chance!) I think the subject of using a pyxis/omnicell (BTW i am familiar with both :) ) as a type of small satellite pharmacy begs the question, what ever happened to pharmacy techs? what kind of money is a hospital saving when a pyxis stocks all of those meds on every floor? Seriously, there are probably over 1000 pills in these Pyxi (I liked that plural form of Pyxis that somebody else used.) I am sure each pyxis costs some big bucks as well, and I'm not talking about deer.. I should also mention this..somebody had a comment about using a Pyxis scanner or something. While I have noticed a barcode scanner on the pyxis itself, I do not know what that is for. Nursing has never ever used it to my knowledge. I am talking about having Computers on wheels (COWs) and barcode scanning from that. Just clarifying!

Thank you all for your thoughtful responses! They are great, please keep them coming. I think the "that's just the way it is and that's just the way it's going to be" mindset is almost a dangerous one. Instead of jumping through hoops and "pretending" to double check and triple check meds with another RN and then having her countersign twice in the required two different spots just in case one area of the MAR spontaneously combusts, I think it is important to recognize the difference between what is safe and what is realistic. I'm not saying that there aren't times when a medication should be double checked, and I'm certainly not against barcode scanning meds upon administration, but I am saying that the solution to the aforementioned problems (pyxis stocking all meds in addition to barcode scanning plus the double checking of coumadin and lmwh) should not be a backdoor work-around or a cheat code or doing a run-by scanning of another rn's badge for all of the meds that need double checked. Sometimes I think that problems like these might not exist in the first place if we weren't so busy with the acuity of the patients and actually had enough energy to speak up about these changes and how they are negatively impacting patient care. How would a pharmacist or a clinical manager know the best way to pass meds if he has never passed meds on a floor before? Just because I drive a car does not mean I know how to build one, and vice versa! I'm not saying RNs are infallable, or that RNs know the best way to do everything, but I do think that RNs should have more of a voice in these kinds of issues and I encourage everybody reading to stick up for your patients, yourself, and your colleagues when you think that an issue is negatively affecting how you care for your patients. And to the person who replied saying that EVERY med had to be double checked except for tylenol--I am at a loss for words.

I am looking for opinions on the following situation. Right now an entire hospital is using the Pyxis for the storage of all medications. For example, each unit has one large Pyxis for all meds for all patients. In other words, pharmacy does not come up with bags or drawers for each patient. The nurse must pull all meds from the Pyxis for all of her patients one by one. Respiratory therapists also use the Pyxis as many of the respiratory meds (except for inhalers) are kept in the Pyxis as well. I felt the need to clarify in detail because I have told others this situation and they have been thoroughly confused. This hospital also is about to go to the electronic medication administration, including the scanning of meds and the patient. The practice of "double checking" all anticoagulants, including Coumadin and any subcutaneous, e.g. Lovenox, is also about to begin. My question, I guess, is whether or not this system is reasonable, from an outside perspective. Here's my two cents--In theory the Pyxis system for storage of all meds seems like a good one. MANY meds are kept in the Pyxis and if a patient is put on a new med and it is stocked in the Pyxis, or if you have a new admission, you don't have to wait for the meds to arrive from pharmacy. There are a lot of negative things about the Pyxis system though, IMHO. When the acuity is high, one RN may not have time to stand at the Pyxis for that long fighting with the drawers and waiting for them to open. There is an option to assign yourself patients and remove meds by time, and this does make it somewhat helpful. Also, I should mention that this Pyxis system is rigged with a very large refrigerator-looking section with bins inside. So instead of the medication being spit out or a drawer and compartment opening, sometimes you have to sort through many bins and medications looking for the right one. There is also the inherent problem with the Pyxis--when you are forced to stand in line with the other RNs, RTs, and pharmacy techs if it needs filled, waiting to get out that one pill. Another annoyance about this system is that the Pyxis is monitored by the pharmacy, and there is a minimum bin level where the pharmacy is supposed to come and re-fill. The reality is that this rarely happens and the pharmacy is always getting calls to send more meds. Oh, and the extra narcs? Yeah, they are still kept in the old narc drawer--requiring a daily narc count and taking away any of the aforementioned convenience of said Pyxis system. Now that each med has been painstakingly removed from the Pyxis, the idea is that each patient will be scanned. Then each med is scanned. Is this redundant? My exact thoughts on this matter are.."Are you serious? One or the other, Pyxis or the barcodes on all these meds! I am already taking one out at a time from the Pyxis!" That being said, back in the day when Pyxis was used for mainly narcs, I could see myself being ok with doing double duty and removing from Pyxis AND scanning..it is only the pain med afterall, that takes considerably less time removing and scanning that one PRN rather than removing and scanning every scheduled med. THEN Coumadin and lovenox are supposed to be double checked and will require a witnessing RN to swipe her card at the time of administration. I understand the necessity to have IV Heparin and I will accept the fact that insulin needs double checked as well. But Coumadin and lovenox? Is this just to look good for the Joint Commission? Why don't we double check every med while we are at it? Oxycontin can be given with one RN, but Fragmin is suddenly so dangerous that it requires a witness. I understand the need for patient safety, but where is the line drawn? People have died taking aspirin too--will that need a double check? Is an RN no longer competent enough to administer meds? How long before three nurses need to check insulin? Or until 2 RNs must assess together? Sure this is all great in theory, sure it would be great if the doctor and pharmacist could come to the floor and scan their badges too, but there is no time for all of this, ESPECIALLY with the advent of the E-MAR and the documentation of the exact time of administration. There are not enough nurses and there is not enough time in a day for all of these requirements. So let me take you through the process if your patient is on Lovenox or Coumadin.. Sign onto Pyxis, remove all meds, take meds to patient room, sign onto E-MAR, scan patient nameband, scan all meds, have another RN swipe to witness, and give the meds. I am all for correct patient identification and I will concede that scanning every med is actually a good (albeit time consuming) thing. I am all about correctly identifying the patient and what meds he/she will be receiving..essentially, patient safety. But removing the meds from the Pyxis (although it was implemented first in this change to the E-MAR) seems like whoever thought of this "ingenious" system has never once administered a medication on the floor, and is inadvertently and unknowingly putting patient care/safety on the backburner. It is taking time and wasting it--and while it is meant to increase patient safety, it actually works against it. The burdens of this Pyxis system outweigh its benefit. What say you?