simvee

That's hardly fair. Whatever earlier disputes you guys have had here, I wasn't part of that. I just did a ten page concept analysis of the concept (apparently it's just a nursing concept) of independence. I had to define it, then identify antecedents (which I guess are requirements to have independence) and consequents (of having independence) - these are kind of covered in the definition, but I had to find several citations - any citations I could find were fine - in the nursing literature to back up this simple concept. Also, the citations can't be from anything older than 5 years, because independence apparently changed since then. We had to write a paper on the metaparadigms, which are, if I recall, the human being, the environment, the nurse, and....heck, what was number four? We're just making up and misusing terms. Like here's one of my favorite quotes: As Orem used terminology at various levels of abstraction within constituent theories, the reader is advised to thoroughly study SCDNT concepts, including the synonyms. For example, agency is also called capability, ability and/or power. I.....yeah. This isn't science. This isn't even good theorizing. Sorry, I know I'm just ********. I do very much like being a nurse, which is why I chose this track. But this is just nonsense to fluff up and justify academic doctoral positions, as far as I can figure, and the rest of us have to suffer through it or else the whole house of cards falls down.

Giving serious thought to switching to a PA program. They seriously cannot be as bad as this, can they? I feel being part of a medical program they just can't be as bad as a graduate level nursing program. I'm in the throes of Nursing Theory and it's killing me. This is such bogus, nonsensical, endless garbage. The textbooks are the most disorganized and poorly written I've ever seen. The teachers' writing is a little bit better. But I'm churning out papers that don't make any sense, yet getting A's. Everything has to have extensive citations back to the nursing literature, so I'm finding the most BS articles I can possibly stretch to cram into a citation in my papers. This isn't learning. This isn't science. Talk me out of it!

Thanks for all the helpful info, this is great. My question is do you foresee being able to work in an inpatient or hospital clinic setting? I was told our heart failure clinic (which is in our outpatient center, but on the hospital campus, and staffed by NPs who work outpatient and inpatient, sometimes in the same day) might not be eligible because it's not a generalized outpatient setting. But I think I'd like to work something like that. You said you had job offers - what kind are they? Will you be working under a family medicine doc in their clinic, something like that?

I too am curious about the Chicagoland area. Can we just use any family doctor? They said we could use MD or NP centers. My family doc had a NP student with him once, so I'm thinking of asking him.

I think I'm going to ride it out, evaluate other BSN programs, and evaluate other ways of paying. Even if I take out a small Stafford loan it wouldn't bankrupt me I guess. Of course taking out a loan for no financial compensation whatsoever stings a LITTLE. I asked my manager tonight about how our institution wanted us all to become BSNs but then pulled this. My manager's response, shaking her head a bit, was that our facility started hiring only BSNs as a way to eventually get rid of tuition benefits. Well, there ya go. I guess it helped them achieve Magnet status. Because I don't give a rat's ass about the BSN. My ADN was academically brutal and more than adequate for me to hit the floor running in a difficult urban Level 1 trauma center intensive care unit. They've been campaigning for years on how great it would be for us ADNs to get our BSNs because it boosts their image and helped them attain Magnet. I finally followed their advice, only to have this happen. I'm only doing the BSN to pursue possible advanced degrees, and the BSN is the easiest bachelor's I can obtain at this point.

I'm writing here seeking advice. I work for a large teaching Magnet facility which I really love. It used to (I'm sure still claims to) strongly encourage nursing education. I am an ADN RN who is in an RN to BSN program already. Recently I wrote about our hospital changed the status of 0.9 FTE nurses (three twelve hour shifts) to part time. I'm a 1.0 nurse, I fit an extra four hours at some point in the week, so this did not affect me personally. Existing 0.9ers were grandfathered in to some full time benefits. Well, I just got shafted today. All nurses are being reduced to 0.9 FTE status. This means: my health premiums will be higher and my benefits will be less. my vacation time will be reduced. my education reimbursement will be reduced from $4,000 a year to $1,000 a year. My manager recommended taking fewer classes to have less out of pocket expense but one grand pays for one college class. Or less. It's insane. Essentially, they pulled the rug out from under any ADN nurse who wants to become a BSN. Despite being a Magnet facility that harps on and on about how they encourage all their nurses should become BSNs and how BSNs produce better outcomes. What would you do? Find a new job? Take years to graduate? March to Human Resources and demand to be grandfathered? (As a side note, my manager asked me to become 1.0 to help out the unit. Then they immediately told me they "just found out" 1.0 people will not be grandfathered if they go back to 0.9. So I got screwed back then, as well.) Can I complain about this to Magnet or the ANCC? (That probably wouldn't accomplish anything at all, right?) Do you think they'll just start axing the ADN nurses next? I'm not putting anything past them anymore.

I've been reading many of the threads here re: tuition debt load, but I still feel compelled to ask - is anyone else in this situation? I'm speculating about CRNA school. I'm an ICU nurse with four years' experience. I have a mortgage (not much equity). We're a single income home and we have kids. Everything depends on me. I have no other debts - no car loan, no tuition debt (thank God ADN programs still exist), minimal credit cards. Probably entering an RN-BSN program this year so we're talking at least two years before entry. Living in the Chicago area, it looks like school costs between $50k to $78k. I would need cost of living loans, I'm sure, for at least one to two years. That would be, I don't really know - $50,000 a year? So I'm looking at $150,000 to $170,000 in student loan debt before graduation. Looking at loan calculators, paying off that much in ten years would be $1700 a month or more! That's a mortgage payment! An SRNA friend tells me that his school maintains their new grads earn about $170,000 in Chicago. I don't know if they're just feeding him a line. Honestly I don't know - is the investment worth it? It's scary with everything hinging on my income - to go without income for two years, and accumulate that much debt. I'm pretty certain, barring tragedy, I'd graduate. How's the job field looking in 2013? Chris

Our hospital just quietly transitioned to a new policy, wherein 0.9 FTE nurses (3 12 hour shifts) are not considered full-time. They reassure us that this policy only affects new nurses, and old 0.9ers will be grandfathered into full time. Of course, some of us just recently moved to 1.0 status because they asked us to​, so we're not happy that we can never go back to 0.9 without paying sky-high part-time insurance premiums! Has anyone else heard of this? They're insisting that the "0.9 = full time" thing was an incentive to attract nurses in a shortage. I think they're just lying. I thought the whole idea was that employers wanted nurses to go to 12 hour shifts (which nurses wanted as well) because it's financially better for the company, but the only way they could convince anyone to do that was to make three 12's count as full time. I think the take-home message here is "It's a bad economy, you're not going to find a job anywhere else, so eat it." Anyone else's thoughts? What's the history of this?

Do you guys find you have to work out just to stay fit enough to work? I'm finding work so much easier now that I've lost 25 pounds (due to other reasons - found out I had super high cholesterol). The lack of strain on my back is amazing. Now I find when I skip the gym for a week I feel the ache in my lower back again. I don't want to slip a disc or destroy my lumbar spine working with these big patients...! I've found it helps immensely with CPR, too. Personally I think chest compressions need a lot of physical endurance to be able to do them correctly. Any thoughts? They should have work fitness programs.

Yeah, I jog the stairs at work sometimes if I'm bored or need a pick-me-up. Sometimes with push-ups at the top and bottom flights.

Christ still takes 50 externs a summer as far as I know.

Working Class is expensive IMHO. Does anyone have any experience with Chicago Scrubs Outlet? http://www.chicagoscrubsoutlet.com/ Saw their good reviews on Yelp. Speaking of which, here's a Yelp search for ya: http://www.yelp.com/search?find_desc=scrubs&ns=1&find_loc=chicago+il

One of Masonic's sister Advocate hospitals has serial residency programs, like two a year. It's a new thing but I think Masonic's doing the same thing.

We insufflate just to have an idea, and then x-ray. Incidentally I have heard a wet gurgle on auscultation, only to have it in the bronchus apparently! So insufflation really isn't totally accurate, just mostly accurate.

I'm pretty sure when I was inserviced by the Roche Accuchek folks about using their machine, they said that one of the benefits was that I could use blood from any source, not just capillary (a fingerstick). So I can use blood from anywhere, right? I mean, I guess it would be laborious to draw from a PICC if you have to waste first, but it wouldn't be hard to get it off an art line rather than sticking a patient. Just a thought as I had to stick my patient for a fingerstick, their insulin, and SQ heparin, all in the same visit to the room. Another question: since heparin and insulin have Y-site compatability, what's the worst that would happen if I combined the two in a subcutaneous syringe and just gave one injection? Just a thought. I'm not going to start doing it, but it seems plausible to me.

For some reason we use D5 .45%. Also I think they reserve mannitol for actual cases of swelling and not for prophylaxis anymore? But I'm not sure. That's a good point. I'll remember to say that.

Soon after I graduated I joined the American Association of Critical-Care Nurses, because I thought it might help me with my new job in the ICU. And I was kind of idealistically thinking that joining your supporting association is good. But frankly, I don't glean much from the three publications they offer. I mean, I have a personal interest in, say, how hypoplastic left heart babies are managed (I'm not being facetious; I almost applied to a pediatric heart unit) but it's not helping me as a new adult ICU nurse. I suppose they aren't meant to. At any rate, I'm probably going to switch to online delivery. They keep asking me to switch to online delivery anyway, which I suppose saves publication costs but also leads me to wonder if these articles are really meant to be read, or if the value is more for the writers, i.e. meeting milestones for academic or career advancement; for instance, to achieve the highest tier of pay in our hospital, you have to organize and publish a nursing research study. Half the mailings I get were trying to get me to go to the NTI conference, which I'm not yet financially able to do. I also didn't appreciate having my mailing address farmed out to different insurance companies, not just malpractice insurance (which kind of makes sense, though it's still just marketing) but dental as well? Like I need junk mail. Some of the political aspects of ICU nursing I'm interested in, such as improved palliative care, don't seem to be a main focus of the group. I do like the AACN Newswire email, but I believe that's free. Should I renew next year? It doesn't seem worth $78. Chris

I've assisted at central line insertion a bunch of times, even before I was an RN (I was an ICU tech), and that's pretty sufficient. As long as you are masked and gowned and protect the sterile field and items, what else do they need? And as everyone else said, a physician should be able to do this alone. Where I work they even expect first-timers to pretty much do it alone. Also we fill out a tracking form (consent, timeout, guidewire counts, etc).

Short answer: no. Don't turn or lift people without adequate help. You can't be expected to do things that you can't physically do safely. No one in management or on the medical staff (the other people concerned with preventing skin breakdown) would be expected to turn these people without adequate support. If you can't do it, you can't do it. Of course, you'll be expected to bring this to their attention, because you're the nurse and they can hold you accountable if you didn't alert them to the obvious facts (which seems to be the usual thing, holding your license to their insufficiencies)...but still. Don't do it. Also keep yourself in shape, and consider short-term disability insurance or accumulate six month's worth of income in case worker's compensation doesn't work out.

Hi! I'm new to a neuro ICU. Had a head trauma patient with a subdural and a shift. Low GCS at first, but they did a massive craniectomy (entire parietal/temporal bone flap). By the time I got the patient (3 hours post-op) he was following commands and nodding to some questions off sedation. Pupils equal and brisk, moving all extremities equally. The neurosurgeon seemed surprised and impressed. Follow-up CT scan showed the shift had resolved. Two questions: 1. Should I worry about too much fluids with this patient? Would it cause brain swelling? He was getting maintenance fluid and he was on a protocol for potassium replacement (standard for trauma patients, not necessarily neurosurg patients). So with a K rider I was running 250 ml/hr intake. I decreased the maintenance to KVO but didn't know if they maybe needed the fluid as traumas often do. 2. What kind of prognosis and outlook would this patient have? I encouraged the family that it's good he's able to wake and follow commands, but cautioned them that swelling might still occur. Could this patient be, you know, okay today and then swell tomorrow and be in a coma forever? Could they be okay today and then still suffer cognitive deficit or personality changes as TBI patients often do? I mean, it's great that this patient seemed resolved, but that's without half their skull in place. What happens from now on? Chris

Thanks! I was just going to ask about this.

You guys are right, follow the chain of command. It's kind of annoying to do this for little issues, though. Oh well. Tri-RN, like I said, I'd rather them say they have no clue and ask me what to do than to make up a pat answer that I know is wrong.

peep and zofran - thanks for understanding my plight. Like I said, there is no way to document these boluses. I already posted the only workaround I could see (volume boluses) which is ridiculous but at least it works. Kinda. The problem which you guys illustrate is that any solution they come up with is probably going to be stupid. Who dictates that these boluses can only be given Q1H? What if you have to bolus once, it's not enough, and you bolus again? It'll look like you're violating orders, when the ordering physician probably doesn't even know or is too busy to notice that these artificial restrictions were automatically placed on his or her orders. That's the rub. CPOE is enabling physicians to enter their own orders, which is cool, but it's being designed by nonmedical staff, which is not. The same with eMARs. So you have automatic orderables which sneak in artificial parameters and you have unworkable and impractical charting software that doesn't allow you to reflect what happens in reality. Like I said, this happens with other drips too. One of the intensivist physicians was asking me how to determine what rate of levophed a patient was on. Charting this is not the easiest thing in the world (especially trying to correlate it to your automatic BP charting, which always seem off by 15 minutes!!), but I realized that there was no easy way to view the titration either! It's all bad, I know. I'll take some of these suggestions into considerition. CAVEAT: When I said that other nurses might not chart their boluses, I realize now I was making a grandiose assumption and I need to actually verify this before I go suggesting they're doing something ILLEGAL. Like everyone pointed out, I'm new, and I'm sorry I said that.

Flying ICU RN - I still fail to follow you. How exactly are my coworkers going to abuse a drug that's confined to IV drip bags and the tubing running to the patient? I suppose if you were creative you could angiocath yourself and attach yourself in the patient's room, or you could bolus the line into a paper cup and drink it...? Anyway, a properly programmed pump that is properly cleared and accounted for does the same work without the extra syringes and easily stolen glass bottles. Isn't it more likely that you would remove a glass bottle of a narcotic and take it home but simply chart you gave it to the patient? It's harder to make the pump lie than it is to falsify charting. emse - I don't recall saying I was wiser than the physicians. I don't see how that could be construed when it's the physicians writing the orders. This is how the orders are universally written. I've seen this at a few different hospitals. Maybe it's different in your state? It certainly could be. For instance, in our hospital, the physician orders a paralytic agent. We start it using hospital guidelines. We adjust it using hospital guidelines based on our assessment findings. The physician almost never dictates a dose, titration, or bolus. In fact, it's generally assumed (i.e. a head pharmacist said this) that we know more about the intricacies of dosing than the physician does. Which is no shame on him or her at all! But regardless of who you think is in charge in this situation, all of our actions are legally covered by (in fact obligated by) the physician's order. There's no such thing as a nurse giving or titrating a paralytic agent without an order. Our use of analgesics and sedatives are governed exactly the same way. The only problem I have is that the hospital guidelines are a bit hazier, i.e. there's no "Go up by X amount if the patient is acting Y or Z." like there is with paralytics or pressors or antihypertensive drips. And my original question was whether boluses are covered by this, and that's what I wanted input on. I didn't expect the entire concept of RN-led titration would be called into question and that people would call for my license to be revoked! I admit that our charting software is not ideal. In fact, we've had to recently hound some physicians for getting lax about adding the "titrate to sedation" part in the computer. So maybe I will bring up the difficulty of charting boluses and the confusion the RNs have over whether boluses are technically covered under that order any longer. Maybe it will be fixed? Like I said, I chart them as volume boluses, but that doesn't feature as prominently in the charting flowsheet as the dosage titrations do. Anyway. I do thank you for your concern. I just didn't realize there were so many people who have apparently never heard of RNs being delegated (with hospital guidelines and protocols) the titration of medications. Chris

David Carpenter (core0) - bolus injections are not easily available from the electronic med cabinet when your patient is on a drip. In fact I think the software tries to prevent people on drips from being double-ordered injections of the same med, but I'm not sure. At any rate, don't you think that's a waste of time and resources? Why should I waste the time it takes to get a bottle, draw it up, inject, and then throw away all the garbage generated by this, when our pumps are DESIGNED to give boluses? They're designed with the medications, dose per volume, drip rates and bolus injections pre-set.