Always_Learning

If you work in labor and delivery, you might also consider getting some additional training on perinatal loss. There is some great information out there on grief, loss, and palliative care specific to many different areas (critical care, L&D, oncology, etc.). Best wishes!

I prefer to use a butterfly for all of my draws...your mileage may vary. My best tip for drawing blood from an elderly patient is to maintain traction on the skin. Typically, an older individual will have less subcutaneous fat, so it takes a little more work to stabilize the vein you are aiming at. As I am right-handed, I form a "V" with the thumb and index finger of my left hand and stretch/stabilize the skin above the vein. Then I do the stick with my right hand. I don't move my left hand until I see blood return. Also, take a look at your patient's veins before you do anything. I have found some thin, elderly patients with HUGE, distended veins. For these patients, I do not even use a tourniquet at all, because I have found that the veins typically blow if I do. I might take more time than most when I am "shopping" for veins, but I prefer to "measure twice, stick once." A little investigation often reveals a good vein "no one else saw." After all, there's no sense aiming for that dodgy vein in the wrist when, for example, you could have looked a little higher or lower (or on the back of the arm) and found a nice plump one. Also, warm blankets, warm washcloths, or a glove filled with hot water and tied off (like a mini hot water bottle) are helpful for making veins dilate and stand up. But most of all, practice makes perfect. :)

I wanted to add a few thoughts to the discussion... First, "terminal weans" and/or hospice care are NOT euthanasia. The line is difficult for those outside the field to see, but for starters, you can research the "principle of double effect." We give medications that have the possibility to somewhat hasten death, but it is not our intent to do so. In this case, motive has a great deal to do with it. If a COPD hospice (DNR-CC) patient is short of breath and nearing death, I will give morphine (as ordered by the MD) without hesitation to relieve their suffering. Morphine is a narcotic, a vasodilator, and also acts on the sensory cortex to relieve the sensation of dyspnea (shortness of breath). As such, morphine helps with pain AND breathing. For what it's worth, nurses who may seem "unfazed" to the casual observer are not necessarily heartless. Rather, nurses must "be" what the family and pt. need them to be. I am often moved by many of the situations and patients I encounter, but if I - the caregiver - am sobbing, how does that help the family? This is not to say that I have never shed a tear, but as a whole, I must be the emotional support for the family and patient. Lastly, you commented that it was hard for you to understand how this lady could "sign her life away." However, you mentioned she was on a vent, on dialysis, and had a wound vac. The devil is in the details here. If you have witnessed the violent reaction of anyone who is endotracheally suctioned, you have an idea that this is very uncomfortable. Hemodialysis - likewise - is a horrendously uncomfortable, time-consuming, and restrictive process. Patients are poked - several times a week - with a large-bore needle to access their dialysis site. For hours (pretty much an entire day), they are connected to machinery. When their blood is cleaned of its toxins, they are helped temporarily, but the vast change in their system's equilibrium causes them to feel exhausted. So they bounce back and forth between feeling crummy because they need dialysis and feeling crummy because they got it. The wound vac is another discomfort. I don't know the nature of this lady's wound, but typically vacs are reserved for those long-standing wounds that just won't heal any other way. The wound might be infected, or chronic, or smelly...or all of the above. Each vac change - which is typically several times a week - involves peeling off an adhered dressing, applying and/or packing in a new one, and connecting it back to suction. All of this is frequently significantly uncomfortable. Not to mention the times when the wound vac starts beeping in the middle of the night because it is clogged, or loses suction, and requires an urgent dressing change. Put all of this together (and much more that we likely don't know), and I can absolutely see why the patient might decide to enjoy a short, blissful time of not being poked and prodded. I hope that you will look into hospice/palliative care some more, as I am very passionate about the need for this field. But even if you never do, and even if you never work in this area, I hope that you can recognize that each patient has a right to determine what treatment they receive...even if that's no treatment at all. We must advocate for patients' decisions, even if we don't agree with them or understand them. I hope this information gives you a bit of an idea on why some patients and families choose hospice and palliative care.

There is no shame in saying you haven't done something before. In fact, asking questions is essential to being a safe nurse. However, when dealing with patients, I like to say, "let me find out for you" or "let me check on that so I can get you more detailed information." For colleagues, it may be "would you show me how you like the room set up for this procedure?" (or they may have documentation or a list for how they like it set up). After a while, you will lose the fear of admitting you don't know something. If it's any consolation, even if you knew EVERYTHING about all of these procedures, there would likely be some differences based on equipment variations from place to place. As such, there is nothing wrong with saying, "Can I watch you once or twice so that I can observe what equipment you use and where items are stored?" Sometimes it's just a matter of wording...there is a way to ask for help professionally. Additionally, if I only need help with one specific thing, I try to phrase my question thusly: "I have been signed off on the catheterization procedure and I feel comfortable, but I am having trouble finding the straight cath trays...could you help me?" By asking questions this way, you save your colleagues time, and you also inform them that you are not groping blindly. Similarly, "I know that XYZ med is used for XYZ indication, but have you ever encountered patients with XYZ side effect?" Showing you have "done your homework" helps a lot. Best of luck to you!

Honestly, it happens more than you think...particularly if you are working in a hospital for the first time or working in a new area. There are all sorts of bugs floating around that you're not used to. When I started working in the ED many years ago, I and a co-worker who started with me both got really sick during orientation. The manager said, "We kind of expect that until your immune system catches up!" Now I think I have a cast-iron immune system. Hope you feel better soon.

This made me LOL.

A Limerick for the (Delicious) Know-It-All New Nurse So you think your preceptor a hack, for harping on skills that you lack. When your patient is dyin' Please don't come a-cryin' When you don't know V. fib from V. tach. (uhhh...should we shock 'em? Anyone...? Bueller?..................Bueller?) PSA: I am, in fact, a new nurse.

Some of the best advice given to me was, "In Hospice, the 'patient' is anyone you encounter behind that door." You have to get out of the mindset of caring for just the patient, because in Hospice, the patient's family and loved ones need just as much - if not more - care and support. Although I have been a Hospice nurse for just a short time, I have already found that quite often then family needs much, much more support than the patient does in coming to terms with death. Some nurses rail against how the family complicates things or "gets in the way," and these interactions can be difficult at times. Grief brings up a whole slew of other emotions which aren't always pretty, and may be directed at you. Try not to take it personally, and remember what the family is having to deal with. If you can adopt the correct mindset from the beginning, it will be a help to you...and you will have some very thankful family members.

I'm in. This is my last one, thank God.

"Ksssh.....kssssh.....uh.....bad reception here.....can't hear....you."

Go here...index and click on "Vents and ABGs." This site was always my best friend; in fact, I purchased it in book form. It's easy to read and even humorous. :)

I don't think I ever squawked too much about getting an admission; somebody's gotta do it. Some admits are easy, some are complex. I help others when I can; they help me when they can. Some charge nurses are helpful, some less so. Such is life.

Only slightly off topic...at least in my area, there are pediatric Hospice organizations in conjunction with local children's hospitals. That's something you might think about (and be uniquely qualified for), unless you have your heart set on working with adults.

Ehhh...Serotonin syndrome?

I've always wondered if updating Facebook while on the clock could be called into play if a legal situation arose. For instance, patient dies (unrelated to care issues), but family is angry, says care was inadequate. Could the nurse's Facebook/social media posts be subpoenaed...as in, "See??? They weren't focused on care; they were posting on Facebook?" Just curious. It's enough to make me avoid it.

Hilarious, and oh-so-true...I used to have the market cornered on rumination!

I'm not sure why you or the patient would feel uneasy about assigning a pain rating, but if so, you can always educate the patient on the purpose behind pain ratings: they enable us to tell if subsequent pain relief measures were (in the eyes of the patient) effective or non-effective. Not sure why you would be scolded, but asking the patient about their perception of pain (not ours) is generally a good thing.

Yeah, these were just my general observations/musings, and I really only thought that OU students would reply, so it's interesting to hear from other folks whose schools use Blackboard well. It's a little heartening that some of the disorganization may be due to a professor's method of arranging things, and not just inherent in the software. Maybe I can pass along some of these ideas when we do a survey at the end of the course; thanks for the feedback.

All righty, then... :rotfl:

Sorry to gripe, but I do. This is the first class I have taken in Blackboard, and it's annoying how much time I am spending hunting for things. It's not that I was necessarily in love with EPIC, but Blackboard seems so much harder to navigate. I miss having everything neatly packaged in one module...readings, assignments, quizzes, etc. I also miss having a handy task lisk to show me what I needed to do, and the fact that items - once completed - would drop off the list. I am able to make Blackboard work; it's just not nearly as streamlined, it seems. Am I just not using Blackboard correctly, or is anyone else experiencing this?

We use propofol and fentanyl routinely, and Precedex alternatively and for weaning. However, studies have shown there are some adverse effects from longer-term propofol use. (I'm in class right now, though, so pardon me for not taking the time to find and post a link! ). I am inclined to think your medical director may have a point, though...we sedate vents pretty decently, and I have noticed quite a few patients recently with difficulty weaning off the vent, and they end up going for trachs. I know there are multiple factors involved in failed weans, but I need to research more the role of sedation in these instances. As you said, OP, we don't want folks bucking the vent and freaking out, but you don't want them totally snowed, either. That "happy medium" is often easier said than done, though. I will say that sedation is always very individual. There are those little old folks where a tiny bit of fentanyl knocks them out, and then there are patients maxed out on everything and still kicking and trying to self-extubate (often these folks have a history of drug abuse or ETOH, so I sometimes think all the sedation in the world wouldn't cut it). Looking forward to seeing others' comments and experiences.

My course is up on Blackboard as of yesterday.

Hilarious.

Without ACLS certification, I would think that you could not give them without an order (e.g., in a code situation, before an MD arrives to give a direct order). If the doc is there to give the order, then I think you could. Not positive, though.

Yes, because Valium is the treatment of choice for a CVA....sheesh!