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HamsterRN

HamsterRN

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  1. HamsterRN

    Would you question this order?

    I'm not sure what the rationale was the first Doc was using. It's not unheard of to have supratherapeutic INR and a thrombus, since the the thrombus could have formed when the INR was lower and Coumadin won't dissolve a clot. Usually what I see done is to reverse the coumadin and start the patient on a high dose heparin drip since the heparin is a thrombolytic and the coumadin is only an anticoagulant.
  2. HamsterRN

    Would you cut your hair for your career?

    We have a similar rule where I work but it doesn't group a dreads into the same category. Our policy allow's dreads that occur naturally, such as with AA employees. The issue is with those whose hair can only be maintained as dreads by never washing it for months or years. I worked with someone in a restaurant who cultivated his dreads by not washing his year for nearly 5 years. He came in one day with peanut butter caked in his hair which he explained he had to do occasionally to "suffocate the bugs". I can see how that could be considered unsanitary.
  3. HamsterRN

    If it wasn't charted it didn't happen

    Where would you consider it appropriate to draw the line? Do all standards of care need to be charted on specifically? Pt specific standards of care only? Interventions only? How do we define an intervention?
  4. HamsterRN

    PCA discrepancy (too much med?)

    The pump senses the supposed volume based on the height of the plunger, this can vary slightly and I rarely see it say exactly 50ml.
  5. HamsterRN

    Question about staff ratios?

    That's extremely unsafe, we can't all be as spoiled as Cali nurses but that's excessive. Normal tele units should not be higher than 1:6, your description of your floors falls somewhere within a step-down unit and progressive care, depending how you define each, but either way it should be closer to 1:4. Are you saying it's possible to have 8 post hearts? That is insane. Has your manager ever actually worked your floor, or even on any floor in a modern hospital for that matter? My advice would be to speak with your Department of Health.
  6. HamsterRN

    If it wasn't charted it didn't happen

    Being a floor nurse myself, I believe floor nurses should have the final say in how they chart since it's their practice and their license. My personal preference is to only chart what others need to know to care for the patient, so I'm trying to make sure I'm still advocating for a nurse's veto power on changes to charting even though I agree with the proposed changes to how we chart. Some of this is coming about due to the new HITECH act and meaningful use requirements. If you're not familiar with this yet, you'll probably encounter this at your facilities in the next few years; If you don't currently use an electronic health record (EHR), medicare will start to withhold re-imbursements starting in 5 years. The same goes for implementing computerized physician order entry (CPOE). EHR's will also need to be certified which will place some restraints on their structure and may limit charting that doesn't support clinical decision making. I would think that if nurses wanted, they could still chart a minute by minute diary, but they would need to follow the structured note first based on our current plan and then chart the "diary" elsewhere. Would charting what groups of standards of care in place without charting each standard individually be sufficient for all nurses to feel comfortable with such a system? (ie "Fall risk standards of care in use" instead of listing each one and charting on them separately)
  7. HamsterRN

    If it wasn't charted it didn't happen

    Wouldn't every patient have the call light within reach? If so, why chart that was done for some patients but not others. What happens when a patient falls that you didn't see coming and chart specifically that the call light was within reach? These are all standards of care for a patient who is a fall risk. Charting on standards of care one-by-one is a good example of what we are trying to do away with, particularly when it is inconsistent.
  8. HamsterRN

    If it wasn't charted it didn't happen

    At my facility, we are going to be changing our charting system to one that will be truly "by exception" and I foresee some friction from some staff. We currently use an EHR that is essentially "by exeption", but it allows a lot of leeway for nurses who want to chart more than needed, both in their note and their worklist. The unneeded charting in the worklist won't be possible, and we won't really be able to allow nurses to write the minute-by-minute shift summaries that some use currently (ie 1400: gave patient blanket 1410: Pt watching TV, etc.) For those that are opposed to or feel uncomfortable with charting by exception, what specific issues/concerns could be addressed that would help you feel more comfortable and supportive of such a system?
  9. HamsterRN

    Skin Integrity

    In our system, we don't consider an IV insertion site or CT insertion site a wound because we chart on the condition of the insertion sites under the assessment of the IV or chest tube. Once a CT is D/C'd, then we consider it a wound a chart on it as a wound (drainage, erythema, etc). I suppose you could make the argument that an IV insertion site becomes a wound once it is D/C'd, although charting on that seems like a waste of time.
  10. HamsterRN

    why dont you monitor prophylactic SC heparin?

    We check CBC's on day 3 of DVT prophylaxis heparin therapy and every 3rd day after that if they don't already have CBC's ordered. I've been told the reason why we don't monitor PTT's on these patients is that while the PTT will rise from the patient's baseline, it won't necessarily rise out of the normal range, and there is no established goal range for ptt for the purpose of DVT prophylaxis; the studies it is based on looked at dosage levels and not ptt's.
  11. HamsterRN

    Scope of Practice Question

    Diagnosing and treating is not outside the scope of practice of an RN, in fact it's the bulk of what we do. The procedures you describe are are not by definition outside the scope of an RN, but they aren't in your scope if you are have been trained on that procedure where that training has been validated and maintained.
  12. HamsterRN

    Cough related to CCF

    Coughing is one way the body removes excess fluid from the lungs, lasix helps do the same thing through a different route.
  13. HamsterRN

    Missed diagnosis - just a vent

    So they drew blood first and then did the U/S but the blood draw didn't include a d-dimer? That does sound like bad form if they were concerned enough to do the U/S but didn't think to run a d-dimer first.
  14. HamsterRN

    Filter needles...are they necessary?

    While it is true there are no RCT's involving the injection of glass particulates in humans for the final confirmation of a risk, there are also no RCT's that compare jumping out of a plane with a parachute to jumping out of a plane without a parachute. So no, there is no true scientific evidence to confirm any increased safety of using a parachute when jumping out of a plane either. What we do know is that a significant amount of glass shards are drawn up when using a glass ampule without a filter and that this causes harm to other animals. Should the burden of proof lie with proving it's safe to inject the glass shards or with proving it's unsafe in humans? For me, I'm probably going to continue to wear a parachute, even in the absence of a confirmed risk, until it's safety can be proven given the logical risks of falling out of the sky with no parachute, or having glass shards in your circulatory system.
  15. HamsterRN

    Filter needles...are they necessary?

    As much as we all hate them, there are a few reasons why glass ampules still exist. The primary reason is that some medications just cannot be stored in any type of plastic. NTG for instance is absorbed by plastic over time. It's not a significant amount when running through plastic IV tubing, but if it was stored in a plastic bottle or bag then the actual concentration would vary significantly by the amount of time it had been in contact with plastic until there was essentially no active medication left in the solution. Even worse, some medications not only become less effective when in contact with plastic, but they can actually become potentially harmful. Some medications react with some plastics but not others, such as Aviva plastic. Another argument for glass is that rubber stopper vials are universally seen as multi-dose, even though some medications stored in them become inactive even after a small amount of oxidation, glass ampules have the advantage of being single dose by their design. There are even arguments that more medications should be stored in glass vials for other reasons; I heard of a nurse who emptied out all the morphine and dilaudid PCA syringes through the rubber stoppers and refilled them with NS, which can also be done with carpujects and vials, but not with ampules. I absolutely agree that for storage reasons, we still need to use glass, although I don't know that I would advocate putting all narcotics in sealed glass just for security or as a replacement for education on multi-dose vs single dose vials, but they are both arguments out there for the continued use of glass.
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