HamsterRN

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.

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.

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?

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.

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.

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)

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.

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?

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.

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.

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.

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

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.

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.

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.

When I first started on nights it was actually easier than now, I think because my system was so confused it didn't know when it was supposed to be asleep and when it wasn't. Now, after years of nights, I find I can't to a complete switch to a daytime schedule on my days off without being a zombie, regardless of whether I'm behind on sleep or not. I work long stretches on and long stretches off (6 on/8 off) which I've found works best for me. I actually sleep best during my stretch on because it is the most consistent. During my time off I go to sleep progressively earlier for the first few days until I'm going to sleep at about 2 or 3 and getting up around 10 or 11. I've found this is the most I can adjust to a "normal" schedule without being miserable.

The evidence suggests that the chances are closer to 1 in 1, not 1 in a billion. There are more important things to concentrate on than filter needles, hand washing, aseptic technique, documenting allergies, etc, but they are still important, and I wouldn't say that a Dr is always the best example of good practice habits. If your Docs aren't using them then you need to stop them and educate them. Personally, I'd prefer to have bacteria injected to me than glass, at least the bacteria will probably go away at some point, the glass may be permanent, and even if it never causes any harm it's more commitment than I like. It is possible to be so detail oriented that a nurse misses the forest for the trees, but using filter needles, or non-coring needles with a rubber stopper, isn't that distracting from the big picture, it's just not being lazy and unnecessarily reckless. The Checklist Manifesto explains the issue of our failure to do the basics better than I can; but basically it doesn't matter how good we are at the complicated stuff if we're harming patients by missing the basic stuff.

The rationale can be found here (starting on page 22, it's a long article but there is a summary at the end) http://www.calnurses.org/publications/national-nurse-mag/nn_mag_apr2010.pdf While you do need to consider that this is the position of not only a union, but the main competitor of the ANA (which awards magnet status through ANCC), they do make some valid points. Their 2 main complaints are that magnet can put Nurses in a position where they are advocating for their facility potentially at the expense of patient advocacy, and that magnet doesn't address the biggest patient care/nurse satisfaction issue which is ratios, something that is the claim to fame of the CNA (the main founder of the NNU). I think it can go both ways; If initiated by staff RN's, Magnet can be used as a carrot to waive in front of an administration that offers a plaque for their lobby and a logo for their website in exchange for allowing and facilitating better patient care. But on the other hand, Magnet initiated by Administrators often wastes energy and resources on an ineffective program, which often only exists in any meaningful sense for a couple months prior to each magnet review. To get back to the OP's question, its good to check which category of Magnet a facility fits into before putting all your eggs in one basket.

I get the same amount deducted from my paycheck for health insurance that it would cost me to get insurance on my own. I know this because my employer dropped coverage of my newborn daughter because they said they were missing a form, they neglected to tell me this until after the open enrollment period closed for the upcoming year, leaving me with over a year until coverage could kick in under my employer's plan. So I found a plan that's actually better than the one I had, with approx. the same monthly premium as I was paying through my employer for my spouse and child. Either my employer doesn't really contribute that much, if anything, to our insurance plan, or they get a really bad deal.

In this job environment, if you can find a job you should consider taking it. I would base your decision more on the location than Magnet status, since Magnet status does not always produce the environment it was intended to produce, which is why the largest nurses union in the US is opposed to the magnet designation system. If you get the chance I would suggest talking to some of the nurses their or even visiting the facility if that is at all possible to make sure it's what you think it is.

While 1-10mg is an unusually huge range, sometimes a patient's minimum and maximum pain control needs do not equal a 1:2 ratio; sometimes their pain might be controlled with 1 mg and sometimes it might take 3mg, which is why my facility didn't go along with that particular (or any other) JC range order suggestion. If they do actually require 10mg at times why does it make sense then to require that at least 5mg be given whenever Morphine pain control is needed? I am curious about how the range order ratio limit works in practice. If a patient's pain can be controlled by 1mg at times then is the upper limit set at 2mg? Or do you go by the maximum pain control dose requirement which may be 4mg, and require that at least 2mg be given even though only 1 might be sufficient. Either way it doesn't make much sense to me since it guarantees either under-treating or over-treating, but maybe I'm missing something?

Mentors by definition are not meant to be instructors. Instructors are often the reason why students need mentors.

It is sort of frustrating to be taught to think in Nursing Diagnoses and yet to think critically as well, sort of hypocritical.

There seems to be some confusion about the difference between "walking rounds" and "safety checks". Many have responded that they like walking rounds in terms of checking drips, dressings, equipment settings, etc but they don't do the whole report in front of the patient. These are "safety checks", not walking rounds are seem to be universally agreed upon. Walking rounds involves doing the entire report in the patient's room, which they love at 1130 at night, as do their roommates. As with many Joint Commission suggestions, walking rounds are often seen as a mandate, when really there are no true mandates from the Joint Commission; there are goals, standards, and suggestions as to how to meet those goals and standards. Walking rounds is a suggestion as to how to meet the standards of including the patient in their care planning but is by no means a mandate. While it's definitely not optimal in terms of privacy, walking rounds are not a HIPPA violation, although I wouldn't be opposed to making this sort of thing a HIPPA violation if it would require facilities to do away with multi-patient rooms. We tried Walking rounds for about a week, we found we weren't getting adequate information without access to patient information and the ability to discuss and write comfortably, we basically said thanks for the suggestion but we get final say on how we do report; it's the floor nurses that are responsible for making sure they get an adequate report, not the administration, although we kept the "safety checks" part of it and we involve the patient in the plan of care by discussing their goals during the initial assessment.

Now that we're a few years out from the Joint Commission's suggestions on Narcotic range orders, I'm curious what the response has been; How many facilities have done away with range orders all together? How many still use range orders but have significantly altered the policies regarding their use? Where changes were made, was there any noticeable change in rates of oversedation or other adverse events? Was there any noticeable beneficial or negative effect on pain control?