NCNocRN

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Well said, Healingtouch. NCNA supports women's abortion rights without any restrictions whatsoever. The ANA/NCNA proabortion stand is the ONLY reason that I will not join. These organizations need to become more inclusive to prolifers deeply held beliefs.

Is the SVT wide complex or narrow? Very important to distinguish, as treatments are very different and what is appropriate for one may be LETHAL for another. Also, look at NEW ACLS algorithms, for standards of care (treatment guides).

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Perclose was introduced at our facility a few months back, and we frequently have cases on our floor for us to monitor overnight as the patients also frequently receive IV anti-platelet inhibitors (such as Reapro, Integrilin, or Aggrastat) for 12-18 hours post-procedure. I have not personally seen or heard of any complications with Perclose. One nurse stated from her prior experience with Perclose that there is an increased risk for retroperitoneal bleeds. I am cautious, but so far I have not seen this. On the positive side, patients are up faster (bedrest up after only 2 or 3 hours!). With this procedure, as with all post-caths, carefully and frequently monitor pt hemodynamics and groin site (auscultate site for bruits), pulses, perfusion and over all skin appearance (skin pink, warm, dry). If a pt complains of pain in the lower back, keep in mind the possibility of a retroperitoneal bleed--this may be more than just discomfort from laying flat. Here's some pt info: Understanding Perclose Suture Mediated Closure A Patient Guide Suture Mediated Closure (SMC) Suture Mediated Closure (SMC) is a new procedure which allows your doctor to close the femoral artery access site (opening in femoral artery) following your diagnostic or interventional catheterization procedure. Your doctor will perform the catheterization procedure through the skin (percutaneously) using vascular catheters (small flexible tubes) designed to open the blockage. The vascular catheters are introduced and advanced to the blockage in your coronary or peripheral artery through a small access site in either your right or left femoral artery. At the end of the catheterization procedure your physician will use the SMC Device to perform another procedure which closes the small opening in the femoral artery with one or two stitches. How Does SMC Compare with Conventional Treatment? Before the SMC Device was available, the femoral artery was closed by applying direct pressure to the access site (compression) anywhere from fifteen minutes up to one hour. Applying direct pressure to the access site compressed the femoral artery allowing a blood clot to form in the opening of the femoral artery which closes the site. Any movement could dislodge the blood clot resulting in bleeding from the femoral artery, so it was necessary to remain immobile for 4 to 8 hours after compression was removed. Another method for closure of the access site involves plugging the site with collagen. The SMC Device does not rely on blood clot formation to close the opening in the femoral artery. Instead, the stitch placed around the femoral artery closes the access site. Since blood clot formation is not required to close the opening, patients who receive SMC may sit up in bed soon after the procedure rather than having to lie flat in bed for 4 to 8 hours. Depending on the results of the catheterization and the SMC procedure, patients usually may get out of bed sooner than when compression is used to close the femoral artery. The SMC Procedure The SMC procedure is performed by introducing the SMC Device through the opening in the femoral artery. The SMC Device allows the physician to put one or two stitches in the femoral artery to close the opening. The stitches delivered by the SMC Device are the same as those used over several years in blood vessels and other surgical procedures. Therefore the stitches are safe for both short and long term use. What to Expect During the SMC Procedure The time of the SMC procedure may depend on the amount of scar tissue you may have from previous catheterization procedures. It may take longer to place the SMC Device if there is significant scar tissue from previous procedures. Prior to the SMC procedure, your physician will administer a local pain medication to ensure that any discomfort is minimal. During the introduction of the SMC Device you will feel some pressure as your physician exchanges the introducer sheath used for your catheterization with the SMC Device. This pressure generally is not uncomfortable and lasts for just a few seconds. Most patients do not experience any discomfort during the SMC procedure. A few patients will feel some momentary discomfort when needles and stitches pass through the artery wall or when the surgical knots close the opening in the femoral artery. Saline (sterile water) is used to saturate the stitches prior to advancing them to the artery and you may feel the cold water on your leg when the saline is applied. At the end of the SMC procedure a small dressing will be applied to the opening in the skin. After the SMC Procedure After the SMC procedure you will be moved to a post procedure care area or a standard hospital room depending on your catheterization procedure and whether you will be sent home later in the day or remain in the hospital overnight. Your heart rate, blood pressure and pulses will be monitored and the access site will be checked regularly for any bleeding. In most cases you will be able to sit up in bed soon after the SMC procedure and your doctor may allow you to get up to use the bathroom. This will be dependent on the results of your catheterization, the use of a venous sheath (vascular catheter in the femoral vein), the medications administered during the procedures, and any oozing from the opening in the skin. Some oozing from tissue may occur if you have received blood thinners and other medications which prevent blood clotting. Light compression may be applied to control oozing. Going Home Your physician will tell you about any limitations in activities and how to take care of the groin access site. In general, you should limit any heavy lifting (greater than 10 lb.) for one week to allow for complete healing of the opening in the skin. Clean the access site by washing with soap and water to minimize any risk of infection. Keep the site clean and dry. Any bleeding from the groin should be reported to your physician immediately. Any increased oozing or oozing which persists should also be reported to your physician immediately.

Perclose was introduced at our facility a few months back, and we frequently have cases on our floor for us to monitor overnight as the patients also frequently receive IV anti-platelet inhibitors (such as Reapro, Integrilin, or Aggrastat) for 12-18 hours post-procedure. I have not personally seen or heard of any complications with Perclose. One nurse stated from her prior experience with Perclose that there is an increased risk for retroperitoneal bleeds. I am cautious, but so far I have not seen this. On the positive side, patients are up faster (bedrest up after only 2 or 3 hours!). With this procedure, as with all post-caths, carefully and frequently monitor pt hemodynamics and groin site (auscultate site for bruits), pulses, perfusion and over all skin appearance (skin pink, warm, dry). If a pt complains of pain in the lower back, keep in mind the possibility of a retroperitoneal bleed--this may be more than just discomfort from laying flat. Here's some pt info: Understanding Perclose Suture Mediated Closure A Patient Guide Suture Mediated Closure (SMC) Suture Mediated Closure (SMC) is a new procedure which allows your doctor to close the femoral artery access site (opening in femoral artery) following your diagnostic or interventional catheterization procedure. Your doctor will perform the catheterization procedure through the skin (percutaneously) using vascular catheters (small flexible tubes) designed to open the blockage. The vascular catheters are introduced and advanced to the blockage in your coronary or peripheral artery through a small access site in either your right or left femoral artery. At the end of the catheterization procedure your physician will use the SMC Device to perform another procedure which closes the small opening in the femoral artery with one or two stitches. How Does SMC Compare with Conventional Treatment? Before the SMC Device was available, the femoral artery was closed by applying direct pressure to the access site (compression) anywhere from fifteen minutes up to one hour. Applying direct pressure to the access site compressed the femoral artery allowing a blood clot to form in the opening of the femoral artery which closes the site. Any movement could dislodge the blood clot resulting in bleeding from the femoral artery, so it was necessary to remain immobile for 4 to 8 hours after compression was removed. Another method for closure of the access site involves plugging the site with collagen. The SMC Device does not rely on blood clot formation to close the opening in the femoral artery. Instead, the stitch placed around the femoral artery closes the access site. Since blood clot formation is not required to close the opening, patients who receive SMC may sit up in bed soon after the procedure rather than having to lie flat in bed for 4 to 8 hours. Depending on the results of the catheterization and the SMC procedure, patients usually may get out of bed sooner than when compression is used to close the femoral artery. The SMC Procedure The SMC procedure is performed by introducing the SMC Device through the opening in the femoral artery. The SMC Device allows the physician to put one or two stitches in the femoral artery to close the opening. The stitches delivered by the SMC Device are the same as those used over several years in blood vessels and other surgical procedures. Therefore the stitches are safe for both short and long term use. What to Expect During the SMC Procedure The time of the SMC procedure may depend on the amount of scar tissue you may have from previous catheterization procedures. It may take longer to place the SMC Device if there is significant scar tissue from previous procedures. Prior to the SMC procedure, your physician will administer a local pain medication to ensure that any discomfort is minimal. During the introduction of the SMC Device you will feel some pressure as your physician exchanges the introducer sheath used for your catheterization with the SMC Device. This pressure generally is not uncomfortable and lasts for just a few seconds. Most patients do not experience any discomfort during the SMC procedure. A few patients will feel some momentary discomfort when needles and stitches pass through the artery wall or when the surgical knots close the opening in the femoral artery. Saline (sterile water) is used to saturate the stitches prior to advancing them to the artery and you may feel the cold water on your leg when the saline is applied. At the end of the SMC procedure a small dressing will be applied to the opening in the skin. After the SMC Procedure After the SMC procedure you will be moved to a post procedure care area or a standard hospital room depending on your catheterization procedure and whether you will be sent home later in the day or remain in the hospital overnight. Your heart rate, blood pressure and pulses will be monitored and the access site will be checked regularly for any bleeding. In most cases you will be able to sit up in bed soon after the SMC procedure and your doctor may allow you to get up to use the bathroom. This will be dependent on the results of your catheterization, the use of a venous sheath (vascular catheter in the femoral vein), the medications administered during the procedures, and any oozing from the opening in the skin. Some oozing from tissue may occur if you have received blood thinners and other medications which prevent blood clotting. Light compression may be applied to control oozing. Going Home Your physician will tell you about any limitations in activities and how to take care of the groin access site. In general, you should limit any heavy lifting (greater than 10 lb.) for one week to allow for complete healing of the opening in the skin. Clean the access site by washing with soap and water to minimize any risk of infection. Keep the site clean and dry. Any bleeding from the groin should be reported to your physician immediately. Any increased oozing or oozing which persists should also be reported to your physician immediately.

These days, short staffing, which used to be for emergencies only, is now becoming an unfortunate everyday occurrence. I know many people are confused as to what constitutes "abandonment." Below is a statement on short staffing from the NCBON which will clear up confusion for nurses practicing in NORTH CAROLINA. The BON would not consider refusing a patient assignment prior to receiving report as abandonment. Clocking in would not constitute accepting an assignment. NORTH CAROLINA BOARD OF NURSING Interpretive Statement QUESTIONS REGARDING SHORT STAFFING & ABANDONMENT The Board receives many calls from nurses who are concerned about jeopardizing their licenses due to inadequate or short staffing. With the current cost-containment trends in health care delivery systems, some nursing services are having to "down-size" or "right-size" their workforce. From time-to-time, staffing situations arise that may be considered unsafe for the clients who are being served. ACCEPTING ASSIGNMENTS: The licensed nurse is accountable for the care that he/she provides to the client , as well as all nursing care which the nurse delegates to other staff members. Therefore, it is essential that each nurse have the knowledge and skill to perform an activity safely before accepting such a responsibility. When a licensed nurse comes on duty to find that the mix or number of staff is not adequate to meet the nursing care needs of the patients, what should he/she do? Before accepting the assignment, the nurse should contact the immediate supervisor to report the unsafe situation and ask for assistance in care planning based on the available resources within the agency. Such assistance may include: - acquiring more staff - negotiating "periodic" assistance from the immediate supervisor for delivery of specific care activities - prioritizing the care activities that will be delivered during that shift or tour of duty; and - notifying other health care providers regarding the limitations in providing optimal care during periods of understaffing. Although it may be impossible to deliver the type of nursing care that would be delivered with a full complement of staff, there are certain activities that must be carried out regardless of staffing. These activities include: - accurately administering medications and implementing critical medical treatment regimens; - protecting clients at risk from harming themselves; - monitoring client's response to medical and nursing interventions consistent with each client's health care problem; - notifying the physician of deteriorating or unexpected change in a client's status; and - accurately documenting the care delivered to the clients. WHAT CONSTITUTES ABANDONMENT? The following activity may result in disciplinary action by the Board: . . . "abandoning or neglecting a client who is in need of nursing care, without making reasonable arrangements for the continuation of care." [21 NCAC 36.0217 © (10)] Abandonment can only occur after the nurse has come on duty for the shift and accepted his/her assignment. If the licensed nurse leaves the area of assignment during his/her tour of duty prior to the completion of the shift and without adequate notification to the immediate supervisor, it is possible that the Board would take disciplinary action. However, when a nurse refuses to remain on duty for an extra shift or partial shift beyond his/her established schedule, it is not considered abandonment when the nurse leaves at the end of the regular shift, providing she/he has appropriately reported off to another nurse. NOTE: If a nurse resigns and does not fulfill the remaining posted work schedule, this is not considered abandonment under Board of Nursing regulations. NURSE MANAGER ACCOUNTABILITY: During periods of understaffing, the nurse manager may have to reassign staff to different patient care areas, as well as approve extended tours of duty (i.e.: double shifts) for nurses who volunteer or agree to work extra. If a nurse has agreed to extend his/her hours of duty due to short staffing, but has informed the nurse manager of a limit to the extra hours they will work, the nurse manager is responsible to provide a nurse who can accept the report and responsibility for the patients from the over-time nurse. If a replacement nurse cannot be found, the nurse manager is responsible for providing the coverage. The nurse manager is accountable for "assessing the capabilities of personnel in relation to client need and plan of nursing care . . . and delegating responsibility or assigning nursing care functions to personnel qualified to assume such responsibility or to perform such functions. " [21 NCAC 36.0224 (i) (2) (3)] This includes making a judgment about situational factors which influence the nurse's capabilities for delivering safe nursing care to clients. For example, the staff nurse who accepts a "double shift" and then must return for the next regularly scheduled shift with only a few hours off may be significantly sleep deprived, and thereby, not competent to provide safe care. The nurse manager must carefully assess the capabilities of this nurse before delegating nursing care activities/responsibilities to him/her. It is important for nurse managers to remember that they could be liable for disciplinary action by the Board for delegating responsibilities to a staff nurse when the manager knows or has reason to know that the competency of the staff nurse is impaired by physical or psychological conditions . . . [21 NCAC 36.0217 © (6)]. WORKING TOGETHER TO PROVIDE SAFE CARE: Both nurse managers and nurses in direct client care positions are accountable for providing safe nursing care to their clients. During periods of understaffing or limited numbers of well-qualified staff, it is essential that nurse managers and nursing staff work together to provide safe care to all clients in a manner consistent with nursing law. If you need further information regarding the legal scope of practice for licensed and unlicensed personnel, you may contact the Board of Nursing. You should also refer to your Nursing Practice Act and previous publications of the BULLETIN which contain important information regarding nursing practice in North Carolina. 9/90, Revised 1/91, 12/96 http://www.ncbon.com/prac-rnistate.asp#QUESTIONS updated 6/24/04

A good preceptor is essential to a good orientation experience. Your preceptor will either make or break you. If you feel that the preceptor assigned to you is not a good "match" (for whatever reason), do not hesitate to let your concerns be known to the unit nurse manager. Ask for a different preceptor. Also beware of being assigned to many different nurses during orientation, due to scheduling "glitches." Makes for wasted orientation days and poor continuity of learning. A good preceptor should be genuinely supportive, competent and should enjoy the role of preceptor. Also, negotiate the time on orientation--make sure it is adequate.

Lack of control over practice environment, to me, is the thorniest problem we nurses face. As the frontline health care providers, we have tremendous responsibility and accountability. However, nurses are often disenfranchized from involvement in vital decisions that dramatically affect the patient care environment in which we practice. Nurses often lack a collective voice and political clout. Even under the most optimal circumstances--adeqate staffing, safe nurse-pt ratios, fair benefits and salary--all of this can change drastically overnight without warning. We are subject to the whims of the marketplace, governmental cutbacks, or the latest "in vogue" cost-cutting schemes. This lack of security and ownership is why nurses seldom stay in the same practice environment for more than 5 years.

With the "I can't sleep at night" scenario, history of hypertension, and coughing up pinkish sputum, the man has left-sided congestive heart failure. The blue-tint to his skin show he has hypoxemia and hypoxia secondary to his lungs shunting blood and not exchanging 02 (pulmonary edema--lungs full of fluid)--frothy pinkish sputum is also a classic sign of this. With the type II DM history, the gentleman may have had a "silent MI" (no classic symptoms, just feeling short of breath and fatigue) also leading to left-sided heart failure. Eating all that candy certainly hasn't helped, probably hyperglycemic as well.

Just 150 years ago, the nursing profession did not exist as we know it. In 1895, the American Nurses Association was formed and called for laws to raise nursing standards. In 1902, nurses in NC decided to organize and enact changes in the law to legally define the scope and practice for nursing. Mary Louise White was instrumental in this process. North Carolina was the first state with a nurse practice act in 1903. Other states' nurse practice acts were then modeled after North Carolina's model. North Carolina also has the proud distinction of being the only state in the US to elect its own Board of Nursing (all RN's, LPN's in the state are eligible to vote) (Other states' BON are formulated by doctors polititicians, etc.) The American Nurses Association and North Carolina Board of Nursing would be excellent sources of information.

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