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kristine_bean RN

Acute care and rehabilitation
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kristine_bean has 10 years experience as a RN and specializes in Acute care and rehabilitation.

kristine_bean's Latest Activity

  1. kristine_bean

    Oral vs IV Pain Medication

    This question is specifically targeted to nurses that work with inpatients in the hospital. If you have 2 options for administration of pain medication, when would you chose to give IV over PO if they are both available? Usually, I give IV over PO if they are NPO, vomiting, end of life or the pain is severe enough to warrant immediate release vs waiting for PO to work. Recently I had fresh admissions from the ER, one with bilateral PEs and bilateral DVTs and the other with probable cancer with metastasis. They were both rating their pain 10/10 and we're visibly in a lot of pain so I gave them both the IV doses even though there was also oral pain medication available. It was near the end of shift and since IV is shorter acting the night nurse questioned when she could then give the oral dose because they were q2h frequency for the IV and the result would completely wear off before 2 hours. After reflecting I think that I should have just educated the patients and let them know that the IV route was reserved for "breakthrough pain" AFTER the PO has had a chance to work. So, my question is would any of you have done the same thing or had them wait for the oral to work when they were in severe pain? Thanks
  2. At our hospital we don't usually lock piccs with heparin but occasionally we have picc lines that have different end caps and clamps on the lumens. We were instructed to heparin lock these types as they were prone to clotting. So I have a couple questions 1. Do we always draw the heparin out prior to using the line again. I ask this because the heparin doesn't just sit in the line, it mixes with blood and when you go to draw it out, blood is immediately what you see. So how can we know how much made it to the patient and what volume of heparin remains in the line? Not to mention the amount inserted is 2.5ml and PICC lines depending on the length only hold 0.5-1ml. 2. With normal saline flushes we do 20cc to flush PICC lines. If it is an IJ which is about half the length of one inserted through the arm, would it be reasonable to flush with only 10cc of saline and then follow it with the heparin? Thanks a bunch!
  3. kristine_bean

    Transfering patients

    I'm looking for two things here, opinions and advice. At the hospital I work they follow the same model as Toyota in regards to organization, efficiency, and cost effectiveness. When they have a problem area they put together a group of people and they come up with a solution. The solution is tested and data is collected and reported out every month for 3 months. We're in month 3. Our unit did one on the admission process (for hospital subacute rehab). The problem was patients were being transferred very late in the day. This was in part because our nurses were always waiting for a time that they were busy (which is rare) and the sending unit would hang onto the pt to avoid an admission of their own. The solutions were *A goal time to get report within 30 min of being told they had an incoming admit *A planned time for the patient to transfer *Two staff members would leave our unit and go to the pt to bring them to our unit The first two solutions were very effective in getting the patient admitted sooner. The last one has been very challenging. Some roadblocks are - *When one staff member is ready, the other is not *The pt is not ready when we arrive *The pt has needs when we arrive (toileting or clean up is the big one) *Who is responsible for the care of the pt has come into question. *Liability if an injury were to occur in our hands while still technically admitted to their unit. I have brought these concerns to management and so have others but the consensus is upper management believes it is good for the patient and good customer service to greet them before they come to our unit and escort them. What do you think about this process and how might I again bring this to their attention so that they can understand how inefficient it is. Today it took about 40 minutes. 1 RN and 1 CNA were off the floor at this time basically waiting and being nonproductive. This isn't the norm. Usually the patient is ready and it's a 5 minute thing. But when it's not quick, it is very frustrating for the staff.
  4. kristine_bean

    Nurse-Patient ratios in rehab?

    I work in inpatient rehab. We get a lot patients that no one else would take because we're expected to offload the hospital that frequently goes on diversion. We're the only rehab in our area that will take a pt on peritineal dialysis. We have a lot of tube feeds, iv antibiotics, and wound Vacs. And when a patient gets sick we don't get to send them away in an ambulance. We call a rapid response and a team of people assess the situation, many times the pt will stay on our unit because they say we can manage them. Usually only new stroke, PE, MI or need for telemetry monitoring will move them to another unit. With all that being said our ratios are usually 6 to 1 and you can expect to do 2-3 discharges and admits every day with staff of 3 nurses and 3 CNAs if we're adequately staffed.. a huge difference I notice with staffing ratios and doability is the burden of EMR/eMARs vs paper charts. They each have their benefits but computerized everything is a huge time sucker.
  5. kristine_bean

    Have you ever had one patient ruin your mood for the entire day?

    Thank you for your reply. Unfortunately I work in a rural hospital with very few resources. We don't have a wound nurse, charge nurse, risk management team. We do have a social worker though, thank goodness. As far as getting a doctors order right then and there, looking back I may have been able to get the ER doctor to assess and order a dressing (the only doctor that is available in person). His provider while hospitalized though, is a nurse practitioner who honestly doesn't know what needs to be done with this patient. Our hospital has two MDs that look at the admission and either decide to take the patient or pass them off to one of our PA's or ARNP's. The other nurses and I have all looked at each other and scratched our heads wondering why they passed this one off, because his care is not straight forward and is quite complex. Had he been assigned to an MD, these problems wouldn't even have arisen. The order should have come from his hand team originally. I attempted to contact them, again with no response. I actually have applied to a larger hospital with more access to resources because issues arise quite frequently where I feel like I don't have the tools or people available to do right by the patient. Its hurt my self esteem quite a bit because though I know I'm not at fault, It makes me feel uncomfortable, puts my license at risk, and not only does it make me look bad, it makes the hospital look bad. You're right though, I shouldn't let this patient get under my skin, I am a little too sensitive. It's something I've been working on. Just needed to vent and get some feedback.
  6. I had this patient today that just made me feel like the most incompetent nurse. That's my button. I usually handle myself really well when it comes to emotions. But when I feel bad about myself because I feel like I can't do my best in this situation. I can't help it, I get emotional. So lets get to the story... This patient was in a severe accident and has had multiple surgeries to reconstruct his left extremities. The last time I was his nurse, there were several orders to question. The patient remembered being told one thing, but the orders said something different. His surgeons office was called, message was left, follow up fax was also left. No response was received that day and I didn't have him as a patient again until today almost a month later, they ended up with clarifications but the next nurse probably got the credit in the patient's eyes. A month ago, his dressing to his left hand was to go untouched until the next follow up appointment. This time around, I got in report that he went to his appointment 2 weeks ago and the nurses have been changing his bandage without an order. This patient is very involved in his own self care and most likely told the nurses that the doctor wants us to change the dressings now. I can only presume that. I walk in the room hoping to see a dressing, take it off, clean the wounds, and redress it the way it was. But I walk in the room and the dressing is not there. He had just taken a shower and apparently was allowed to have it washed in the shower. Now it is sitting open to air and I have nothing to look at. So I ask the other nurses I was working with if they knew how it was being dressed. No one knew. My next option was to ask the patient. So I did. He was perplexed that I didn't know. I explained, we don't have an order. So I don't know what we're supposed to be doing. You are involved in your own care, so tell me what has been done the last several days and that's what I'll do. He tried to describe a piece of hardware I was totally unfamiliar with. He said it came from the ER. I went to the ER, no one knew what it was. I came back to him and asked him to describe it with different words and maybe it would click. Finally another nurse said, I think I know what you're talking about, she went to the ER and finally the patient said yes that's it! We had what we needed. As I'm applying the dressing and following his instructions, he's grilling me saying "how is it there are no orders for this, I brought papers in from my appointment and no one else has questioned this before, just you. In my head I thought, well they were probably communicating but no one told me, someone should have asked for an order between then and now, so situations like this didn't occur. I honestly don't remember how I responded. He was just very demeaning in his tone. The remainder of the day I was very busy with my other patients too, I tried to make it back in the room before he went to physical therapy to change the leg dressings as well. I came later than I hoped because I was pulled in a million directions. When I got there is was too close to his appointment time so he wanted me to wait until after. Then I got an admission that needed a lot of attention and I ended up telling him I wouldn't have time to do it and night shift would have to follow up. He didn't like the night nurses doing it apparently so made the choice to wait until the nurse tomorrow morning came on, and thank god it wouldn't be me. 30 min before end of shift I was drawing up an antibiotic for another patient and he is at the nurses station, and asks for a pain pill. I say I'm in the middle of something and I can't get it at the moment but I will when I'm through with what I'm doing. He replies "Come on, you have GOT to be kidding me!". I mean clearly, this guy did not approve of me and the way I had handled him the entire day. I just felt aweful and was so unhappy all day because of his attitude. I've had patients who are just plain mean to everyone and for some reason I can handle those guys, piece of cake. But this guy is different. He has that favoritism type of attitude like only one or two people can do a certain thing right. He seems very passive aggressive too. In hind site, I may have been able to find specific details on his dressing change in the nurses notes or called one of them at home but it's not something I thought of until after the fact. I did end up requesting specific dressing change instructions from the provider. So then I'll be the only one who looks bad and anyone else who comes along will know what to do.
  7. kristine_bean

    Flumist administration

    According to CDC guidelines for administering flumist it says that you should have the patient tip their head back and inject into each naris while the patient is breathing normally. At the clinic I've been working at, we have been having the patient sniff it while it is injected, as if they were sniffling with a runny nose. Is this an ok method? I don't want to go around telling everyone they're doing it wrong if it is still affective when given that way. Thanks :)
  8. kristine_bean

    Tips for giving Flu Mist

    Tell the kids its similar to getting a little bit of water in their nose. They shouldn't blow their nose for 30-60 min after the immunization is administered. And according to CDC they should tip their head back while your hand supports them behind the neck. While they breathe normal spray one half into one nostril (without removing the divider before administering or it will all go in one nostril). Remove the divider and administer the rest in the other nostril. Hope this was helpful. And be sure to tell them its much nicer than a shot! They love that :)
  9. kristine_bean

    Tdap vs DTap

    Thank you!! I'm so glad I ran into that, or I never would have known they were different. :DD
  10. kristine_bean

    Am I just being a big baby?

    At the LTC facility that I worked at, as an aide, we all divided the care equally. Normally we would have 2 aides caring for 20 medicare beds and 5-6 aides caring for 60 patients but every now and then the census would get low and we would mix a couple aides into doing some LTC rooms and some medicare rooms. That way you wouldnt have 2 aides caring for 12 (6 each) and 5 caring for 60 (12 each). We also got rotated on which patients we cared for so that way if its a tough group, at least you don't have it every day. You may want to make a couple suggestions like this to your management. Unless of course the halls are not a close enough proximity to have CNAs splitting areas like that. Another really great thing is to have a float. This is a person who has no assignment and just helps answer call lights and assist with 2person lifts. I LOVED days when we had enough aides for a float it was wonderful. Also a nice thing about the Nursing home that I worked for, was that the nurses made the decisions about where the aides would be and what the assigments were. Because they were the ASSISTANTS OF THE NURSE, so why not be able to make those kinds of decisions for your assistants. I hope this was helpful, I kind of rambled on too >.
  11. kristine_bean

    Tdap vs DTap

    Is there a difference between DTap and Tdap? I thought they were both Tetanus, diptheria and acellular pertussis but I was just reading an article that suggested not placing two vaccinations that look or sound alike next to each other to prevent errors and used those as an example.