manchmal

Can anyone tell you NOT to file an incident report? Say a doctor or supervisor tells a nurse that something doesn't require incident report, or specifically not to fill one out. Or an RN tells an LVN not to fill one out. The incident reports require supervisor or physician signature. Should staff fill one out anyhow if in THEIR estimation it's an event worth writing about, and submit it to supervisor or physician anyhow (probably making them annoyed, if they have said it isn't an incident report event), just to cover their own butt and assure pt. safety? I feel pressure not to fill out incident reports when I think I should, but it's not an autonomous nursing action (i.e. I have to report it to someone else, who has to sign it, and they can be irritated that I filled it out to begin with, or tell me it isn't incident-worthy).

Thanks!! In this instance, it WAS signed by day shift, and they didn't catch the error. So I figured that WHATEVER my signature meant, I didn't want it to appear in 6 months time that I was the third "checker" to sign when there was a dispensing or prescribing error. Where I am there are three sigs -- LVN or RN who takes off order signs, another RN signs, then night shift signs. In this case, the pt was already gone with a mistaken quantity and dose of meds, so I couldn't "fix" it at 0300. Wasn't a serious mistake (ie the pt was fine when they got ahold of them on days). The pt was fine. In cases where there was a mistake on dosage or whatever (wrong thing in MAR) and I could fix it, I did that, but was still unsure whether to write. I know you don't mention med error report filing or incident report in the chart, but it sounds like I could write "error -- not executed" or similar. Or just "not verified." I'm glad others think I did the right thing. In my mind, the incident report is sufficient and I wanted to leave the chart with no red sig, but people were insisting "well it HAS to have a red signature on it." ok, but I want to know what the red sig means! I'm glad I stuck to my guns on this one, though it always feels bad when you're new and not super confident and someone insists you do something with the rationale "we always do it that way." They will prolly be annoyed I wrote what I did in bright red ink, but I tried very hard to just leave it alone! From now on I may write "MAR verified" or "DISCHARGE MEDS NOT VERIFIABLE" and then sign. So everyone is clear what I am saying when I sign. :) I did tell the original nurse who signed. Felt bad doing incident report as it was a confusing order but I had to, as the mistake was already made and hopefully they will fix process so it isn't made again.

I responded to a real old thread but I am not sure if it will show up and I really want info. So...who can tell me what "redlining" is, its history, etc. Nursing school trained us in a 21st century digital world and all the jobs want me to know what nursing was like before computers. There's an article topic for someone!! Anyhow...can any night shift RNs respond to what I'm going to paste here, which was a question I posted below someone who had discovered a med error redlining: "I know it's an old thread but I have a similar question about "redlining". Night shift at my facility goes through the day's written or computerized orders and signs (after the staff that pulled the orders off or acknowledged then) and "verifies" they were written into the MAR correctly, etc. Then they sign their name in red ink. I was trained in a digital charting environment and I'm a new grad, so this is new to me. Anyhow. My question is for anyone who has experience with this "redlining." Say you are redlining and you find an error -- like the original poster here. Obviously, you notify doc and fill out incident or med error report. So DO YOU STILL SIGN YOUR NAME if the order was NOT executed correctly? Say a patient was discharged with a wrong dose of a med, and you are to "redline" a printout that has an order for a different dose. I don't know what "redlining" means. I have recently said I was not going to sign my name on an order that was not executed correctly, and I was told to sign it. When I repeated I was uncomfortable with it, I was told "okay, fine, write ERROR and sign it." To me, that is vague and weird to have hanging out in a pt chart without explanation. So I wrote something like "not dispensed as written ERROR" and signed and dated. I cannot find policy on this but people seemed annoyed I wouldn't just sign it. However, I don't see the point in a red verification signature if it doesn't mean everything was executed correctly! I want to know what exactly I'm agreeing to when I sign orders after another RN has already executed them (correctly or incorrectly). HELP! :)"

I know it's an old thread but I have a similar question about "redlining". Night shift at my facility goes through the day's written or computerized orders and signs (after the staff that pulled the orders off or acknowledged then) and "verifies" they were written into the MAR correctly, etc. Then they sign their name in red ink. I was trained in a digital charting environment and I'm a new grad, so this is new to me. Anyhow. My question is for anyone who has experience with this "redlining." Say you are redlining and you find an error -- like the original poster here. Obviously, you notify doc and fill out incident or med error report. So DO YOU STILL SIGN YOUR NAME if the order was NOT executed correctly? Say a patient was discharged with a wrong dose of a med, and you are to "redline" a printout that has an order for a different dose. I don't know what "redlining" means. I have recently said I was not going to sign my name on an order that was not executed correctly, and I was told to sign it. When I repeated I was uncomfortable with it, I was told "okay, fine, write ERROR and sign it." To me, that is vague and weird to have hanging out in a pt chart without explanation. So I wrote something like "not dispensed as written ERROR" and signed and dated. I cannot find policy on this but people seemed annoyed I wouldn't just sign it. However, I don't see the point in a red verification signature if it doesn't mean everything was executed correctly! I want to know what exactly I'm agreeing to when I sign orders after another RN has already executed them (correctly or incorrectly). HELP! :)

Well, after re-reading the original post NOT on my tiny screen phone, I see that I read into the situation a bit r/t the substance abuse -- the OP didn't say the pt. was intoxicated...must have been someone down the thread a bit, or reminded me of patients who have suicidal ideation and are intoxicated.

I think there are some insightful comments on this topic, and also a few that seem to be written by a person who doesn't really "get" severe mental illness, etc. The OP says this pt had no prior psych hx. Yet a "normal" person doesn't behave like this. A manipulative pt might, or someone on illicit drugs (bath salts, PCP) might. It may be true that many patients try "game" the system by saying they're suicidal when they're not. But there are just as many who don't, or who don't look/act like you'd expect a suicidal person to look (not crying; manic, whatever). Here's my main point, anyhow: as everyone knows, psych units are becoming fewer. And there are hardly any with medical capacity to tx pts who are unstable due to drug or ETOH abuse. They don't have enough beds for actively psychotic long-time schizophrenia patients, so they probably aren't going to take someone who is completely intoxicated and may or may not have a diagnosed psych problem. It's sad -- people fall through the cracks because they have substance abuse illnesses, but they never get intensive tx like they need. Maybe that's why they become "***holes". It sounds to me like the OP is talking about a substance abuse pt. Maybe he has a coexisting psych dx; maybe not. Either way, sounds like the ER didn't think he needed to be there. Psych units often won't admit a pt under the influence of drugs or ETOH *unless they have a psyh history* -- so a suicidal pt would still need to be suicidal when their ETOH level was down to be admitted (IF there was a bed for him). So who keeps him? Seems like a big problem to me these days in hospitals -- and likely why we see many of these people over and over. You don't need inpatient psych tx if you are completely intoxicated. If it's medical concern, the pt must need a medical focus to their care. If they're "just" intoxicated...well, there aren't many places for them to go and be safe. Jail? Eh, maybe but not gonna be any sort of permanent solution. It is frustrating to see this, and I'm sorry to the OP for having to endure it. But a pt who is intoxicated needs different services that inpatient psych usually will tackle -- until the person is no longer intoxicated, at the least. Lots of people are suicidal when they drink or do drugs, then aren't when they're sober. This is definitely an issue, because a. They DO need help and b. substance abuse/ mental health services are dwindling, and many think that they are ineffective. I'd argue that they are becoming ineffective because of fixable reasons, but there it is from my point of view.

Thank you both for taking time to share your experiences! If anyone else has any other insight, I'd love to hear it, too.

Hi everyone. I did a few searches on here for this topic, and found a couple things, but the site is working too slow for me to keep searching for exactly what I wanted to ask, so I hope you'll forgive me if this has already been discussed! I start a new job soon, in an inpatient psych facility. I'm a new grad, and this is THE job I wanted, and in the area of nursing that I love, so I feel so fortunate and excited in this job market. And also nervous, of course. My question(s) are about emergency IM meds. 1. Is the dorsogluteal site used in emergency med administration? If the person is in restraints, which site is preferred? Or is this an institutional policy thing? 2. I've not yet medicated anyone with more than 0.5ccs (delt injection per institution policy) who has had to be restrained -- do they release the restraints on one side so you can get to the back side? or the ventrogluteal? I worry about finding the right spot in an emergency! 3. Do you aspirate for blood return when you're giving an IM med to a combative patient? 4. The facility I was in before gave some injections in the deltoid -- mostly just 0.5cc Ativan, etc. Are there certain meds you wouldn't give in this spot, even if it were a small amount? 5. Say a patient is being actively combative, violent, etc. and has to be put in restraints or held to keep others safe. At what point do you offer a PRN med? Before they are restrained? After they are restrained? I've seen this all move very fast, and I know I'll be responsible for documenting it -- say the patient has already "crossed the line" of safety, verbal deescalation isn't so much an option, and has to be restrained, do you then give them the option of taking a PO PRN, or is it acceptable to "force" medicate them with rationale that they are/have been a danger to others unmedicated? THANKS in advance. I'm feeling nervous but okay about this new role, but emergency meds is one area I'm not very confident in.

Near Central Ohio -- outside a major city, but within driving distance. So I imagine in northern NJ, the cost of living may be higher. Rent for a 2 bedroom house here is approximately $850/month. A 1BR appt would be between $450-700/month, if that helps. I was always curious what the starting wage was in other areas of the country. A friend who is a new grad just got hired at $19.85/hr at a doctor office. Another at a local hospital (level 2 trauma), $23/hr.

Congrats!! I took my test in Ohio last Wednesday morning. Started at 8am, finished around 8:50, 75 questions. Got good popup at PV about 2 hours later. The next morning around 10:30am, I was able to search for my name on the ohio BON website, and it listed me with an RN license # and "valid" status. My quick results didn't pop up on PV until Saturday night, so I didn't pay for them cuz I already had a license number. I got a certificate in the mail yesterday from the BON. Friends who took the exam Friday and Saturday got PV quick results Monday at around noon, and valid licenses by around 2pm Monday. So sometimes the BON is super fast!! :)

Wow, $25/hr would be considered a VERY good starting salary in my area of the country. That's over $50,000/year. I'd say average starting salary for an RN is $20-$23/hr. here. Is the cost of living high where you are?

I don't understand why these places are refusing prescriptions that we try to bring in to self-disclose LEGAL medication use! I had a pre-employment drug screen last week, and am still kinda weirded out by it and hoping it's okay (dream job). I take a prescription med at bedtime (a benzo), and have for ~10 years. I never take more or less than what is prescribed, etc. I went to a local lab/testing facility with a slip from my potential employer for a urine test (pre-employment screen, am hired based on successful negative urine test). I tried to tell the tech that I wanted to give a copy of my rx to her, and she refused, said she "wasn't allowed to talk about medications with me." I asked who I could talk with them about, because I wanted to show them my prescription for the med, and she said "no one." I obviously don't want them calling my potential employer and saying something like "X's drug test was positive." She told me that some other agency manages the testing (they send out the samples), that she just collects the specimen. The other agency was like 15 states away from me...there was some medical officer's name on there, along with a larger agency. When I left the testing facility, I called the agency and asked if I could send a copy of my rx, and no one seemed to know what was going on. One guy told me they would call my employer, and ask "for my contact information" and then call me for info on any rx scripts I have. Another woman told me they would call me first, and then make sure the levels were "within the therapeutic range." I'm not even sure at this point that the test tests for benzos? Anyhow, I was shocked I couldn't just list my dang medications when they did the screen! This was a lab (not the employer), so I don't see anything wrong with sharing my med list, and I do NOT trust these people not to screw up and just report to my employer that I have a +drug screen for a drug that I take legally/safetly, and have had an rx for for years. I also don't figure my employer has much right to know that I take this medication?

Are you guys in rural areas, or urban areas? I am curious, because job availability seems to vary quite a bit depending on whether you live somewhere where a bunch of other people want to live, or whether you live in a place that is less populated. I just wrote on another thread, but wanted to write here, because I am a new grad who just (by luck? hard work? a good resume? all, definitely) got my "dream job," the same day I got notification of passing NCLEX-RN. I had been super worried about this, so I wanted to give you all some hope. I wanted to throw out there to consider non-traditional, non-hospital settings (MR/DD state or government jobs, nurses at residential or group home type facilities, nurses in the corrections system, or (for states that have privatized many of their jails) those companies), behavioral facilities...I was researching all sorts of facilities that had one or two nursing positions available, but weren't traditional hospitals. And I think what made me so, so lucky and fortunate in getting my job was that I had volunteered at this hospital for a number of years. I was able to honestly tell them that I am committed to this area, to this facility, and to this field. I definitely did not have the most experience as an RN of all the applicants or interviewees (I have never worked as a PCT or nurse aide or LPN before), but I was also probably the only person they interviewed who had spent as much time devoted to THAT hospital, so they knew that I was devoted to their team. So if you have time to volunteer in any capacity, do that -- you are in a good position to meet those people who can help you get the job you want. You never know when you're meeting someone who knows a manager or director, so treat everyone with respect, and sell yourself! Good luck to everyone. I live in an area that is semi-rural, but is still fairly saturated with RNs from local community colleges, etc. The people in my class who are new grads and have jobs lined up seem to be those who are proactive and assertive with calling managers, etc., and also people who have some experience with the facility they are applying. There are still plenty of classmates who don't have jobs lined up yet, and some considering moving to different areas where fewer people want to live.

I'm a new grad, and I got my NCLEX RN results and a job offer the same day. I had been very worries about finding a job, and I feel extremely lucky. The job offer is actually my "dream job," in psychiatric/mental health, which I know isn't everyone's dream job. I am in a semi-rural area in Appalachia, college town, but it is saturated a bit with RNs. I have two bits of advice: 1. Look at state psych facilities, developmental disability facilities, or VA hospitals, and be willing to take a job that's not your dream job, just to get some experience. 2. Volunteer where you want to work, if at all possible, even if you can only do a little bit per week. I feel like volunteering throughout nursing school demonstrated to the facility that I am committed to this field, this area of the country, and this facility. And that's true; I am. I applied and interviewed before I had my license. I feel so, so lucky, as I said, but I think what maybe made me stand out was that I had demonstrated over time that this is what I am committed to. Other than that...my grampa always told me to do the job no one wants to do, or to think outside the box. So don't limit your search just to mainstream medical hospitals, because there are a lot of RN positions outside that box, in facilities that I never even would have thought of. Good luck everyone!!

Good article. I agree especially about the NCLEX and questions early -- and also don't get totally bummed if you don't do great in Fundamentals...to me, that was the absolute hardest class because it was abstract and because my background was NOT nursing. Once we got to the "harder" stuff related to diseases and disorders and applied nursing, I was at the top of my class. I credit doing about 8 billion NCLEX questions after fundamentals class with part of that change -- once you learn how they are written and start to see patterns in how they are answered, you can game them out a little better. I always told students I tutored not to get totally down on themselves for getting a B- or a C+ in fundamentals. Also, I started 3rd semester a sheet on every disease we learned about. On it was: Pathophysiology of disease: Signs/symptoms: Expected labs or diagnostic tests: Nursing diagnosis: Nursing interventions: Pharmacological interventions: Surgical interventions: Complications: Pt. teaching: That REALLY helped me nail down what I needed to know for exams. I tend to over-study, so this is helpful to me. One thing I disagree with is the support course recommendation you shared. I was one of a few of students who was accepted into clinicals/nursing before taking A&P I and II, microbiology, psychology, etc. It was very difficult to take the first three semesters of nursing school at the same time as these courses, but those of us who did scored higher in nursing classes because the stuff was fresh in our mind -- we were learning about the physiology of the endocrine system in A&P right before we learned about nursing interventions for endocrine disorders. We took psych and child psych right before we had nursing psych class and peds rotations. So I think it depends on how much time you have and how you learn. I don't have a job (I do volunteer in the medical field -- if you can't work, or don't want to, VOLUNTEER and get time in), so I do have a little more time than many of my classmates I think. I ate, breathed, slept nursing and A&P and micro the first year, but that for me was a very good decision -- those who had taken A&P a year prior had forgotten everything by the time we got to it in nursing school. I think it is also important to point out that balance is very important. I'm a bit of an obsessive studier, and I'm not the only one in my class who has had significant problems at home related to lack of time to spend with friends, family, etc. There are some days in my final days of nursing school that I have opted to study a little less, get a B instead of a 97%, and spend some time with friends to keep my head on straight and maintain a support system that I know is very important to me. I wish I had done more of that earlier. Edit: Also, DEFINITELY research the school you go to before you go!! Do you need to pass the HESI or ATI with a 95% or some other ridiculous %? How many of the students who enroll 1st semester actually graduate? What happens if you fail a course halfway through the program -- do they kick you out? What is their NCLEX pass rate? What is their retention rate? Obviously there are + and - points for each school, but make sure before you enroll that you're okay with their policies and rules! I was so happy to get accepted that I didn't pay much attention and kinda regret that a little. I have a MA in another area, and am very comfortable in the world of universities, but even I was not prepared for how different nursing school was.

You did the right thing by trying to talk to her first. You probably wouldn't have gone to the manager if she had been more receptive to your talking to her. So she seems pretty much to have chosen her own destiny. It would have been acceptable, but maybe not effective or considerate, to go to the manager first -- but you didn't do that; you tried to talk to her, and she was defensive. I have similar problems, and have had them my whole working life (in my non-nursing career), with feeling bad about asking someone I'm working with to do something if there was any way I could possibly have done it myself. But I wind up growing resentful as I continuously do the other person's job and they do less and less and I do more and more. And I don't like being resentful, so when I finish school and get a nursing job, it will be a top priority NOT to be the one who everyone knows will "just do it all" (I know where this road leads...). She's lucky to have someone who talked to her first, and she's stupid to have been nasty and defensive when you were taking time to talk to her.

OK, I'm probably dense, but... what do you do with 2 different colored pens and a highlighter?? Like, specifically...cross off stuff when you're done, or... Also: Is there a thread on here about what people's "organizational sheets" look like. I have one, but I'd love to see someone else's. My pockets... Hmm, a little less predictable. On a good day, 1 or 2 alcohol prep pads, bandage scissors, tape, my iPhone with drug guide, lab guide, diseases/diagnoses handbook, IV compatibility book, etc. all on it (!), my cool LED pen light that looks like a tire gauge, 1 black pen, a tiny sheet of scrap paper, and a couple 3mL flushes. Sometimes those blue cap things for the IV tubing. Stethoscope there, or around neck. Usually around neck. I also carry a black clipboard with a cover on the front for privacy, but I try not to take that in and out of pt. rooms very often for infection control purposes. That clipboard has a pad of paper, the report sheet, a blank assessment sheet from before we went computerized, a sheet with my 'to do' list for that shift, a laminated quick reference to lab values I made, some referral/info cards for domestic violence shelters and escape plans, and a one-page quick-reference sheet for psych behavior terminology definitions.

Yes. Nursing school teaches you: to be diligent, to do your homework/research, to work very hard, to learn to sift out good info from the crap, to be resilient and brave, to put up with crappy supervisors, to admire and respect talent, to make good friends, and to put your own problems in perspective.

Oooh, here's an interesting one (to me): what about long-term inpatient psych? There are both voluntary and involuntary admissions, some forensic and some not at state hospitals, and I was thinking just the other day about sexuality, sexual frustration, and 20-somethings (and all ages, really) being hospitalized for months or years. I'm not saying they should have sex in their rooms (the issue of competency/incompetency comes to mind here), but I am saying that there's no way that not having sex for months doesn't impact their moods and their behaviors. I think it should be discussed more, and I'm not sure how I feel about it aside from agreeing that sex is a physiological component of well-being for many, many people. So ignoring it sort-of does away with nursing's goal to look at the "whole patient," etc. PS: this is an example that disproves whomever said "if you're well enough to be having sex, you are well enough to go home." That's very short-sighted and applies only to a limited area of the medical/nursing world.

Hey, in nursing school they teach us that sexuality is a physiological need according to ole' Maslow... :) Not that I totally agree with the whole Maslow thing, but I do think it's interesting how rarely sexuality is considered in patient care.

I'm a last-semester RN student who started this program specifically to do psych nursing. I was open to being interested in other things, though. Last semester, I was in ICU...and while 90% of my class was LOVING their long-awaited ICU experience, I realized I never, ever, ever could do ICU nursing. How I dreaded ICU...most of the patients were on vents and didn't talk! Everything was so focused on the acutely physical problems and so much of the acutely psychological problems were (understandably) on the back burner, and it felt like I was monitoring machines more than people that...I was...BORED, even. :) I like the patient interaction, sometimes longer-term stays, socially/behaviorally hectic unit, interesting and underserved population, and unique clinical skills I need to know to do a good job as a mental health nurse. I guess if you weren't interested in that stuff, it might seem easier, but only because you'd kind-of not really be taking the job to be good at it and good for the patients. Anyhow. Psych isn't by default easier than any other unit. It's different, for sure, but in the same way as a cardiac unit is different from a hospice unit -- different priorities, different illnesses, different needs, different skill sets emphasized. And like others have said, there often is med surg going on on a psych floor, and there oughta be more psych interventions going on on general med surg floors, too. I happen to be really interested in mental health nursing, and that's because I find it more challenging and rewarding (for me) than med surg or critical care. Good thing there are some of us interested in most areas. I've spent 2 years of nursing school fighting off any and all faculty members who tried to convince me I don't want to do mental health nursing. :) I wanted to do psych nursing when I started, and I want to even more now that I'm almost done.

Oh man, we had to do the McDonalds drive thru style flu clinic, too -- the whole school did it, with first semester students drawing up vaccines, and students who have taken pharm and passed skills tests in pharm giving injections. I totally agree that students need to learn to pass meds. I have the same theory about that as I have of prisoners who have 2 year sentences: they're not gonna be students or prisoners forever, so it is wise to teach them how to function once they get out. :) Edit: we precept over 130 hours our last quarter, too, and the expectation is that we will take 80% of the RN's patient assignments and do everything the RN would do, so long as it is in the scope of what we have been trained to do. They mostly expect by that time we should be trained to do almost everything for basic patient care. This is, of course, supervised precepting but students are supposed to delegate to UAPs, do assessments, meds, etc.

78/44 during c-section of mom with twins with 900 or so ccs of blood lost. They got it up pretty fast. Listening manual, I've heard 102/40 and patient had a hx of heart disease of HTN -- I was a student, wasn't sure whether to give the calcium channel blocker that is due in such cases but doc wanted it given (based on history and that typically it is held for systolic Have had 88/68 myself, no symptoms. Have seen those numbers on a patient who was dizzy and puking, so it does depend on the person.

Did anyone else's school not tell them anything about this sort of thing? I mean, I got a student handbook that told me that I was to do x, y, and z, and most of it was somewhere along the lines of "if you don't follow your instructor's instructions, you can get dismissed from the program. ask your instructor if you have any questions. this is subject to change at any time. be nice. don't mess up." Maybe my school is disjointed, but in my experience, every clinical instructor is different and has different preferences and rules about what students can and can't do. And the guiding principle seems to be what the hospital system dictates is acceptable, which I assume is in accord with state nurse practice laws, else they'd probably be in trouble come JC certification time, right? Like if student nurses were systematically running around on every shift and every floor callously passing meds unsupervised, and with overconfident reckless abandon, in direct insubordination to what nurse practice laws say? I think what a student can do varies by state, like several people have said. Nursing education programs have their own section in the state legal code, separate from what an RN can delegate to a UAP (at least in my state), so I think it's different. Personally/not from a legal point of view, I don't see any problem whatsoever with nursing students executing some independence as they are trained to do tasks. There's no magic *thing* that happens inside you once you are licensed as an RN, and since that is the case, I'd prefer nurses who are caring for me to have practiced (hands-on) skills they are performing. Part of being an RN is learning to make independent (informed) decisions, and so I feel comfortable with nursing students learning this as they go along (with practiced skills, such as reading a MAR and pulling meds, IV placement, or walking into a room to give an IM vaccine), rather than granting them 0 independence, and then thinking they should be magically totally independent once they have a piece of paper/license.

Also: as an RN you can refuse a task and go to a supervisor or a different job if it's a frequent thing that you are asked to do something questionable. It's considerably more scary for a student who doesn't yet know nursing scope (we are in school to learn that) and refusing to do what an instructor says is sort of saying "I'm a student and I know better than you." Students get yelled at and intimidated for that, at best. Maybe a good lesson in pt advocacy and thick skin but I'm not an expert in nursing yet so it would make me nervous. I've done it, but it ain't pretty.