queenjulie

Got a dilemma: I am a nursing risk manager at a family practice. PA at our office has a patient who is refusing all treatment for what are probably multiple (now old) strokes. Has fairly serious motor deficits, but can walk and talk. Pt is a professional truck driver. She STRONGLY recommended he stop driving. He told her absolutely not; his next license inspection isn't for a couple more years and he plans to continue driving a tractor-trailer at least until then. Refused all meds and PT/OT. She wants to report him to DMV and have them evaluate him now, but is worried about violating his rights. Any thoughts? Our other experienced providers have only had this happen when someone came in asking whether they need license re-evaluation, not someone refusing it. I know HIPAA has an exception for reporting a public health issue, but all my research shows that driving is a really underregulated area and there's very little law around it with regard to patient privacy versus road safety.

My husband and I are considering relocating to Sparks to be near family who moved there, and because my husband is retired Navy and interested in working for Tesla. I'm an RN with five years' experience primarily in telemetry and Step Down with some ICU and house supervisor work. I've got BLS and ACLS. Does anyone know about how much a day-shift RN makes at NNMC? Do they pay PRN nurses more in exchange for not getting benefits? (I'm currently PRN at my hospital, and I get a big hourly increase because I don't get insurance.) Do the Reno hospitals have a higher pay scale than Sparks (i.e., would commuting into Reno be worth it)? Any info about working in the area would be awesome!

I got a new admission one time of a CHF patient, and the family was furious when they asked what diet he had ordered, and I told them it was our low-sodium cardiac diet. They insisted, "He doesn't eat ANY salt! He has heart disease! He is on a NO SALT AT ALL diet!" I tried to explain as gently as possible that eating no salt at all would lead to death fairly quickly, and they were absolutely enraged. I have no idea what they actually fed the guy at home.

Yep, it's real, and I've used it a bunch of times. Whether it's helpful is a mixed bag. It can give you a good view of the location of veins in someone with very dark skin, which is the best benefit as far as I'm concerned. However, it doesn't help you get in the veins if they're flat, dehydrated, rolling, etc. Also, they aren't much help if the patient is very swollen--the veins get hidden under all the fluid (which also makes them hard to feel manually, so you just have to do your best!). I think of it as giving you a head start, but it won't get the job done for you.

I got an ER admit today who has COPD exacerbation. The ER nurse reported that she was given 2 g of magnesium IV to help with her oxygenation. I'd never heard of such a thing, and neither had the most senior nurse on my unit. I Googled and found one somewhat sketchy article that says that magnesium can increase oxygen binding to heme: http://drsircus.com/medicine/magnesium/hemoglobin%e2%80%99s-oxygen-carrying-capacity-magnesium/. Does anyone else do this or know if it's true? --Julie

SummitRN is quite right--it's incredibly common to have a little blood leaking around a heparin or Integrilin drip, because they are anticoagulants. Now, if it's bleeding a lot, or the IV won't flush or the arm is swollen or something like that, that's a whole differen thting, and yes, you should pull out that IV and start a new one.

I'm on a primarily cardiac, high acuity step-down unit. Our Coumadin patients generally get a PT/INR every day or every other day, and if they're new to Coumadin, we refer them to our local Coumadin clinic, where there is a specific protocol. I think it's every day for three days or a week, then every other day, then weekly, etc.

I'm on a Step-Down tele unit, primarily cardiac, and I just realized that I don't know the difference between a Lexiscan and a stress echocardiogram. Can anyone explain? It seems to be the difference checking for blood flow versus structural abnormalities--is that correct?

Thank you! I thought I was going crazy when she said that!! I'm wondering if maybe she was thinking of Primacore. That makes me feel so much better!

How slowly do you push a 20 mg Cardizem bolus on a person with afib with RVR? My patient was an elderly woman with stable BP but HR up to 150 BPM. I pushed her Cardizem bolus over four minutes and her BP stayed stable, but within ten minutes, her fragile little vein turned bright red and was extremely painful. She had crappy access to begin with and we couldn't get anything but a 22 gauge in a tiny vein. Lots of saline flushing alleviated her symptoms, and we started her drip at ten ml/hr. I looked it up, and most references say to push over two minutes, but my charge nurse said she takes 20 to 25 minutes for a 20 mg bolus! Is that crazy, or did I do it way too fast?

Is getting a Progressive Care certification worth it? If you have one, did it help your career at all? I'm a relatively new nurse on a Step Down unit; I've been an RN for a year, so I'm just now qualified to get certified. My hospital just had a round of layoffs, and then our unit had a huge number of nurses leave due to the layoffs and management craziness, so there's room for new charge nurses, but I'd have to pay for the test myself. Until a few months ago, they paid for it, but now that our budget has been slashed, we have to pay for it ourselves if we take the test. Should I bother?

I had a patient recently who was actively dying, and during her last few days, she developed petechiae and purpura essentially all over her entire body. It was more than usual, but I know that petechia is very common in the elderly. Her family asked me why it was happening, and I realized that I didn't have a really good answer for them (I'm a relatively new nurse, and I rarely work with hospice or palliative patients). It's because of weakened capillary walls that allow blood to seep through, right? Or am I totally off base?

Why would a college *not* require you to write papers? Learning to do research and write critical papers is a vital part of a college education--one of the most fundamental parts, in my opinion.

Honestly, our local psych facility is so understaffed that they definitely don't require anything but an RN after your name to work there. I'm sure they prefer med/surg experience or other psych experience, but it's not mandatory. But it's not a great facility and it's in a poor area, so there are good reasons why they have a hard time finding people--your local psych place may be different. You might call them and ask! Maybe ask you talk to the charge nurse and tell her you're interested in working there after graduation, and how does she feel about new grads? HR people often have very different expectations than the actual floor staff.

We used to have that kind of BP cuff, but our hospital got rid of them because of concerns about infection, so now we have disposable cuffs that come sealed, and we give each patient one on admission and throw it away when they go home. Apparently the ones we had built into the wall were not disposable, and they obviously weren't going to throw away a permanent cuff with each patient! :) I actually thought the disposable cuffs were becoming a JCAHO standard, but maybe not--the change to disposables happened before I started working here.

How do you handle infection prevention doing it manually? Do you just constantly scrub them with wipes? I also work on a cardiac floor, and we have disposable BP cuffs for each patient for our automatic machines, but our manual ones come with an attached cuff that you would have to reuse for each patient. We use the manual ones for checking if the machine is not registering or appears to be wrong (i.e., an obviously stable and okay pt has a BP of 40/20 or something), but we aren't supposed to use them generally because of infection control issues.

How do you hold the skin taut, hold the needle, and release the tourniquet at the same time? I'd need three hands! Seriously, though, I usually try to advance the cath with the tourniquet on or let the skin go to release the tourniquet. Maybe that's where I'm going wrong!

Thank you all for all your advice! This is great. A phenomenal IV starter at work told me yesterday something interesting--she said she always goes in the side of the vein, not down on the top of it. She said running along the side keeps her needle at the lowest possible angle and seems to keep from going all the way through the vein and blowing it. Does anyone else do this?

Actually, at our hospital, we aren't allowed to start IVs in the legs or feet without a physician's order, because of the hazards of diabetic foot ulcers and circulation problems. I figured that was pretty standard, but maybe it's because I'm in a state with probably the highest rate of diabetes in the country.

Thank you, everyone, for your advice! Yes, I'm getting the vein, getting flashback, but then when I go to advance the cannula, it just goes in a tiny bit and then sort of sticks, and the flashback stops, and that's it. Then, if I try to flush it in, I just make a big swelling under the skin. I think I forget to advance the needle that tiny bit more after I get flashback a lot of the time. Maybe putting the tourniquet on higher up the arm (or not at all with the elderly, which I do sometimes, as recommended) would prevent some of the blowouts. I am generally just putting in IVs for regular fluid and antibiotics--we don't do chemo or anything like that. I'm not sure what an introcan is; my unit just uses normal IV needles, 20s and 22s. I don't think we even keep 18s in stock on our unit.

I've been a nurse for seven months, and I'm doing well, except that I suck at starting IVs. In school I was almost completely unable to do them, and I've improved to the point that now I virtually always can find and hit the vein with blood return, but I blow them constantly. I don't know what I'm doing wrong--I try to be gentle and advance the catheter very slowly, but they barely advance and when I try to flush, I just get a bubble under the skin and the patient gets a lovely bruis. I just suck at it, and my poor patients end up getting re-stuck by our charge nurse or someone who is actually capable of doing a decent job at it. It's incredibly embarrassing. Any advice? If it matters, I'm on a high-acuity step down unit with mostly cardiac patients.

I'm still a fairly new RN, but I don't think I've ever seen a PRN scheduled as BID or TID for exactly this reason--they are always Q8H or Q12H or whatever, so there is no question about the spacing required. If I gave a PRN Ativan and needed more right away, I would need to page the physician and make them aware that there is some kind of special circumstance going on.

Why on earth is it 80 degrees in your facility? Maybe you should ask maintenance to adjust the A/C. :) Seriously, though, drinks and food have never been allowed anyplace other than the nurses' lounge where I work. Even doctors aren't allowed to have drinks out at the desks.

How about, "I don't do cocaine! My girlfriend was snorting it off our coffee table, and I slipped and fell, and my face landed in a pile of it." Seriously.

Oh, now it makes so much more sense! I have never heard anyone say "refractory to" when they mean "wasn't fixed by"--that's really odd. Thank you so much for clearing that up!!