glovedgoddess

HI all nurses, I am finishing my final practicum of nursing school, I graduate at the end of May. The thought of graduating was really exciting a couple months ago, but now that I have only a couple shifts left and will be losing my student status I am honest to god terrified! I am sorry this will be all over the place but I just need to get these thoughts out! I just got off a night shift and I need to vent badly! I really try to approach my clinical days with a positive attitude but lately the days haven't been going well for me. My mentor emphasizes that I am at the point where I should be doing "everything" as the role of an RN. It boggles my mind how an RN can ever get to the point where she is organized and knows everything about all 8 patients and sound like a total pro when reporting off. Last nights shift went not so great for me, I felt really behind in everything I was doing. I had planned on assessing 5 of the 9 patients we had but I ended up only assessing 3, while the LPN and other float nurse assessed the rest. I was really hesitant about asking for help b/c I know that I really need the practice to get the hang of assessing at least 4 but being aware of all 8+. There were so many moments during shift that I had to hold back tears and just remind myself that it wasn't a good time to breakdown (to save that for later at least!). One patient was a really agitated, jumpy neuro surg pt that took so much time and energy to get her to take her meds. I would spend at least 10 mins each time just trying to talk her into opening her mouth to take them. In the morning when she was being extra difficult about it, I was stressing about everything I still needed to do and it was all I could do to not burst into tears b/c of how frustrated I was, she was just pulling on my last straw. I felt horrible having those thoughts b/c I am supposed to be the caring nurse at all times but when the stress builds up I really struggle! I feel huge pressure to impress my preceptor b/c she is such a good nurse, every time I ask a stupid question or forget something I feel like I am sinking further and further down in her books. Did I mention I don't even really know how to probably transfer or safely ambulate a patient? (Nope didn't learn this in school, thanks university that was money well spent..) Or that I don't really ever know how to decipher what prn meds to give when I have multiple pain meds/anti-nauseants/sedatives to choose from and all sorts of routes... To end the shift my report was less than stellar (I never really know what I am supposed to say), I never have time to read progress notes or even look through my patients' histories b/c I am so darn busy the entire shift, running running running I literally don't sit EVER! During report the nurse asked me well has this patient improved? What's the plan for her? ..my answer, "To be honest I'm not sure, I didn't get a chance to read through her chart". The nurse just shrugged and gave me the "thanks for nothing" look. I had a knot at the back of my throat for the entire last hour of shift and as soon as I was in the safety of my car the tears started flowing. I have been feeling so overwhelmed, unorganized, unknowledgable, incompetent, & STUPID for the last couple sets and tonight I reached my breaking point. During shift I kept thinking "I hate nursing..", I don't really believe I hate "nursing". I just hate knowing that I am struggling when I am used to being such an over-achiever is all other aspects of my life. In nursing school I have achieved top marks all 4 years, but it seems as though that doesn't help me in real-life nursing. Leaving shift feeling frustrated and torn apart inside every day is really taking a negative toll on my self-esteem. Graduation is supposed to be exciting. I feel like a total fraud saying I will be a registered nurse, because I don't feel that way at all! It's just so frustrating that 4 years later I feel like I am barely prepared to begin caring for 8+ patients on a daily basis. Thanks for taking the time to read my vent sesh. If you are a new graduate who at some point felt similar to how I am feeling please speak up and let me know if things "really do get better" like the nurses keep telling me (although there is no way I can imagine how things can improve right now). Even experienced nurses, you were students once too..do you remember ever feeling the way I do? What can I do to help myself feel more confident that things will get better?

A patient on my team was a fresh hip replacement post-op from the afternoon and it was now the evening. He was running a bit of a low BP (80/50) He hadn't voided post-op yet and had >900ml in his bladder, we decided to catheterize him. Before catheterizing he stated that he was feeling "fainty", he was lying flat in bed at this time. I inserted that catheter which he was a bit anxious about and I coached him on deep breaths through the procedure. After insertion he was saying he still felt pretty fainty and he looked pale, shallow resps (denied SOB), was closing his eyes and his jaw was chattering quite severely (At first glance I thought he was seizuring b/c of his jaw jittering but he responded to my questions appropriately, so alert & conscious). I took his BP again and it was till low around 85/55. I gave a cool clothe for his forehead. His HOB was at only about 20 degrees but in hindsight I guess I should have lowered it all the way, but than again his resps were pretty shallow b/c he was feeling unwell. Dressing was dry & intact. This was one of those times that I wasn't sure how serious this behavior or S&S were. I'm still new to the orthopeadic/surg area and I wasn't sure if maybe these kind of episodes are sometimes seen with fresh post-ops (maybe after effects of anesthetic? hemodynamic status a bit irregular after being under the stress of surg?) Also some more info you may be wondering: he was receiving IV morphine q1h, which I knew may be contributing to the low BP as well... This was around the time of shift change and the head nurse on the team was not overly concerned about the low BP or fainty feeling complaints. But I thought it seemed like a pretty abnormal episode, anyway it's still bugging me so I'm asking you nurses too! What do you think was causing the intense jaw chattering? Do you think this what they call a vaso-vagal type of episode? If this was your patient what would have done differently or what would be your first thoughts/interventions? Thanks for your input!! I learn a lot by others thoughts and suggestions, helps me to think reflect on my actions for the future. -uncertain nursing student.

yup makes sense! Thanks for taking the time to answer my questions :)

Thanks for your reply! I'm just still a little bit stuck on the vasodilation/vasoconstriction...Your example of holding the brachial artery and witnessing vasodilation, I'm confused why it would vasodilate if the body wants to get rid of the co2, wouldn't it want to vasconstrict to build up more pressure to get blood flowing more quickly to the lungs?? (how does the vasodilation facilitate excretion of the c02?)

Hi all you fabulous nurses out there! I have frustration built up and I would be so grateful to get some help on this stuff.... I have a couple questions: 1) Ex. A patient has Gravol ordered IV q4h and Ondansetron IV q6h-q8h. If I gave the patient Gravol at 0800 and the patient c/o of unrelieved nausea at 1000, would it be okay to give the Ondansetron at 1000 (b/c they affect the body in different ways)...Is this the same idea with pain meds like giving Tylenol and 2 hrs later giving Advil, b/c the two meds work in different ways? **Please correct me if I am wrong! This kind of decision-making for medications makes me quite uneasy! *If two meds are ordered for the same thing, can it be implied that the doctor wants you to try one and than the other or use them together as needed (if safe of course)? 2) I have been studying like crazy for the final RN exam. As I have been reading my mind has become so frazzled and I am gotten myself in a huge confused mess. Lets go back to the basics... vasoconstriction & vasodilation-> Why do the vessels vasoconstrict in a stress response, I understand that the peripheral vessels will constrict to shunt the blood to the vital organs. But wouldn't the vasoconstriction actually work against the body which is trying to get more perfusion of oxygenated blood?? I hadn't really thought of it in so much depth, but now I'm questioning EVERYTHING i know!. Also, why does CO2 cause vasodilation?? (if this is similar to vessels constricting to shunt blood, wouldn't the vessels want to constrict to shunt blood back to lungs to get rid of CO2??) Please help! Thanks in advance!

thank you jra2127, i appreciate it! :)

Thanks for your answers anyways! Many of these questions I had asked during clinical but didn't always get a clear answer so I figured this site is a good resource too.

hi all nurses! i have many questions that i have compiled during my time working as an undergrad nurse. these are questions that i think about lying in bed at night after a day of work! so i apologize if my questions are all over the place because they truly are about anything that occurred during some of my shifts! thanks ahead of time for any answers or words of advice... alright here we go..18 questions coming at cha!: 1) are pts allowed to leave the ward as they please if independent & stable? like go down for smokes of cafeteria? does dr need to write permission for this? 2) scenario: >500mg/100ml metrondiazole (flagyl) over 20 mins given at 2100 >400mg/200ml ciprofloxacin over 60 mins given at 2100 - would i give the flagyl first because it is the faster med? i checked the iv manual for compatibility b/w the two meds and it said “compatible admixed” does this mean that it would be okay to attach the cipro to primary line right after the met has finished? what if the two meds were not compatible? would i need to flush the line from the very top port where the first med had been connected? 3) pt brings own meds in that the doctor has ordered. does pharm need to see & label them? 4) how does bowel elimination protocol work? 5 levels, when you know what level is appropriate. they say to start at the lowest level (fruit lax) and work your way up as needed. but if the patient hasn’t had a bm in 6 days i don’t think that fruit lax is gonna cut it? 5) how do you know if the central line is non-tunnelled or tunnelled? i think it has something to do with whether or not the line has a cuff under the skin which would make it tunnelled? 6) do only open-ended central lines have clamps on the port lines? when the ports have positive-pressure devices on the ends do you close clamps before removing syringe or after? i heard that the clamps can somehow cause the positive-pressure devices to fail? 7) iv abx in hospital – how long on average do abx doses last? do all abx change to po route at the end of the course or do some just d/v on iv route? 8) do you need to waste meds like heparin (vials) or just narcotics? 9) if pt is npo, does pt receive no meds? certain meds? all meds with only sips of water? 10) what the heck is med pass(?)? 11) do all patients have a specified care plan?...i’ve only seen a few of these in kardexes. 12) charting: do you write the time that the assessment was actually done or time of actual documentation. what will hold up in court? 13) is written consent the doctor’s order to go ahead with treatment? where do i find this, i can't find it anywhere in the patient's chart! 14) pt going for bone scan#2, techs want pt to have a cath in so that the bladder will be completely empty. no dr’s order for this, does nurse just do it and ask for a cover order later? 15) when changing an iv solution due to new orders for ivf change, do you prime brand new tubing along with the new solution or can i just spike the new solution with the existing line if the iv fluids are compatible? 16) when an order says give 1l ns bolus pre-dose of med. how fast does “bolus” run at? 17) what can you say to patient’s when they make comments like “i’m not in very good shape am i?” or “i’m at the end of my tether”, “the lord is going to take me”... (i get all clammy and don't know what to say! i know that silence is okay sometimes but sometimes it's more appropriate to have some sort of response for the poor patient) 18) for intake should i record intermittent medications as well? or is this only for patients when specific intake is needed? do i record intake for every patient with an iv infusion running?

Thanks for everyones answers!

Hi there I am a student nurse and I was hoping someone could help me out with organization and time managment ideas for typical shift on a heavy medical unit, The part that I have a hard time with is the time period directly after morning report has finished... What is the first thing that a nurse should tend to? I understand the idea of checking in on all the patients and tending to the needs of the most acute patients first. However, after you have done a round of all the patients on the team and have dealt out PRN meds, what should be the next task? For example, last shift after report I went to see one of the total care patients on the team because I know that she would take a lot of time in the morning to feed breakfast, change benefit, wash up etc. So right of the bat I decided to do her vital signs to get them over with. Next thing I knew the RN on the team came in to help me get the pt up and ready for breakfast. She seemed almost annoyed that I was doing the patients vital signs at that moment. Than breakfast came and I was occupied feeding the patient for a good half hour. Now by this time it is 0830 and I haven't even had a chance to do vitals, assessments and meds for other patients on the team. What should've been my next move? Should I have gotten another nurse to come help me do her morning washup and up into her wheelchair, or should I have left the washing up for later in the morning and begin assessing the next patient? I guess what I am trying to say is how can I be most time efficient and effective? Also when would be the best time to have a look over most recent Dr's orders for all the patients on the team, would this be good to do after checking in with all the patients and before handing out the 0800 meds? Sorry for this being so long and wordy! It is clear that I am pretty scatterbrained! Thanks so much for you replies!

Hello nurses! Here are some more of my usual random questions...Thank ahead of time for your help it means a lot! 1) How do you obtain a CDiff/stool sample from a total care patient?? Sounds silly but...say if patient is unable to bridge, would it be appropriate to obtain the sample from a incontinence pad? What if the patient is not incontinent but is unable to bridge? So silly I know! 2) How much information is appropriate to tell to a patient and family? For example, pt with pancreatitis and daughter are asking about the patients bloodword that was taken today, they want to know if things are improving or getting worse. What am I allowed to tell them? this happened to me, I checked over the most recent bw and his lipase enzymes were at 600, compared to the previous day it was sitting around the same. I mentioned to the patient and daughter that things were looking similar to the day before and that the doctor would be able to tell them a bit more when they would see him the next day. These kind of situations have occurred before and I just have a hard time identifying what my scope of practice is when it comes to providing the patient with informaiton like this. 3) I had a patient that was quite unsteady on his feet the day before and yesterday he was really unsteady and could barely weightbear, he would put most of his weight on me when attempting to stand. As a nurse could I just start making him use a wheelchair because his risk of falling is too high? Or maybe just tell him to stay i bed? Or do I have to do a PT or OT consult of something? Plenty of more silly questions coming your way!

Hi there, this sounds silly to me too but I can honestly say I have never been taught about this.. Who are the doctors in a hosptial? Are the doctors that work in the hospital, only hospital doctors? Or do family doctors work in the hospital and in their offices? I am wondering this because in the computer it should say who the pt's family doctor is, but who is the doctor that is going to look after them during their stay in the hospital? When you need an order are you calling their family doctor who may also work in the hospital? If it's not the family doctor, than how is it decided who will be their doctor in the hospital? Are all doctors in hospitals specialists? And what the heck is a hospitalist? Sorry that my questions are so all over the place, it seems to be a refleciton of my brain these days!

Thank you!

Okay, I had the read the responses super slowly and I kind of understand. So this is my understanding...You cannot attach two different solutions by y-site using the same pump if they are going at different rates (that makes sense because you wouldn't be able to set the two seperate rates). BUT, I was speaking about a double pump which has 2 seperate tubing insertion areas and flow rate screens (if I didnt have this I would need to use 2 seperate single pumps, like you were mentioning..correct?) So even though the 2 flow rates are different I can still attach the the 2 compatible sltns or meds via y-site as long as they are running on seperate pumps? For some reason I remember another student saying to me that you always need a bag of NS to be hanging when a pt has a Heparin infusion (even if the patient does not have a regular continuous NS infusion ordered). Should I just have the NS hanging there and primed ready-to-go just in case. OR should I hang the NS as the primary line (not running) and attach the Heparin via y-site (only the Heparin running)? I hope I am getting my questions across clearly! This is a confusing topic for sure to communicate over typing! I will ask my clinical instructor and nursing preceptor some of these types of things when I begin practicum coming up. Although I have a million questions all the time and I don't want that to backfire on me with my instructor. She is VERY critical!!

hi there allnurses community! i have some questions for you lovely helpful nurses! i suffer from a lot of confusion regarding iv infusions! questions: 1) patient has a continous infusion of ns going at 75 ml/hr and than dr orders a continuous infusion of heparin (30,000u) in 1000 ml of d5w to go at 50ml/hr. would i be able to attach the heparin tubing to the lowest port on the ns tubing and run them at the same time? would i use a double-pump because there are two different flow rates? **say if they were going at the same flow rate, both at 75ml/hr, could i just use a single-pump and still attach the the heparin tubing to the ns tubing? (of course, with knowledge that the 2 solutions are compatible). 2) i have be told that when a continuous infusion of a med is ordered it is ideal that this continuous infusion not be interrupted with things like iv pushes or intermittent minibags. hypothetically...if an iv push med was compatible with the infusing med could i just give the iv push med through the continous infusion tubing without stopping the pump?? if the meds were not compatible is it correct that i would need to start another iv site? (would i make this iv a saline lock?) thanks so much! many more questions to come! lol

questions: 1) when can nurses make referrals without a doctors order? or in other words what kinds of referrals need a drs order? who does a nurse need to talk to, to make a referral? for ex, if pt is stating that finances is an issue, does the nurse call the social worker? or does nurse pass info onto ward clerk to make referral through computer? 2) what is the difference between a ward manager and a patient care coordiantor? 3) what kind of schooling do unit clerks have to have? what is their scope? 4) how does pharmacy work? is the pharmacy in a hospital open 24 hrs? what if you need a medication at 0200 and it isn't available on the ward? thanks for all your help with these questions!:)

What are some good mneumonics for ASSESSMENT of CHEST PAIN and ASSESSMENT of ABDOMINAL PAIN? I have an interview in a couple weeks at the hosptial to work as a student nurse and I'm guessing that they may ask these types of questions about assessment. I need something to help me remember under pressure! I am on the right track?.. Pt complains of chest pain: -Ask patient when it started? (onset) -Ask patient what the pain feels like? (quality) and is it radiating anywhere? -Does pt seem SOB? Ask pt is they are having SOB? Assess lung sounds. -Ask patient if they have had chest pain in the past? -Where they doing something that brought on the pain, such as exercising? -Ask about medications pt is on? ..... Abd pain: - onset? - where is pain located? radiating? quality? pain scale? - Any nausea or vomiting? - Last BM? flatus? - Bowel sounds - Gentle palpation to feel for masses, tender areas, rigidity, rebound tenderness? **What am I missing for both pain assessments?? Thanks so much everyone! Your responses are greatly appreciated!

Thx! MUCH appreciated, both of you!! ...CYA

things i haven't gotten straight! (thread #1...): 1) do doctors make rounds every single day? say a patient is in the hospital for 3 days only, is the doctor going to come see this patient each day? 2) how the heck does pharmacy work...? is pharmacy always open (what if you need a med stat that is not in stock)? do pharmacists make rounds as well (like doctors make their rounds), do they go around to each ward at certain times of the day? (are there general times that they prefer to come up, like early in the morning and in the mid-afternoon?). if you do not have a medication in stock that you need to give in ½ hr, do you phone pharmacy and let them know? will they bring the med up to or do you go down to retrieve it? 3) can a nurse adjust iv drip rates, based on own discretion? or do we follow the order and than if we feel that the flow rate needs to be increased or decreased do we phone the doctor for a change in order for iv rate? 4) a topic that came up in class last week was pain management... example: patient is having 7/10 pain and has a prn order for morphine 3-5mg q3-4h. nurse gives 3mg at 0800 and patients pain decreases to tolerable level, then at 0930 patient pain is back at 7/10. can the nurse still give 2mg of morph because that total is still within the safe dose range? i would think that this would be better pain management, small amounts more often; rather than large amount less often. would this be considered legal or best practice? or is it tweaking with the doctors order too much? .....another scenario, if you have given the full 5mg and the patient is having 7/10 pain in 2 hours and there is no other prns meds available would i need to phone doctor and let him/her know that the pt's pain is not under control and is in need of another prn for pain? 5) if a doctor writes an order for a patient and the nurse carries out the order, if the medication is contraindicated with the patient's condition and the patient is harmed...who gets in trouble? (nurse or doc?) what if somehow something was missed, does nurse get hell because she didn't catch the contraindication? thanks to all those who reply!!!

Thanks that helps to put it into perspective!

Thank you Esme12! Very helpful =)

for example, why is so important that a patient with a respiratory infection or tonsillitis is drinking a lot of fluids? -for the resp infection patient, is the main concern to help loosen secretions and therefore promote healing? -and for the tonsillitis patient would drinking lots of fluids help wash over the infected area, keeping it moist and washing out bacteria?? -what are the general reasons why good hydration is so important for any kind of patient in the hospital?

hi all! in the hospital hydration is obviously one of the keys to healing and good health! so i have looked this up in textbooks, but i would appreciate nursing answers on this one... why is hydration so important for patients while in the hospital? why are doctors concerned about a patient's fluid intake before discharging them? i like to know the reasons behind things, it helps me to rememeber better! thank you for answering my silly but curious question!!

" I agree with Murphyle. I always stop it if it's not NSS, flush, push, flush. I also disconnect the tubing, as I will not put another med in tubing with something other than saline. " smikya- So when are you exactly disconnecting the tubing?? When something other than NS is running?? Wouldn't you just check the compatibility to avoid doing the disconnecting? Do you mean when there is a continous or piggyback med running through the line that you disconnect? even than you only mean when that med and the med you are giving are incompatible right?

That's usually what I have been doing, but because everyone does it differently I haven't found what is the RIGHT way to do it.. lol sigh.