ascRN

Ambulatory care = all outpatient care where patients are well enough to not need to be inpatients. It's a very broad and vague definition. Ambulatory surgery = what is listed above. Usually takes place in an outpatient clinic or ambulatory surgical center. The procedures that occur in this setting typically are invasive (though minimally so) and require a standard of intake, sedation and recovery.

I understand this and it's a two-way street. I think the worst experience I had was a floor nurse who called and complained to my charge nurse and then also called ME back to tell me she had complained to my charge nurse. Her complaint: My patient was AMS with a diaper and had been changed but on a stretcher in the hall for 6 hours waiting for a room for admission. He got to the floor and she found that he needed to be changed immediately. Does this suck? Yes, and I get it. It is a common courtesy thing. Did I even bother checking? No, I didn't, because even if I did, I didn't have an open room to move his stretcher into to change him in. Yes, it's night time and that sucks for med-surg nurses because that's when they get all their admissions. But there's a reason for that, it's because the ED is way over capacity from 7 pm to 3 am. There's a disconnect between the ED and other floors because we all have very different priorities and demands placed on us at any given time.

I did not read all 84 pages, so I apologize if any of these are repeats. Like all of you I had a love/hate relationship with the ED. 1. Your mom/dad/grandma/grandpa decided to receive only palliative treatment for a reason. No one forced them into hospice. Those wishes that you or your siblings are directly defying when bringing them to the ED and making them suffer a traumatic arrest or worse will not bring you into the good graces of your ED docs and nurses. Yes, I do know why your loved one appears so gaunt/thin/lethargic. They're DYING, and your inability to cope is not garnering any sympathy. 2. Please don't tell the police you're on PCP, they will be required to bring you here. Furthermore, if you injure one of my coworkers while coming down, five of us will be on you in a second and you'll be in 4-points before you can say "this is bull****". You very well may get injured in the process. Drs: If we ask you to be attentive to a substance abuse pt, it's because we can feel one of these events coming and would like to avoid it. Do us all a favor and get them out of here, or if you have ICU players to attend to, at least honor our request for prn ativan/haldol. 3. Triage is the least fulfilling and most dangerous place to work in the ED. Do us a favor and don't assault/harass your triage nurses. As many people have already stated, you should expect a wait. 4. Don't spread your ****ing quarter pounder w/cheese value meal over my difficult airway cart. If I need it, it need it fast, and all of that will be going into the nearest trash can/on the floor should I come to retrieve it.

While I am all for creating a therapeutic environment, when you come into an inner city ER complaining of HI/SI, your safety and everyone else's comes first. Period. No questions. Of course the order of my actions will reflect exactly what a patient is telling me and/or what I am assessing. Even for patients that are distraught, when rationalized the vast majority have no problem putting their belongings into a bag and changing into a hospital gown.

I commend you TennNurse, I gasped in horror not once, but TWICE while reading this.

Don't know where all the DRABCD'ers are from. It was new to me as well. I went to school in Virginia and it was just ABCs at the time. edit: in retrospect, it appears you are all from Australia. Must be a difference between the AHA and whatever your CPR credentialing body is there.

GWU has one.

If you have an ACLS book from your last training, go read it and focus especially on the difficult airway/airway maintenance section. Pull out your pharmacology book and flip to anesthetics, paralytics, sedatives, and hypnotics. You will want to be intimately familiar with every drug used by your hospital for anesthesia (everything from roc to vec to succ to ketamine to versed to propofol to etomidate, etc etc etc). Particularly know your side effects and antidotes, and focus on the side effects that might correspond to whatever the surgical chief complaint/significant med hx was (dysrhythmias and BBBs when combined with bupivicaine or what have you). If you're lucky enough to be assigned to only one type of post-operative patient (OB, cardio, etc) then know the adverse events associated with whatever the most common surgeries are that you might see. Brush up on your non-responsive assessment skills as although patients are SUPPOSED to be extubated before getting to you (though I know some hospitals extubate in recovery), if it's busy you might find yourself with someone whose LOC is still pretty altered. Most of all, check on your patients often! Most hospitals have policies for exactly how often and what sort of assessments you need to do for the first 1 or 2 hours post-surgery, so make sure you're well within those guidelines. Good luck! I love perianesthesia nursing and I hope you will too.

Great a physician who isn't concerned about the safety of his patient or the other staff/patients. CiWA protocols are wonderful things.

Yeah, I don't care who you are. You come in with any psych/substance abuse complaint and the very first thing that's happening is you're stripping down to nothing but a hospital gown and your belongings are going in the locker while psych evaluates you.

Night shifts in the ED. I never personally got hurt but I routinely participated in restraining patients who had injured staff. Usually PCP or some other psych/substance abuse thing.

My best advice (along with most posters it seems) would be to remove yourself from the situation entirely. Your actions have jeopardized your nurse-patient relationship and you risk further potential litigation by remaining involved either as the child's nurse or as its former caregiver continuing to be romantically involved with a family member.

As long as HR isn't going to come down and spill all your news to your nurse manager (I don't know just HOW small of a hospital it is) then why not? As far as your chances are concerned - if it's your first 4 months on any floor with no critical care/OR experience, you may not be taken seriously. But as others have said, what does it hurt to try!

My apologies for misunderstanding the original question. I thought you were talking about a medical resident as in a doctor! Telling anyone, especially another patient about another's treatment is of course a violation of HIPAA. I'm surprised your coworker is so cavalier about it. The only situation in which talking about a patient's treatment in front of someone not involved in their care is appropriate is when that patient orally or in writing gives permission to discuss their care with XYZ person.

if both parties are involved in the patient's care and need to share information pertinent to the patient's care, then it's not a HIPAA violation. if patient identifiers are left out and a case is simply described in the context of the resident's action then it's not a hipaa violation (gossipy though it may be). if one medical professional gossips to another about a patient without taking care to remove things that might identify the patient (date, room number, name, birthday, what have you), then it's definitely a hipaa violation. it sounds like you just might have a friend who likes to gossip about their coworkers =)

my last post was rather general. let me answer some of your more specific questions i didn't address. the risk of complication directly correlates with the age of the pregnancy at termination. surgical complications are more likely in later pregnancies that require greater mechanical or chemical (laminaria) dilation of the cervix for evacuation of the contents and/or curettage. these complications typically include hemorrhage. pharmaceutical complications often result from improper adherence to the regimen (often misoprostol/mifeprex). even proper adherence results in retained tissue in ~5% of women, which is why follow-up care is important to determine if a second regimen or surgical evacuation is necessary. pharmaceutical abortions are typically only administered up to ~8 weeks of gestation. though now rare, surgical procedures provided by untrained practitioners in non-sterile and unsafe settings are vastly more likely to result in complication. you seem to be asking two different questions here. yes, the same procedure is used (often intact d&x depending on gestation at fetal demise). whether or not you or your patient considers this to be akin to an elective abortion is a more loaded political question that doesn't have much bearing on their need for medical care. if you work in a practice that specializes in providing abortion procedures you will get extensive training on pre-procedure counseling as well as access to tons of referrals. it is negligent for a practitioner to terminate a pregnancy in a woman who has not given informed consent, which means she must be able to give that consent (not under duress, distress, etc). for women who decide to undergo elective abortion but remain troubled by personal feelings about elective abortion, there are many support groups that allow them to talk about it. some practices even use social workers to follow up with these patients. nurses interested can join the association of women's health, obstetric and neonatal nurses. most training is on-the-job, and as far as i know there is not a desirable/industry-standard certification for women's health nurses. whnp and cnm are advanced practice specialties involved at all levels of women's health care. violence toward abortion practitioners has subsided though not disappeared in the past 2 decades. occasionally there will be a news story about threats toward physicians and nurses. in 2009 you may have heard about the assassination of dr. tiller, a provider in kansas who provided elective abortion services up to 26 weeks (which is what has been interpreted as the limit of acceptability in roe v wade). dr. tiller was one of only a few clinics in the country that provided services this late in a pregnancy, and it is likely that this is why he was targeted. women who learned of their pregnancies late (or were unable to seek care previously for another reason) but still wished to terminate would often fly from many states away to receive services. although it has declined, it is still a reality we as nurses have to accept. in the past i have worn plain clothes to work and/or entered through a back door, especially in the presence of protesters. some of us are vocal about where we work and what we do, while others simply choose to say they work in women's health, especially in mixed company. physicians and nurses are obligated to their patients to provide complete care. physicians and nurses may sometimes find themselves in a position in which their moral beliefs conflict with the services they are requested to provide. in these scenarios, the nurse or physician must find another practitioner who is qualified and turn over care of the patient to that individual. often times these scenarios are self-limiting as providers perform their own follow-up care. in an emergency situation where no other providers are available, it is generally accepted that the physician/nurse must care for that patient if it is needed to immediately preserve the life of the patient. this is a subject of some contention and there is a lot of case law out there if you're interested.

OP, having worked in women's health for a long time, I thought I might be able to shed some light on the topic for you. In medical terms, any circumstance in which a pregnancy is ended prior to completion is termed an abortion. For surgical or pharmaceutical procedures performed where maintenance of a pregnancy is not compatible with the (physical or psychosocial) health of the woman or fetus, it is termed a 'therapeutic abortion'. What we commonly call a 'miscarriage' is usually a 'spontaneous abortion.' And what is typically described as abortion by the media is known as an 'elective abortion'. You may see all of these terms in a patient's medical record, and they are often carelessly used interchangeably. You may also see the word abortion replaced with termination of pregnancy (or TOP). Circumstances in which a new graduate nurse who is not working specifically in an OB/GYN setting that provides surgical or pharmeceutical abortion services will likely be limited to patients who complain of post-surgical complications or spontaneous abortion. You are right on the money, hemorrhage and infection are of greatest concern. These can occur due to uncontrolled bleeding through the uterine wall, retained products of conception (POC), or uterine perforation. Similar assessment methods to what you learned in OB nursing are used to determine this (pallor, pulse, BP, palpation of uterus with or without a pelvic for boggyness or rigidity, excessive lady partsl bleeding, etc). A woman who thinks she is experiencing a spontaneous abortion may be in need of immediate care, and should be directed to an urgent care/ED or other clinic where she can receive a ultrasound. Depending on the circumstances behind the loss of pregnancy, psychosocial care may vary widely. For women experiencing complications following an elective abortion, psychosocial needs may be minimal. For women who have just miscarried, they may be great. Of course, reactions of individuals to traumatic events vary widely, and the best way to determine what type of support your patient needs is by using good therapeutic communication skills. Start by listening to what your patient is and is not telling you during your initial assessment. Ask open-ended, non-leading, and non-judgmental questions. As pregnant women are at a higher risk for domestic violence, asking about safety in interpersonal relationships may be appropriate. Learning to recognize coping strategies takes time, and will come with practice. By taking a good psychosocial history, you can paint a much better picture of how to care for your patient. If you ever feel you are in over your head or that you don't know what to do, talk to a more experienced RN or call the social worker. If you carry strong personal feelings about abortion yourself and are struggling to remain objective, recognize those feelings and remove yourself from the situation.

Thanks for the link, HouTx. It appears that though the board discourages it as a trend, if the physician the RN is assisting is competent in advanced airway management,including intubation, then administration of anesthetics by the RN is permissible (assuming the physician the RN is assisting can quickly abandon the surgical site to help maintain the airway). I think I'll still call the board for clarification. I have ACLS, though it seems the board is encouraging something beyond that as far as airway management is concerned (for which as far as I'm aware, no certification program exists).

Hello all, I'm a nurse new to Austin. I've taken a job in an ambulatory surgical center where I'll be doing perioperative care. The center uses RNs to push anesthesia while the physician is performing procedures. I know that back in Chicago, nurses could push fentanyl and versed, but not other things like propofol. Does anyone know what the laws are in Texas surrounding RNs administering anesthesia (specific drugs, settings, requirements for physician supervision, etc)? Just want to make sure I don't overstep my scope of practice at any point. Any links to relevant texas state health code would be helpful too. Cheers! Dave