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akulahawkRN ADN, RN, EMT-P

Emergency Department

Wee bit about me!

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akulahawkRN has 5 years experience as a ADN, RN, EMT-P and specializes in Emergency Department.

I have approximately 20 years experience doing patient care in some form or another, finding along the way that Nursing has been calling me about 10 of those years. I consider myself fortunate that I am now able to answer that call. I hold a Bachelor's in Sports Medicine and now proudly hold an ASN. I feel lucky to have found a position in the ED, a position I have long desired and I enjoy every minute of it.


Got a license to learn! 

Had around 3k "likes" before the new format...

akulahawkRN's Latest Activity

  1. Having ACLS and PALS as a new grad is pretty much a baseline thing. Wait until you're (quite literally) about to graduate as these courses are only good for 2 years. These courses aren't cheap either. It's not easy to get an acute care job in Sacramento as a new grad, but it's not impossible either, though it's tougher if you don't have a BSN as some hospitals preferentially hire BSNs. Don't just focus solely on Sacramento, also apply to some of the more rural hospitals. Just 1-2 years of experience can open some doors as you'll be faster to train because you won't be a new grad and someone else has taken on the expense of your initial training. Also be aware that nursing jobs in Sacramento can post and close very quickly. Keep a close eye on those job boards.
  2. Assuming you're truly setting up a primary/secondary system, as MunoRN says, emptying the secondary bag completely depends upon the height the secondary med is above the primary bag. With those systems, the pump simply infuses at a certain rate and changes to another rate after a certain volume has been infused. It's otherwise "just" a gravity based system. If you want to more completely empty the "secondary" bag, just raise the height of the bag well above the height of the primary bag. You won't entirely empty the bag or the secondary tubing, but it won't suck air into the primary line from the secondary until the fluid level of the primary line drops below the port the secondary tubing is attached to. You'd see the fluid column in the secondary drop and remain level with the fluid level in the primary line. That's thanks to the way water columns work. I've used pump systems that kind of mimic this kind of system but those require you to be a bit attentive in ensuring that air doesn't get into the cartridge. Getting air into one of those cartridges can be a real headache. Such systems can be nice in that you do have an option to use a "secondary" type tubing or a syringe to infuse a med concurrently with a primary fluid. Bottom line is that you need to know your pump system and how you must set up your secondary infusions. Once you've done it a few times, you'll realize it's a lot easier than you think.
  3. akulahawkRN

    Gloves at all times?

    I rarely use gloves for a med pass. Most of the meds I give will go directly from packaging to a medicine cup or into an IV line. If you wash in and wash out (or at least foam in/out), your hands will be sufficiently clean. I will use gloves if I'm expecting to deal with body fluids. I'll double-glove when cleaning patients as it's difficult to put new gloves on when I've got sweaty hands... the first set of gloves generally stay dry so putting new gloves over them is relatively easy. Personally I get the feeling that "Miss Perfect Nurse" could be a closet germophobe. It's not necessarily a bad thing, just that it could result in some behaviors that may not be welcome. When I first started doing patient care stuff, I was told that I must wear gloves during all patient contact. As I learned more and more, the amount of time I wear gloves during patient contact has decreased quite a bit. I rarely wear gloves, but when I do, you can be sure that the wearing of gloves is a good idea.
  4. akulahawkRN

    ICU or IMU telemetry?

    That's pretty much the order I'd look at things as well. Most important is getting a good foundation as a new grad. After that, the rest is just mapping your way into an ICU where you'll see some seriously sick patients. If all things were equal, the more distant facility would be a great choice, but my suspicion is the closer facility will provide a better foundation and the OP should be able to transition more easily into ICU after a good run at an IMU/PCU type unit. I'm not saying a new grad shouldn't go straight into an ICU, far from it! I was a new grad hired into an ED. My orientation took longer than I would have needed had I had experience as a floor RN first. One thing to watch out for is that some people have very strong feelings about new grads being hired directly into a high-performance type of position - particularly that new grads shouldn't be. Those people can often try to undermine the new grad to get them to quit or transfer out, and these people don't want to take the time (literally) to bring a new grad up to speed. I've had the misfortune to work with such people. Fortunately I also got to work with people willing to take the time to bring me up to speed.
  5. akulahawkRN

    ICU or IMU telemetry?

    From my perspective, the choice for you as a new grad is absolutely clear. Whether or not you agree with it is entirely OK. You have an offer of of an IMU Tele job at a magnet hospital that's 30 minutes from home. Chance are you'll be working 12 hours/day, so with a 30 minute commute, that's 13 hours. The HCA hospital that's 1 hour away means a 14 hour day. It might not seem like much but believe me, when you're exhausted after a full and busy shift, it makes a HUGE difference. You've made it clear you're gunning for a CRNA position, with all that entails. Put that out of your head for now. What you need is a good job that will teach you the basic stuff of nursing while impressing upon your brain the critical thinking skills you'll need. You'll probably have an easier transition to ICU practice by going through an IMU than by going straight into an ICU job unless the ICU job is going to offer you a very extended orientation period. This is because they'll have to teach you how to be a nurse along with being an ICU nurse and that's not easy to do simultaneously. You got a good look at what being an M/S or M/T nurse is during school. The IMU job should reinforce that and give your critical thinking skills a good kickstart. After you've done IMU for a year or two, then you should be ripe for a relatively fast transition to ICU as it should then be an extension of what you've learned in the IMU job. You'll have also gotten through the most dangerous years: 1 and 2... Then after a year or so of time in the ICU, you'll probably be ready to take the leap into CRNA (or any other mid-level program for that matter) and be ready for all that. It'll also give you time to save money as you'll probably be working less and depending upon loans during school so you can use the time to defray future costs and make your overall student debt much more manageable. You could also find that you really like something else along the way and end up doing something other than CRNA. My advice: take the magnet IMU job. You'll likely have a more solid foundation and you'll have room to grow there.
  6. akulahawkRN

    termination :(

    So you haven't worked as an RN for 7 years and got hired into ICU and didn't make it through orientation. I'm not all that surprised. The fact that they took a chance on you and said they want you to reapply when your skills have been sharpened, is a very good thing. To me it means that personality-wise, you're a GREAT fit for the unit, they just don't have time time to bring your skills up to where they should be before you're turned loose on the unit. I'd say to give it a whirl on a Med-Tele floor or something similar for a year or two and then reapply for a spot in the ICU, especially if the same director is there. You're not being listed as "ineligible for rehire" as that's an invite to never return. If you do get a position in the same hospital on a lower acuity floor, see if you can keep in contact with the ICU director. You could find yourself being invited to apply again. I'm an ED RN, I'd probably initially make a less-than-stellar ICU RN as I got a bit o'Squirrel in me. That and I'm very much problem-oriented. Fix the immediate issue and move on. It would take time to retrain my brain back to M/S or M/T type thinking... In a way, I think you're in a better spot than I'm in this. If you start doing M/S or M/T, you'll get your brain into gear in a way that should make it easier for you to transition to an ICU. It's not going to be easy. Lack of recent experience is going to be your nemesis. However, you might be able to use your ICU orientation (even though you were let-go) to an advantage. You (should) have gotten GREAT feedback as to what you need to work on and what your strengths are. That's an incredible gift!
  7. akulahawkRN

    Can’t a nurse be fired?

    If I found a deceased person who was in rigor mortis, I wouldn't start CPR. That's an obvious sign of death. The bigger question is if I had any legal/moral obligation to that person in the first place. If I'm out in public and I find such a person, my obligation (if any) is to call it in and report what I found. If it's someone that's a patient of mine, then it becomes an issue of whether I was providing adequate observation/rounding. If the patient has been adequately rounded on (per orders/protocol/whatever) and the patient died and became so obviously dead that CPR wasn't to be administered, then so be it. If facility protocol requires that ALL DEAD PERSONS have CPR initiated absent a DNR order, then ALL DEAD PERSONS will receive CPR, even if they're rotting... Some facilities have protocols written in such a manner that all employees are determined to be colossally stupid and unable to determine whether or not someone is actually and irreversibly dead. Violate the rules and you get disciplined for violating the rules and not necessarily for starting CPR when it's clearly unwarranted. If I were working at a place where they required that all non-DNR people that had died receive CPR and I found someone that was clearly dead, I would still start CPR because that's the facility rules and let the on-duty emergency responders determine death. While I haven't worked for such an entity (either in the field or in hospital), I have lost count of the number of times I've had to inform a provider that an automated alert has "fired" and I'm required by rule to inform the provider of the alert... when we BOTH know that the patient actually doesn't fall under the reason for the alert and doing actions the alert prescribes is inappropriate or we've already been treating for the underlying condition and the alert "fired" late into therapy.
  8. akulahawkRN

    Oversight from nonclinical staff?

    If a nurse is fired from an organization for commission of an act that may or may not have been clinically appropriate but the administration deems that the nurse is too great of a legal risk, then the termination is going to be OK as long as the administration can show that the legal risk to the organization is the reason for the termination and not the "act" per se. However, in those instances, there will be much discussion by HR and others in the matter before definitively deciding on a termination as a wrongful termination becomes a costly endeavor. Terminations can end up taking a while because the administration wants (and needs) to have all the proper things documented properly before going forward with a termination. They're avoiding risk. From the "nursing" end of things, that would include the nursing management doing their documentation that would show that an RN employee is engaging in actions that is outside the established norms of acceptable practice and therefore is a risk to the patient and/or hospital along with (perhaps) an assessment of whether or not the RN can be adequately "rehabilitated/re-educated" into following the established norms and a less risky pattern of behavior. Most organizations are "risk-adverse" so they generally will choose the least risky path when dealing with an employee. That's one reason why sometimes a person who should be let-go is retained, their position modified, or whatever until such time as it becomes clear (and clearly documented) that termination is appropriate (and less risky). All that being said, it still doesn't give non-clinical management the legal authority to provide clinical oversight.
  9. akulahawkRN

    Oversight from nonclinical staff?

    If the CEO is trying to get you to do or not do something that is within your nursing practice to determine, then the CEO is basically trying to do Nursing without a license. The CEO is there to handle non-clinical business aspects of running a business. Here's an example: My CEO isn't an RN or MD and therefore isn't in my Medical or Nursing chain of command. If my CEO came into my patient's room and told me to take the patient off BiPAP with Heliox because it's too expensive, I might have to tell my CEO to look into billing practices. This is an extreme example and my CEO wouldn't do this because my CEO very much understands limitations. If my CNO did that, I'd happily give report and have my CNO do it and take the responsibility for what happens. My CNO also knows better, very experienced, but knows better. Now if my CEO wants to remove all the chairs in the area because us Nurses look more professional when we're standing (and clearly aren't therefore sitting around playing cards), that's well within their decision to make. That CEO would also have to deal with any other legal issues with removing all the chairs from an area, but again, that's their responsibility. So, a non-clinical manager can oversee non-clinical aspects of your job but their authority ends there. You could lose your job because your manager doesn't like what you're doing clinically and you push back against that, but disciplining you can put said manager on shaky legal HR grounds. This is why hospitals that have non-clinical CEOs will have a CNO and CMO in the "C-suite."
  10. akulahawkRN

    I think I made my first mistake..

    Quite frankly I doubt the humidifed O2 through the NRB did anything significant to the patient. While there could (eventually) be a problem with water accumulation in the reservoir bag, it pretty much has to get to sloshing water for a problem to occur. Best to avoid that... longer term you could have bacterial or fungal growth in the bag. When you use a NRB, you have to ensure that there is sufficient flow to avoid CO2 trapping. What you're looking for is somewhere north of 10 LPM, often 12-15 LPM. You end up with an inspired O2 in the neighborhood of 60-90% at those flow rates. I really like the Oxymask for those times I need to give more than 4-6LPM via N/C as it's very titratable and usually more comfortable than a NRB, but you can't do a breathing tx through it. Another thing to consider is that if your patient needs a high concentration of O2 for longer than perhaps a couple hours, you might want to consider asking RT or MD to think about CPAP or BiPAP therapy. Also consider that while you might have a patient with good SpO2 numbers, unless you're also measuring EtCO2, you might not see hypercapnia until it's very late thanks to hypoventilation. I had such a patient on my last shift. Did well by SpO2 numbers, holding 90's on 5-6 LPM by NC, started getting loopy and drowsy/tired. That's a warning sign... Pt ended up on BiPAP for a while and mentation greatly improved thanks to better ventilation. On the whole, sounds like you were handed a patient that was initially OK for a Med/Surg or Med/Tele floor but decompensated enough to need a higher level of care. Your job is to basically be a tripwire, be alert to a need for increased level of care, and sound the alarm if/when it happens. By the way, I'm an ED RN and a Paramedic. You are, even with a year or two on your floor, far more expert in taking care of those patients than I am. If I respond to an issue on your floor, I take care of the immediate issue and get the patient to a floor/unit that has the experts to provide care beyond the immediate situation.
  11. akulahawkRN

    Scheduled and PRN Doses

    Restlessness usually isn't a pain issue. It's more of a psych issue or it can be a reaction to a medication. It can be an expression of agitation. As for following a PRN dose after a scheduled dose, give the scheduled dose sufficient time to take effect before you administer a PRN. The reason for the PRN is to allow you to administer a medication in addition to what's scheduled. You should also be judicious in administering PRNs and wait for those doses to become effective before you administer additional PRN meds for the same reason. For instance, I'll look at recent NSAID or acetaminophen-containing doses before administering a PRN for pain if the ordered meds contain an NSAID or acetaminophen. How much and when was "it" given previously? If my patient is complaining of moderate to severe pain, I'm not likely to give a PRN pain med for "mild pain" before advancing to a "moderate to severe" pain med. If the order is for 1-2 doses as a PRN, I'll give a first dose, reassess for effectiveness and give 2nd dose if needed and consider it as following a single PRN order, of course documenting 2nd dose as such.
  12. akulahawkRN

    Failed clinical. Feels like the end of the world...

    I'm now about 5 years into my career at this point... the specifics of why I failed clinical isn't necessarily all that important. What I did do was hinted above, I did a lot of introspection about the reasons they gave me for the failure and what I did that contributed to the need to fail me at that time. There were multiple reasons, but all fell into needing adequate preparation. Also part of the equation was needing adequate sleep. I wasn't getting enough at the time. I became a LOT more proactive and protective of my sleep needs and also ensured that I was as prepared as I could be. I also had to become a lot more communicative with my instructors. Academically, even with the sleep deprivation that I'd had, I was doing VERY well. Once I'd figured out the root causes of what caused my clinical fail (just days away from finishing the semester and going on to the next one) I ended up going from a relatively middle-to-low performer they had to look after to a star performer they never had to think about. Also because of the school's rules, I couldn't be assigned to the same clinical group with the same instructor that failed me. It also helped, in a way, that the CI that failed me wasn't brought back the next year, probably due to many complaints...
  13. akulahawkRN

    Gender Separation and Nursing for American Muslim Man

    As a male, I routinely perform tasks/procedures on females, even those areas one usually considers "intimate." This does NOT mean that I simply go ahead and do that stuff without concern for my patient. If the patient is able to answer, I will always tell the patient what needs to be done, and I let them decide if they prefer a female nurse or not. Unless there's significant urgency in the matter, I will always have a female in the room with me, preferably another RN, but any staff will do. I do not take offense if a patient prefers a female for that stuff, I just let them know that occasionally it may take a while for a female nurse to be available as they've got their own assignments. Because males may also request another male for certain procedures, I will also make myself available as much as possible for those occasions when a male makes a similar request of their female nurse. Generally speaking, if it's been medically ordered or your nursing judgement deems that something is necessary (and within nursing to do autonomously) then it's OK to do in the medical environment. If the patient prefers that someone else do the procedure, try to make that happen.
  14. akulahawkRN

    Oxygen Use During STEMI: Beneficial or Detrimental?

    Be ever so thankful that your area practices this. Other places aren't so eager to follow that and are very resistant to change. I'd be quite surprised if some of this resistance has to do with lawsuit avoidance because "withholding" oxygen in the normoxic patient isn't exactly considered standard practice. At least not yet.
  15. akulahawkRN

    Oxygen Use During STEMI: Beneficial or Detrimental?

    Lack of oxygen in hypoxic patients is going to be "inherently more lethal" but in the normoxic patient, the patient isn't hypoxic. You don't have flood MI patients with oxygen, you just have to keep their SpO2 levels between 94% and 99%. People that do hyperbaric medicine have known for a very long time that oxygen can be quite toxic to the body. That being said, hyperbaric oxygen can also be beneficial but those situations are very specific. Mixed gas divers are probably about the most attuned to oxygen levels as nearly anyone I've ever met... but I digress. What I've seen over the years is that it appears that simply keeping patients between 94% and 99% is pretty much the Goldilocks zone. Do what you must to achieve that. Ventilation is yet a different, but related beast.
  16. akulahawkRN

    ARC/SCC ADN FALL 2019

    That means you have been accepted, and your first Semester will be in Spring 2020. The "provisional" part means you still have stuff to do and there are deadlines associated with those things. Pay very close attention to that stuff and make sure you meet all those deadlines. That stuff is very much a part of your selection process and you are being looked at as of right now for your ability to follow directions. Your entry to the program will not be "finalized" until you've completed all the requirements that they want you to do and this includes the first days of school because they will go over all the paperwork and such to finalize entry at that time. Basically the first couple of days are "housekeeping" stuff to finalize your enrollment in the program. As long as you do your part, congratulations! The SCC program is very good and you'll need to be a bit flexible about your actual on-campus classrooms as they tore down Mohr Hall and are replacing it. Mohr Hall housed much of the healthcare programs, including LVN and RN.
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