-Emma-

So, for those who were turned away from emergency care because of no insurance, were they going to a for profit hospital? I've heard of them turning people away because they have no, or less political/tax/funding connection. I work as an ICU RN in a not for profit hospital and we frequently care for uninsured customers. I still get payed, but our managers are always going to budget meetings where we are always getting deeper and deeper. Just a thought.

Our nurses have been dealing with a lot of problems with our present way of documenting our nursing process. It's involved, all hand written and confusing. I was wondering if some of you out there can share what form of nursing process documentation you use. We have a care path, I've also heard some places using a kardex. Our care path is four pages front and back. The cover has patient ID, allergies, history, contacts and fall risk. Inside has two pages where for six days the nurses prioritizes the nursing diagnosis, interventions and goals. Then are two pages for six days of ordered labs, active orders (IV fluids, diet, activity, etc.). Then are two pages for education. The last pages is for treatments (dressing changes, ventilator weans, etc.). After the allotted six days, we trade that care path out for another care path. If the patient had a medical care path and codes on the floor to become an ICU patient, the medical care path is changed to an ICU care path. Any thoughts, suggestions or "here's how we do it" is greatly appreciated. Thank you all.

There's been some recent confusion over HIPPA violations regarding nurses following-up with transfered patient's. Our secretary knew a patient who was recently admitted and subsequently passed away. She called in checking on the patient and was told by a nurse that he passed away. Our manager found out and told the nurse that she could have violated HIPPA and was stripped of charge nurse duties. I don't know what happened next, but the nurse has since quit. This all happened within a month (I believe.) So, my first question is: Did the nurse violate HIPPA? Was it because the secretary knew the patient/family? So, now us other ICU nurses are curious. Can we give information to ER nurses who are curious as to what happened to a patient they admitted some other day? Can we call a medical unit to see how our patient is faring who was transfered? We had in interesting case with a young woman who had extreme headaches and started with some twitching. The neurologist brought the patient to ICU to do a spinal tap because she would not do it without the consious sedation. We've been curious what she may have had and how she's doing. Is it OK for us to check? Thank you for your help in clarifying these issues.

Hi there. I've just started toying with the thoughts of going back to school after 5 years hospital nursing (4years ICU) for MSN. I'm not sure if I want NP or Nurse/Patient Educator. MSN would be the right next step from BSN, correct? I live in the north Boulder/Denver Colorado area. Any thoughts on good colleges to look into in this area? Anyone with experience with University of Pheonix online? Are all the classes online with maybe local, self found clinical? Thanks for your help.

Hi there. I've just started toying with the thoughts of going back to school after 5 years hospital nursing (4years ICU) for MSN. I'm not sure if I want NP or Nurse/Patient Educator. MSN would be the right next step from BSN, correct? I live in the north Boulder/Denver Colorado area. Any thoughts on good colleges to look into in this area? Anyone with experience with University of Pheonix online? Are all the classes online with maybe local, self found clinical? Thanks for your help.

This is extremely unsafe practice. If this happens again where you feel that your assignment, that you cannot change, is unsafe for your patient's, make sure that you are noted to have protested the assignment. If your manager or supervisor says you have to take the unsafe assignment, say that this is unsafe practice and you want it documented that you are protesting the assignment. Also, you can go up the chain of command. Go to someone above your manager to tell them of the unsafe practices going on. I believe that you can also anonamously report the hospital to the state. If I had them all 3 days in a row and then knew I had one more day to work, I'd call in for a personal day that forth day.Your patient's are losing their right to safe nursing care. Good-luck. Don't get discouraged, get assertive and know your and your patient's rights.

From what I know and have experienced, DNR is a doctor's order relating to a patient's "living will or advanced directive." (I can't remember which one I'm thinking of, so I will just call it Living Will. Living will being a document (legal or just for reference depending on the state, local law, etc) stating what someone would want done if the he enters a terminal state (ex: end stage anything, vegetative) or becomes unable to make decisions for himself (ex: Alzheimer's, Dementia) and doesn't want to appoint a durable power of attorney (someone designated by the patient to make medical decisions for the patient.) As far as how much power this document has, it depends on where the patient lives. In Pennsylvania (PA), the Living Will is just a document, the patient's family could override the Living Will and change decisions, I think that is because there is no law protecting practitioners from lawsuit; which the family can file for if the patient dies because they followed the patient's Living Will. I have since moved to Colorado (CO) where I'm told that the Living Will is legal and practitioners are protected from lawsuits that the family may file for after a patient dies due to practitioners following the Living Will. I've not been here long enough to see this play out. It's all about communication with your next of kin. Make sure they know what your wishes are. The DNR order doesn't come into the picture until the patient is terminal with no chance of recovery from that end stage illness (unless the document states otherwise). So, if you have a Living Will at the age of 20, that's excellent. I've get to see someone come in with a document called "DNR." I hope that I've gotten across what I wanted to say, in an understandable manner. :)

We encourage oral tubes to nasal ones when the patient is intubated because the nasal ones can increase the patient's chance of getting a sinus infection. I probably would have inserted your mother's nasally because of her alertness and potential for extubation. If she was alert and awake enough, which it sounds like she was, I would ask her which she preferred. But, I have definately heard of, and mostly insert, oral gastric tubes.

Thank you for the responses. The links were especially helpful. I was at a loss searching online by myself :)

We often have to do orthostatic blood pressures on our patients. I'm not really sure I'm doing them correctly. If the doc. writes "orthostatic BP's" does that automatically mean lying, sitting, and standing or just lying and standing? How long do you wait between position changes before taking the BP and HR (3min? 5min? both?).

We also try to put the blanket under the patient but with a sheet between the blanket and the patient. Ours has a thermometer probe that can be used for manual or automatic use. We usually use the automatic and set the temperature around 99F if the doctor didn't specify. I've never really checked a protocol for this. Not sure if we do have one.

Unfortunately the patient did not survive. She was off of the sedation the next day and didn't wake up. EEG confirmed no electrical activity. Family was refusing a cerebral blood flow study until a week later. Family was having a hard time accepting, of course. The next of kin was a 22 y.o. daughter, so all decisions landed on her. They finally agreed to the cerebral blood flow study (which was the first I went to and was interesting to watch) which confirmed no blood flow and brain death. To my pleasant surprise, the family agreed to organ donation. So then Gift of Life took over and had me draw the most blood I have EVER drawn on a patient. I'd bet there were about 40 tubes to draw. Within 3 hours of getting started with Gift of Life, there was a candidate for the liver transplant. This was an unfortunate case for the neurosurgeons who did her laminectomy, but I think they did an excellent job with the family and breaking the news to them and not giving false hope from the beginning.

I had an interesting patient yesterday. A 47 y.o. otherwise healthy female had a lumbar laminectomy the day before and she was getting out of bed for the first time with physical therapy and her shell back brace. She passed out and luckily the neurosurgeon was near the room and facilitated the code. She had a pulse and was breathing, but her oxygen saturation was in the 50's. STAT CT scan showed a massive PE blocking practically her entire right lung. She was intubated in the ICU and started on Diprivan and Heparin. She was still only saturating in the 70's even with peep added because she was suspected to have also aspirated. Chest x-ray confirmed proper tube placement. Patient was then whisked off the radiology to have the PE embolized. She had a one minute seizure while on the radiology table and never saturated above 60%, even after the procedure. The pulmonologist tried norcuron which didn't seem to help either, although she was not resisting the ventilator. An ECHO with Bubble Study (new thing for me) confirmed a right to left shunt. I read up about it a little on-line last night and found that it can sometimes be caused by the pressure from the PE. The cardiologist mentioned that maybe the embolectomy was performed incorrectly. The patient was given 1L NS bolus and then 200cc's /hr. Also, she was going to be getting TPA 100mg over 24 hours. She arrived to our unit at 1015 am and I left around 8pm and she never saturated above 80%. I fear for her prognosis. Any thoughts or experiences with right to left shunts in adults?

We have a sedation order sheet that has diprivan, versed, morphine, norcuron, etc. on it. One is checked off and then the rest is fill-in-the-blanks. Bolus, starting dose, max dose and titrate to ...(ramsey scale of..., comfort, sedation). There's also a place on the sheet that reminds the nurse to remove the sedation once a day to check neuro status with no sedation. Often times the patient starts getting restless and starts fighting against the ventilator, so the assessment has to be quick and the sedation gets started up again. Is this the sort of protocol you were looking for?

I can't say that certain nurses have done this for their patient's, but when I came into work the other day, my patients' rooms had some decorations on the wall. They were outside by the room number and some up by the dry-erase boards on the wall at the foot of their bed. Some were decorated with bows. Or you could make or get a small ornament to hang on the wall. You could let families visit during non-visiting hourse (with the explaination that it is only for that one day).