CapricaNurse

I had an older (60s) patient with a lot of generalized edema (from co-morbidities). He was getting 125 ml per hour IV fluid all my shift, into a Left midarm IV that had just hit the 70 - hour - since - insertion mark. The IV cath was 20 gauge (1 inch long, I think). His right arm couldn't be used for IVs or anything (a medical condition was the reason for that). So his ordered IV Fluid (normal saline, not a vesicant) goes in at 125 ml per hour all shift, no complaints, and the IV machine never alarms occlusion or anything else. However, at just about shift change I noticed that his left arm (the one getting the IV fluids) is swollen - swollen in just about every place except for a 4-5 inch area around the IV cath insertion site itself. I put his left arm up on pillows, and again made sure that all around the IV site itself was soft, (which it was), although the rest of his left lower arm had taut skin. Weird. So I left the IV fluid running. Since report was in 45 minutes, I figured I'd ask the next shift nurse to call IV therapy to put in a new one. When the next shift nurse came in and saw the man's left arm swelling, she turned off the infusion (didn't check the area around the cath insertion itself) and she immediately pulled the IV cath out (the tip was intact, there was no bleeding after, we did apply a pressure dressing, there were no signs of infection). Long question short: Should I have stopped the infusion immediately when I first saw the peripheral swelling? Second question (if so) should I have immediately removed the IV cath, while waiting for the new IV (even though it would have left the patient with no IV access)? The patient has a condition where it was more than possible that he might have needed emergency meds pushed into an IV line between pulling the old one out, and IV therapy finding time for putting a new one in. The IV she (my next shift replacement) pulled out (in the left arm site, which as I mentioned had baby - soft surrounding skin for a hands-span area around it) was the only IV access the patient had at the time she pulled the IV out. Brutal honesty is appreciated here. I promise I won't argue, I just want to learn, so if there is a next time, I do things 100% right. If that area 4-5 inches or so around the 20 guage 1 inch IV cath insertion wasn't baby soft, I'd have turned off the infusion immediately myself. However, I wouldn't have pulled out his only line, even though it was not an ideal line, until IV therapy had gotten up there and placed a new one for him. I did recognize that the patient's arm swelling was not a good sign, and did place it up on 3 pillows. He denied any pain in the arm or at the IV site, and he was afebrile. Thanks for any feedback.

I've heard that the NCLEX is almost designed to leave you feeling horrible. That's not its intent, but it does seem like its a result of the test's structure. I don't think we are supposed to talk about the test's structure, but the prep material put out by the testing company itself has some useful info along these lines. Good luck

Ever wonder how much richer the world would be if more people kept to the motto "Live till you die"? All too often we are the ones to ground ourselves and clip our wings, not realizing that there is a wealth of wonderful experiences awaiting us, just ahead, if we will only embrace them. Big big congrats on not clipping your wings! Way to keep on keeping on, journeying towards what you want from life! I applaud you. You have so much to give now - priceless things you have gained since you were in your 20s. Your patients will benefit from the wisdom gained from living those extra years - that's your gift to them, just by being who you are. And, you know that you are doing exactly what you really want to do in life (it can be very hard, at 20, to tell what path to follow to find one's heart). Nursing can be tough at times, tough for the young, and tough for the less young. Getting extra physical and emotional rest can really help keep you spunky. (And for the days that de-spunk us all, you have the experience to know that those will pass) You now have invaluable insight into what really matters in life - insight that you might not have possessed with such clarity at 20. You know not to sweat the small stuff, you know that in the end, if we live long enough, we will all get older. You understand patience in a way that your 20 year old self might not have. At age 20 if there was injustice, I remember that I wanted it righted, there and then. Years later, I've learned that time has a way of dealing with many unjust people / circumstances in life's own way, with no intervention necessary. Call it fate, call it karma - life just turns out to spontaneously take care of a lot of things that would have been troubling to the 20 year old version of me. This attitude, this sure knowledge, frees up mental energy - which you can then give to your patients :) Don't hesitate to share abilities with your fellow classmates - give to them from your strengths, and accept the gifts of your fellows strengths. We each have unique gifts to give each other, especially in the tightly bonded world of a nursing-class group. You have done a brave thing, a very good thing, and your passion for nursing and life experiences are priceless attributes. Way to go! Your (soon to be) patients are fortunate.

It'll pass, as will any other symptoms of being new. The suggestion to down the caffeine (if you can do that and still keep your eyes at least partially open, assuming you drink the stuff) might help. Regular meals to keep up your blood sugar may also help. Knowing that everyone you see on the floor started just where you are (that is, nervous about what they didn't know as a new nurse) might help, too. Personally, I found that a lot of my new nurse symptoms faded when I changed my focus from thinking about "How much of an idiot does the patient think I look like right now" (which IS where my focus was, initially, when putting in IVs) to keeping the mechanics of the procedure smoothly in mind while trying my best to relax the patient (like, by distracting them with small talk and the like). If you don't mind I'd like to share an IV insertion tip: You know those little rubber bands that hold the rubber tourniquets in a circle? (So thetourniquet drawer is full of a bunch of tightly coiled circles instead of a mess of long snaky bands?) Well, they can be useful: When I apply a tourniquet to my patient's arm, I always pop that little holder - rubber band onto the tip of one of my fingers. Then, I glove up and do the insertion. With that physical reminder on my body, I have never forgotten to take the tourniquet off my patient (because if the big rubber tourniquet is on my patient more than a couple minutes, the little rubber holder band on my finger tip lets me know, by starting to ache). This memory aid is especially important if the unit is hectic and there are multiple emergencies going on. Just a suggestion I've found helpful. Alert and oriented patients would say something, but I've come across more than one confused older patient in the emergency department with the tourniquet band still tight on their arm - scarey stuff.

In some nursing job interviews, I have been asked variations of the question: Of peds, the elderly, and regular med surg patients, what is your favorite group and why? Since I don't have a favorite group, I have trouble with that one. I prefer not to be sticking IV needles in children, but that's not really a good sounding answer. Has anyone else come across this question, or does anyone else have thoughts on the management thinking behind asking a question like that? No wrong answers here :)

.... I'm not sure that cultural purity and silencing dissent are ideal. If history is any indicator, they are far more toxic than one person's opinion.

Nurses are said to be the most trusted professionals. I've been in nursing a long time, and over that time I've heard many patients and staff express agreement with that evaluation. I've also heard a few nurses disagree strongly. There has been a lot of discussion about how compassionate nurses are, how much we give of ourselves, how nursing is more a calling than a career. I agree with those descriptions as well. I respect nursing as a calling rather than simply a job, and I treasure the souls who give their all to care for others. There is occasionally another view of nursing, one that sees more humanity than saintliness. We all know of nursing as a profession that can eat its young. Many of us know or have heard of units where the culture is all too often one of back-stabbing. This thread is offered for ask if there are any nurses who would like to share their own views or experiences to answer the question: "Are there some work places where our ideals fall short, and the facility or unit culture needs healing as much as the patients in it?" Put another way, ARE we always kind to our own, or are there instances when the "team" culture is one of exclusion rather than inclusion?

If you have done everything you rationally can do about this, I'd say find another place to work. Its not fair that you should have to, but as we all know all too well, the world isn't fair. I'm very sorry this happened to you - and very hopeful that you are able to come to use your talents and gifts in a place that treats you better. With this economy its reasonable to say I can't afford to quit, but 1- You can't afford to get hurt and possibly put out of work for some indefinite period, and 2- Your mental health and quality of life are very valuable, and 3- You can job-hunt and not quit the old place till you have a firm offer from the new place. You are being terrorized and abused, its not right and it sounds like it may not be changeable. You deserve to be treated better. Plus, you win: She is going to be staying in a place that is toxic (as any place she stays sounds like it becomes), while you are free to give yourself the gift of a better quality of life.

I think one of the hardest things about nursing is the amount of stuff you have to let "just roll off your back". Seems like everyone thinks they have the right to take out their life frustrations on you. It doesn't matter if you are in the wrong or right, you are where the buck stops and the yelling-at begins. You are expected to somehow know everything there is to know about everything. You are expected to magically somehow make the manipulative patient (who is getting their jollies by expecting the queen bee treatmen)t become reasonable and appreciative of your care plan to get her more independent. And when she uses her highly polished manipulation skills to report you to management for not having been 'nice' enough, you are expected to nod appreciatively and thank everyone for their feedback. Fair is fair- I don't expect a pat on the back from the 'everybody has to wait on me' patient, even though I am sincerely trying to help her gain the ability to have more real control over her life by encouraging her to do things for herself. But I do expect at least some of my coworkers to understand the situation. We've all had patients like this. Instead I find that the coworker who told me she' totally understood' that the patient was just resisting positive change, and to 'not worry', turned right around and reported the patients comments to my boss. The only details my coworker left out where the nice things the patient said about me before and after getting mad for having been (gasp) encouraged to become more independent. This same coworker makes very - not- at- all - funny "jokes", all the time, about taking (stealing from work) controlled meds for herself. I don't laugh, but she keeps it up. She snoops on rooms where a spouse is staying over with a patient, using the facilities fall risk cameras, to 'see if they are doing anything'. Last week she came in having had so much 'coffee' that she was literally bouncing off the walls. But she is the one tapped for charge nurse, and I am the one sent to the bosses office to get chewed out for trying to help some one who I guess didn't want to be helped. I feel frustrated and overwhelmed. The CNA yells at me for not doing her job, saying: "but you were in that room a long time". I was in the room a long time, doing things I can't delegate to a CNA, but that doesn't mean I want to or can afford to add in doing her jobs too. The phlebotomy guy wants to yell at me because I got an order for a stat lab and asked for the draw, when it turns out he normally does other things for the 5 hour block of time my request landed in. Does he think I can tell my patients when to have their heart attacks? I choose this midwest hospital because it was supposed to be all about teamwork, but that's not happening. And yes, there are lots of great patients and great nurses here most of the time, just not so much now.