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Mr. Murse

Mr. Murse

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  1. Mr. Murse

    heparin drips and lab draws

    I've had the conversation with 2 or 3 different pharmacists lately who have all agreed that it is unnecessary to pause a heparin drip for 10 or 15 minutes before drawing a ptt, yet I still see nurses doing it. Does anyone still do this and if so, why? A 15 minute stop in the heparin is also enough to potentially alter the ptt, so you'd be adjusting the drip to an inaccurate result. Even if you're drawing from a PICC/central line where the heparin is running, pausing the drip and using a thorough flush is still sufficient. I'm just wondering how this little habit got so widespread without evidence prompting it, or is it just around the facility I'm at?
  2. Mr. Murse

    IV Drip Rates

    I've noticed this is different in the various facilities I've worked at also. What constitutes KVO is quite different from facility to facility and I've seen everything from 5 ml/hr to 15 ml/hr considered KVO. I'm curious what the consensus here is.
  3. Mr. Murse

    ICU or Step down

    I recently made the post about new grads in the ICU, and in general I think it's a good idea to get some experience outside of the units first. Stepdown sounds like an awesome way to get some well rounded skills and a taste of critical care without jumping all in. Also, if critical care is your goal, having experience outside of the ICU gives you a better rounded perspective of the whole patient experience and the process, not to mention time management. Many nurses that have only ICU experience have a very narrow perspective of what any other nurses do. On the other hand, if the opportunity to work at a level 1 trauma center ICU is hard to come by where you're from then it might be good to take the opportunity. Finally, a lot of this comes down to you individually. Some nurses go into the ICU out of school and excel. Some really need the less acute setting to get their feet wet. I, for one, am really glad I got 3 years of med/surg before jumping into critical care. As someone else suggested, see if you can go spend a day or at least part of one on the units to get a feel for it. Too many choices in jobs is a good problem to have though, congrats and good luck.
  4. Mr. Murse

    New Grads in the ICU

    yes, I didn't even mention this part. The experienced nurses on the units are constantly training and having to pick up the slack. Our night shift is made up of probably at least 80% of nurses with a year or two experience, so the minority with substantial experience is carrying a lot on their shoulders, especially during codes and truly critical situations where textbook knowledge alone just isn't enough. As Pheebz777 said though, new grads do have an eagerness to learn that gives them an advantage. I still can't ignore the fact that there has been a noticeable increase in errors and dangerous situations since we've been hiring primarily new grads.
  5. Mr. Murse

    New Grads in the ICU

    I'm just curious about the general thoughts on new grads in the ICU. The units I work in have been seeing a huge influx over the last 2-3 years, mostly out of necessity. For the most part, they have been doing well, and we all know there are nurses of 30 years out there who can be more scary than a new grad. We are a medium acuity ICU and it's probably a good place for new grads interested in critical care to get into. On the downside, there has definitely seemed to be an increase in rookie mistakes, some of which have been potentially deadly to patients (pneumos from badly dropped dobhoffs, extubation without turning off sedation, missing critical changes in condition, etc). Part of me feels like we've dumbed down the nursing process to the point that even in critical care any average nurse can do it. ICU used to be a respected nursing position and they were considered the "best of the best" (I've even heard patients say that a time or two). We were called on to start IVs and answer tough questions and handle difficult situations, but now we have a bunch of one year old nurses who have barely put in a foley running around the units. Again, most are doing well, and I don't intend this to be a condescending post, but I find myself skeptical of the decision I've seen in at least 2 or 3 hospitals to allow a lot of new grads into staffing. We need the staffing, yes, but when a rookie mistake is putting patient's lives at risk, is it worth it?
  6. Mr. Murse

    Post-Extubation Policy

    Similar to the above post, we stop sedation and check alertness and command following and put them on spontaneous/pressure support for at least an hour. Sometimes an hour is all an agitated, non-sedated patient who's eager to get the tube out can stand, but usually we go longer if tolerated. Then RT does a few tests involving NIF, tidal volumes, cuff leak, etc. Then if physician is okay with it we go ahead and extubate. We will go straight to nasal cannula and increase oxygen delivery if need be.
  7. Mr. Murse

    Normal Saline as a flush for PEG

    I think missmollie's comment is probably on the right track. I've worked in neuro ICU quite a bit and never seen saline flushes through a feeding tube, but my guess would be that it has to do with cerebral edema/ICP. I'm not sure how taking it through the GI tract would be advantageous, but we often have people with various crani's and potentially elevated ICPs on high sodium drips like 3% NaCl or others like Mannitol, which affects the pressure by altering osmolarity/osmolality (and I don't really remember the specifics of those). If I were you I would ask. In part because it's possible that it was a mistaken order, but moreso just to learn. When the ordering provider rounds, present the question along the lines of "I'm just curious why we're giving saline through the PEG", not accusing them of a mistaken order but just wanting to learn more about what you're doing.
  8. It is highly unlikely for you to test positive from second hand smoke unless either the smoker is blowing it directly in your face or you are in a small enclosed space with them, like a car. Honestly, anyone who knows anything about smoking would laugh if you used that as an excuse for testing positive. Either way, there's no harm in asking them not to smoke around you, or if they seem to need it for medicinal use then just don't sit near them or stay in a small space with them.
  9. I'm surprised no one has said this, but if money is the only factor you're considering then don't do it. The last thing this field needs is another disgruntled nurse who hates their job and isn't actually ever satisfied with they're making anyway. RNs don't really make that much, and it all depends on where you are geographically and if you have a specialty. As a new nurse in the hospital you will make crap. If money is the main concern you can find other things to do.
  10. Mr. Murse

    Accused of not giving dilaudid

    Like others have said, forget about it. This certainly won't be the last patient like this if you stay in the field. I distinctly remember one patient a few years back that did this sort of thing, and would say things like, "I know how you nurses are" and what not so it got to the point that we would take the unopened vial into the room and draw it up and talk him through the process. It was annoying, but life went on. There's a good chance too that if you diluted the med maybe one of your coworkers had not, so she didn't feel the rush of the pure drug going in and so thought she didn't get any. Just make sure you're documenting everything, including her accusations. Then forget about it.
  11. Mr. Murse

    Turn Q2 and patient refuses

    how mobile are they? I mean if they're physically able to reposition themselves then chances are that they are repositiong slightly anyway, maybe not fully turning and tucking a pillow, but enough to relieve pressure points. Don't get too stuck on technically turning them if they're mobile enough to turn themselves. I often chart "turns independently" on patients who are able to do so, and I just remind them to move around in the bed. Otherwise try to compromise. A lot of times patients are hard headed and refuse treatment just to feel like they have some control over their situation. So ask them if you could just pull them up in bed and slightly tuck a pillow every 4 hours, or when they're awake. Mechanically going through nursing tasks makes people feel like they're on a production line......or a piece of meat. Treat them like a person, ask them how you can keep them comfortable but still accomplish what evidence based practice has shown is best. Then if they still adamately refuse, just chart it.
  12. Mr. Murse

    How did you spend your first nursing paycheck?

    I worked full-time through school and so my first nursing paycheck wasn't very significant. A slight pay increase but nothing to really celebrate.
  13. Mr. Murse

    racist patients

    I will not pretend that I know what it feels like to be discriminated against in this country (I assume you're in the US) because of my skin color, but I will say I have seen nurses discriminated against for countless stupid reasons and this is certainly a field that you have to learn to let stuff roll of your back quickly. On the other hand, reading through a few of the other comments, I have a serious issue with condoning any kind of unfounded and ridiculous prejudice, whether it be race or some other dumb excuse. Reading some other responses saying they put notes on the patient's chart saying "caucasian caretakers only" or whatever is asinine. I realize we're not going to change their mind, but catering to narrow minded bigotry shouldn't be an obligation of our either. I doubt these people go to a restaurant and refuse service from a black employee, or refuse to check out at a register with a black employee.
  14. Mr. Murse

    nurses who are bad patients

    I don't feel like this really falls into the category I was talking about. Drug and illness induced hallucinations and delirium leading to unruly behavior is not the same as a perfectly lucid nurse-patient just being a terrible, evil patient to their nurses when they're perfectly aware of it and capable of not being that way.
  15. Mr. Murse

    nurses who are bad patients

    No, i don't consider the patients who just go along with everything to be good patients at all. That's not remotely a factor in how I would define a good or bad patient. In fact, I love patients who ask questions and participate in their care, as long as it's not accusatory or demeaning questioning. If you can honestly say you've never had a "bad" patient then I'm curious as to where you work. I listed a few traits of what I consider a bad patient in my original post, but if I need to elaborate I can give many specific examples. I think most people on this thread know the kind I'm referring to though......
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