Linka

if the post-op hip was really POD2, then yeah it's a really questionable patient for SNF.

You want to get a lot of things done. Relax, have some post-its with what you want to accomplish and delegate.Don't expect to pass meds for a lot of people, reassess, chart and implement preventative measures. Talk to the CNAs and tell them that you want the patients turned frequently, verbalize expectations, check later on....once the expectations are there, you guys can work like a well-oiled machine.

Sepsis is subtle until it's not; if this was a patient recovering from sepsis, it's appropriate for LTC. - for the hip guy, check the intraop records for estimated blood loss. Sometimes after surgery, hemodilution occurs (fluids after surgery, hemoglobin can be one point less, it's ok generally), but if you have any questions, page the surgeon and talk to him. IMO and I'm not an ortho nurse, hematoma would have happened right away if something was seriously wrong. There is also the possibility (I think) for retroperitoneal bleed, so keep an eye out for hematoma on the flank/ back (late sign), instruct patient to notify you of back pain (earlier sign). Pain management will be an issue, but administer the norco per order, don't allow pain to get to 4 if possible, administer the short-acting ones for breaktrhough. Be aware of approach used to repair hip (anterior vs posterior) and follow those specific body mechanics when turning, getting up etc. - you can get order for anxiolytic from the MD if patient is alert and oriented- it does not matter legally what the family wants. Especially if heart rate is high, or if the patient is used to taking them at home routinely. A good question is "what do you do when you are like this at home?" You kinda would have to do damage control with family and I personally found that extremely challenging. - I don't think the CHF hypokalemic patient was appropriate for SNF. with fluids, you dump the potassium even more. and depending on how much the ejection fraction is, this can have a bad effect on somebody. Was the doctor trying to correct his creatinine or something? was the baseline high to begin with? the doc needs to figure it out on his own, in the hospital. because what are you going to do when he/ she is SOB? provided it's not too late. give lasix, and then your K is really in the toilet. if you're gonna give IV K you have to be on tele unit, if you give PO it's very tricky for non-tele. How are you going to recheck K in 4-6 hours? -bleeding from the rectum might not be the worst thing- sometimes people have hx of hemorrhoids- check when the last BM was and their bowel sounds. do an occult stool, call MD and check HgB in the am. as long as there are no clots...well, it's hard to tell. Listen, I think you are doing great. You sound smarter than I was as a newgrad- i kinda ended up being a little bit smart later on haha. It's easier said than done, but try to take a break and eat, because not doing so might cloud your judgement, you might end up running around all shift ineffectively. your supervisor should be approachable and ready to help, and generally constructive. Approach her in a nice manner and tell her about the difficulties you are facing. Let us know.

My hospital hires travel nurses constantly in Ca. It is a contract, but from what I know, the shortest assignment is a 6 week- period. You get extra pay from what i hear. It covers expenses.

Yes, agree 100%. Be the first to show the smile regardless. You never know why somebody is in a bad mood or why they are so quick to judge. And yes, it's quite tough as an introvert to make small talk, but what can we do- we live in a society, and it can make somebody else's day better, it can build rapport too.

It sounds like those coworkers are relaxed at their job and have time to question a nurse's facial reactions. Whenever I hear statements like those, I personally think that it doesn't have to do with me, but with them- what they made out of it, and implicitly how they have a sensitive area in their life if that was the first thing they thought of. For myself, it doesn't help that I have a resting b***h face, or that in the past I have, continuously during report said "Yes, Yes", and "yes, go ahead". I guess it came across as uptight, when in reality I was greatly impressed by how much the nurse knew (it's rare on my floor), I was "getting it", and was super focused and pumped LOL. Again, I come from a different cultural background- we are encouraged to not show emotion and to be tough I think you are fine, it is normal to be concerned with how the shift will go etc at the beginning. Don't bring it up because it might show that you are bothered. Try to make it a habit to look up and smile at the beginning of the shift and you will be fine. hope this helps.

Herd immunity, low immune systems in elderly etc

You sound just like me. a microbiologist.

Zahtar, or Za'atar!! Good stuff!

I thought you started with meds over compressions. would the fresh sternotomy wires go through the myocardium? and is there a special protocol for acls s/p CABG?

This is cool. Does it have to do with cell potential of cardiac muscle?

This may be a tad late but my first thought from the title was Mantoux test. And hey, if he tests positive, he gets to stay for longer To answer your question, resources are local shelters. from my experience, people without a home have already been in those shelters and for some reason refuse to go back. They'd rather go back on the street. This transition is heavily handled by case management/ social worker.

The handbooks are different for each facility. In my organization, it is allowed to speak in another language among each other. Don't assume the worst, and if it bothers you to that extent, bring it up to your manager

Yes, I have experience with your situation. I was on nigh shift, I received report from a nurse (at bedside), and after a while I went in to do the patient's vital signs. Well, I noticed his food tray intact and about 5 different pills in a transparent pill cup on the food tray. I was wondering what to do, because on one hand I wish the patient had gotten his pills (coreg 25, lasix40 or something like that), but on the other hand I knew it would not be right for me to give them at this point. I consulted with the charge nurse and she told me to throw the pills away and fill out an incident report. Apparently, the same day the same nurse left a syringe with medication attached to the tubing for another patient. Next day, the charge nurse went up to the nurse and scolded her for her actions, which was completely unprofessional. Of course, the nurse comes up to me and asks me what happened, and told me that the charge nurse scolded her etc; ugh like can we just get over it and give me report? thanks. The nurse in question proceeds to tell me "she didn't know this was the place people went after each other", and "patient wanted to wait until finished eating and take his pills with food", and "next time I guess I can let my other patients fall but witness these ones take their pills" "I wish you can come to day shift and see how crazy it gets":nono: We continued being cordial after that, and she ended up quitting. It bugs when managers or charge nurses do not know how to act in these situations.

When as a novice nurse you crossed your name off from the assignment and you return to see you have been assigned to that patient, floor nurse that gets along with charge says "I think since you know the patient and all, you'll be fine. Why are you scared, just because he is a DNR?" It did end up being my worst shift yet.

I'm super caffeinated right now, and I must admit that I did not read everything in detail. Also, my background is stepdown only. The only thing that sounds questionable to me is the fact that regular insulin starts acting 30-45 min, and peaks in 2-4 hours, so how come the MD wrote orders for hourly sugar checks and sliding scale for this particular type of insulin? I think you treated the patient well after noticing the blood sugar level.

I know the anxiety that you speak about. I was night shift and I used to dread going into work, I questioned and doubted myself constantly. I think I was intelligent, but lacked experience and always assumed the worst. I went to day shift, and I felt like I was more exposed to things, learned more, talked to the doctors more. My unit has a high turnover rate, patient are more and more acute, and our manager micromanages constantly, but would do anything to keep us working. Nurses with 14+ years quit my floor. The med surg floor next to us has some of the happiest nurses that have been there for 20+ years. Their ratio is 5:1, they only chart once per shift and changes, the patients are in and out in 3 days, nurses help them get better, they get their surgery and are on their way soon thereafter. You might feel better on a med surg floor. A lot of nurses say that everybody should start there before venturing off on tele. Good luck!

I first learned Oxford English, knew this word and used it- until I realized that not a lot of people had heard about it. I actually thought for a while this word was not American English.

Could have went the other way UGHHHHHHHHHH:no: Past participles have been my grammar pet peeves for a while. Also, my husband likes to create pleonasms, I just can't think of an example right now. I got over could of hallelujah!!

Nursing is 24/7 and in my opinion she overreacted. Who cares about a messy room??? I care if the patient is stable and the nurse can tell me what is going on with the patient, that's all. And the answer to your original question in my opinion is "whoever has the time to do it".

I have/ have bought about 5 different Littman's (including electronic), my husband has an MDS. I recently got a Welch Allyn DLX after I've played around with my cardiologist's one! Love it and will stop buying stethoscopes officially!

Very cute story!

http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=4&sid=2a2b970f-8e7f-48df-a3e5-ea1b1adb07d1%40sessionmgr1 Flynn Makic, M. B., Rauen, C., Jones, K., & Fisk, A. C. (2015). Continuing to Challenge Practice to Be Evidence Based. Critical Care Nurse, 35(2), 39-50. doi:10.4037/ccn2015693 just in case you can't find the article, i copied everything in the article about chesttube patency Review of Current Evidence The earliest method to maintain patency of chest tubes, primarily mediastinal tubes, was known as stripping.The clinician would grasp the drainage tube veryclose to the patient's body and while collapsing the tubebetween the thumb and fingers, pull down the tube fromthe insertion site. The rationale for this procedure was to increase the vacuum pressure in the tube to assist inthe removal of the drainage within the chest and removeany clots that might be forming within the tube. Whenstripping was performed, clinicians (the author included)were taught, and probably taught others, that this was avery important procedure to maintain tube function andpatency, and to prevent infection, pericardial tamponadeand the need for emergent reoperation, and even cardiacarrest. A rolling device was sometimes employed to assistwith the stripping procedure for clinicians who mightnot have the hand strength to ensure consistent pressure based on single studies,” the conclusion wasthat there was no difference in output, cardiac tamponade,or surgical re-entry between stripping, milking, andno manipulation. Day and colleagues determined that no manipulation of drainage tubes should be done on a routine basis. Finally, the 6th edition of the AACN Procedure Manual for Critical Care echoes the recommendations offered by Day et al. The manual states, at level C evidence, that stripping and milking of closed chest drainage systems are contraindicated. Implications for Practice No manipulation of drainage tubes should be done on a routine basis. The management of these tubes should be based on the best evidence available. If current practice, unit protocols,or even physicians' orders suggest stripping or milking chest tubes, which does not match the evidence-based practice recommendations, clinicians need to review the evidence and consider changing their practice. The research and evidence available on care of chest tubes clearly indicates that stripping and milking are not necessary to maintain chest tube patency and probably cause more harm than good

Hi, thanks for the reply. As a stepdown unit, we take CABG on insulin pumps, our ratio becomes 3:1, we have an internal protocol for dosing that is quite detailed. The stockings being off was just me venting, it's not a big deal (and you can tell, because the nurse has to order them in the system with a code, long story aaaand patient stated he never had them on, why did I have to put them on). However, we have order sets that state daily cleaning with hibiclens and dressings on graft sites during hospitalization; those and the stockings are an absolute must. I agree with the HgB being 7-8 and normal, but this guy had hypoperfusion, low urinary output immediately after and SBP 90s. HgB 5 days prior was 12. But in conclusion, do you think the HgB question was stupid? thank you

"Rehab" as in "Skilled Nursing Facility" or drug and alcohol rehab? And would your role be that of a supervisor, admissions, and IVs, or will you have your own patients assigned? Sometimes LVNs have years of experience, and would be able to help in any emergency. I would be aware of your DNR patients, and review your BLS/ACLS. Learn the questions to ask, like previous posters said, what is your turnover rate etc. If you decide to accept the job, learn as much as you can during your orientation. I pushed the med cart my first day, my first med pass lasted 3.5 hours, and it only became easier after that.