rn/writer

Not sure how old this kiddo is, but if mom smokes, she might have been going through nicotine withdrawal. I've noticed that breastfeeding seems to help with that, as they get a little nicotine in the milk. Definitely a mixed message--breastfeeding and smoking, but it does happen. Glad to hear the little one is settling down.

We use all of the above, depending on the situation. I would also encourage you to consider the source of the pain. Is the patient sore from pushing? Did she pull a groin muscle? Did she have episiotomy or a tear? I have seen some 4th degree tears that look far worse than a c-section incision. How about hemorrhoids? Ibuprofen is the go-to med for cramping, muscle aches, and general soreness. Percocet (or Norco) along with ice pads, ice diapers, and Dermoplast spray help a lot with stitches. Tucks pads and ointment give relief with hemorrhoids. Used in combination, we can get nearly all of our vag patients comfortable. We also encourage them to use their water bottle to spray while they're urinating to decrease stinging. I'm so glad we no longer advise the use of those plastic inflatable doughnuts. I tried to use one of those after I had a baby and all it did was squish the tender area in the opening.

It's fine to share possessions, food, clothing, etc. freely and without reservation, because no one is going to be graded on eating the casserole or wearing the donated jeans. Patient safety won't be riding on the box of dishes you gave a friend. There will not be an exam for the toys you passed on to a neighbor. Sick and vulnerable people will not be shortchanged by your generosity. Learning will not suffer nor will good study habits be compromised if you are motivated to help others. The same cannot be said for schoolwork. Although it may seem like you're being kind by giving away your materials freely, ultimately, you are not. I'm not talking about helping a classmate in a bind now and then. But spoon-feeding those who have poor study habits (other than helping them to learn better ones) or enabling people who just want to coast through the class is about as responsible as letting someone copy off your test paper. Some have protested that it doesn't cost anything to be "nice." I disagree. If you gift-wrap a superficial grasp of the material (just enough, say, to pass a test) you give the message that it's okay to game the system. Undisciplined takers (as opposed to genuine study group participants) learn that ethics don't really matter. The end justifies the means. Besides robbing classmates of the chance to internalize the subject at hand, you may also short-circuit a much-needed reality check. Imagine the difference in outcome between a person who found a way to skate semester after semester and one who, with the clarion call of a failed exam or a flunked class, realized this isn't high school anymore. Add all of this to the concerns some have stated about plagiarism, and it doesn't appear to be a good idea to post or share certain items. In many (if not most) academic honor codes, the one who assists the cheater is viewed to be as culpable as the one who does the cheating. I imagine this would only intensify if money had changed hands, an arrangement that bears an uncomfortable resemblance to buying and selling term papers on line. It boils down to doing someone else's work for them. That isn't fair to anyone in the group, and it could expose many people to extra risk down the road. Just to clear up any confusion, I think we're all pretty much in agreement that there is a big difference between a generally responsible person taking part in a study group or needing help through a bad patch and a loafer who just wants someone else to do his or her heavy lifting. Sometimes being nice means saying no.

Generosity does not require you to enable poor study habits. Sharing your notes, calendars, concept maps and other materials without a darn good reason could mean that, far from being a better person, you could be helping someone else to become a lesser student/nurse. I don't recommend lies or cutesy excuses. The shorter the answer the better. "I'd rather not." "ExCUSE me? You want what?" "Sorry. No." If you think there is a good reason to help the person (she wants the notes from the class she missed because her child was sick), make it clear that it's "just this once," and only because there were extenuating circumstances. Invite free-loaders (those riding other people's coattails) to start a study group, or even to join yours if they are prepared to contribute. None of this need be done with a snarky attitude. You just shouldn't feel pressured to let others use your efforts while they skate by. Their future patients deserve better. One last thought--you could print up a sheet with your study habits and all the ways you prepare for tests and exams. Make some copies. Then when someone asks for your help, you can provide the recipe for success. If all they're interested in is a handout, they'll be able to see (though they might not admit it) why you're reluctant to just fork over your notes, etc. Anyone who is really serious about learning stands to benefit from your information. Anyone else . . . maybe they'll get the idea that this isn't a game.

If you were asked to assist or cover for another nurse and you looked up information for that purpose you should sign the chart and also note what you did. This covers you by showing that you had a legitimate reason for accessing the patient's information. Even so, I wouldn't go tip-toeing through the tulips. I'd stick to the areas that pertain to the current need or assignment (pain orders, dressing description, etc.) and leave the rest alone.

I was thinking more along the lines of giving a new med or doing discharge teaching. I agree with you that it isn't necessary to go through the whole shebang each time. Sorry that wasn't expressed better.

If the bracelet can be used to verify name and date of birth, that part of the review does not need to be stated out loud. But the rest of the med review--name, action, dosage, times, and other pertinent info--should still be done verbally (unless the patient is unable to do this--then it needs to be done with their designated assistant). The teach-back technique requires the patient to say what they are taking, why they are taking it, and all the rest. We're not reviewing the meds for ourselves. We're doing it for the patients. Many misunderstandings have been clarified and mistakes have been prevented during this crucial step. Of course, we need to be as discreet as possible, but we don't want to omit such a valuable part of patient teaching in the name of keeping everything secret.

Wow. I was not expecting such common sense in a government directive. Good information to have. Thanks, EricJRN and GrnTea.

It isn't about age so much as maturity level. Some folks are level-headed and responsible at twenty. Some are still self-centered and undisciplined at forty. Maybe it's time for clinical sites to dust off (or come up with) their expectations for students in a clinical setting. Yes, the students are under the direction of the instructor, but while they are on the floor, they represent the facility in the eyes of patients and their visitors. It is not the least bit unreasonable to require respectful and responsible behavior, demeanor and appearance. If the students can't rise to that level for clinicals, they don't seem like good candidates for employment. I would go so far as to present the students (and instructors) with a contract clearly outlining the rules and requiring them to sign it if they want to proceed. I find it laughable that a student would say that she didn't want to take vitals because they "already covered that." Are you kidding me??? New skills don't replace the old ones--they are added to them. The goal is to integrate all the individual pieces of patient care into one functional unit, so that by the end of the clinical the student is doing everything she has learned that semester for those under her care. People who don't get that need an attitude adjustment. If I were an instructor, I would want to make it clear to my students that they are on the floor to learn and become proficient at nursing basics. If, after a warning or two, they found their phones or their classmates or anything else to be unmanageably distracting, if they couldn't be bothered to take learning opportunities offered by the staff, if they displayed an entitled mindset and showed anything other than respect for the staff and patients, I would show them the door with only one chance to make up the missed time. Instructors who aren't willing to shepherd their flock, so to speak, may not be up to the job. Clinical settings have been lost due to the actions of an irresponsible few. For the sake of the group, bad apples need to be dis-invited to the party. Instructors who are unwilling or unable to enforce the rules should not be in that leadership role. Clinical performance may open or close doors to students after they graduate. Many times a reference from an instructor or a precepting clinical nurse has helped someone to get a job. The smart ones know that.

I would check with your state BON. Letting your license lapse is a pretty extreme measure. Some states do not allow an easy reinstatement. They may require more education or have other hoops for your to jump through.i And, think about it--if you are hired as a CNA and it comes out that you did, in fact, have an RN license which you allowed to lapse, you could be fired on the spot if you hadn't disclosed that information earlier. If there were ever any legal problems, you'd be hung out to dry because of your elevation to RN status. You'd be held to a higher standard because of your advanced knowledge. Letting your license lapse wouldn't look like a shrewd career move. It would instead suggest that you couldn't handle the responsibility. A plaintiff's attorney might imply that you "surrendered" your license rather than have it revoked. Take a long hard look at this before you do something this drastic. I'm sorry you haven't been able to find a nursing job, but I've heard lots of hopeful things of late. Nurses are beginning to retire again after their 401K plans have recovered somewhat. Hospital hiring freezes are slowing lifting. Some people are cutting back to part time because a spouse has become employed again. Hang in there. Look at taking an inexpensive refresher course at a community college if you feel your skills have gotten rusty. Volunteer at a facility you might consider for employment. There are many steps you can take before you do something as serious as allowing your license to lapse. Let us know when you find a job, so we can rejoice with you.

Five seconds of not breathing does not constitute apnea. Think about it. A low-normal respiratory rate of 12 breaths per minute would mean five seconds between one breath and the next, and that certainly isn't apnea. If the patient had been hyperventilating, that five-second gap could have seemed quite a contrast without presenting any actual threat. Hyperventilating can cause something called circumoral cyanosis, meaning the area around the mouth can look bluish, or in the right lighting, even gray. Taking small, shallow breaths for more than a few minutes can by physically taxing and the patient would very possible work up a sweat. The fact that the patient could stop and start this behavior at will (when asked to, when no one else was in the room); his ability to wander the halls, eat and converse with others; and his removal of O2 suggest a problem rooted in anxiety rather than physical pathology. I DO question why the patient was intubated if the "apnea" lasted for only five seconds. Diminished level of consciousness is not the same as loss of consciousness, and if the patient resumed breathing on his own, why would the doc perform something so invasive and unnecessary. Even if the patient passed out, I would hope the doc would wait longer than five seconds to determine the need for intubation. Hyperventilating blows off too much CO2. This, in turn, lowers blood pressure. If the blood pressure drops too far, the person can pass out. Even though his initial blood pressure reading was elevated, it may well have dropped after his lengthy bout of hyperventilating. The ABGs bear this process out, as you said his O2 level was fine but his CO2 was low. I'm thinking you witnessed a good old-fashioned panic attack followed by a fainting spell. It doesn't matter if the patient was or was not intentionally manipulating the situation. The result would have been the same either way. The treatment, as you described it, seems questionable, at best. Unless there was underlying pathology--contraindicated by the labs and other diagnostic tests--normal breathing would have resumed as the CO2 level built up in the patient's blood stream. This is the flip side of the little kid who holds his breath and turns blue when he doesn't get his way. Breathing too much or two little can cause you to faint. But then the homeostatic drive kicks in and the body works to regain its normal balance. Intubating someone who is hyperventilating makes about as much sense as it does for the stubborn child. It is simply not necessary and introduces a lot of potential for more problems.

NOT asking about sexual orientation makes it seem like "that which shall not be discussed." It's the elephant in the room. Young people especially might be hesitant to initiate conversation but would respond if someone else brought it up. If a healthcare provider can ask such questions in an honest and matter-of-fact manner, this could be a message to the patient that this is a safe environment in which to confide and seek assistance with whatever they need. If a healthcare provider is not able to ask in a non-emotional, non-judgmental way, they might want to work on that.

This seems short-sighted at best. Some patients are not "community-based" material and will endanger themselves or others without close supervision. Where in WI are you?

You're wanted here. Thought you'd want to know that.

We can't tell from this one interaction if the husband has control issues, dominates his wife, is a bully or is simply a caring man who feels protective of the woman he loves. People often show their worst side when they feel threatened by medical problems. You did a great job of tracking down the information needed at the time. She got the care she needed, thanks to you. It wouldn't be a bad idea to have a social service consult to size up the overall situation. If for nothing more than to come up with a back-up plan should the husband be unable to give the shot. If he is ill or has to be away, there should be some alternative arrangements in place, whether it's a neighbor coming over or a relative stopping by. Ideally, the patient would be willing to learn to give herself the injection, but I do understand that some folks just can't go there. Instead of playing any kind of tug-of-war with the husband, praise him for being so conscientious with her care (never mind that he forgot about her injection that first night), and see if you can engage him in a good discussion about being a caregiver. If he doesn't feel challenged/threatened, you could well have a productive conversation that will help him see staff as allies rather than enemies.

Yow! This was not a good situation for anyone involved. Your facility needs to have policy in place for the most common adoption scenarios, including one in which the birth mother doesn't want to see the newborn. If the patient received prenatal care, this should have been discussed ahead of time with social services (private agency, Child Welfare Dept., etc) trying to set up at least a foster home placement before the birth. But even if she was just a walk-in patient with no prenatal care, she deserved better than she got. I'm not faulting you or your coworkers. Management that doesn't recognize and accommodate a birth mother's request not to see her baby is seriously out of touch and out of line. The baby should have been taken out of the mother's room and cared for by staff, even if it meant calling in an extra person. So, she decided to keep her baby. I'm guessing some will say that this was the best outcome, and it may be, but it could just as easily be an emotional decision that she will eventually regret. Because of the language barrier she will probably not lodge a complaint, but she was treated disrespectfully, all the same.

I hope you meant "cooling." Seems like cooking was already happening.

Document what you see, hear and feel (not emotions but things like getting hit or scratched)--not what you think it means. Not, "Patient became rude and hostile," but, "Patient threw wash cloth, grabbed this writer's arm, and used vulgar language." This takes your judgment out of the picture and allows the facts to speak for themselves. If you're going to be giving this patient for something for anxiety/agitation, it's much better to have an objective record of their behavior than your personal conclusion, which could make it look as if you medicated them because you were upset.

This is probably moot since you've already gotten hold of the supplies, but doing a blood glucose on someone tells you very little about their overall diabetic/non-diabetic status. You can get a reading of 60 on someone who will register 260 after a meal. For more dependable information I would do hA1c tests on subjects. That would give you a much more accurate result.

Just so you know you're not alone, here is a link from another nurse with a speech problem. She got some good advice along with much-needed encouragement. Don't give up just yet.

HR departments often tell new hires that they do not need their own insurance because they will be covered by the hospital policy. That such coverage exists is minimally true. But if there is any conflict of interest between the facility and the employee, which one do you think will take precedence? It is, unfortunately, not uncommon for the risk management folks to find a tiny deviation from policy and procedure and jettison the nurse so that they can show how concerned they are and that they have taken action to remedy the situation. SHE was the problem, but we have gotten rid of her, so everything is peachy now. If the nurse is no longer affiliated with the hospital, there is even less incentive to stick up for her. Professional liability insurance offers many benefits at a nominal cost. Mine runs me about 3-4 hours pay for an entire year. The policy covers anything you did while insured with them. Not sure if there is a stature of limitations. But think about it. Your personal liability policy is attached to YOU, not the facility. In that sense it is portable and not divided in its loyalty. This kind of insurance also covers you if you volunteer your services as a nurse or if you are called to be a witness against someone else, Relying on the hospital policy doesn't do either of these. I know money is tight for a lot of people just now, but a full year's premium costs less than one hour of legal consultation should you ever find yourself with the need for this kind of service.

Doughnut holes, cut up fruit and/or veggies, mini muffins, fun-size candy bars. If you do fruit/veggies, bring toothpicks. Also think about bringing in small paper plates and napkins. Even if these are available on the unit, it's polite to avoid using hospital supplies for what is essentially a personal matter. Whatever you decide to do, please, accompany your efforts with a nice note, thanking the staff for their help and expressing your appreciation for all that you learned while with them. Gestures like this are usually quite well received, and cards and letters from students are often kept for a long, long time. It's nice of you to think of thanking the people on the unit.

You might also get in touch with a unit manager to ask about job shadowing. Read the Ob/Gyn threads here at AN. Try to get a feel for the reality of L&D, postpartum and gyn patients. A lot of students/nurses have a romanticized view of the whole L&D experience. It just sounds like such a great opportunity. You get to help women bring their children into the world and take care of babies and do a lot of teaching about breastfeeding. Those things are a part of the job, but there is a lot more to it. Some get disenchanted when they find out how much you have to learn and how many other challenges go with L&D and postpartum. If you can get past the idealized, emotional attraction and go a little deeper, that alone will give you an edge over someone who goes in and talks about how she's wanted to take care of babies since she was twelve and got her first job as a sitter. I don't think there's anything wrong with that. It's just not enough to say that the candidate has a realistic understanding about what the job entails. If you familiarize yourself with some of the terminology and the kinds of skills you hope to gain and practice, that will say that you have done your homework and are willing to work hard to learn more. Google things like NRP, STABLE, obstetrical nursing, breastfeeding assistance and anything else you can think of. You'll find thousands of links that will help familiarize you with this area of nursing. If I were an interviewer, I would be looking for someone who has gone beyond the emotional attraction and started delving into the learning and development necessary to be successful on my unit. I hope this goes well for you. Let us know what happens.

Sending babies to the nursery is not an all-or-nothing proposition. Many of our breastfeeding babies are what's called "out on demand," meaning that we keep them in the nursery until they start to rouse. Then they go out to mom for a feeding. And many times they come back to us afterward. This works the best with babies who have cluster fed prior to leaving Mom's room, but even if that isn't the case, sometimes just a couple of hours of sleep really help both Mom and baby do better. The question that should help keep everyone honest is, "Whose needs are the biggest priority?" If it's the administrators who are trying to squeeze every last buck out of the situation, that tells you where the babies and mamas rank. The other important consideration is that you really need to take a hard look at any LDRP or PP unit that ends up pitting moms, babies, and staff against each other when collaboration should be the rule of the day. Guilt is a poor choice for a motivational tool, especially when information and inspiration can accomplish so much more. The bottom line is that moms should do what works for them and their babies.

The first internship program ran from April to September of 2011. Not sure if it continued after that. Maybe you'll be the one to find out firsthand if someone emails you back, and you can share the information with us.