cardiacqueen

Just gave this today for strep! Very painful for the poor patient. to answer your question about giving it iv - no, it can't be given IV because it can cause severe neurovascular damage

Interesting...what do you mean by one order with a range? I know that our docs have been criticized, for example, by pharmacy for putting in range orders such as "1-2 tabs for pain." Not sure if this is what you meant though. I have had that thought that specified doses for certain levels of pain has some issues. Mainly related to patients having different pain tolerances and perception, as well as varying tolerances for certain medications. But what is the alternative? Say for example I have a patient who is 2 hours post op, not tolerating PO intake, and says they are beginning to have pain, 4/10. I have orders for Percocet and Morphine. I am concerned about giving a larger dose of morphine (say 6 mg is my only order option) to patient who is drowsy and whose pain is at a level in which the risks may outweigh the benefits. Sorry for the long post! Just curious as to what you guys think!

While we're ranting, here's what frustrates me... Why does lab, radiology, and pharmacy call nurses to ask questions about DOCTORS orders? "Dr. X ordered this but did he really want it?" I am not the doctor and I didn't place the orders. I may be able to give you some insight on the patient, but when you call, I now have to call the doctor, relay your concerns and call you back. I just don't get it! You could get your answer faster if you asked for him directly when you called the unit.

No, this is outside of our scope of practice. Unless you have parameters. One of our surgeons, for example, will put 3 different orders for morphine - eg. 2 mg for mild pain, 4 mg for moderate pain, and 6 mg for severe pain.

If the blood was pulsing strongly up the tubing, then I would feel pretty certain yes, you hit an artery. I have had an inadvertent arterial puncture once, in a patient with a very thin arm, while aiming for the basilic v. I didn't even get to the point of flushing it...as soon as I removed the needle from the angiocath I could tell the blood flow from the hub was pulsatile - and strong! Both the patient and I were wide-eyed! Removed the line, applied pressure and started over. I have noticed that sometimes with a particularly patent IV that a small amount of blood (maybe a few inches max) has backed up into the tubing if the IV is infusing at a really slow rate, or if I stop the pump for a few minutes to take a blood pressure or something. In this case, the pressure in the vein is greater than the pressure being exerted by the fluid in the tubing (especially if you have a BP cuff squeezing the arm :)). Bottom line, if you suspect arterial puncture I would err on the side of caution and remove the catheter. Part of your medication "rights" is "right route."

Thanks. I did read about the ostomy cones but I haven't been able to find them in our facility. Back at work tonight a few days later and the patient is improving without signs of perf, so thankfully looks like no harm came of using the regular enema. But, good to know for future reference.

I have another one. I once had a patient tell me he had "tickly-itis" (diverticulitis) when I was taking his health history. Still makes me laugh!

thanks!

MeTOprolol, NOOOOT meTROprolol

I had a patient admitted last night with an old RLQ stoma - either an ileostomy or colostomy (look to me based on the location like an ileostomy). The patient needed a CT abd but radiology would not scan the patient because he had residual Barium from a previous study in his bowel. Therefore, the physician ordered a warm tap water enema - when I asked for clarification, he said yes - through the stoma. I have never given an enema through a stoma before, so I asked our supervisor. I was told to just give the enema like a normal rectal enema except obviously, through the stoma. I used a soap suds enema kit sans the soap (the one with the plastic tubing + irrigation bag) and inserted the end of the enema only about 1-2 inches, no resistance. Due to the poor sphincter control of the stoma most of the water immediately drained out and the rest after I removed the enema tube. After completing the procedure I decided to go home and read up on the current literature regarding ostomy irrigation. I now have 2 huge concerns. #1 - For the enema, was it Ok for me to use a normal enema tip? I'm reading that these can potentially cause bowel perforations? It seems hard for me to believe that a gently placed plastic tube can rip through the bowel...do I need to worry if I didn't "hit a wall" or insert the tube far? I am panicking! I have read that foley catheters can be used for irrigation as well. This seems similar to the plastic enema tubes. #2 - Not sure if the patient had a colostomy or illeostomy, but illeostomy irrigation is not recommended due to risk of dehydration, but this patient needed cleared out for CT. Do you think giving an enema through an ileostomy was OK in this case? I know I was following Drs. orders, but after doing some extensive research I am second-guessing my actions...please help!

On a side note...have you ever had a patient think that your 1mg dilaudid + 5 cc NS is ALL concentrated dilaudid?

Like most posters here, I dilute all iv narcotics as well...unless it is an extremely small dose and the patient has fluid running.

KelRN, do drug companies manufacture a different syringe device for peds...like one with a smaller needle and appropriately smaller doses? Or do you draw your Lovenox up from a vial and give in a short sub-q needle? Just curious.

thanks so much! Makes sense!

So we've all been there...you have a 30-some kilo very ill lady to whom you need to administer Lovenox.. This seems like a dumb question, but is it possible to puncture/damage the intestines or other underlying organs of a very emaciated patient by administering Lovenox at the recommended 90-degree angle? I know the needle is only 1/2 inch...but it scares me because pinching up the skin on these patients is just that, only skin. Doing that would result in an intradermal injection and likely a needle stick for the me. I want to give these injections properly in the proper tissue but I also don't want to put myself at high risk for needle stick injuries...I have tried introducing the needle only about half way into the tissue (without pinching skin) to prevent the medication from being injected too deep and hitting musculature. Several of my coworkers say that hitting organs is impossible and it's actually not necessary to pinch up fat as the needle is so short. I have heard of a few rare cases of muscular hematomas resulting from lovenox but never any organ damage? What do you guys think? Any tips for giving Lovenox to very very emaciated patients? This has always bothered me.

Yes to decadron. I've also seen iv vancomycin ordered po, just because the po pills are so expensive. no to zofran-if no iv access why not give IM or the ODT by mouth?

I've been a nurse for a year and I have made 2 med errors; reported both. No harm came to the patient either time...and I will never make either of those errors again...I was lucky, and honest. I did not lose my job.

So, last night I gave my first bag of platelets to a male patient. While verifying the platelets with my 2nd RN we discovered the platelets (4-6 units from platelet pheresis, single donor) were from an RH-Positive (A+) donor . Our patient was RH-Neg (A-). ran to call the blood bank thinking we had just caught a major boo boo but BB insisted that RH-incompatible platelets were safe to give because platelets do not have RH antigens, only ABO antigens. This seems weird to me. Research I have read has stated that due to scant amount of RBCs that are present in units of platelets, RH antibody formation may occur, so transfusion of RH positive platelets to RH negative donors should be avoided when possible, especially in childbearing females due to the possibility of hemolytic disease of the newborn in future pregnancies. Article went on to state that the RH neg patient who received RH pos platelets should get a dose of RHOgam to prevent this. So I'm wondering, what is your facility's blood bank platelet policy? Thanks!

Sharps container for empty vials. If giving a partial dose, I draw out the entire vial worth and waste the extra down the drain per policy with a witness, of course. Gotta love taking a 4mg vial of morphine out (smallest we have) only to admin 0.5mg...

My scores were 93.5 in reading, 88 in science, 90 in math, 92 in vocab, and a 100 in grammar. I had no problem getting in!

Nope, it's not impossible! I kept a perfect 4.0 until halfway through my junior year. I ended up getting 2 A-'s, it was heartbreaking for a perfectionist like me because they were both right on the borderline, but as you know there is NO ROUNDING OR EXTRA CREDIT in nursing school! I'm graduating this week with a 3.98 - with the same honors I would have graduated with if I had 4.0 :). Work hard but don't stress if you break that perfect 4.0! A high GPA is a high GPA :).

HESI is a series of nursing school competence exams developed by the Evolve-Elsevier textbook company. The exams contain NCLEX-style questions and are supposed to "accurately predict" NCLEX passage rates. There are several different HESI exams: an entrance exam that assesses the student's knowledge of basic academic topics like Chemistry and Math, Small, 50-question exams focused on specific nursing topics (Pharmacology, Med-Surg, Mental Health, etc...), and a 260ish-question exit exam, a comprehensive assessment of any material that should have been covered in nursing school. The majority of the questions on HESI, like the NCLEX, are application questions that require not only memory of facts but application to patient scenarios and critical thinking. It is not a computer-adaptive test (CAT) like NCLEX, so you take all of the questions regardless of "how well" you answer the questions. When you complete the test, HESI immediately generates a score and percentile based on the amount of questions you answered correctly and the difficulty of those questions. A score of 850 is generally thought to be the benchmark for NCLEX success, but a score of 900 is recommended. Many nursing schools require "passing" HESI exams (scoring 850 or higher) in order to pass specific courses or, in the case of the Exit Exam, to graduate.

I took the Exit HESI a couple months ago and passed it. Just this week I did the Hurst Review (loved it!). From my experience I think there is a slight difference in philosophy between the HESI questions and the NCLEX (Hurst) questions. HESI seems to want you to assess more before performing interventions, while NCLEX tends to want you to pick the intervention that will keep the patient from dying (more realistic in my opinion). In other words, when NCLEX gives you a list of acute signs/symptoms they want you to assume that the worst possible disease process is going on and choose an intervention that will help the patient. HESI doesn't always follow this philosophy in my experience; a lot of times (but not always!) the questions want you to gather further assessment data before intervening. Again this is just my theory. Honestly I think the HESI is a horrible exam with many bad questions, but in order to pass you need to get into a HESI mindset. I would recommend purchasing the NCLEX Review book WRITTEN BY HESIon Amazon (I think it's called Comprehensive Review Guide for the NCLEX or something). Read the entire thing! There are a lot of helpful hints in there and it also comes with access to HESI-style questions. We took HESIs after every course in my school. Before reading this book I was bearly making 850 (for those I passed). After reading it I made 1000 or over on all of them! Good luck! Once you get the HESI over with go back to your Hurst material and think NCLEX-y!