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OB, M/S, ICU, Neurosciences

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  1. bestblondRN

    Reimbursement Expenses for CM's who work at home.

    I am interviewing this week for a Telephonic CM job that will transition to a home-based position. Would you be willing to share pros and cons of home telephonic CM? Thanks!
  2. bestblondRN

    Female pt. dies ignored by nursing staff

    Noryn, In all fairness to the triage nurse, she was far from being the only person witnessing this event and I'm quite certain she was not the only staff person in the department at the time this occurred. This is really an extreme example of how a system breaks down and how desensitized health care personnel can become. I have worked triage in a crazy inner city ER and have an appreciation of working in a constant crisis mode, so I do understand the dilemma of underbedding, understaffing and the inability to provide care immediately to everyone who walks in the door. But triaging carries with it the responsibility of determining who needs care right now and who can wait, does it not? Also, I believe you misinterpreted what I said about an acute abdomen. I think all of us who have worked in an ER in an urban setting have an appreciation of the insanity and BS that comes through the door, but I think most of us err on the side of caution when it comes to triaging patients, especially someone presenting with severe pain and hematemesis. G.I. bleeding is a medical emergency in anyone's book, and it would warrant an immediate trip back to the department. The CT and other diagnostics would be an offshoot of the initial assessment made by the triage nurse to get the patient back so that they can be assessed quickly by a physician. It is then up to the medical staff to come to a conclusion about diagnosis. It comes down to the simple fact that EVERYONE has a role and responsibility in providing care to patients once they enter the hospital. In this case, EVERYONE failed miserably..... One of the finest physicians I ever had the opportunity of working with told me something I will never forget: "There is no substitute for a good, thorough physical assessment--get your hands on the patient and use all your senses and knowledge to get a complete picture of what is happening. Once you have done that, the diagnostic tools are nothing more than the technology available to support your assessment." That advice has served me well in almost 30 years of practice. It will be interesting to follow what happens as a result of this. Too bad the media seem to feel that the antics of Paris Hilton, et al, are more important stories.......
  3. bestblondRN

    Female pt. dies ignored by nursing staff

    As I understand from the video released by GMA, there were a group of staff, including nurses and physicians standing by watching this woman vomit blood onto the floor while a housekeeping staff member mopped the blood up around her. The 911 calls placed by the male translator and female witnessing this atrocity were terribly mishandled by dispatchers. When calles like this are received by 911, they know to contact administration to report it. And the fact of the matter is that the patient lay where she was for 45 minutes before she was finally given any aid at all. And guess what? It's ALL on videotape..... This goes beyond malpractice and malfeasance. This was maybe the cruelest thing I have ever heard of being done to someone in an urban ER EVER. I know there are always two sides to the story, but where is the basic humanity folks? The lay people who were bystanders did more to try to help this woman than the staff in the ER. It never should have gotten to the point that she was left on a floor to die. I don't care who watched this unfold--triage nurse, housekeeping, the maintainence guy or whomever was there. They had a responsibility, as hospital employees, to assure that this woman received attention immediately by contacting their supervisor, a physician, or another nurse. I don't want to hear all about how nurses don't diagnose.....no, we don't, but if you can't make a basic assessment on an acute abdomen and determine that this person requires immediate care, you shouldn't be doing the job. Harsh? Maybe.....but what if that had been your mother, sister, aunt or girlfriend in the same situation?????
  4. bestblondRN

    Leaving the Profession!

    Hey Chris--best wishes in your new profession, and congratulations for taking the plunge into something different! I've been in this for 28 years and have seen the good, the bad, and the ugly also......Nursing has taken it's toll on me as well--just had a spinal fusion in February and now how a rotator cuff problem as well as a labral tear in my hip, not to mention the stress-related stuff in dealing with patients day in and day out. I think I've lasted longer than many, but it's no longer a game of endurance for me--I need to segue into another profession that utilizes my knowledge and skills, but doesn't tax me the way nursing has, both physically and emotionally. I'm still trying to figure out what that profession is :smackingf , but figure it will come to me at some point......there is no utopia, but there's gotta be something easier! Anyhow, good luck to you in your next endeavor!
  5. bestblondRN

    RN duties in outpatient setting?

    I work for a large, incorporated group practice with a number of specialties and each office does their own thing when it comes to care models. There are practices in which the RNs are used only for phone triage, paperwork and refills and the MAs have the clinical responsibilities (rooming patients, VS, chief complaint, meds, etc. I have worked in Neurology and Neurosurgery, both of which have RNs working for 2-3 physicians, NPs working with one physician, and no MA or only one for an entire practice of 20 MDs. Obviously, this is the other end of the spectrum--we clean and stock our own rooms, perform phone triage, run our clinics (4 days per week), set up surgeries, exams/testing and perform other coordination of care duties, fill out all LOA and disability paperwork, make appointments at times, and see patients in Nurse Visits on half-day or non-clinic days for suture and staple removal, reassessment and education. As I have said in the past, I feel like chief, cook and bottlewasher! There is almost never downtime for lunch or even a bathroom break at times....... If it were in my power to design a staffing model which accomplishes the end of excellent patient care and running the clinics smoothly, I would have MAs partner with RNs (1-3 depending on the patient load and clinic schedules)where the MA spends 85% of their time in clinic, 5% of their time stocking, ordering supplies and straightening up rooms, and 10% of the time returning calls that are appropriate to their experience level as well as doing some of the coordination of care--setting up exams, tests and such. RNs would continue to do phone triage but would also see all new patients to establish a relationship, obtain a history, and identify specific care and educational needs. Return patients should also have access to the RN as needs are identified. I believe that RNs are terribly under-utilized when they are "chained to a desk" and never see patients or perform hands-on care or teaching. Every office or practice should be evaluated individually, and the question of how a RN is utilized within the practice should be asked during the interview. I would also find out how flexible they are about having RNs develop educational programs and actively perform teaching and other care responsibilities during clinics. Good luck to you in returning to Nursing!
  6. bestblondRN

    Run Into the Ground (rant)

    I'm here at home thinking about how much I DON'T want to go into work today--to another day of 50-60+ phone calls, disability and FMLA forms, scheduling cases at several different sites, following up on patients who are scheduled to have procedures this week who HAVEN'T gotten their labs and preops sent in, as well as the usual Monday crap hanging over from the weekend! I work in a huge multi-specialty group practice for 2 neurosurgeons--1 is extremely busy with procedures and a high-anxiety population of cerebrovascular patients, and the other is a functional neurosurgeon who has lots of chronic pain patients. I am seeing patients in clinic 4 days a week plus my own nurse visits for wound checks, suture removal, etc., as well as anything not major enough to see the surgeons about. I am one of 3 nurses who have a 2 physician practice--the remaining 4 have one physician assigned to them. Of the 3 of us with 2 docs, 2 of us have UNREAL workloads that lead to 10-12 hour days, no lunch breaks, etc. Our clinic is a mess from the ancillary support standpoint with no MAs, lousy phone people who can't get basic information correctly from callers and who like to hit that transfer call button rather than get information and put the message on the computer so we can triage the calls. Consequently calls end up in voicemail that may not get checked all day if we are seeing patients. The checkout people will only schedule a follow up appointment--they will not assist patients in scheduling scans, tests or other procedures so the nurses end up doing it. We have spoken with the nurse manager a number of times both separately and as a group, and she is very good at taking the path of least resistance when it comes to dealing with the business-based practice administrator. Our exam rooms are filthy, unstocked--we run out of suture removal kits on a regular basis--and the red trash bins and needleboxes are usually overflowing. It's an embarrassment, especially considering that we are supposedly the "mecca" in this area........HAHAHAHAHA!:rotfl: :rotfl: :rotfl: At any rate--having been a manager, I see most of this for what it is (keeping budget under TIGHT control so our docs and administrators get their $30,000+ annual bonuses), but I am tired of feeling like I am being beaten to death every week--there isn't enough of me to go around! I come home in the evenings and my husband says I look like I've been through the war! I realize I have the option to walk, but I am just 5 months short of being 100% vested for retirement (if you leave beforehand, you lose it all, and I've worked too hard for that money--they aren't keeping it!!!!!). I am just disgusted that more and more the business end of healthcare is the only thing that matters, and that the administration here is so damn greedy at the expense of the staff and the patients (who are no walk in the park--lemme tell ya'! Wealthy, entitled, and very full of themselves--they are the ONLY ones who matter and will tell you so! ) I am feeling increasingly burned out. I've survived 28 years of healthcare, but am at my saturation point now. Do any of you in outpatient nursing experience the same thing? Are nurses usually chiefs, cooks and bottlewashers in most practices? I apologize about the length of this--I really needed to get this off my chest before I jump in the shower and head off to the salt mines. Thanks for taking the time to read this.......
  7. bestblondRN

    The nightmare returns---Hunter Group is coming!!!

    prmenrs--I hope your organization survives the Hunter Group. My former place of employment did not and is one of those mentioned in the article you cited. Like many others on this board, I have seen these groups come and go--West Hudson, Hunter and a few others--and when they leave, it's like the path of destruction and ruin in their wake. I hope never to have to run into another of these groups again in my career! Good luck--I hope your job is still intact when they get done with your place!
  8. bestblondRN

    Infratentorial Herniation

    The tentorium is a fold of dura mater that covers the cerebellum and supports the occipital lobes of the cerebrum. Supratentorial refers to anything above the tentorium and infratentorial refers to the structures beneath the tentorium. Infratentorial herniation is prognostically worse because it directly involves the brainstem and as those structures herniate, the regulation of hemodynamics and respiration becomes affected and then will cease.
  9. bestblondRN

    When did we stop washing hair?

    I recently had a bilateral L3-4 laminectomy with foramenotomies for severe stenosis (the neurosurgeon said he'd never seen nerve roots so compressed in a 44 year old before). Before I get into the care issues, I should preface this story by saying that this is occuring in a "world-class" hospital and that I was on the unit I formerly managed during my post-op stay. The doc and his nurse were terrific--no complaints there--everything went smoothly and I was prepared well for the surgery. Of course, as often happens, my period started with a VENGEANCE the morning of surgery. Post-op, I had a 6 hour stay in the recovery room due to no beds on the unit. The nurse kept me well-medicated, got me an inspirometer, and helped me change my peripad when I asked. When I got to the unit, I was still feeling pretty good from the Marcaine they inject into the operative area before they close, so I got up and voided, changed my pad and walked the length of the hall and back. Well......all that changed when the local anesthetic wore off several hours later and I began having the most unimaginable nerve pain and spasm in my right hip (due to retraction of the nerve root) and down the leg, as well as in my left leg. I couldn't get into or out of bed using good body mechanics and was absolutely miserable. My IV was also phlebotic and extremely painful. It took 8 hours to get the IV site changed and the resident "wouldn't order anything for the spasm because I had been under anesthesia that day". What a bunch of BUNK! I asked to see the resident, but he never came in. Through that horrible night and into the next day, I couldn't even turn myself over despite q4 hour Percocet. My urine hat was full, and no one ever emptied it--I just would struggle to get into the bathroom (it took WAY too long for anyone to respond to a call light) and sit down in the puddle of urine and let it overflow into the toilet. I asked 3 aides and a RN to help me with pericare since my pad hadn't been changed since the recovery room and I had bled all over and had clots everywhere. Everyone said--"oh, OK, sure, be right back." Of course no one ever bothered to show up. I never received a water pitcher, bath basin, but was finally given a pack of OB pads after asking for help with changing my pad. The day shift RN walked in as I was getting out of bed the morning after surgery and just looked at me like I was a bug and said, "Oh my God....you are a neuro nurse and your body mechanics are just terrible. You know better than that." I promptly growled at her, "RIGHT NOW I AM NOT A NEURO NURSE--I AM THE PATIENT IN SEVERE PAIN, AND I SUGGEST YOU SHOW ME WHAT TO DO!" She jumped back about 5 feet and coached me through getting up and down out of bed. She ran in hurriedly about 2 hours later, gave me some Percocet and had me sign the D/C orders. I never saw her again. When my surgeon showed up the morning after surgery, I simply said, "Fred, when I am not in so much pain and can put a little distance between me and this situation, you and I will talk. Please discharge me--I will get better care at home." He obliged, ordered me Valium, Vicodin, and Flexeril (use whatever works) and put me on a Medrol dosepak when none of the above decreased the pain. The first time I got any care was when I got home and my husband and parents saw the excruciating pain I was in and met my needs. I was so embarrassed that my 70 year old mother was cleaning my perineum and putting a clean pad on me, that I just cried like a big old baby. My family members were awesome in providing me with everything I needed once I got home, and as soon as I started the dosepak, I had relief of the extreme pain within 12 hours so I was able to provide most of my own care. Now for the best part......some statistics that may blow your mind as much as it blew mine...... The unit was at 22 patients when I was there (23 is max census). Neuromedical, neurosurgical and complex ENT (there were no ENT pts. during my stay). I used to run the unit with the following: 7-3: 4 RNs/3 NAs 3-11: 4 RNs/2 NAs 11-7: 4 RNs I had to fight for that staffing and went to all the upper management with statistics supporting the addition of RN staff and NAs on nights, but could never get anything for my floor. I left after 2 years because I couldn't take the headbashing anymore. The killer is, this was and is the current staffing on the unit while I was there: 7-3: 6 RNs/3 NAs plus a unit based Case Manager and Social Worker 3-11: 5 RNs/3 NAs 11-7: 4 RNs/2 NAs My point in all of this is that staffing doesn't always have direct bearing on the care that will be given. Just like the patient who needs their hair washed to feel better (I spent three weeks in a hospital on bedrest while pregnant without washing my hair, so I have some knowledge of how atrocious this feels), controlling pain and making the patient feel cared for is an enormously critical part of what we do. I have worked many shifts "short-staffed", but tried never to let a patient or family member with questions feel as though I didn't have time for them or couldn't meet their basic needs at least. I assure you, the staffing on my former unit allowed for very reasonable ratios, but I felt like I was alone and on my own to meet my own needs. All I know is that we never did that with our patients on that unit when I managed it. Thanks for those of you who have been patient enough to allow me my rant. It feels good to get it off my chest, and I hope it will make us all a little more sensitive to the needs of our patients. Suzanne
  10. bestblondRN

    Divorce & Nursing

    I am currently separated from my husband of 2 years (second marriage for both) after being together for 5 years. I knew when I married him that I would continue in the pattern we had established of my working 12 hours and then coming home, fixing a meal, doing whatever chores needed to be done, and basically having no time for myself. I thought I could keep going, and that this was what it was all about.....taking care of everyone and doing everything. About a year ago, my back became so bad that I could no longer work, lift even a laundry basket or go grocery shopping. But, because I allowed him to be dependent on me, I found myself being very angry and frustrated that he wouldn't help with things I had always done. There have been a number of other dynamics that have played into this, not least of which was trying to blend 2 families with teenage kids.....bad move on our parts, since we didn't see eye-to-eye on childrearing. When the hostility and anger at home got to be too much, I became very depressed and decided that I had a greater obligation to myself and my daughter to provide a healthier environment for both of us to live in. I am now living in an apartment with her, and although I miss aspects of the relationship with my husband, I feel a sense of relief being alone again. I have always had that "rescuing" behavior in my relationships with men, and it's worn me down over the years. I am too tired to care for everyone but myself, and now is my opportunity to start caring for me again. Selfish? Yes....but in a good way. It feels good not being stretched from A to Z anymore!
  11. bestblondRN

    Wasting Blood

    Also need to consider how frequently blood is being drawn and pt's H&H, esp. with kids. I generally draw 5 cc on a normal weight, non-volume depleted adult from an art line or other heparinized line.
  12. bestblondRN

    first grader in NICU?

    In the places I've worked, we assess the situation, along with Child Life and Social Work to determine whether or not the child is emotionally and developmentally ready to see the parent in the ICU. In my experience, when the child and family and well-prepared, the visits usually go very smoothly, and are generally brief. It's a very individualized process based on family dynamics, maturity of the child, etc...... I don't think there is any right or wrong with regard to children visiting--just make sure they are ready to handle it.
  13. bestblondRN

    Neuro Nurses please advise

    It sounds like you may have developed some compression. Which level was fused? Have you had RECENT films done of your neck? Is there any plan to re-MRI you for another look at those nerve roots? Have you had PT or OT yet? It's not unusual for there to be some residual symptoms following surgery (especially sensory sx), but it sounds like you have a new motor deficit, and that is definitely NOT normal, especially this far out from surgery. Please, for your own sake, follow kc ccurn's advice and get another neurosurgeon to look at you. Let the WC folks know about your problem--and your plan, since they are the ones paying the bills, and think about getting an attorney. Good luck!
  14. bestblondRN

    Work in the Carribean

    I've only been to the Carribean on vacation, but always thought it would be an interesting option to work there during the nasty midwest winters! I don't have any inofmration to offer you, but wanted to wish you both the best as you pursue what sounds like a dream retirement!
  15. bestblondRN

    Beware Gastric Bypass with stapeling!

    The arguments pro and con for WLS are all valid. It is truly an individual decision that needs to be made with full knowledge of the lifestyle changes required and the potential for complications, including death. I have fought my weight all my life. I have had sustained periods of normal weight which required severe calorie restriction and heaps of exercise to maintain. It all went to hell when I went on steroids in 1995 for disc/compression problems in my thoracic and lumbar spine. I am now in my mid-40s and have mild to severe degenerative changes throughout my spine, including cord compression and severe lumbar stenosis which makes it difficult to walk. Standing stationary for a minute or two produces bilateral leg numbness. It ain't pretty, that's for sure.......which leads to my argument for WLS. I am at a point where cardio exercise, except water exercise, produces more injury and pain. I've gained about 50 pounds over the past 3 years, and am hypertensive on meds. I am 280# on a 5'9" SMALL frame--literally DOUBLE what I should be. I realize there are no guarantees, but I think reducing my body weight to a reasonable range would alleviate a lot of my spine pain and compression. I am also hoping to experience the other physiological and psychological benefits. It's like I am trapped in car that is functioning poorly and on it's way to the mechanic to be fixed.....just hoping I'm gonna' make it that far! I remember being a thin person. I remember walking into a room and having heads turn. I remember being able to go out and run a 10K marathon and swim a mile. I remember being able to go out and shop for size 8 instead of size 22. I am not a lazy fat slob who sits on the couch all the time eating cheeseburgers and bonbons. I work full time, deal with my pain as best I can, do my back exercises, and eat a balanced diet. I feel that the WLS tool is what will help me able to acheive some sense of physical wellbeing again. Do I expect miracles? No......I realize it will be a long road post-op. Still, I feel that it is my best option at this point. I don't think this is a surgery that should be done without meeting the criteria established by the ASBS--it has way too much potential for complications. 'Nuff said.......I'm getting off my soapbox now.........