aprilleverett

I'm new to critical care nursing and have a question that the other experienced nurses I work with seemed stumped by: I had a patient the other night that had a cardiac cath with 4 stent placements in the RCA. Part of the artery was 90% calcified and another part was 70%. After the cath he had chest pain off and on, which was only controlled with 20mcg/hr nitro gtt. His ECG initially showed substantial ST elevation (no big surprise), which resolved over apprx 12 hrs. His cardiac enzymes were quite elevated initially (again, no surprise). So after apprx 24-30 hrs after stent placement his CP subsided and he had been asymptomatic for at least 12 hrs on the nitro which I had slowly titrated down. I drew his cardiac enzymes at that point and his Troponin was elevated by 4 points (from 8 to 12), but his CK-MB was actually lower by over 100 points (however it was still high). What would cause this dissociation between the two levels? Why would one go up and one go down?? I know Troponin is much more reliable, but if it goes up doesn't the CK-MG always go up also - or at least stay at the same level? I can't seem to find any reason in books and articles

While in nursing school I worked as a CNA part time. One night the LPN that was working over me asked if I wanted to watch her put in a foley because we were getting ready to do lab check offs on it in class. I was excited and went to watch her do this. I watched her as she carefully set up her sterile field, when she got to the lube she opened the foil package with her teeth, then squirted it all over the foley tip, which she was holding with her bare hand. After cleaning the lady with betodine she went to insert the foley. Even I could see the urethral opening, this lady had actually had fully inflated foleys pulled out before, so it was almost impossible to miss. She went to insert it, and she missed... went in the wrong hole. I was like well, I'll get you another foley, she was like no, it's ok. She made the same mistake 5 times, each time attempting to insert the dirty foley into the urethra. Finally she's like well I guess I'll get a new foley so she laid the dirty one on the lady's bed. She was almost out the door when she turned back around and is like, maybe i'll try it one more time. And she did, and she got it that time. I told the DON about this but nothing ever got done, and fyi the lady did get a raging uti and died of urosepsis.

Hey guys... another update.. the administrator called me today.. thanked me for bringing all this to her attention.. begged me to stay, offered me an evening position (i work nights right now) cuz she said i am a strong nurse and she believes i can help straighten things out on evenings.. she also informed me that she has suspended 3 aides and one nurse for things going on.. i'm so glad to see they are doing something.. like i said i dont know how u all believe.. but PRAISE GOD! I have really been praying about this stuff and hoping against all hopes that something would get done.. and it is!

Well just an update.. I had a 2 1/2 hr discussion with our administrator the other day and she has promised me that things are going to change.. there is one nurse who is the one who never does txs, orders meds, takes of orders, blah blah blah.. well she is on 30 day probation, if she does anything wrong these days she is gone.. the aides i have been having problems with are also on probation.. the administrator said give her 3 wks and i'll be surprised at the turn around. we are supposed to be having a charge nurse meeting this monday and all these issues are supposed to be brought out in the open. I have heard her say all these things before. But i hope she really does something this time, i told her i will give her the 3 weeks.. partially because 2 of those weeks i am on vacation and if the stuff doesn't change i'm gone.. i already have jobs lined up if i need to leave. I don't know how you all believe out there.. but if u believe in prayer please do so for this place.. like many of you have said the elderly.. in fact a dog does not deserve to be treated the way the res. at this facility are treated at times and i'm tired of seeing it.. it's heart breaking and very frustrating :angryfire

wow thanks for all the advice, i am definately going to start keeping copies of my write ups and documenting things much closer and being more observant. i really am attached to this facility and i want to see it improve to where it was when i first started there, i love the residents and some of the employees there and i would hate to leave there and always wonder if i could have done more. again thanks for all the input.. more is definately appreciated

wow, i didn't know that some schools require the cna thing.. i think that's very cool the good ones will help you when you call,and the others...they call you every half hour to do something as far as that statment goes.. i work with nurses who are absolutely ridiculous... they call a cna clear from the other end of the hall to do something as simple as wiping a face when they are right there to do it.. that, to me, is stupid.. if u don't have time to do something that small and efforless you need to work on your time management skills... then there are always the ones that say "i don't get paid enough to wash dirties" (actual statement i heard a nurse make one time) well if u they arent paid enough to do it, then why is a cna paid enough to do it? lpn's are not any better than cna's and arent above aide work.. but they do have other priorities to take care of first

wow, i must say that i am glad i started this post.. i didnt even think about the benefits of ms with the heart and oxygenating the pt. DUH lol i feel stupid now.. ok i feel much better about giving it now and kinda stupid for questioning it.. but i guess that's how we learn :) thanks everyone!

Ugh! I didn't see the report, but saying something like that? (about the foley) No wonder some of the public is so afraid to go to the hospital, I'm not saying the places are perfect.. some are FAR from it.. but anyone who did any proper investingating at all would easily find out that in a hospital foleys are usually inserted for monitoring accurate urinary output.. especially post op!

One more thing.. even after going to LPN school I think all nursing student should be required to do so many hours of CNA work just to show them what it's like.. it would greatly help some nurses in their leadership skills over the aides

Just want to say.. probably like a lot of u out there.. i was a CNA before I went to school for my LPN. I worked as an aide for 3 yrs and got SO frustrated at LPN's who acted like I was stupid and totally ignored me when I thought something was going on with a res. I vowed to never be like that when I became a nurse and proud to say that so far I havent.. I think the problem with some nurses is that they havent had to be out there doing the dirty work and gettin paid crap for it. I personally loved being a CNA and would have made it a life time career if it wasnt for the pay, back pain, and the fact that you arent heard. I love being a nurse and advocating for my patients and actually feeling like I can do something! as a CNA i felt my hands were tied and all I could do was report my findings and if the nurse didnt address it then nothing would get done. I am now getting ready to go for my RN and hope to be the DON someday at the same facility i work out now.. I want to make a difference in people's lives.. I love CNA's (the good ones of course) it's great to see ones that care and LTC facilities and hospitals couldnt function without them.. I just wish that they got more for all they do! Here they make like 7/hr and get all the icky work... well, for the most part, but I must say I do help them when i get done with my stuff, i give them a hand cuz I remember what it was like!

Indeed.. i have worked with MANY LPN's and RN's who know less about their res. than a stranger walking in off the street.. and i'm sure that would be frustrating as an EMT, especially if u got a lot of calls from the same place with nurses like that... i wish all nurses were as good as I, then we wouldnt have this problem.. j/k lol

Just want to say that I don't think just cuz i've had more "book learnin" than an EMT that I am better than them.. i just think that when (especially in this area) they come to pick up a res that they should think about that fact that I know that res better than they do.. if there is something wrong and I and the DR feel they need to go I don't see why they have to have attitude.. a lot of times the ones here walk through the door acting mad or annoyed... in this area all we have is the 911 ambulance.. no private transport and so that's how they have to go.. I don't think i'm above anybody.. and i appreciate what EMT's do.. we do have like 2 that come in and are nice and friendly.. lol all i know is when i was fresh out of school working night shift i was almost afraid to call the EMT's when i needed to ship someone out cuz they were so mean lol also.. about the laceration that had been there 2 hrs... it's taken me longer than that to get ahold of the dr before.. especially on noc shift.. if neuro checks were fine maybe that's why they didnt call sooner? just a thought

Thanks for your input... just to let u all know, state has been called (a few times by me) but things seem to well "improve" while they're in the building.. no one is going to tell a res. to shut up or die in front of a state inspector.. this place was hotlined by family members twice two weeks ago and four times last week. state came one day, looked at charts and left! just this month we have had 14 res move to another local LTC facility because of the lack of care.. we live in a relatively small area and word is getting around about how this place is.. just another question.. have u all ever felt like obligated to stay somewhere? honestly one of the main reasons i stay is because there are just a few of us out there that actually care.. and if we leave then what does that leave the res. with? I keep talking to the administrator and trying to get stuff done about these situations... it's so hard to leave the res that i've taken care of for so long

I just want to clarify that I am not against giving morphine to someone dying and in pain.. i'm not against using it on a scheduled basis either, i was just curious to see is it is as commonly scheduled everywhere else as it is in the facility where i work. When it is scheduled i give it.. unless RR is extremely slow (like 4/min) I don't want to see anyone dying in excruciating pain..

Well for me.. i like to be able to vent.. my husband don't understand fully the things i go through at work.. and i dont want to gripe at work (well not too much lol) cuz it creates a neg. atmosphere and also... well i like to read how others suffer.. it lifts me up lol j/k :chuckle

I don't know if this is common (i've been a nurse about a year now) but i work 11-7 LTC and EVERY time I call 911 to send a res to the ER the EMT's act like JERKS... they question me about the why i'm sending them (in a very sarcastic manor) actually state that "there is nothing wrong with them but guess we'll take them anyways" and all around treat me like i'm stupid. Not that it matters, but every time i've sent someone out they've been admitted and although they may be a little better by the time the EMT's get there than when i first found them they still need to go! For instance one day i went into a res room cuz she was makin all kinds of moans and talkin to herself (not like her).. her 02 was in the 70's and wheezes all over.. starting to get cyanotic in her nail beds and not acting right at all.. i called the doc he said to put her on 02.. some of her symptoms subsided due to the O2, i explained all of this to the EMTs they accused me of calling them before i fully assessed the patient and of not checking on her before i called.. which i did.. i was in her room literally like 15 times in a 1/2 hour and had sent aides in there on top of that.. I don't know what the deal is with them.. but i am just wondering if this is common.. i mean correct me if i'm wrong but dont' we get a little more schooling than them? AND i think i know my res a wee little bit more than they do...

yeah, i mean i'm not saying that it shouldnt be done ever.. it just seems kinda routine (where i work anyways)

Well trust me.. nothing is done.. well honestly they MIGHT have got called in the office.. but these ppl have been working here for 4 yrs and it still happens one of them even got employee of the quarter recently! this girl is great friends with the DON by the way and I am not the only one who has reported her and the other aide.. ugh! it makes me sick.. i absolutely feel horrible for the res under there care

OK.. i have wondered this since i was an aide... i totally agree that euthanization is wrong.. but in a way we do it often.. in LTC.. especially those on hospice we give res so much morphine and ativan scheduled.. .25 to .5 roxanol q hour sometimes that they die much quicker... now i agree in quality over quantity but.. why do they schedule roxanol and stuff? why couldn't it be q 1 hr PRN for s/s pain or discomfort? I always am leery of giving so much roxanol to a dying patient any opinions?

Ok I need to vent. I have worked in this LTC for 4 yrs, 3 as an aide, 1 as an LPN. Since I have worked there, there have been 2 CNA's, one on day shift, one on evening shift. They both are verbally and at times physically abusive to the res. they both defy authority, if u ask them to do something they don't agree with.. as simple as laying a res. down or taking a set of vitals they flip and refuse and on top of that they think ...actually they do run those shifts (i'm 11-7) Well occassionaly i work those shifts and have a horrible time getting them to do anything.. I worked with them both when i was an aide and i have heard one of them tell res. " you need to die" "we're poisoning you" "shut up" they both refuse to care for some res. and family members have actually kicked these two out of several res. rooms and these two aides are not allowed to go back in there! well I have personally reported the two of them SEVERAL times, talked to the DON, did no good, talked to the administrator, did no good, called state.. nothing got done cuz of course they arent gonna act like that in front of state.. I am at my whits end.. there are tons of other stuff going on where i work.. tx not getting done, meds not ordered.. some res going 2 to 3 days without meds because they werent ordered.. narcs missing and it keeps getting worse.. is it like this everywhere? Or does this place need to be shut down? I am honestly afraid for my license at times.. any input/advice?

I work 11-7 in a LTC and it greatly depends on which "side" i'm on.. on north side (about 16 RCF and 20 some SNF) I am bored stiff.. we have 1 nurse 1 CNA at night over there and i find myself doing mostly aide work to keep from falling asleep, on south side it's totally different ..usually about 60 snf res 1 nurse 2 aides and it's crazy... alzheimers mixed with A&O x 3.. people up and down all night.. call lights out the wazoo.. tx after tx and in the morning the med pass is like 2 hrs long on top of atleast 16 BS... i stay busy over there... and then there is all the crap that 3-11 loves to leave us.. skin assessments (at 2 in the morning, come on!), dozens of meds to put up, blood draws, urine cultures.. and the list goes ooooon

Hey guys, I have been an LPN for about a year now. Before this I was a CNA for 3 years in a LTC and I currently work there as an LPN. Anyways I am looking for something a little different and I was considering correctional nursing. A local female prison is hiring and pay relatively well for this area. The main thing I am concerned about is having to detach myself emotionally from my work. Working in a LTC has made me very compassionate about nursing and I love getting to know my patients and getting close to them, I like the family enviroment, but I am thinking that in a prison setting you'd have to be very cold and detached and I'm not sure I would like that. Is this how you have to be? or is it just me stereotyping? Also what are some perks and some downfalls to this field? Thanks! :)