Spatialized

My unit is in the process of starting an observation unit. It will be detached from the ED, under our Internal Medicine service, catering to CP r/o MI, COPD, CHF, Cellulitis, Syncope and Pneumonia observation status patients. Obs is based around CMS guidelines regarding outpatient treatment, where the patient is a little too sick to go home, but not really sick enough to be admitted as an inpatient. Goal is a less than 24 hour stay, but CMS allows up to 48 hours of observation status. A couple of questions for those out there dealing with this kind of unit. 1. Charting. According to our understanding of the CMS rules, we have to be "doing" something for the patient to be there, documented every hour. A good example to me is the patient who is waiting on cardiac enzymes to either rule out, or rule in. How/what do y'all chart about these patients during this time frame? Simple focused assessments and/or vitals every hour? Or some variation thereof? 2. Discharge. Is discharge protocol and nurse driven, or are the physicians still intimately involved? 3. Testing. Echos? Stress tests? Ultrasounds? How involved are y'all getting? Any other information about what has/hasn't worked would be appreciated as well. Thanks for reading and sharing! Tom

When we have someone who needs bicarb, they get another line. Easy to get around incompatibilities that may happen that way. Yes, it is inconvenient for the patient (and the staff who has to start the IV) but it seems to be the best work around. Our cath lab will look at lab values and let us know if the doc may want bicarb so we can start another line. Tom

Our image too often is formed based on the twisted stereotypes portrayed in the popular media. Sexy nurses, pillow fluffers and doctor's handmaidens is the image shown to the world and they all believe it (well, not all of them, but a good majority do!) Until the lay public actually begins to truly understand what it is we do, the level of knowledge and professionalism required to work and thrive in our environment, they will still perceive us as such. And with those people who believe in such a twisted way, you could have said the exact same thing the doc said and they would not have believed it without the white coat of "authority". It sucks, plain and simple. We can attempt to correct this mis-assumption, but sometimes it's just not worth the breath it would take. I hear though, it is frustrating and it makes you want to bang your head against the wall, but think about it this way: maybe they absorbed all of what you said and the doctor confirmed it for them. It was your teaching that laid the groundwork of their understanding and the doc confirmed it for them. Keep your head up! Tom

The odds of developing a hematoma 3 days out is fairly slim, but if by chance the MD accidentally created a pseudo-aneurysm during the procedure it could manifest itself later like that. Usually a hematoma is a firm/hard lump, sometimes ecchymotic, sometimes not. The lump may differ in sizes depending on how bad the leak is. There is always a small chance of bleed from a cath site, you did just have a large bore hole placed into it afterall. Hope this helps a bit. Tom

There are days I still don't feel like I have it together and December will be 3 years for me. If you really think about it, 6 months is not that long at all on an active cardiac floor. There's a very wide scope of information that you have to understand and figure out how it all weaves together which takes time. Instead of thinking how little you know, try to think about how much you have learned. I can remember when I was a newly minted RN on my floor and the very thought of having someone in active chest pain scared the dickens out of me. Sure, I knew what to do, but I hadn't done it. Then late one night I had a patient decide to clot off the the 5th out of his 5 grafts. 10/10 crushing chest pain, he's freaking out, his wife is freaking out, I'm freaking out. I'm giving nitro, morphine, starting a nitro drip, more morphine, beta-blockers, the works and finally as the sun was coming up transferring him to the ICU. But I learned a lot that night. Now, when someone has chest pain, it all becomes near-automatic. I know what I'm doing - but importantly, I know why I'm doing it. That first night I'm going, "Beta-blockers? Why?...OK if you say so." Now I can ask the doc if they want it in an evolving case. You learn as you go. Last summer we hired a big bunch of new nurses and I watched as they struggled through and between 6-8 months in they started to "get it" some faster than others, but nonetheless, still they were getting it. And those that felt the exact same way you do all asked the same thing as you. And I counter with the same thing: look at what you HAVE learned and achieved, then start looking at where you feel you're weak. Some positivity can go a long way y'know? And for awhile, nursing will be task-oriented for new nurses, that's a given. Until you can get the tasks under near-robotic control, having the time to think about the bigger picture is rough. Be patient, it will come, just give it some time. Good Luck, Tom

I just smile and say, "Nope, I love poop too much!" Then in all seriousness I relate how that I wouldn't even be done with residency until my forties and would like to raise a family and lead a semblance of a normal life. Beside, my last name doesn't exactly sound great as a MD - I can hear it now, "Dr. Long, Dr. Long, please call your answering service." Yeah, at that point the cheesy Mediao-film funk starts up... Tom

Whatever y'all. Nearly everyone in PDX is a transplant of some sort or another. Sure, some have been here longer than others, but what does is matter? How long you have been somewhere makes no difference when it comes to the caliber of the nurse. Were they new grads as well? If they were experienced, maybe they should get the job first? Maybe they had stellar recommendations or fit a particular need on your unit... Hiring new grads isn't easy. It takes a lot of time, energy and money to train new grads and get them up to speed as new RNs (believe me, we hired 5+ new grads last summer and it took awhile to get everyone comfortable). Hiring an experienced RN cuts that down dramatically. And as for PDX being a new LA, I'm more worried about it becoming a clone of the city we love to emulate, Seattle. The reality is, who cares? A nurse is a nurse. If they are better than the next, shouldn't they get the job? I've worked places (not in nursing) where people got the job due to connections, not merit, and it isn't pretty. Yeah, it's a tough, bleak outlook here in Portland, thanks to a poorly timed recession and a glut of new nurses. BUt there are places where it isn't. Problem is that they aren't in PDX. Cheers, Tom

'Tis the season for low census, that's for sure. We're getting canceled (or at least placed on stand-by) at least once a pay period at Good Sam. And as for hiring? Nothing. Nada. Zip. We had a student do her senior practicum with us and she's going to continue to work as an aide as she can't find a job for her as a RN. Last year she would have already had a job with us. We've hired no one in the last 2 typical hiring cycles (December grads and now Spring grads) where we usually hire at least a couple. Every senior I talked to that rotated through our floor has pretty much said the same thing. Good luck to all... Tom

My night shift co-workers rock, plain and simple. Not such a big fan of the day shift, but I don't hate 'em by any means. It's sad when it is perceived as "odd" or "strange" to like ones co-workers. Says something about our profession eh? Tom

Yep, you've got it. Practice until you see strips in your dreams (uh, I wouldn't know anything about that...). Ask questions of more experienced nurses, bug the tele tech (if you have one) and if you hear that someone is doing something funky, check it out if you can. Starting you may not be able to differentiate between "intermittent high-grade AV block with junctional escape beats", but you'll be able to know that, "hey, that doesn't look good, maybe I should look at my patient." And the second part is the key. Technology is great, but getting our eyeballs on the patient is much better! Cheers, Tom

It is possible, but it isn't pleasant. Sleep is a foreign thing when you do so. I did it because I had to, working 2 jobs, combined full-time through the end of school having worked 1 job full time the first year. It sucked, weekends were non-existent and I had to make time to study, but when you need to do things, you'll figure a way out. That said, would I do it again? Ummm...h*ll no! Lucky for me though, my wife is a rockstar and we didn't have kids, so your mileage may vary. Cheers, Tom

:yeahthat: Pretty much what Dianah said. We don't use sandbags as studies have shown that the weight distribution is too large for adequate control of a bleeder. If you get a bleeder, direct pressure just above the site (remember you anatomy...) for about 5 minutes then reassess. For our stent/intervention patients it is pretty much the same. You may have a higher amount of bleeding issues as the standard is to give antiplatelet meds post-stent as well as meds during the case. Typically our stents were coming back with orders for 300mg of Plavix on arrival to the floor, but I hear that has jumped to 600mg. Just keep a close eye on your pulses and any signs of bleeding at the site. A large increase in pain, above and beyond what the patient may have been having previously may be a sign of a further complication, like a pseudoanuerysm or retroperitoneal bleed. Also with your intervention patients, there is still the possibility that they may have additional blockages or in-stent stenosis while fresh out from the lab. On-going chest pain while somewhat expected (see microembolic phenomenom and clot wash-out), pain that doesn't go away or gets worse needs to be attended to. Lastly, sometimes, I've found that the Angioseals tend to ooze, not sure if anyone else has had this issue. Also, closure devices can fail and you need to know what to do in that case. Cheers, Toms

Typically ST depression is indicative of myocardial injury, the myocardium is not getting enough oxygen due to blocked arteries, vasospasm, poor cardiac output and on and on. Yes, it's not a good thing, usually. Although you can have pseudo depression due to lead placement, body habitus and other factors. Hopefully you'll get a good dysrhythmia class and at least a basic run though on 12-leads, especially how to identify ischemia, injury and infarct. The others above are correct, no one will expect you to be ready to go right out of the gate! IFit means all that much to you, I would suggest taking ACLS and picking up a used copy of "Rapid Identification of EKGs" by Dale Dubin. It's an easy basic read if you feel the need to have a head-start. Good luck though! Tom

Hiring freeze it is. My floor usually hires a handful of new grads, usually due to turnover and people moving on, but there is none of that this year. Same thing goes for all the floors at Good Sam. The ICU there is not even doing their usual internship. It sucks for sure. None of the seniors that we had for their senior practicum have jobs and it sounds like none of their classmates do either. I have heard rumors that Salem Hospital is hiring however and the VA too. But they're just rumors. Good Luck! Tom

Yep, push away, you're really only going to help. I responded to a code on a post-op day 4 CABG and ended up doing compressions. They went to the Unit and came back. I was helping a nurse with their bath and he said, "Be careful around here -pointing to his chest- it still hurts." But he was alive and later went home. The moral: just do the compressions. As for decompressing post-code, we all need it. It doesn't happen all that much, many times we just run back to whatever was interrupted for the code and carry on. Best of luck, Tom

I second the others thoughts above, don't beat yourself up, we've all been there before. One of the first codes I responded to I walked (well, ran) in with the code cart and went completely blank. I "woke up" as a second nurse pushed past me into the room! Now it's better. Don't apologize, thank them for their help. Tom

When I started on a 43 bed unit, we got abbreviated report on ll the occupied beds, the idea being you're able to help out easier and by aware of who might be in line to crump. We no longer do that, and the unit has been split in half. When I am in charge though, I tend to point out patients that may be either trouble or unstable, just as an FYI. We too have a printed unit census, but our managers are very accepting of it thankfully. When we're full, we can have 7 nurses, plus 1-2 aides, can't imagine having 12 patients...blows the mind! Tom

Many of our docs write parameters to ensure the meds get given, not held. When you have a CHFer on the "cocktail" (ACEI, B-blockers, lasix, et. al.) many times they need the meds, even when it seems like their pressure will not support it. If it is a chronic med then the effect will be less dramatic than if it is a new med. It's nice to have parameters to eliminate some of the gray areas that exist. I've seen parameters for beta-blockers, CCBs, ACEIs, hydralizine, nitrates, even lasix. Many times though there is some nurse discretion involved. For our post-op CABG/Valve patients, the holding limits for beta-blockers was SBP But back to your question, really anything that can change the hemodynamics could have parameters, but most often it comes down to nursing judgment. Good luck, Tom

Just because you're a bedside RN, doesn't mean it's all changing beds, cleaning poop, rubbing backs and whispering comforting words into the ears of LOLs. Sure, when necessary I'll do that, but also I'll be interpreting their rhythm, trying to figure out why they hypotensive, seeing if they need a tweak to their meds, how they're handing the drip, treating chest pain while shooting a 12-lead or watching for the signs and symptoms that their condition is deteriorating. There's plenty of science at the bedside as well. So maybe being at the bedside isn't for you. Big deal. It's not the end of the world. Nursing is so wide open that you can find your niche that speaks to your needs and desires. But I do think that if you feel this is just "doin' time" to get to where you want to be, you won't take the lessons available to be learned. Yeah, sure it sounds a little hippy-dippy, New Age estrogen influenced and maybe it is... At first, I chafed under the realization that the whole "CNA duties" was all I was doing, but you know, it's part of the game. I also came to realize that by being willing to the CNA-type tasks, I gained credibility with the CNAs, which in the end made my life easier. It's just part of the job that I accepted. Don't worry, find the niche and you'll be fine. Good luck, Tom

You just have to find your niche, like someone stated above. Don't go into the experience with pre-conceived notions of where you want to work - you may be surprised where you end up. I thought for sure I was going into the ED (emergency department) but instead am working on a Progressive Care Unit and loving it. Sure, there are many guys in the ED and ICU, but that might not be where you're truly happy. Good luck, Tom

You've got it right, take the number of QRSs in 6 seconds and multiply by 10. Because the rate is irregular you're not going to get an exact rate. That is unless you print a minute of strip and count, which is a little silly. The better way for calculating an irregular rate is the 300, 150...method. Counting each big box you get 300, 150, 100, 75, 60, 50. Counting from the first complex count the big boxes to get your rate range. This link gives a visual for this: http://medinfo.ufl.edu/~ekg/Rate%20and%20Rhythm.html Technically you shouldn't use the x10 method, but it gives you a quick idea of how fast the rate is going. Hopefully your instructor will take a range, because it is near impossible in a 6-second strip to get an exact rate. Good Luck! Tom

Actually, blood cx prior to ABX is a core measure for pneumonia. It is not required, but it goes into audits for our friends at the Joint Commission and reported on the hospital compare website. So it's neither a standard of care or a regulatory thing, it is an arbitrary measure of performance foisted upon us by a faceless commission. And we all know that evidenced based medicine and practice is something TJC is not too keen on (sometimes). Cheers, Tom

If someone develops a STEMI while on the floor, we can call in the cath lab team who are on-call 24-7. We've had a couple of times where the patient comes through the ER with mild symptoms and they are being admitted for observation, then start to extend in a bad way. Our typical protocol is to contact the cardiologist and they can decide to activate the cath lab if they feel it is warranted. Usually we're only calling them for new ST elevation and/or large jumps in cardiac enzymes. Sometimes they'll have us treat conservatively with nitro, heparin, Gp IIb/IIIA inhibitors, beat blockers (if appropriate) and morphine. Others they're in the cath lab in 45 minutes. Tom

If a patient is being admitted under our CHF order set then they get q6 basics and potassium replacement protocol. Any other patient who is placed on a Lasix drip is left up to the MDs discretion for checking labs and K replacement. If I'm the one to start the drip I do check vitals more frequently for the first couple of hours and obviously pay attention to the urine output, but we have no solid protocol for initiating the drip. Tom

I noticed this thread was originally from 2007, any further updates? In Arizona where I went to school, it is a felony to assault a health-care worker. They have signs all over ERs there noting this. There is no reason why we as nurses shouldn't have this sort of protection and a law would make it so that employers would balk at interfering with nurses reporting violence and getting charges filed. We've had run-ins with families at my work, I've had patients swing at me and have never felt that if push-came-to-shove, management would have my back (frightening, eh?). Now it's one thing when Mr. Demented Sun-downer swings at you out of fear and delirium, but it's something else altogether when a cognizant adult does it. For some reason we're just supposed to take it. What gets me is when the Hospital Association work against somehting like this. You better believe if someone walked in off the street into their office and hit them, they'd be filing charges in a heartbeat. Double-standards like this...well let' say it doesn't make me happy. Cheers, Tom