vampireslayer

I was reading that I should avoid soy sauce and red wine vinegar because they may cause a positive alcohol test result. And vanilla extract too. Are there any other foods that might cause a positive result? What about apple cider vinegar? Now I'm feeling paranoid about everything! I use red wine vinegar a lot! And I frequently use soy sauce in my marinades when I grill chicken.

I'm wondering what the benefit is to self reporting to tpapn, versus waiting to see what your employer plans to do with you, and letting them third party refer you to tpapn if that's what they decide.

I already mentioned this earlier, but wanted to reiterate, PLEASE think about the basics, the ABCs and the nursing process. If the question is about what you would consider for a patient just arriving, remember you'd always assess before acting. Also, on the ABCs, I found several, probably 4 or 5, where I think I probably got them right because I chose "A" (airway) over the "real world answer". The only example I can think of was about a patient who comes in hypotensive and tachycardic. In real life, you'd start a line and give fluids ASAP, but on the test, there's a "put the patient on oxygen", can't remember if they were also SOB, but in any case, I still think most of us would jump to the "C" and start an IV and give fluids, but I answered using the "A" answer, which was oxygen, and you don't get results about exactly which answers you got right/wrong, I remember thinking there were several questions just like that, and I passed with several more right answers than I'd needed for a passing score. VS

chicagobsn, i feel your pain! i went home MANY times in tears! in fact, i recall actually crying in the bathroom on break a few times as well. my preceptor was ex-military, an EXCELLENT nurse and he taught me well, but at the time, it was hell. i kept thinking "i'm too old to feel this stupid". although a different preceptor might help, please try to hold off on that for a few more shifts. i can tell you from experience, i had a friend who was precepted by a really good, but REALLY....harsh, i guess is the word i'm looking for, nurse. my friend ended up requesting a new preceptor, and even if it's not right and it's not fair, the word got around that my friend was a "know it all", was "whiny" etc. she would question her preceptor, and it came across NOT as "ok, help me understand why we're doing this" it was more "i disagree with what you're telling me we should do". make sure you're questions are very obvious attempts to learn, not to disagree. also, sometimes now when i precept, i can get the same way...we have SO MANY things we need to do, and it's easier when things get critical with patients to have the orientee go do the things i know they can do, while i make sure our crashing patient doesn't "go to the light". it is more helpful for the orientee to be right there in the thick of things, of course, and you should have been allowed to stay in that code, but in the end, we still have to make sure all our patients get the care they need. i'm not defending her actions, but i've been there as a preceptor myself and it's hard when you have a dozen things you know that need to be done, not to take the "easy way out" with your orientee, just to get caught up...with the intention that once you get caught up you can slow down and explain things. i don't know if this happens at your ED, but sometimes with us, when we have an orientee with us, we end up getting more patients, or more of the higher acuity ones, because the triage nurse or person who assigns the EMS stretchers knows there's 2 of you...you're SUPPOSED to be treated as one nurse, while you're working together, but when things get tight and there are patients who NEED A BED NOW, the preceptor/orientee team gets more than their fair share. that's not the way it's supposed to be, but it happens. i remember my preceptor taking another pt, then another, then another, until we were carrying twice as many patients as anyone else, and he'd have me running all over doing things on all of them...he pushed me HARD, but after orientation, i learned how to push myself when i needed to, because of the way he'd taught me. it was really awful at the time, but now i am grateful for what i went through with him. he was mean sometimes, and hard on me a lot, and i may have learned just as well with someone more gentle and supportive, but i do think in the end i learned a lot from him. good luck!! this too shall pass. VS Editing to add: didn't realize there were 3 pages to this post, and i missed your post about getting a new preceptor when i typed mine. i'm glad things are better for you!

Woo Hoo XIGRIS!!!!! CONGRATS!!! Did you find yourself dazed afterwards and unable to really recall the questions you'd had, like I did? In the end, which study materials did you find most helpful? VS

I remember going through this! EXACTLY THIS. Thinking "this is not brain surgery, why can't I get these?" I hate to admit, but just getting practice is the big key, but for some pointers, first off, make sure you're holding down the skin below the stick point so the vein doesn't roll away from you, and make sure that stick is fast, it can roll away so quick, you need to be quicker! Also, check out the vein you're going for while it's still wet from the alcohol or chloroprep. What I do when I can't find one is rub several common sites, (the AC, the hand, the thumb side of the wrist, you'll usually find a big one there) with alcohol first, just to see what it looks like wet (with a tournaquet in place). Then use the cholorprep or whatever is your protocol prep, and let that dry. Veins show up much better when they're wet so that's a good way to find them. And finally, I think what my biggest mistake before I finally got good at them, was I didn't know where the vein was going. I was "aiming" at the bulge I could see or feel, but you really need to see or feel the course of the vein, figure out which direction it's heading or you'll go right through it at a right angle to the vein! I know that sounds stupid, but I really think that I just assumed I knew, from the small section of bulging vein I could see, that I knew which direction it was heading. Feel it, look close, if you aren't sure, start lower so that the last 1/2 of your catheter ends up in the section of vein that you can see, in case it bifurcates right at the point you're entering. Not sure if that's clear, but I remember MANY times getting in and getting flash, and I couldn't advance the catheter...my preceptor would take over, redirect the catheter a good 45 degrees one way or another and it'd slide right in! And one last thing, don't give up if you get flash then get stuck...either it won't advance or it won't give blood...maybe you did go right through, you can salvage that without a 2nd stick. Pull the catheter out SLOWLY until it starts to bleed for you...draw the labs you need, if you need them, then flush it in with a saline flush and it often will just slide right in. Either you'd hit a valve, so it wouldn't advance, OR you'd gone through the other side, but pulling out you'd ended up in the vein and the 2nd puncture (if you went straight through) will seal itself quickly. Good luck! I really honestly remember feeling so helpless, when I couldn't get my IVs. Can't get anything going, no meds, no labs, until you get an IV, and it took me so long to master this! But you will do it! VS

I passed!! I just got home, and there is a big disclaimer at the beginning of the exam that says I can't reproduce in any way any of the questions from the exam. So I'll just give you what I learned about the studying materials. There were several people taking the exam at the same time, some CEN and others were resp. therapists, and some others. First off, I like the MED ED CEN Exam Review CDs by Jeff Solheim the best, as far as study materials, and liked the CEN Secrets the least. The CEN Secrets seemed to me like just an outline. Like someone who'd attended a lecture, learned stuff, took brief notes, and copied those notes into an outline. Now, of course, if I'd actually attended the original lecture, those notes are what I would have ended up with, but for me, I need to hear or read the original material first, not just a brief terms or outline of s/s. Now to the big shocker, I don't think you can really study for this thing. It's tough! I know I passed, so I must have studied ok, but still, I am shocked at how many questions I had to outright guess on, and how many I was convinced every single answer was the right one! And all the details I studied about specific disease processes, wouldn't you know those diseases were on the test, but not the stuff that I studied! Some altogether unrelated question! I know that one thing I did, was just without question chose "put 100% oxygen on" no matter what!! I don't know which questions I got right and which were wrong, but I do know that was an option frequently and I always chose it! You also have to keep an eye on what they are asking...like one question was asking about how you'd go about planning the patient's care, and all the answers were "implementation" answers except one assessment one. So even though all those implementations were things you'd really do, that's not what they're asking, they're asking about how to prepare the plan of care, which would involve assessment first. There were honestly things I was digging back into my brain that came from nursing school, that hadn't been covered in ANY of my review materials, neither of the 2 CEN Review classes, nothing. And some were so obvious they were laughable! It just covered the spectrum from incredibly easy to incredibly difficult! And finally, I think if I could give advice, I'd say get one good study material, a text book, a set of CDs, whatever, that covers systems, but honestly I do think sitting down and doing sample questions would probably have helped me more. Use Mosby or the one that ENA offers for practice questions. That may have highlighted things, not details on diseases, but thought processes to go through, that I could have used. I didn't do that cuz I HATE sitting down doing practice tests, even though every study reference I have ever seen advises you to do that!! I figured if I know the topic, I can answer the questions, but maybe??? I don't know, maybe it would have helped. But then again, I passed so maybe just studying the topics was enough. And by the way, I started studying in earnest a couple months ago by taking the practice test from the ENA website. I didn't look up the answers in a text book and try to choose the best one, and I didn't let it grade me as I went, I just sat down and took it like it was a regular test and got my score at the end. I got 84%, and my score on the real thing today was 84.7% so I think maybe that practice test is a good indicator of how you'll really do. Whew! I'm glad that's over with. Good luck everyone. VS

Ok everyone, it's time. I take the test this Friday. It took several weeks after I sent in my card saying I wanted to sign up, before getting the authorization letter in the mail that gave me the permission to sign up for the exam. I took the week off work, and have been going through a set of CDs while driving to/from work in my car during the last 4 months or so. It's hard to do that when I hear something that I know I'll need to write down, but can't take notes while driving! So this week my plan is to review, again, all the CDs (its the MED ED CEN Exam Review set of CDs), while taking notes only on the things that I didn't know or think I'll need to memorize, like the locations of STEMI and which areas (lateral, septal, inferior, etc) are infarcting if certain leads show ST elevation. Also things like the Parkland burn formula. I KNOW this info, but have taken notes just to review it before the exam. Now I'm done with the CDs, have 4 pages of notes to review, and will review those today. Then I'll move on to the rest of my study materials that I've accumulated over the year that I've been planning on taking this test: Mosby's CEN Review, Sheehy's textbook, the ENA CEN Review book, and the CEN secrets. On all of those, I am going to concentrate on Neuro, Respiratory, Cardiac and Ortho, because those have the highest % of questions on the exam. I feel like I've got enough review and work experience in the other areas, and I only have today and tomorrow to review, so that fills my plate for these next 2 days. I'm studying throughout the day, taking frequent breaks, and trying to wrap up by evening, 6 or 7pm, each day. No point in overloading my brain and not retaining it all. So I will take the test Friday June 6, and will come back and let the rest of you know how I did. Does anyone know the legalities of actually giving out any questions or topics that I remember from the test? Seems like somewhere on the NCLEX there was some statement that said you weren't allowed to discuss the questions afterward. Is that the case here? If i can't remember exact questions, I will at least try to remember topics that showed up on my exam, to help the rest of you. VS

well, i started out trying to study a little every day, and i did that for a while. i have lots of study materials available, keep hearing about more and i guess i think if i throw enough money at this, i'll pass! so i keep buying more! anyway, i did go ahead and buy that "CEN Secrets" thing too, haven't looked at it too close yet but got one good thing so far out of it for ME: don't overy study. if you are at a level that you can pass, then you've studied enough and just take the stupid test. i know there are people who'd taken it several times cuz they didn't pass, but for me, i tend to take tests well, always have, got great grades (straight A's) in nursing school (not bragging, it's just that i retain things, and don't get test anxiety). so what i did was take the sample exam on the BCEN website. it cost $30 to have it graded, and once you grade it you can't go back and review it over and over, but it did have the reasons why each answer was right, after it was graded, whether you'd gotten it right or wrong. by the way, i scored an 84% so I figure that's good enough to pass the CEN. Now of course the sample was only 50 questions, NOT 175, but overall, i think i already have the basic knowledge and don't need months of study. so i went ahead and sent in my card to request "permission" to sign up. if understand the process right, i'll get an email or card in the mail saying "you now have 90 days in which to take the test. sign up for your test date on this xyz website". so i haven't gotten that yet, but as soon as i do, i'll give myself something like 6 weeks, and then take the test. so my game plan is to use all my study materials, sheehy's, mosby's, dr. laura's, and the "CEN secrets" clinical parts (that one has lots of test taking strategies too) and concentrate on cardio, resp and neuro. then i'll study the other stuff as my study time (6 weeks) runs out. and just hope for the best. its not a great, well thought out study plan, but i have the materials here, i have the basic knowledge and the experience, so i think at least this first time that's what i'm going to do. no sitting down with a calendar and figuring out # of hours to spend on each topic, # of review questions to take each day etc. NOT that those aren't great ways to study, just that i am hoping i can do this more casually. we'll see! i'll let y'all know. VS

Our ER is trying to revise our triage template (computer charting) to remove any questions that are not needed at triage. Not saying we won't ask them EVENTUALLY, once the patient gets back into a room, but to avoid the backup that we've had, where people may sit out in the lobby for an hour before anyone ever speaks to them, we're trying to find ways to triage faster. We've had nurses say certain questions MUST BE ASKED during the triage process, as per JCAHO (I think...and maybe EMTALA??). We're screening for suicide & abuse, of course, TB, fall risk, alcohol use, drug use, smoking. All that along with an assessment. So what REALLY HAS to be done at triage, and what can wait until the patient gets a bed? I really think the problem is that the new nurses (who shouldn't be in triage in the first place, but that's another story, staffing is stretched to the limit right now) can't do a quick focused assessment. Their triage takes way too long, and we get backed up. NOT because of the previously mentioned questions, but because they're assessing every little thing rather than doing a focused assessment. Obviously quicker assessments will come in time for all of them. But for now, what exactly are REQUIRED triage screening questions, and what can wait until the person gets a room? Can anyone give me a sample of exactly what is asked in your ER? Our assessment screen even has things like "behavior" and "appearance". That's appropriate if the person is suicidal or homicidal and the behavoir is "agitated" or "combative" or whatever, but 99% of the time, nurses will write "apearance is uncomfortable" (yeah, duh, they have abdominal pain of course they're uncomfortable) and "behavior is cooperative" (that doesn't help me, where as agitated or combative might). Same with respiratory...most nurses think it's crucial to chart ALL the Resp. fields "breathing is even & unlabored, airway is patent, breath sounds are clear bilaterally" while others are happy with "no deficits noted". We have LOTS of that, where some nurses are fine iwth "no deficits" and move on, while others insist upon charting "abdomen is soft & non-tender in 4 quadrants, bowels sounds present in 4 quadrants, denies n/v/d" even when the chief complaint has nothing to do with GI! And cardiac is another one that most people feel is crucial to at least chart "denies chest pain, denies SOB", they won't just chart "no deficits", and they won't skip the field altogether. Dermatologic "skin is intact, warm, normal color and dry" rather than "no deficits" or skipping that field altogether. We are "supposed" to be charting by exception but they feel they need to "CYA" by charting all of it...hence triage is taking a few minutes longer for each patient, which isn't a big deal until you get 15 people behind that haven't been triaged. So what are our legal (or EMTALA or JCAHO) requirements on charting and screening in triage? And what are our liability risks for "no deficits" or not charting something at all? I've never been involved in a court case where my charting came up so I honestly don't know how to help the triage committee pare down the process within legal and liability constraints, and we have nurses who simply refuse to triage any way other than the way they've always done it, which is a complete and full assessment (with NEVER a "no deficits noted" comment)! Maybe they're being smart and I'm naive, and if so, I need to know that! Any help would be appreciated as we try to streamline our process. VS

Sounds like we have a lot of review sites & materials to choose from. My problem is I get overwhelmed when I have too many choices! Even in a restaurant, I can't stand it when I get a menu that's pages and pages and pages! Just give me a few things to choose from, please! Anyway, I am PRN and we get NO incentive to get our CEN, other than "personal satisfaction". Ok fine. My hospital offers full time employees reimbursement for the test fee, but not for me. But even so, I am so happy with the flexibility of PRN, working only when I want, picking up 1/2 shifts or 3/4 shifts whenever I want to, that I wouldn't trade it for a full-time position anyway. CENs at my hospital are fairly rare I think. Maybe 10% of our ER nurses? I'm just guessing, it might be even lower, but not common, I know that. VS

I've gotten several emails, some from the hospital I work at, some random emails from schools that somehow got my email address, about "RN to BSN" for ADNs. I have my 2-year ADN, I'm an RN in the ED at a great Level 1 trauma center. I like my job, it's a 2nd career and have already gone down the path of teaching (I liked it OK, but don't plan to go back) and management (yuck!) from a previous corporate career. But for some odd reason, I feel, maybe because of all these "RN to BSN" offers, that I SHOULD get my BSN. I can't get into management without a BSN, but I don't want to! I can't go back to a nursing school and teach without my BSN (and MSN), but I don't want to! I like bedside nursing, I've only been doing it for 2 years now so maybe that'll change as I get older, but for now, I love my job. I am a "straight A's" kind of person, so when I was in nursing school, it dominated my life. I studied all the time. I have 3 kids and would continue working if I went back to school so I am sure I would expect myself to get straight A's again, and I'd obsess about school for the entire time I was going. Sounds like a lot of work and no fun. I don't understand this feeling I have, it's kind of a feeling that ADNs are just "inferior" although I don't believe that I am...it's sort of the LVN vs RN concept in my mind, ya know? ADN vs BSN. LVNs (LPNs) are being "phased out". Same thing here: I have been told that in the future, some hospitals won't hire ADNs at all...but with such a huge shortage I don't see that happening any time soon. I know Magnet status is based on having a certain % of BSNs, I think that might be where some of my feelings of "inferiority" come from, I work at a Magnet hospital. So what do all you BSNs and ADNs think? Is it worth it? Should I bother? Why do I even consider it? My sort of "informal" life plan is to wait until I become interested in a new job, and then get turned down for it because I don't have my BSN...then that'll spur me on to get it. If that never happens, then I guess I never needed it. VS

I started studying about 6 months ago, then it kind of went by the wayside when something came up...can't even remember what it was that interrupted my studying! I was all excited about it, attended a CEN review course offered at my hospital, bought several review materials, then....nothing! So I'm going to start again, and try to take it over the summer. Mosby's CEN Exam Review was recommended to me by another nurse. I could only find a used one, maybe they don't publish it anymore, and all the ones I found online were missing the CD that gives sample questions, but it does have questions in the book. What I liked about this book is that the sample questions are organized by topic, whereas another book I bought, the CEN Review Manual published by the national ENA is just a whole bunch of review questions. They're good questions, gives you the rationale for the right answers etc, but it's organized like a sample test, just random topics thrown together. I like to study system by system, ya know? And THEN I bought the ENA's Emergency Nursing Core Curriculum. I thought it would be like a textbook (I'm a geek, I LIKE reading textbooks!), but it's not. It's in outline form, not in paragraph form. Really hard for me to get into, to read. I was given Sheehy's Emergency Nursing Principles and Practices when I started my ER nursing orientation 2 1/2 years ago, and it's a basic textbook, and pretty good. I think I'll spend some time reading that. Ok, FINALLY, I got the CDs of Laura von Frolio. I listened to them in my car, and will go back and listen again soon, but I did worry it was outdated. First off, no there are NOT 250 questions anymore. If you read on the ENA website, there are only 175 (I think). Anyway, that worried me, if that info is outdated, how much of the rest of it is, and I just don't know it? Like, she uses "Dilantin" for all sorts of things, but we NEVER use Dilantin anymore. For seizures we use Cerebyx, of course actively seizing we use Ativan, but the lecture mentioned Dilantin in all sorts of other ways, nothing to do with seizures, and I just don't ever see it used in my ER. I actually contacted them, and asked if the material is reviewed for up-to-date changes, and gave them the example of the # of questions on the test, which was clearly outdated, and they of course assured me it was all still valid. Also, the CDs were simply someone recording one of her review classes, and while it is very entertaining and she is a wonderful and interesting speaker and obviously incredibly knowledgable, I was surprised at how poor the audio quality was. Sometimes the sound went out completely for a minute or two, then came back on. Usually it sounded like whatever material I missed was repeated, but you'd think if they're making money off this they could edit out the audio errors like that! Anyway, so I have bought lots of books but don't really have a study plan. There's another CEN review course I'm going to take in a few weeks, hopefully that'll help me get motivated. One thing I did realize, a "word of advice" was that when I attended my first CEN review course, a lot of the stuff was review, a lot was just "oh yeah, I'd forgotten but now I know", and then there were things that were totally "uhhhh, I NEVER knew that". I thought (stupidly) I'd remember what things I needed to go back and review, but of course I didn't, after walking out of the auditorium I forgot everything I'd told myself I needed to re-learn and review, so next time, make sure you keep notes on things you feel the need to go back later and review. I was making notes in my notebook but then couldn't find them all later, so this time I'll have a separate sheet of paper of topics to review on my own later. Good luck to us all! VS

OMG, I think we work with the same woman! I have one that is just exactly as you describe. I'm not much of a "confronter", and I don't think it works most of the time anyway. The whole "clear the air" idea generally results in more animosity, from what I've ever seen. I agree with everyone who said that if you do speak to her about it, don't do it alone, I guarantee it won't go well! She's already proven she won't be receptive to reasoned conversation about your working relationship. In my case, the only time I ever sort of confronted her (after many instances just like the ones you mentioned) the nurse rolled her eyes at me when I did something, can't even recall what it was, and I lost it, just outright said "WHAT IS YOUR PROBLEM???" Any normal person would have replied "nothing, nothing at all", but of course, witch from hell couldn't just deny, she said soemthign about "well I just don't see why everyone has to try to make everything so complicated"...had to do with me & a tech, and possibly a 2nd nurse, if I remember right, doing a bunch of things with a patient at triage, all at once...you know how it appears chaotic when there's a lot of activity going on, when in fact it's just a lot of necessary tasks being done all at once. Anyway, I ignored her. And now, when I see her I just look directly into her eyes, with absolutely no expression whatsoever, I just want her to know that I see her, I know she's there, I don't greet her, I don't do anything, I just look, then walk away. Sorry, that makes me as big a witch as her I guess...but the "kill 'em with kindness" didn't work on her, not at all, made her more condescending, the small confrontation (the "what is your problem") had no effect, so now I just make every attempt to ignore her existence. She does the same to me. She has a core of friends, she's been there a long time, I just don't get it, she instantly took a dislike to me. But I've also heard other people say the same thing so it's not just me.. We do currently have a program going on right now that's specifically about "horizontal violence" in this very way, people being condescending, trying to sabotage others, the whole "nurses eating their young" thing, and our educator is leading this initiative. It's more trying to reward the opposite behavior, rewarding people who have shown that they're helpful to their coworkers, rather than punitive to the people who are mean...but our educator is also a friend of mine so I did give this person's name to her, just on the off-chance that she might hear that name again from some others, and it might go somewhere. I don't plan to escalate it myself, but if that name is brought up about that subject enough, maybe someone will look more closely at her. Who knows. So anyway, no advice, I know I don't handle it maturely, but I dont' want a confrontation with her, I dont' want to escalate anything, and I don't work with her often, so....I feel your pain! VS

I have SOOOO been there! I was a new grad in the ER, and stressed myself sick for months! One thing you never mentioned but I thought might be an issue is the fact that you were a tech. You have skills that the nurses don't, so I wonder if you're doing things that other nurses would request a tech to do for them, just because you know how to do it? Simple things like wound care, splinting, arm slings, crutch training, foleys, NG tubes, our techs do those things. I know some hospitals require the nurse to do some of those things (esp NG's and foleys) but ours doesn't. Doesn't mean the nurses can't do them or don't know how, but those are some of the things we can delegate to a tech, to help keep up our pace. Techs can also draw blood (can't start IVs though, but can draw blood and blood cultures) and at some hospitals techs can do d-sticks (ours can't). Anyway, my point is maybe you could lighten your task load a little if you sit back and think of things that can be delegated to techs, but that you're still doing on your own? It will get better, really. And the chest pain had priority over the DC, at least until you get them on a monitor and get IV access in them (had a CPR just yesterday, SOB, just came in, not on the monitor yet, no IV access yet, was talking when she arrived, then crashhhhhh). You can't do more than one thing at a time, just set your priorities. Sounds like you really do know what you're doing, it just takes time to get the speed up. VS

Sorry I didn't take the time to read all 8 pages of replies so this may be a repeat, BUT the absolute most useful feature I've seen on a scrub tob is a set to 2 pen pockets on the shoulder. They're 2 side-by-side, and narrow, so they'll hold your sharpy for writing on blood tube labels in one, plus a regular pen in the other. I have only ever seen this feature on MOBB brand scrubs, and it's always on the left shoulder (I'm not talking about the left breast pocket that's in front, I'm talking ON THE SLEEVE itself). I've had many many comments from other nurses who see it and think it's really handy-looking. However, since I'm left handed, I'd prefer the opton to have my pen-pockets on my right shoulder, so I could reach across, grab the pen, and use it immediately. As it is, I have to reach with my right hand, exchange it over to my left hand, to be able to write. But I never lose my pens, they never fall out because they're deep enough, and narrow enough, to hold them in place when I bend over. Check out a MOBB scrub top to see what I mean. Might be nice to have them a tiny bit wider to accomodate those fatter ball point pens, but then again I'm not sure if making them wider would cause the normal size pens and the sharpy felt tips to slide out when I bend over. VS

Read all the tips in the threads that were posted above. I went through this very same thing, could NOT get an IV when I first started. I got so frustrated, kept thinking "jeez louise, this is not brain surgery!" but I just couldn't do it! At first, even the easy ones, the big ACs, I could get in but couldn't advance! What I found helped me, for one, with the ones that won't advance, try to figure out the angle of the vein before you ever start sticking. You need to know which direction that thing's going, sometimes it's not obvious until you feel (with your eyes closed, that really does help). Make sure the thumb on your other hand is holding the skin taut so the vein and the skin don't move once you insert the catheter. Sometimes using an alcohol wipe, or your hibiclens prep or whatever, to wet the skin, makes the veins more easily seen. Make sure you look up along the vein further than just the insertion site, look for bumps that indicate valves, bifurcations, twists and turns (which you can often straighten with some pressure from your thumb), because you have to make sure the entire catheter, once fully advanced, has a nice straight shot. Look at upper arms more often. Lots of people stop looking once they get up to the AC, but I've had lots of luck with upper arms and shoulders. Same with the inside of the wrist. There's more nerves in this area and can be painful, but if you're very careful, don't go too deep, and MAKE SURE you aren't aiming at a tendon! I've seen someone do that, boy that's painful! Feet are options too, if they aren't diabetic. Not ideal, but it works. I hate to say this, because I heard it a million times when I was where you are now...it just takes practice and time. It really does. I started an IV last week, first try, after 3 other nurses had stuck the same patient a total of 6 times! And for me, I'm not afraid to go down to a 22 gauge, if I have to. I know lots of people won't even consider that, they want a 20 or 18, and keep sticking and sticking. From my experience, a well placed #22 will give me a nice fast flow of IV fluids, will flush just fine, and I've had CT use my #22's for IV contrast with no problem, even though they usually "insist" that they need an #18 in the AC, and my #22 was in the wrist! That might depend on the policy of your department and your CT people though. And for some reason, I always get the #22's, especially the ones in the upper arm/shoulder area. Good luck! VS

I would guess (hope) your ED has a set of protocols for common complaints, get a hold of that. (Chest pain-CBC, CMP, troponin, chest xray, EKG, oxygen. Abdominal pain- CBC, CMP, amylase/lipase, UA and UA HCG if female of childbearing years with no hysterectomy). At the very least, try to gather everything necessary to get the patient monitored, locked & labbed. So as you enter the room, or walk your patient to the room, (however that's handled at your facility) make sure you already have your BP cuff, your cardiac leads, your pulse ox, IV start supplies, all the necessary blood tubes. If it's in any way abd pain/flank pain, get the urine sample right away before you start everything else. I'll intentionally walk them by the bathroom first, before even entering the patient's room. Get your entire rainbow (all the blood tubes) regardless of whether or not you think the doc will order everything. Try to develop a standard set of assessment questions, you'll see common threads come up as you see specific types of patients...if they have chest pain, is it sharp or dull? More like pressure? If so, then off you go on the cardiac route, any pain in the left arm, shoulder, jaw? Diaphoretic? Nauseated? Short of breath? If it's sharp pain, worse when they take a deep breath? Coughing? Any woman of POSSIBLE child bearing age with a uterus should get a UA and a urine preg. Try to get IV access as soon as possible and get them on that cardiac monitor (and admitted to the central bank of monitors) as quickly as possible...so if they do go south when you didn't expect it (duh, they didn't LOOK that sick), they can be cared for immediately when they call the code! There's nothing worse than getting a patient back from their xrays to find they're profoundly diaphoretic, decreasing LOC, BP in the 50's, and NO IV ACCESS (ask me how I know, no, it wasn't my patient)! Try not to let them go anywhere without IV access! Go back to the charts of your patients that you've started, and see what other things the docs ordered on them that you hadn't thought of. It's a great learning experience. Ask the docs why they ordered what they did, if that's something you should consider initiating (labs/xrays/whatever) yourself. Come up with a standard report to the doc that you can rattle off in 30 seconds: Age, history, complaint, and whatever vitals you find abnormal, and usually, once you get more experienced, you'll finish up with "do you want ____________" as far as labs, xrays, CTs, meds, and the doc will just agree with you! But until you're comfortable with that, just stop with the brief report and ask the doc what he wants done before he gets in the room. I dont' know if that helps, or just makes you more stressed! My biggest and best advice is to watch what happens with all the patients you can, not just yours, any of them. See what their complaint was, what their final diagnosis was, how the doc determined that, what labs were ordered, what scans were ordered, and why. Good luck! VS

I wanted to second some of the things oldiebutgoodie just said. I was one of the first few "rah rah" posters on this thread, and yes I still think you should go for it, but YES, nursing school is TOUGH. It's much tougher than you'd think, I remember staying up until 1 or 2am working on careplans, drug cards, etc. They are VERY tough, it truly does appear as though they're trying to weed out the weak ones. I saw MANY people fail out of nursing school, even though they may have been successful in previous careers. And as far as being a newbie on the floor once you're out, that's true too. There are lots of nurses and doctors who don't want to have to train yet another new grad, it slows everyone down and they resent it. Everyone has to start somewhere but somehow they forget that. I remember more than once thinking "i'm too old to feel this stupid!". I also remember thinking, many many MANY times that I'm just not USED TO feeling dumb, inadequate, I was always good at anything/everything I tried. But my first few months in the ED, I felt stupid so many times, had people laugh at something I did or said and literally cried in the car on the way home! Sometimes I didn't even get to the car, I was in the bathroom crying, because someone had yet again made me feel like an idiot! Having said all that, I made it through. The one year mark people talk about didn't do it for me, maybe I'm a perfectionist, but it took me a full 2 years to feel as though I'm competent and really good at my job. But I got there. So yes, nursing school is very very tough, and so is the first year or 2 after graduation. But you can do it, if it's what you want to do. VS

DEFINITELY go for it! I had been in a corporate business environment since graduating college (the first time), 16 years or so, and then went back to nursing school. I graduated nursing school at the age of 40. NO there will be no disadvantage to being older, although you don't mention how old you are. Somehow, no matter how scared or nervous I was (I work in the ED, went there straight out of school) I repeatedly got comments about people who were surprised to find out that I was such a "new" nurse. They all assumed I'd been an ED nurse for years. I honestly think a lot of that is my age, people just assume it based on the fact that I'm older. A 22 year old, behaving exactly as I do, would be looked upon as a novice. It's not fair, but I think it's true. So I felt like I got more respect easier than the very young nurses who go straight into nursing school from high school. Of course, that wears off very quickly and you have to have the knowledge to earn that respect...I just think it comes to us older nurses easier than the very young ones. Also, in my job interview, I stressed the fact that I have "life experience". I have managed people in a supervisory role as well as having dealt with other life situations and stressful situations that a 22 year old just hasn't had the chance to do yet. I intentionally brought my age into the interview as a positive thing, just to head off any negatives that might come up about it. As far as the school and the studying, I found that I took it ALL so much more seriously than I did the first time I went to college (when I was 18), because I realize now that it really does matter, they really are trying to teach you things you need to know (well...okay, not all of it, but you know what I mean). So all in all, I think being older was an advantage for me. VS

What about the lengths? I just checked it out and would prefer to buy something other than black, just so it would stand out more, harder to "lose". I'm specifically looking at the Littman Master Cardiology, which comes in 22" for black only. All other colors are 27". The stethoscope I have now is 22", and I'm fairly short (5'3")...would an extra 5" make a difference? Get in the way? VS

We don't do paper charting, and in fact I've NEVER done paper charting! I have only worked at one hospital, and we've always had computer charting there. Having said that, I really like the option to do bedside charting, since we have PCs in every room. That way I don't have to try to remember when I did something, I chart it all right before I leave the room. I can see that it would definitely slow you down to try to chart an entire assessment by hand, and have no real solution to that, but I would think that you'll soon get used to jotting very quick vitals, meds given, etc, which will free you up from having to that "catch up" charting. So I have no good advice for you on any of that! BUT I was thinking about what you said about leaving the chart in the room for anyone to see. I can see that's a terrible idea, what about HIPAA? SURELY that has to be a HIPAA violation, as there will be visitors, family, etc going in and out of that room who have no right or need to see that patient's information. If you want to try to fight this issue, that's the route I'd take. You can't just leave that info. lying around for anyone to glance at. If management doesn't agree with the HIPAA angle, if I were you I'd make sure that the papers were at least face down on the clipboard. It takes very little effort for someone to sidle on over to where the chart is lying and glance at it, but if they have to turn them over to read them, it's just a little more difficult and would take just that extra couple seconds that might discourage them from trying, for fear of getting caught "snooping". Another option I've seen is to have a hook outside the room where the clipboard is hung, with the pages turned over so the blank back sides are showing, for privacy. Then you can chart after you leave the room, and most patients wouldn't have the nerve to stand outside their room to get their chart off the hook and read it, where anyone who walked by could see what they were doing! That also has the advantage of allowing any nurse or doctor who's about to enter the room to read through the notes to get the patient's background and what's been done with them so far, before talking to them. VS

I was wondering if anyone knew if, in general (I assume difference insurance companies will have different policies), an insurance company will pay for services if the patient ends up leaving AMA? I'm not really concerned about those people who come in and waste my time and resources, then want to leave...I mean, why come in if you don't want to be helped? But what about those well-intentioned people who really did need to be there, the n/v/d who needed the fluids and meds, and then just need to be discharged? They've had meds, labs, xrays/CTs sometimes, ($$$) and have to wait for HOURS for the ER doc to review all the results and discharge them. They feel better and they just want to go home! I really sympathize with those people. I mean, we're all busy and doing the best we can, and the ER docs are swamped, but these people just want to go home. If they leave AMA, because they don't want to wait any longer for discharge (or what if it's an admit and they don't think they need to stay), will their insurance company pay for the services, or will these patients get stuck with a huge bill? Just curious. VS

I learn so much every time I log on here and browse the threads. I like the ER specialty forum, but learn a lot from the General Nursing discussions too. There is so much to learn in nursing, and so many things that you forget if you don't do them regularly. I learn something new every shift I work, and often find that something I read makes SO MUCH more sense if I've just recently experienced it at work...if I'd read it without having seen it at work, it wouldn't have sunk in as much, ya know? So I read a lot, I read here, I get a nursing magazine, I think it's Nursing 2007 (or is it RN 2007? can't remember, I just know it's a good general monthly publication). I just recently pulled out my Emergency Nursing textbook that I was given in orientation and have started reviewing some of those chapters too. So I was just wondering where everyone else goes to keep yourselves educated? Any other good sites you like, or good monthly magazines you subscribe to? VS

Wow, I'm surprised you haven't gotten more replies by now. Makes me feel like maybe it's just you & me! Because, yeah, I'm right there with you! Well, not all the time, but it's been a year and a half for me too, and I also feel nervous and edgy on my way to work, I think about work all the time at home, after coming home from work I have a hard time sleeping because I'm always running through various scenarios in my mind, what would I do if....xyz happened....what would I do first, then next, etc etc etc. I work in an ER so mostly traumas and CPRs are what I think about, MIs and strokes, anaphylaxis, stuff like that. I find that when I make a mistake, or even when I almost make a mistake then catch it, I agonize over it for weeks, thinking about how I should have known better. But the good news is that it's getting better all the time, I'm getting more comfortable as I become more knowledgeable. And I read read read. I have just gotten my ER textbook out again and am reading it cover to cover. I read here on allnurses, I read nursing magazines, I have a Critical Care handbook that's really good. So I figure that at some point I will have seen and dealt with just about every major medical emergency or trauma that I can, and will be more and more comfortable as I gain that experience. One thing I did decide though, recently, is that because I've been having trouble sleeping, that I need to stop reading textbooks and nursing educational stuff at bedtime. I think it makes me think about it too much so that I can't get to sleep. I am going to start reserving my educational reading for day/early evening, but not right before bed. Since I'm not in oncology I don't know about ratios. I have made a conscious effort lately to change my attitude at work. I am usually very hard on myself, trying to get everything done right away. I see myself racing up & down hallways, for example. So last shift I decided "I can only do what I can do", if you get my meaning. I mean, no one can do everything at once, you can only do one thing at a time, and a nice brisk pace is fast enough, I don't have to race around all shift. Anyway, my point is you are not the only one who still feels the anxiety even after all this time, but I really feel that it's a combination of continuous education and attitude that will help. Good luck! VS