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  1. chemshark

    Vanco Infusion Description

    Hi, I'm trying to create a mobile nursing app. It has a section on Vancomycin (see below). Could you please take a look at it and tell me if the description is dead-on and if there is anything else you'd like to add? Thanks... --- MEDSURG APP: Vancomycin Infusion INTRO As with all medications given, a dose has to be administered to the patient where it reaches a therapeutic level. That is, there must be enough medication concentration to help the patient, but not so much that it causes excessive toxicity. You must maintain a balance. REASON FOR THIS METHOD Nothing applies to this more than vancomycin (Vancocin) infusions. In the United States, the common way to give vancomycin is through intermittent infusion (II). Other countries prefer to continuously infuse (CI) vancomycin rather than intermittently with dose adjustment. Both methods have their advantages and disadvantages, specifically that CI is convenient and relieves the patient and nurse from constantly monitoring the serum concentration level in the blood. That means, less blood draws that have to be drawn 30 minutes prior to the next dose (STAT) and cannot wait due to the time sensitive issue. However, II allows the medical team to adjust dosage at different times to find a custom dose for each patient that works for them. PHYSIOLOGICAL CONSIDERATIONS: Terminology Therapeutic level - the serum concentration level needed to effect the patient's healing process while effectively avoiding adverse events Minimum effective concentration - the area amount of medication that does not harm the patient (but does not benefit them, either) Toxic concentration - the point of area serum concentration where the medication does more harm than good Onset of action - the time it takes for the medication to become therapeutic Peak action - the highest level of serum concentration Half-life - the time it takes for the body to nullify half the medication given in the body Trough - the lowest level of serum concentration (30 min. before the next dose) Duration of action - how long the serum concentration stays in the therapeutic level NURSING CONSIDERATIONS: When you are given orders to administer vancomycin, after verifying you must understand why you are giving the medication. The vancomycin works by attacking the beta-lactam rings of bacteria, albeit in other ways from conventional antibiotics (The Complete (but Practical) Guide to Vancomycin Dosing — tl;dr pharmacy). However, it must reach areas that house bacteria, such as the blood brain barrier (BBB). Current vancomycin consensus guidelines promote aggressive dosing to achieve trough levels of 10-15 or 15-20 mg/L, but also include recommendations to target a daily area under the curve (AUC24 ) to minimum inhibitory concentration (MIC) ratio of at least 400 (Waineo, 2015). So watch for doses to achieve this level. Look for the trough results and see if they achieve this amount. The area under the curve (AUC) is a level used to determine how much dose is present in the body and is determined using classic calculus methods. It's best to leave this to the pharmacist but an awareness of this is useful to the nurse. Just know that you want your patient within 10-20 mg/L trough level (refer to your hospital policy). Vancomycin is used mainly as a last result medication....
  2. ...but he needed to have his Foley changed because it was time. So I went in there. But his wife was there, too. She helped my preceptor & I change her husband's diaper but then stayed when I opened my sterile field to insert the Foley. "No no no! Put the iodine in the tray first. The TRAY FIRST!" She would screech over at me. Apparently, she's the director of staff development over at her nursing facility. How she became the director with an attitude like that, however, is beyond me. She continued to scream at me and criticize my technique which was NOT helpful to me at all. NOT AT ALL. I couldn't cover my ears because I had my sterile gloves on. So I just took a breath, cleaned the penis with sterile technique and gathered my equipment. "Let me have that catheter cover. I will pull it out, you just stay sterile! STAY STERILE!" My preceptor was shocked and stood still. He couldn't get a word in edgewise because of the tone and rapidness of her shrill voice. I had to take a breath. He clearly wasn't going to help me, so I had to try to ignore the woman somehow. "Hold his penis with your whole hand, not just the fingers!!! Lift it up! Feel the base with your pinky! ARE YOU LISTENING TO ME?!!!!??" She clearly wasn't going to leave me alone, and all the blood was shunting to my mouth to try to keep it shut so that I wouldn't yell back at her. So again, I took a breath, and decided to compromise. I let her help me. This didn't stop her squawking, but at least it re-focused her attention on her husband rather than just on me. When I finally inserted the catheter, the husband squirmed and wretched in pain. "WHAT ARE YOU DOING? YOU'RE HURTING HIM! BUT KEEP GOING! Don't stop. I SAID DON'T STOP!!" Goodness. "Think, Howie, think." I said to myself. I had come across a rather large obstruction. I thought about anatomy and that the male's urethra is longer than the female's. So I knew I had quite a lot more tubing to go. But every time I tried to push through the blockage, the husband would scream so much that we had to close the door! There was no way I was going to stop and do this all over again. Then I thought about pathophysiology and remembered that men his age usually have an enlarged prostate (I think I remember reading this on his H&P). And patients with ALOC usually have a lot of infection and debris inside their urethra due to poor personal hygiene. So I made a decision to ignore the woman, ignore the cries of the poor man, and decided to retract just a tiny bit, and bore the catheter past the obstruction. Watching the urine come out was like finding treasure. Inserting a Foley is one of the most basic nurses' skills but doing it while under pressure and still getting through felt like some sort of a miracle. The first few mL of the urine came out with red blood clots. Afterwards, the shrill woman kept badgering me about this & that. It was as if everything wrong about her husband was entirely my fault. I wasn't the one who gave him brain cancer. I was just trying to keep him alive. Even when I was about to take off my gloves, she accused me of touching the vitals machine with them. The room was already full of C-diff! What more was I going to do?? The terrible woman finally calmed down once she saw that I had successfully performed the procedure and that my IVs were infusing into her husband as planned. But before I could leave the room she continued to try to lecture me about proper technique. "You need to never stop once you insert the catheter. Keep going and don't stop! You have to feel the base of the penis with your pinky! Nothing is wrong with his urethra! You just have to hold and SQUEEZE the penis straight out! Like this. Like this!" At this point she's wiggling her fisted hand back and forth like she was having a seizure. "Yes, ma'am. I see, ma'am. Thank you for the lesson." I wanted so badly to show her the clot and maybe even point out that, as a male, I know a little bit more about penises than she does. Then when the intern came in, the woman was SO SWEET to him. The intern even said, "Oh, you know your husband has C.diff but even though we're not entirely sure, we have to put him on precautions just so we don't spread it around. You know, the nurses here *think* that they can smell who has C.diff but, hahaha, they really don't understand. (He didn't even know that the woman was a nurse). Ughhh--to BOTH OF THEM *eye roll*. I held it inside. Even my preceptor said, "Wow, I would hate to be her student. She does not know how to create a learning environment." No, she does not. But then I saw her fussing about the room and squawking at her husband too. Then I thought to myself--her husband of probably 60 years is dying in front of her eyes. I watched her talk to basically a living puppet. And then I felt sorry for her. But I still didn't want to be her friend, that's for sure. Seeing her like that was enough for me to at least pop in once in a while to make sure they were ok. She was never nice to me, and I would resent myself every time I went in the room, but at least I didn't feel spiteful. (Well, maybe a little. I'm writing this, after all.) The patients here in med-surg aren't all that exciting, but I've learned quite a few nursing tricks that I can bring to my practice that will help me in my career. However, now that I'm warming up to juggling a few patients, I find that bureaucracy, emotional games, and even sexual behavior among staff are still rampant! This all takes up a lot of a nurse's time and I'm trying to learn how to stay efficient. For example, we give a lot of IVPB antibiotics here. I usually hang around 10-15 a day. I don't administer, but I do everything including picking up from the pharmacy, priming the tubes, flushing the line, verifying the order, programming the rate, attaching the tubes to the patient. The only thing I don't do is pressing the 'Start' button on the Alaris. My preceptor was sick one day, so I went with another preceptor who was a lot less intense. He believes in charting by exception (thank God). He also prefers to switch tubes of the same piggyback med rather than starting with a whole new set. Therefore, I was able to save time by verifying the same medication, and continuing the infusion using the same tube and flush bag. If the pump alarms, then I know I have to change the tubing anyway. I also learned how to prime the secondary tubing upside down if I'm using the same flush. It's a very useful technique that I've only seen once before. It's a complete time saver! We also mix a lot of insulin. This throws off my regular medication administration schedule because it's not just pills, it's taking the blood sugar and waiting for meals to come in. It puts me out of my normal routine and slows me down. So I either try to delegate it, or try to aggregate it with the rest of the meds, then just keep in mind that the patient will need his Aspart when the meal trays come in. I sometimes mix my insulin if the order requires it. This can be daunting since the bottle is shared between patients. Therefore, I'm not allowed to leave the med room with the bottle. Therefore, I always draw my insulin and label it so it doesn't get mistaken for heparin, saline, or other clear meds to push. I also got tired of forgetting which insulin is for what, and I found that insulin is almost always in my Kaplan tests. Finally, since the Corpsmen and nurses are practically all in their twenties and thirties, there are a lot of hormones involved. I've been here long enough to understand some of the dynamics between who is dating whom (on the down low). It's interesting to see how it affects their performance, as well. All of the staff are still quite competent, but I can notice when some are spending a little too long in an empty patient room, hahaha. And I'm privy to that, as well. I'm very friendly and eager to meet people so I immediately extend my hand and start joking around with new people. I think some of the younger nurses and Corpsmen interpret it as a come-on. I'm pretty sure it's obvious that I'm gay, but maybe some new girls try hard to fit in right away when they come into the unit. I understand that it's like coming in to the same classroom where everybody already knows everybody and you're the new kid in town. It makes you very nervous and you want so hard to fit in. They also like that I'm only temporary and therefore not part of any particular clique. Eventually they get who I am, haha. Even some of the big young guys joke around with me and have started to grow their mustaches, too. They consider me part of their 'boys' club'. Sometimes they ask me for stories about what it was like when I used to be a Corpsman with the Marines (they are so eager to leave the hospital and enter the Marine Recon special forces and the SEALs). But then sometimes they also look at me like, "How did Howie ever mix with Marines?" Bwahahaha. They'll never know.
  3. chemshark

    My First Day at the Neuro ICU

    This is not med/surg. This, of course, means that most of our patients are on vents. They usually assign us only 1-2 patients here, but they are quite acute. But, I also think that my med/surg experience helped me out a lot. For example, most of our sickest patients are on a minimum of six(!) drips. I usually keep two TKOs and draw blood from an A-line. Since this is a neuro specialty, many of our patients are on ICP precautions and use drains to allow the CSF to seep out. The monitors are connected to every part of the patient and they are usually on a Foley or dignity tube (which collects feces). Depending on the situation, each patient is hooked up to a vent, an exterior ventricular drain (EVD) for CSF, an A-line which also has a transducer, and an EEG to read brain waves, lumbar drains, and multiple drips. Since I work during the day, I send many of our patients down to CT scan for an angiogram or a surgical coil to plug up their aneurysm, and to surgery so they can get the catheters inserted into the ventricles of their brain. My basic responsibilities include hanging lines and drips, maintaining the monitors (except for the vent) & ensuring all waveforms are accurate, supplying emergency airway equipment & maintaining the airway until the RT arrives, administering medications via OG tubes, inserting NG tubes, and drawing labs. Nurses here are more apt to chart by exception so it's not as hard to chart as it was in med/surg. But med/surg helped me to become more comfortable with hanging piggy back lines and mixing antibiotics and other high-risk IV meds. What's different about ICU, other than equipment, is that patients look serene because they don't talk to you. But right when you start to go on break, they usually crash and all kinds of monitors are beeping: the Spo2 has gone down to 87% because a patient is desatting, and their b/p is high because they are in pain or are agitated because the family members keep trying to wake them up from their coma, or their labs are off whack simply because they are decompensating. When it comes to physical problems, something is always related to another. MY FIRST DAY Another thing that I've noticed is that ICU nurses must be more keen to criticize medical interventions. I have a story of my first day here. Since many patients would be in too much pain due to their medical condition, they must be sedated and thus are unable to communicate. Every hour, I do my nursing checks to make sure everything is on the up and up. This includes neuro checks. The difficulty of neuro brain injuries is that there are few physical tell-tale signs of distress. The brain does not always make profuse amounts of CSF and propofol keeps them from waking so you cannot ask the patient to respond to your commands or inspect the sheets to see if they're bleeding out. You can, however, inflict pain. LOTS of pain. You can either pinch them in their traps, or hands or thighs or sternum. It is in the hopes of gaining insight into their basic brainstem functions. I had to do this to a poor man who came in due to a spontaneous ruptured aneurysm. His whole family was there. They were quite supportive and talkative, but every time I went into the room to do my checks, I had to inflict pain into him somehow. This caused a hush to come into the room and I would feel ten pairs of eyes watching me pinch, harass, and yell at their loved one. Nevertheless, they showed that they had complete confidence in me even though I had introduced myself as a student nurse earlier. The nurses warned me that families have little to no neuro experience so they perceive that every little twitch made by the patient is a sign that he/she is going to fully recover. Unfortunately, this is rarely true. At the tenth hour, I still had no reaction-and things were looking grim. I yelled and screamed and pinched the patient as hard as I could but...nothing. I looked intently to see if he reacted to any of my stimulation. After a minute or so, I retreated to the computer inside the room to document my findings. The EEG readings hadn't changed. I could hear the family shuffle slowly past me as an entire group and when I walked back up to the nursing station, they were in a forceful huddle. A few looked intently at me, but went back to consoling their mother (the patient's wife). After the shift, I went home. I plopped onto bed, eager to get some sleep. Right then, I sprung up in bed. "Should I have turned off the Propofol before doing my painful neuro checks???" When I returned to shift the next day, I walked in and saw that the bed my first patient was in was empty. "Hey, what happened to the patient that was in this room?" I asked the charge RN. "The family decided to withdraw care." At this point, I panicked. Did they make the decision to let their dad go because of me? How did that make his poor wife feel? Could I have changed the outcome of this decision? I felt like my heart fell all the way down to my feet. I confessed my worry to my preceptor and the other nurses. But they all swarmed around me and reassured me that it was not my fault. There was no way I should have taken the patient off sedation to do an accurate neuro check because the patient was in too much pain and ventilated with an ET tube that it would be nearly impossible to stabilize him if he decided to buck the vent and crash. This made feel a whole lot better about myself, but not so much about the family's situation. Weeks later, I find that this is the norm in the ICU. Most days when I return, the patient I had cared for is gone.
  4. Ugh, I have to schedule my lunch breaks around it. It doesn't help that I have to be supervised to give oral meds, either. It slows everything down. And after finishing my midterm eval, my preceptor told me that it's time to start moving me up to three patients. It's exhausting. We get a lot of critical patients. But when we call a rapid response team--it's not fun. Not fun at all. Firstly, I don't get to participate in the code. Only the ICU nurses and my preceptor do. I could help out, but then it slows me down A LOT and my other patients end up being neglected. The orders pile up, somebody always wants to go to the bathroom or a PRN, I'll end up missing charting timelines, or worse--letting my infusions run dry. So I typically just ignore the RRT. How I feel when the RRT comes in - Sometimes I get a little jealous that my other classmates have such critical patients to care for. They are able to interact with families who are having the worst day of their lives. Sometimes they even lose patients, which I know is terrible, but makes me feel like I'm not part of critical care. Most of my patients are semi-stable, so the unit makes up for it by admitting more new patients after the other. On some days my preceptor and I are giving care five to six patients simultaneously. The Corpsmen do their best, but most of them are gone this week because they are studying for tests for advancement (promotion). One of our patients is mentally ill and he's not allowed off the floor but he's been with us for so long that we just let him walk around the unit. He can't go home because no one will take him and he has no family. So he just rambles to himself and steals other patients' food. Sometimes he'll go to my desk and rift through my bag. It's annoying. But after a while I laugh because it's just all so absurd. At the end of the day, when the entire staff at the end of the shift are scrambling to get things done before handoff, my preceptor patiently goes over my notes with me. Though she never lets me have a mental break: "This entry is not wrong, but it's not the way I want you to chart." I feel like she is deliberately looking to criticize everything I do. But then I remember that even though my next hospital won't have the same policies and procedures, my preceptor is teaching me how to pay more attention to details. She doesn't want any patient to not get the same high quality care that she expects. Everyone gets treated the same--even if they (though mostly their family) are a pain in the butt. When I was discharging my last patient, she watched me give instructions to some family members about new meds, appointments, and how to change a Foley bag. Then I wheeled my patient to the parking lot. When I came back, I started to apologize to my preceptor for taking a long time to teach the patient--I thought she was going to chastise me for falling behind. But then she cut me off. "Actually, I thought it was 150% fantastic that you made the family take turns showing you how to do the procedure. I could see that they became less anxious [about doing it at home]. Well done." Upon hearing this, the entire unit stopped cold and looked up. One of the RNs said, "OMG! she just gave Howie a complement." Even the mentally-ill patient clapped and cheered. I still have a hard time remembering all the policies & procedures, so I take notes of the skills & competency needed to work on the floor. I'm still not done, but I hope that the next person who interns after me will find it useful. I will give it to them when I'm done: 4 Hour Nursing Note APPEND TO NOC SHIFT NOTE; DO NOT ENTER NOELLE'S NAME--JUST SAVE YOURS UNDER ANCILLARY: SOME THINGS TO INCLUDE. LOC; POAWAKC verbal instructions given; fall precautions; SAMPLE: PT awake and in no acute distress or pain. AxOX3 DENIES CP/SOB/HA/N/V/D. PT RESTING COMFORTABLY IN BED WATCHING TV. PT L HAND/ARM +3 EDEMA, ARM/HAND ELEVATED ON 2 PILLOWS, ICE PACK APPLIED. POC = AM MEDS, POSSIBLE DISCHARGE. POC DISCUSSED W/PT, PT COMMUNICATED UNDERSTANDING. LIMB ALERT BRACELET IN PLACE. FALL PRECAUTIONS IN PLACE, BED ALARMS ON. WILL CONTINUE TO MONITOR PT. Nursing Assessment Note Document each system. Do not use an expanded exam if it is all normal. However, make sure that your entries make sense. Choose options in the correct order. Do not guess. Do not lie. Run back into the room and ask the patient before you chart. Better yet, stay in the room to do your charting. Must be done by mid-morning to avoid the rush. Do not sign preceptor's name. She will do it. Save before exiting. Hanging IVPB Verify order. Notify pharmacy, then wait to be filled & delivered via tube. Otherwise, pickup. Verify right drug, dose, documentation from Pixsys. Get solution bag (usually NS or LR) and prime. Then get piggyback bag and place ABOVE solution bag. Prime antiobitic piggyback and attach to the top port. Label ALL bags and tubing with your date/time/initials/number of bags to be infused. Clamp both and deliver to patient's room. Verify 5 rights, including allergies and that you know the medication is compliant with that solution. Flush the catheter site and ensure patency and that it's not expired. Double check the medication, patient, volume and rate again. Program the Alaris pump (both piggyback and basic infusion) and double check again. Hook up the tubing to the patient and start the infusion. Check for flow. Set an alarm to come back when it is almost time to switch/turn off/discontinue. Return w/in 5 minutes if it is a new medication for the patient or if she is sensitive (e.g. Red Man's syndrome). Administer Blood Do Type & Cross. Order and pickup blood at appropriate time (blood must be completely administered w/in 4 hours). Filter blood through specialized filter tubing. Setup 0.9% NS 500 mL and prime and connect to tubing. Provide and administer pre-medications if needed. Flush and hookup saline/meds. Verify blood & identification with both staff, including allergies. Start at 1/2 speed. Document everything. Vitals q15. Do not leave the room. Admitting Patient from Tow Look for COMPLETED NOTES: 1) 24 Hour Note (make a new one), 2) Admission History Note (new, for ICU patients only), 3) Med Requisition Note, 4) Admission Assessment, 5) ED Transfer (ED only). Ensure that transfer notes are signed by resident or attending. AN INTERN DOES NOT COUNT. Look online to see patient's location and call the department for a report and time of expected transfer. Discharging a Patient NOTES to be done: VS, 24 HR Nursing note (make an entry:"Assumed Care" and "Discharge Entry"); Multi-discharge summary; Clear Orders; Print 2 copies of Patient Discharge Summary (create note). Documenting Strict I/O Do not take patient's word. If unobserved, note NOB on the IO. Must be done q2 hours. Chart at top of the hour, do NOT start a new time column! Check that the input and output correspond and make sense every 4 hours. Documenting Vital Signs To be done at 0700, 1100, 1500 (give or take 30 minutes) without fail. Include pain and if they have pain CHART WHAT YOU DID to relieve it, even if patient refuses (chart that). Don't forget to include O2 delivery even if it's room air, then chart 0.00 Liters. Don't be lazy. Documenting Treatments Never leave an entry blank. Make sure that you chart all the education you provided. Change it up. Document at least three teachings q4 hours. Check and chart for O2 setup, dietary changes, pain and positioning. Documenting Invasive Devices Go to Flowsheets > Invasive Devices. Choose the correct options including date placed, how many days it has been in, what location, what type, and that the doctor is aware. Chart that you inspected it, flushed q4 hours, and that it is not infiltrated. Clearing IV Infusions Go to Alaris pump, press 'volume infused' and chart the number (make sure you add 'mL'). Documenting Meds DO NOT document meds. There is no bar code scanner. Preceptor has to do it. But she can watch you give meds. Make sure that you annotate the infusion volume so that you know how much you infused. Labeling Tubing Ensure that you have the correct tube color, if it is a BLUE top it MUST BE FILLED to the cap. Call ahead if you are going to tube the specimen down. Notify physician if it is asked to in the order. Labeling Multi-use Vials Must have date, time initials. Date opened, and date to expire (should be 30 days from first opened) Preparing a New Room Ensure housekeeping has finished sterilizing. Determine if patient needs isolation precautions. Obtain a report. Gather urinals, blankets, and basins if needed. Gather extra equipment such as a commode or seizure pillows if indicated. Ensure that O2 setup is prepared. Urine hats for women and urinals for men. Attaching a Tele Call the Tele department and let them know which patient you are attaching it to. Also tell them the device number. Call if you are ever going to remove it. Picking Up Medications Discharge meds from the pharmacy on the 4th floor. Inpatient meds to be picked up at the pharmacy down the street. PICC lines Keep sterile. Use chloroform only when accessing. Make sure you have an order. All TPN lines are used for TPN only. Code/DNR Status Since I can't see the orders, go to Notes menu and if it says anything on the Topic area, i.e. "resuscitation plan" then it is full code and you can assume that. Admission from ICU Need 5 Notes: New 24 Hr, New Admission Hx Note Admission from ED See admission TOW requirements. There will be 4 notes instead of 5 because Admission History Note will not be needed for ED patients. PICC line removal Request for a physican to be bedside in case clot dislodges (if you know thrombus is present). Glucose stick Do not take patient's word. If unobserved, note NOB on the IO. Unit Policy Flush IV catheters q4 hours; Label bags,[ Chart Mistakes MAKE SURE YOU ARE CHARTING ON THE RIGHT CHART VISIT (NOT THE PRESTAY) Medication Timing You can only retime medication ordered 'daily'. Scheduled medications on qnhours cannot be retimed. Return from OR Re-assess patient and add new entry into 24 hour nursing note; Double check orders -- medications[ Isolation Precautions Chart on the treatment screen ('DONE'); The isolation carts are usually in the isolation rooms. Wheel one outside and place by the patient's room with a sign to indicate what type of isolation precautions there are. Acknowledge order. Notify Physician (MEDS) Call Corresponding Physician. Afterwards, annotate on MAR after right click. Obtain Blood Culture Similar setup to blood draw. One blue one red bottle. Foley Empty q2hours under I/Os. Don't let patient trip on it. Change after 5 days. Charting Giving Meds DO NOT CHART UNDER YOUR SIGN-ON. New Admits VITALS & EKG ASAP. Do not chart anything else until you have orders. Drawing Blood Cultures Obtain TWO SETS: "One boy and girl" pair. Place syringe, butterfly needles and tubing and needle transfer chamber in BIOHAZARD bags with extra bags. Start with the hand. You MUST DRAW at least 10cc--and transfer 5cc to each bottle. Repeat for the next pair. Label accordingly and tube down to the lab. Perform a Road Test Verify order. Notify Corpsman. Attach pulseox and vitals machine. Obtain a wheelchair if you might need one. Never leave the patient. Take to the bathroom first if needed. Document how many laps around the station the patient walked and their disposition as well as pulseox (high and low). Notify physician by phone and chart. Tracheostomy Care Verify standing orders for O2. Check that suction is working and there are suction supplies in the room. Observe O2 sats. Preoxygenate if suctioning or doing trach care. ONLY use specific trach gauze and mild cleaning solution. DO NOT DISLODGE SHILEY!!! If this happens, call for help immediately! Suctioning Pre-oxygenate. Use Yankauer unless otherwise indicated such as deep suctioning catheter. Check O2 sats and respiration rate. Stay clean/sterile. Due to Void Policy If patient is labeled incontinent, then she is usually due to avoid within 2 hours. If she is not able to void spontaneously and on her own at the alloted time, then do a bladder scan. If bladder volume is >500 mL then offer one final chance to use the bathroom. Stress incontinence is still incontinence. Volume voided is what's important. If it is not sufficient (the entire bladder) and there are still >200 mL in the bladder, prepare patient for straight cath or Foley re-insertion. Weaning off O2 If plan of care is to wean off O2, then take off of breathing device and obtain O2 sats. If >93%, allow them to continue on room air. Check sats again every so often. Fall Precautions Must have yellow bracelet, fall severity falling star signage in front of room (bottom if bed A, top if bed B). Document on Nursing Assessment and Flowsheet > Treatments. MAKE SURE BED ALARM IS ON AND CALL BELL NEARBY. Limb Precautions Colored Pink and should be attached to the limb that it is protecting. Document on Flowsheet > Treatments and Nurse Narrative. Vancomycin Infusion Check for Red Man's syndrome. If found, stop the infusion and notify physician. ONLY RESTART IF GIVEN PHARMACY AND DOCTOR'S ORDER TO RESTART -- & usually this is at a slower speed. Suggest medication such as benadryl IV.
  5. chemshark

    Residency: My First Mistake!

    I am also trying to work more shifts back to back on the weekends, but this comes with consequences. Sometimes I forget that this is a job that involves many people & constant human interaction with not just patients, but also staff. They all influence me more than I thought. In fact, I started to become paranoid and thought that my preceptor was gossiping about me. I didn't have proof of that but I felt terrible for 12 hours. I kept hearing rumors and I just felt crushed from the pressure. It was awful. I have a lot to learn. It all started with an incident. Lately, I've been trying to cram all my shifts together to get the endurance needed to become a nurse. For the past 4 weeks, my preceptor and I have been working hand in hand. It has been mostly me shadowing her closely for the first two weeks. But after that, she began to gain confidence in me and gave me one, then two patients. She wanted to try me with three patients today, but then something happened. My first two patients were much older & extremely high fall risks because they were AxOx1 and had active UTIs. I suspected that we couldn't have 1:1s on them because we were short staffed (again). One wanted to beat her husband with her cane and it was sad to see his little limp body crying in the hallway. Apparently, she's convinced that he cheated on her. It turns out that it was true! ...60 years ago. But you can't blame her for perseverating on it for almost a century. (NEVER CHEAT ON YOUR SPOUSE is the lesson here). The other one also had severe dementia, but she could still furiously press the nurses' call button and yell "help, HELP" every 3 minutes. Oh and they both had an ostomy for me to clean q2h & neuro checks. Since I was a 'primary' (my preceptor didn't want a Corpsman to help me because she wants me to do it all on my own), I would drop everything and run if either one of them would try to leave the bed. One of them did leave the bed. How did I know? Because whoever was messing around with the alarm while trying to help her to the bathroom while I was on break forgot to reset the alarm. When I went to do my hourly checks on the homicidal lady, all I saw was an empty bed. Then the Flagyl I had up was still running (it wasn't supposed to be done for 2 hours), but no patient! I followed the line and saw that the catheter was on the floor, dripping. I announced that I was coming into the bathroom and when I went in, I saw my lady tugging at her tele leads, diaper on the ground, ileostomy open (leaking red bile now, btw), pee all over the floor and what looked like gallons and gallons of blood on the toilet (I had given her heparin earlier that morning)! Luckily, she hadn't fallen. So I snatched her up, put the gown over her, placed my gloved hand on the bleeding site, and walked her back to her room and placed a new IV (after 3 tries) while she was wiggling around. My third patient was in airborne isolation to r/o TB. I didn't have an N95 so I had to use a helmet and a papper (machine that blows air down into my helmet) to be able to enter the room. I had him running intermittently on Zosyn q8 and Vanc q12. My preceptor would watch me prime and hookup the bags, program the pump, and flush the PIV through the room window to make sure I prepared it right. Then she'd mask up, walk in, & administer the ATBs. I also had to get three sputum samples by the end of the day, a urine sample, and draw stats lab for his trough levels (his creatinine was up to 2 today). He was a hard stick so I would use his feet. He had continuous meds, like usual, but was also very nauseous and wanted only ice cream to eat so I had to get him new ice chips (because they were stale) and heat his soup. He started to fail to thrive so it got to the point where I went down to Subway to give him something he'd like to eat. Then I'd push Zofran, make sure his SCDs were on, make sure he'd do his spirometer, his oral care (because my assessment note indicated that he needs more of that), and ambulate him around the room while hooked up to the meds. He wasn't really a fall risk but because he said he had syncopal episodes at home we kept him in bed in SCDs and a bed alarm, which he kept telling me that he didn't like. Then something else happened. One of my other disoriented ladies went catatonic. Then her head whipped back, she was unresponsive, and her pupils were pinpoint. Her blood pressure was extremely low and she was barely breathing. My preceptor called a CODE Stroke. Then I rushed to stabilize her. At this point, I was still in the TB room but I started to see the commotion. My guy's Zosyn was done so I d/c'd it but kept him on the NS flush. I was programming it to run continuously, so I put it on rate 999, and was just about to input the VTBI when the stroke happened. I couldn't see with my helmet on so I pressed the start button and ran out of there to help. After quickly stabilizing the patient, the Rapid Response Team arrived and I tried to gather my thoughts. Then it hit me. I had programmed my IV as a bolus. I ran back into the isolation room and suited up as fast as I can and turned off the pump. I assessed my patient (he was perfectly fine) but the damage had been done. I had pushed around 250 mL of sodium chloride without a doctor's order. I had to tell my preceptor and then I had to tell the doctor. No interventions were necessary but it was very embarrassing. It could have been worse. But it is still a grave mistake in my eyes. My preceptor said that it wasn't a big mistake, but it was still a mistake. However, she didn't demote me to two patients because of that! It was because my charting wasn't exactly the way she wanted it. Charting for her is very confusing to me because there are some invasive devices that I have to chart on, such as PIVs, Foleys, but some that I can't, but are still there such as ports. She also doesn't chart by exception so I can't miss anything. And even if I charted everything, I still had to do it in the right order. All the progress I made during these past few weeks felt like it was all for naught. Was my preceptor giving up on me because of the pump mistake? Was she just parading me around to taunt her power to the rest of the staff? One of the Corpsmen asked me to help her transport a patient so I did. While we were walking down the hall she said, "why do you let [the preceptor] talk down to you? You can just ignore her." I told her that I couldn't. No matter how my preceptor acts towards me, she is still teaching me. And for that, I'm grateful. Don't get me wrong, I'm very thankful for my preceptor because she is guiding me to be a stellar nurse. But an occasional compliment or reassurance that I'm making progress wouldn't be such a bad thing. It sucks when I'm only being talked to when I make a mistake. It seems that my charting is always "nearly at [her] standards," but not quite. It's demotivating. I'm only human. One time, I saw her talking to her Corpsman on the screen and every time I walked by, they would hush. Were they talking about me? I thought I was improving...I felt crushed. This was the last straw. Now I felt like I wasn't being taught--that I was being bullied. I decided to call the Professor on break and ask her if I could talk to my preceptor about how I was feeling. I also wanted to ask Professor if, on the chance that my preceptor and I couldn't see eye-to-eye, that she let me reschedule my shifts so that I can try with another preceptor. Any other nurse would have been much nicer. Professor listened to my complaints and my proposal. She encouraged me to talk to my preceptor about what I was feeling and had me practice it to her over the phone (I didn't do too well). Then she told me that changing preceptors wasn't really an option unless my preceptor insisted on it. I had to work it out with my preceptor. Dejected, I went back to finish the rest of my shift. I couldn't look anyone in the face. People were wondering because I wasn't my usual smiley, jokey, flashy self. When my preceptor saw me, she demanded to know if I was 'really' doing my q2hour ostomy checks on my ladies. I said "yes, of course. Up until 1300 before I went on break." And she said, "well, I don't know, because while you were away my Corpsman saw that the bag was red and her stoma was swollen and extra beefy and now her H/H fell 4 points so..." How can this day get any worse? I felt like a spotlight was on me. I practically begged my preceptor to take one of my patients back, but she said no. She would help out more with the ladies but she would still entrust the patients to me. She didn't say why, and then she left. Then one of the other nurses called out, "Hey, bed __ needs some help. His leads are off and he needs a bunch of other stuff." Without hesitating, I jumped up and said, "Oh, he's mine! I'll take care of him." It was nice to know that even as bad as I felt, that I would still take care of my patients. Inside I felt like I was the WORST NURSE IN THE WORLD, but I still wouldn't let my patients see that. I can still be a professional. I can always drink my sorrows away later. But for now, I still had two more hours left at my shift and I'll be DAMNED if I turnover a neglected patient to the oncoming shift. Without prompting, my preceptor came back into the room and said that my charting "only had 1 or 2 mistakes on it, but I changed them online so it's ok now," then flew away again. That was the best compliment I could hope for. My patient looked at me and said, "that nurse preceptor of yours only has one speed, doesn't she? Even after ten hours I only see her as a blur." We both laughed. I really needed it. I came up to my preceptor before handoff report and asked her if we could talk about...things. "What about?" "Well, I just want to discuss...my performance today. We can talk about it together or you can also call my professor." "Which is it? Talk to you or to your professor?" "Well, we can talk first, if that's ok." "Ok. Let's talk. Come with me to the nursing station." Before I could ask her to go to a private room, she began our conversation. "Is this about the stat lab? Because when I tell you to draw blood or get a specimen I want you to do it now." "But didn't you teach me that the flowsheet charting was more important than anything?" "Yes, but this is more MORE important. I feel like you want me to give you a black & white answer, but that's how nursing is. Everyone is different. Charting is different for different people. That's just the way it is. That's why I don't want you to copy your notes forward, I want you to start your assessments from the very beginning without looking back at yesterday's notes." "Okay, but it's hard for me to know how to improve if you don't set a precedent. I can't prioritize if our priorities always change! I'm not trying to shortcut on charting but based on other nurses' charting your notes have way more content. You don't like charting by exception." "I never leave anything to chance. And you should be the same way. But if it makes you feel better, my standards are very high. Not everyone can achieve them. And you seem to be intimidated by me sometimes." "Yeah, I am. Because your opinion is important to me. You are teaching me." "Then keep at it. I think you're making progress. You just have to do things over and over. I've already been a nurse for a year. You still have a long way to go." "Then how do I know if I'm improving." "You are. I just don't have the time to tell you. I have four other patients and I'm watching you while you take care of your two. When you can show me that your charting is not just excellent, but that it is perfect, then I will move you up to three patients again. It's better to be perfect with two patients before you move up. I know you can handle three patients but it's just not up to my standards quite yet. But you'll get there." "Are you sure I'm not getting in your way?" "Of course not! We just need to communicate more. It's easier for me to catch & fix your mistakes if you tell me what you're going to do. Now, when am I going to see you next?" "Friday." "Good. I'll see you in a few days." "Yes ma'am."
  6. chemshark

    New to the ICU Cheat Sheet

    [TABLE=class: listHier messagesThreaded specialLink, width: 100%] [TR=class: hierItemBlock] [TD=class: bogus] I created an ICU cheat sheet. Though not exhaustive, it helped me when I felt overwhelmed. Most days when I get up in the morning, I have a routine: I wake up, take a shower, iron my clothes, eat breakfast, brush my teeth, comb my hair, get my things and go. But when you're in the ICU, things are different. You have your IV drips and they are running nice and smoothly, but then something happens. Your patient starts to crash and the resource nurse is busy helping someone else. So hopefully you memorized the orders and parameters and are able to titrate your various drips according to protocol. If you have time to document each and every single dose adjustments, when they were given, what the dose, rate & volume was, and what time, then great. But that's not likely going to happen. After a few days of the ICU, I felt that it was quite slow. Most of the nursing skills I practice were quite rote. For example, I hung IV bags, gave meds through the OG tube, or turned the patient every two hours. On days when I came in early, I already the patient's H&P down, noted the plan for the day, active orders, lab draws, and MARS. All I had to do was keep up with it and it would be fine. Maybe a family member would come in and fall into tears, but I had learned to expect it. It was better than the alternative, which is when patients' families would scream and yell in the medsurg because they thought it was a restaurant and nurses were the waiters. In the ICU, the nurses were the main source of communication & comfort for the family because they are able to translate what was going on. The family also sees--and are usually thankful for--the hard work that you do because they are in the room right there with you. Another advantage of being by the bedside constantly is that when patients' status changes often, the nurses are the first person to notify the medical team. One time I had a patient who had her tube feedings turned off and when I received her from the night nurse, her intracranial catheter dressing was undone, she had bitten through her tongue, and there were orders for her to still be on hypothermic precautions even though she was taken off the Arctic Sun machine. I had to discuss these issues with the team during rounds so that they could update the orders for me. But what was really important was that the parameters for the IV drips were updated as well. Sometimes the doctors preferred to monitor the patient using MAP instead of the SBP, or they would change the parameters if the patient was too sedated or not enough. This would then change my orders for giving 3% hypertonic solution, or Mannitol, or Fentanyl depending on how the patient reacted to those numbers. I had to remember what dosage strength was ordered initially and what the maximum dose was allowed. And since my access was usually limited, I had to choose which lines were compatible, which lines I could temporarily suspend in case I had to draw ABGs or suspend heparin if I was drawing from the PICC for a blue top. It took too long for me to access Micromedex so I relied on my preceptor's experience to know which medications mixed with what. Mainly, nothing mixes with anything filtered, viscous, or high-risk, e.g. propofol or 3% NS, or heparin, FFP, or even diabetisource. More than once, a seasoned ICU nurse would tell me, "If you no longer have the fear [of making a mistake & killing someone], then you have no business being in the ICU anymore." I hope I never lose that fear. But then I take a look at my "tree of life" and I find that that's not going to be the case for a long, long time. [/TD] [/TR] [/TABLE]
  7. chemshark

    Nursing school gpa

    I've challenged the board. The LVN board. And I was in the military as a Hospital Corpsman. I think that's the main reason why people challenge the boards: so that Veterans can have a meaningful job when they return from war. However, I don't think there is a way to challenge the RN board without a BSN from another state let alone a bachelor's degree in anything nurse related. I'm sorry you had to go through many things. Your willingness to get through the LVN program shows that you are still passionate, though. I don't know how many more obstacles are still in your path to get good grades but I suggest going through that first. Are you still too injured or do you plan to have any more surgery or recovery that may hamper your studies? Maybe think about what are your physical and mental handicaps then have a plan about how you would go about it. I never proceeded without a backup plan, and now I received my BSN and will start my NP program in two weeks. My first degree was in biochemistry, and although I passed, it was a very difficult subject for me. I also found that I didn't like working in a lab anymore. So although my GPA wasn't amazing, it wasn't competitive enough. I had to go through community college to take classes related to nursing that raised my GPA. Then I applied. Good luck with your endeavors.
  8. What can I say? This has been an eye-opening experience. Everything that I didn't learn in class, I learned here. My 3 biggest takeaways are: 1. Time is EVERYTHING 2. If you have a problem with someone, TALK TO THEM 3. Stay positive "Nursing is a people profession, so don't do it alone." (My new mantra). --- FINAL THOUGHTS It's mundane, but to me this place marks my official transition from Marine Corpsman to Registered Nurse. It took me 13 years to get here. And always with the help of others, both military & civilian. And I will keep going until I reach my goals. DISCUSSION "One of the known reasons that newly registered nurses are more vulnerable is because they have known areas of knowledge need and no past experience as registered nurses, making their work more subject to micro-managing or scrutiny" (Griffin, 2004). No truer words have been said. When I had a problem with how hard my preceptor was pushing me, and how she was criticizing me in front of others, I talked to Professor. She encouraged me to discuss my feelings with my preceptor and I did. She didn't realize that she was being so harsh but said she wouldn't back down & would keep her expectations high (especially w/ charting!). But she would at least try to criticize me away from the nursing station & be more patient with me. That was all I needed to regain my confidence. It wasn't until Week 05, but I think I truly started to progress at that point. When the wife (an actual nurse educator) of a patient screamed at me for putting in a Foley on her husband differently from how she teaches, my preceptor & the other nurses gave me reassurance. And when a mother (also a nurse) of a patient I was drawing blood on snatched my tubes from me while I still had the needle & tourniquet on her son because she wanted to label it herself, my preceptor stood up for me and made me redraw it on my own again but this time with support. When I interviewed my preceptor, to talk about the nursing profession/lateral violence/patient violence, at first she said "Don't let anything get to you and just move on." But after a while, she came back and said, "No, you should ask for help. Know when you need it." Nursing is a people profession, so don't do it alone. Now, on to the next thing!
  9. chemshark

    Nursing Residency: Stick to a Plan

    [TABLE=class: listHier messagesThreaded specialLink, width: 100%] [TR=class: hierItemBlock] [TD=class: bogus] This week, I assumed full care for 2 patients. The only time that my preceptor would come inside the rooms were to introduce herself to the patients, watch me give meds, and hang antibiotic infusions or give blood and other procedures. "It's about time that you started picking up your own patients," she said. This took me aback because I was waiting for her to tell me that I could do so. It feels different to fly solo. I explain to my patients that I am a student nurse and the preceptor will step in to help but that I would be their main contact. Even when patients are sick, I see that they only believe me if I believe in what I'm saying myself. I'm patient, though. I assume this will come in time. 0630-0730: Every morning, I try to have a plan. It's more like a timeline, really. I come in, change into scrubs, say hi, then grab the patient assignment list and a blank kardex. If I have been gone longer than two days, I tend to not have any repeat patients so I go straight into the chart and read up on their H&P. Unfortunately, I can't access new orders (very frustrating) but I am notified that there are new ones. My preceptor clears them all for me and lets me know if there are any pertaining procedures for today that involves a road trip. If so, I make space on my kardex for tasks to be done. I get the report from the offgoing nurse--I don't want them to wait longer so I try to be ready when they call my name. I try not to interrupt, but if there's something pertinent that I didn't read on the chart such as a change in diet or a consult from surgery or wherever I ask questions. I try to have the handoff at the patients bedside and I inspect my lines while the nurse is talking to make sure they are secure and patent and that they are the right gauge as on the flowsheet. I don't do my general exam just yet but I inspect the particular site that the patient's chief complaint is about. I.e. most of our transfers are from surgery, ICU, or the ED. Therefore, if someone is here with laparoscopic incisions or I saw that they had >900 BNP then I quickly do a focused exam with the nurse there so she can tell me if something is different or new. Once they leave, then I go back into the chart and list the medications for the day. I try to give the meds within an hour pre and post of the given timeline. If it says, 'daily' then I am allowed to reschedule the med to when it is convenient for me. I can't do that with qhourly meds but it is good to be able to aggregate them together so I don't have to keep going back and forth. It is these little tricks that save me time during the morning rush. After writing the meds, then I look them up quickly so I know what I'm giving and why. The computer system in the Navy isn't as fast as EPIC so I can't bring up LEXICON at the patient's bedside. I have to prepare ahead of time so I don't look like a fool. Next I talk to my Corpsman and we work out an agenda for the day so that we don't waste time doing things redundantly. He or she knows that I will let her do the vitals and strict I&Os for me but if something is abnormal then he must notify me so that I can get the vitals for myself. They can clear my infusion pumps but I need to know how much fluid my cardiac patients are getting because we have to observe how closely they diurese lest they cancel their discharge plan because I'm not charting accurately. I also let them know if I am expecting my patients to make a trip to imaging, the OR, CATH LAB, or if the PT is going to visit today. This way, I can ensure that my patients have been NPO, have had their vitals and samples taken prior to the road trip. 0800-0900: Okay, so now I go back to each of my patients and systematically do a general exam. This is quick, usually takes 5-10 minutes. If they are a concern for something else, then I add an extra few minutes listening to murmurs, ascites, or evaluating their strength and neurological status. Those who are immobile or have respiratory conditions I have to ask my Corpsman to help me turn so I can listen to their lungs while I look at the Mepilex on their butt so I can stage the wound. My preceptor expects this to be done because she just wants to walk in and concur or disagree with my findings. She will let me chart what I see but she will add a new note if it differs from what I wrote. I like that she lets me record my own opinions and assessments (for the most part). Next I inspect and palpate the PIVs and flush them to make sure that they are still viable. Then if there are continuous infusions I verify the bag and orders and check the Alaris. There should be tags on the bags and labels on the lines so that we know when to change them since lines are only allowed to be used for one day if they are intermittent and four days if they are continuous. Then I go over the plan of care with the patient and chat a little bit. This is when I evaluate their pain levels and I discuss pain management and other education with them. I am also charting my full assessment at this time. I do this for all my patients then I run back to the Pixies. 0900-1200: I pull meds for only one patient at a time. If they are on antibiotics or any other intermittent infusions, I check online to make sure that the meds I'm giving are compatible. If I have a question, I call the pharmacy--though they're not always helpful. Sometimes I have to be resourceful: if the order calls for 1500 mL D5NS and I only have 1000 then I label the bags with my date, time, initials, rate, type of fluid, then I write "bag 1/2, where bag 2 to infuse 500 mL only" so that if it is still running at the end of the shift, the other nurse knows exactly what I'm doing. Otherwise, sending the Corpsman to pick up a bag of 500 mL would take too long and I'd miss my deadlines. If the medication is Novolog or Enoxeparin I make sure that the Corpsman has done the BS and that the food tray is on the ward. Then I give the med or watch the patient do it so I can annotate that I educated the patient. If it is a controlled med such as Morphine or any other Norco, then I make sure there are stool softeners in the morning meds. My preceptor makes sure that I also input the exact time of when I administered the Morphine so that they don't overlap. And if I am giving meds with parameters, I take the vitals before giving it to the patients such as pulse for Lovenox, PT/INR for Warfarin, as well as B/Ps for -sartans, -pines, -lols, and -arbs. An additional complication is when a patient is on lidocaine patches. Since these are only to be given q12, if the patient decides to restart taking it, then I have to readjust the orders in the chart so that the q12 countdown begins again. Then I have to remember to write "remove" 12 hours from when I placed it on the patient so that the night nurse will know to take it off otherwise the patient will forget. Then I have to place it in a special bio container. Antibiotics are complicated to, because when I was preparing them for my nurse, the pharmacy or the docs made a mistake on the order and it was actually supposed to infuse for 4 hours, not 30 minutes. So we had to write an annotation on that and an incident report but luckily the patient didn't get that infusion and we were able to backtrack everything and start over. Thank goodness that there is a policy where if the doctor or pharmacist wants to talk to me and my Corpsman answers the phone, they must refuse to take a message and insist that they speak directly to me so that nothing gets lost in translation. 1300-1330: I take lunch. I have to bring my own salad because the food sucks here and we don't have time to leave the floor anyway. : 1330-1700: I start prepping my patients for their surgeries. I coordinate with the OR and we discuss the best time to transport. Then I let my Corpsman know so that he can get all his vitals and I/Os done on the other patients before he wheels my surgery patients out. I continue to take care of my remaining patients and help out with my preceptor's patients while keeping an eye out on the surgical patient's location and status. At this time, the charge usually flags me down and notifies us which patients we are expecting to recieve. I read on their history, and get the telephone handoff report from the nurse. I can't do this on my own so my preceptor takes the report and I listen on the other line. She asks all the relevant questions needed especially on what brought the patient here and what medications need to be continued during their stay on med/surg. If they are on trachs, or PICC lines, and what interventions still need to be done. Finally, if there are bed sores or fall/seizure precautions that we should be aware of. If there are medical interventions that my preceptor isn't familiar with, she drills the nurse and asks for the rationale. She does not accept when the ICU or ED nurse does not understand why the patient is getting certain treatments. She wants to hear it from their mouths or at least have the contact information of the specialist that she can talk to. There are five notes that must be completed before I am allowed to accept patients and they are: 24 Hour Nursing Note; a completed Admissions History Note; Medical Requisition Note; Admissions Assessment; and ED/ICU Transfer Note. They must be signed by the nurse, intern/resident (both), or the attending otherwise they are not legally viable and we will refuse transfer. Badgering the nurse/intern to get it done works. Since I care for the somewhat stable patients, they are usually on their way to be discharged. Before my admit comes in and while my other patients are in surgery, I prepare the other patients for discharge: I take their last vitals and have the Corpsman d/c their PIV lines. I will d/c the PICC line on my own but if the patient has a thrombus, we insist that the physician is at bedside just in case anything happens. Then I check that the interns signed the Patient Discharge paperwork and I annotate my 24 Hour Nursing Note with the Assumed Care entry and start to populate the Multi Discharge Summary Note. I annotate the patient's status and that I have removed all lines, bands, and anything else invasive. Then my preceptor clears all orders and I wait until the D/C orders come through. Then I print two copies of the discharge teaching plan and highlight what is different, such as new or d/c'd home meds, upcoming appointments, and I take it to the patient's bedside after finding out when their ride will arrive. Once they are cleared and ready to go, I send the Corpsman to pick up the discharge meds from the pharmacy. Then I get it and go to the patient's bedside. My preceptor says nothing as I go through the paperwork with the patient one by one. I do my medication teaching and I provide the medication rationale and make sure that the patient can tell me when the next dose of their new medications are. If they have to d/c their home meds or continue it but with a different dose then I discuss that as well. If they have to give their own injections then I make sure I watch them do it. I go over their hospital summary and instruct them to show it to their PCP. Then I talk about their upcoming appointments and who to call if they don't hear from anybody in x amount of days. Finally, I address any questions they have and have them sign my copy while they keep their copy. I send them out with the Corpsman who wheels them to the quarterdeck. I notify the housekeeper to let her know that the room is ready to be cleaned and sanitized. Next I go back to my computer and continue to populate the flowsheets making sure that my I/Os, PIVs, and TXs are backdated. Then I open up the discharge note and make sure that my note times are in line so that there is no confusion. Finally I go back to the flowsheets and annotate that I discharged the patient on all the entries and that medications are all d/c'd so that no one else can come and make an entry later. CONCLUSION: ...I still get overwhelmed. After the 12 hours I am physically tired but I no longer leave the hospital exhausted. I sleep a little better but I am still haven't gained the endurance for three 12 shifts in a row. It is just too much right now still. I talk to Commander Jack when I am feeling overwhelmed. He always has an open door policy and stops everything that he's doing to talk to me. We discuss the difficulties of working with preceptors with very high expectations as well as the challenge of working in an institution that have unnecessary policies that slow things down and makes the work harder. He listens and empathizes with me. I always feel energized after talking with him. Sometimes when Commander Jack isn't in his office, I draw on his whiteboard on his door. On this particular day, the Rear Admiral was going through the spaces for an inspection, haha. I hope he didn't get in trouble. She was actually very nice, though, and was impressed that I told her that my preceptor has an eye for detail and refuses adjust her high expectations of me. [TABLE=class: listHier messagesThreaded specialLink, width: 100%] [TR] [TD=class: bogus][/TD] [/TR] [TR] [TD=class: bogus]WHAT I LEARNED THIS WEEK: Have a plan. Stick to it, so that when things go south, you will have time to figure out what to do. [/TD] [/TR] [TR] [TD=class: bogus][/TD] [/TR] [/TABLE] [/TD] [/TR] [/TABLE]
  10. # NMCSD RESIDENCY EXPERIENCE SEPTEMBER 2017 ## WEEK 2 As I get more familiar with the staff and learn to pace myself for the daytime 12 hour shifts, I begin to find myself getting comfortable. This has its pros and cons. Pro: I'm feeling more "at home" in my med/surg unit. I can now tell the difference between an Alaris pump running dry, a call bell, or a bed alarm going off. A week ago, whenever the bed alarm screeched, I would jump up from the nursing station and rush to the room in a panic--worried that my patient had fallen off. Now I don't think twice about it because my Corpsman will do it for me! Why? Because they are young and between the ages of 18 and 22 so 1) they can react faster than me and 2) are willing to drop *everything* at a drop of a hat if a patient leaves the bed. You see, the Corpsmen allow me to stay at my computer while I chart feverishly my nursing assessments, 24 hour nursing notes, strict I/Os, VS, TX, and invasive lines before my next ICU TOW (transfer onto ward) patient gets wheeled in. It's great to have a dedicated Corpsman assigned to help me every single day! Con: I'm still feeling out my role in the unit. I think the reason why the Corpsmen are so keen to help me is because I have been so willing to help them during the first week. When I do something for them, like help clean or turn a patient, they thank me *loudly* in front of their peers. "THANKS FOR GETTING THOSE BABY WIPES FOR ME, HOWIE," is what they say, usually in the direction of the nursing station. I think they want to feel like they're no longer the lowest ranked personnel on the unit. But I'm no fool. Military rank is not a form of currency to be used as leverage in a hospital ward. A Corpsman who feels disrespected will neither tell me when a patient needs a stick or an IV, nor setup the butterfly needle, vacutainer, and syringe so that I can grab the sample and send it to lab stat (withdrawing from PIV lines is not allowed). He or she will not pass on relevant patient information to me when I'm swamped pushing meds with my preceptor or running out to different floors chasing down End Tidal CO2 equipment or begging for Yankaur tips from other units. He or she will not *ahem* cough at me when I am in a room with an obese PVS trach patient that we have to turn and clean which means that I have to not never ever forget to re-run the TPN to prevent her from aspirating and then remember to clear & chart the TPN flush q2h while the entire family glares at me in the tiny room blocking my way out until everything is in order. Or worse, the Corpsman will not help me find extra pillows! (It's impossible). The interns are funny, too. My preceptor, at 22 years old and one year as an RN, is so competent that she dances around interns like Muhammad Ali. She demands orders to be written *right now* and calls them back if parameters are not to her satisfaction. "As long as [the interns] don't [bleep] with me, I won't [bleep] with them," she said to me.[^does not apply to attendings] I'm glad I finally have access to Essentris to chart because I have about five minutes to annotate my comprehensive assessments based on two minute mini-assessments of each of my patients before we start pulling 9 o'clock meds. And let me tell you that Essentris is a disaster compared to EPIC because I have to type in a number to input an intervention but it wasn't designed with usability in mind. I.e. if I want to chart a numeric pain scale of 0/10 I have to type '1' in the cell! How inept is that? (I'm really thinking about getting into nursing informatics now because whoever designed this software was not a nurse). It slows me down and my preceptor gets irritated when she proofreads my note and finds my neurologic assessment saying that the pupil is 6mm when I clearly meant to type the number '6' so that it would chart that the pupil was 3mm. Yet somehow I still find pockets of self-arrogance like when I watch the residents do assessments on my patients while they teach their med students. One time, I saw a fellow show a wide-eyed med student a comprehensive neurologic test on a patient with AMS. I became very concerned when I saw what he did and said, "Whoa. Did he just have a positive bilateral Babinski's?" "Yes, that's right!" "Well, sir, I don't have much experience with neurologic degeneration, but...what's his prognosis?" I can't believe I said that. The patient was AxOx1 but at that second I knew it wasn't the most appropriate question to ask. I was clearly too attached to my patient or was tired at the end of the shift because c'mon, what kind of answer was I hoping to get from that question? "Uh, it depends." was what the doctor said. Saving me the embarrassment of putting him in an awkward position. They quickly made their exit but at least when I looked down at my patient he had a smirk. He didn't know what year it was or where he was at but even he knew that I asked a dumb question. WHAT I LEARNED THIS WEEK: Time is the best medicine. And management of time (whether cutting it or extending it) is the nurses' best intervention. This week I realized that if I listen and take time to understand the unit's high rushes and low lulls, I can prioritize nursing interventions that take longer but can be forgotten such as hanging continuous infusions. Then I can focus on fast & easy tasks such as prepping discharge paperwork while waiting for the order to come through. This, then, allows me time to focus on giving high risk meds w/ my preceptor such as novolog or morphine or when I'm helping my preceptor setup IVPBs so she can give them without incident or helping her manage her other patients while she stays in one room to administer blood.
  11. chemshark

    Give me some good ones

    Picmonic Nursing App. It helps you study using funny pictures but the content is quite thorough.
  12. chemshark

    Azusa ELM Summer 2016

    Hey phenoma21! Congrats on making it to the family! Uniforms are expensive, but luckily the program coordinator, Renee Dierking, collects used scrubs from the advanced cohorts to donate or sell to the newbies. I made it through the program fine with two pairs (although I had to stitch one of the pants). I'm just about to finish my externship this month so I'll donate them back in December. But for now, you can just ask Renee for it when you check in. She will have scrubs from other cohorts, as well. Roughly 10% of each cohort class of 20 are men. So if finding male scrub tops (bottoms are unisex) doesn't pan out, I would just buy one or two scrub tops from Dove Apparel and then purchase old versions of the scrub pants from the same company, but through Amazon. Good luck with the program and feel free to contact me or the guys anytime! -Howie Cohort 65 Amazon link: Amazon.com: Dove Professional Apparel Unisex Scrub Pant: Clothing [ATTACH=CONFIG]25145[/ATTACH]
  13. chemshark

    Dosage Calc Question

    [ATTACH=CONFIG]24560[/ATTACH] What was missing was that the drop factor units are gtt/mL. That's what you use to setup the multidimensional analysis. Next you just convert the minutes to 6.25 hours.
  14. chemshark

    Failed General Chem...

    Bwahaha, windsurfer8 was a little harsh in response to your post. I can just imagine him giving out meds in the unit: "Take this enema or you'll die!" LOL but he had a point. Anyway, Gen Chem is hard; It's a lot to take in because it involves multiple theories that are difficult to swallow for someone who has had no prior experience. It entails everything from molecular structures, basic nomenclature, stoichiometry, electrolytes, and a basic introduction to atomic orbitals. I failed my gen chem class too because I was too hung up on someone and I was working full time as an LVN. But my thought process was different because I realized that I was the one that had to change, not those external circumstances. But you know what? I pulled myself up by my bootstraps, said goodbye to that person who didn't love me back, and started making a tight schedule. I made sure my friends knew I was serious about my school and eventually earned my degree in biochemistry at a top University of California school (I was thinking about going to med school at the time). I ended up choosing to be a nurse practitioner instead and got into an entry level Master's degree program and then moving on to be a CRNA. All this wouldn't have happened if I blamed outside sources as my reason for failing. I didn't fail because I was heartbroken or too poor to pay for school. I failed because I didn't take responsibility for my shortcomings. One more thing: there are too many students for counselors and they are overwhelmed. Most counselors know nothing about you. They will just tell you what to take because you asked for a chem class. They didn't know you would be too fragile to handle an intense class and neither did you. But now you know understand your limits and I hope you will learn from it. Exercise your critical thinking skills to think for yourself. WHAT TO DO NOW: Retaking classes can be psychologically defeating. I hope you saved your notes and either take the same teacher or find an easier one. I also started making friends and we would write notes for each other if one of us got sick. We would even assign each other questions to ask our professor during office hours and then pool the answers together so the professor wouldn't have to keep explaining the same things over and over. I'd study with them but afterwards I would study alone as well. I also planned my leisure time so I don't feel so overwhelmed. Finally, research shows that lessons are learned when you study for something in intervals. Then you take a break and restudy again and test yourself. Pretend like you're actually taking the test under time constraints and without the book in front of you. Do this with similar problems that have slight deviances from your homework and you'll be prepared for a chemistry test. It can only be done when you take the time to practice and not cram. This is what enabled me to succeed in general, organic, inorganic, quantum, and bio chemistry classes through the years. It should work for nursing school, too. I hope this helps. Good luck.
  15. chemshark

    National University LVN-BSN 2016 Cohort 8

    @July26, the National University programs for California link are all here. But the deadlines for applying differ. Still, they offer programs in Fresno, Los Angeles as well as San Diego (Rancho Bernardo).