jdub6

For me personally, i can attend teaching sessions, read policies and manuals and talk through use of equipment and certain procedures, but the only way i actually get comfortable is to actually do it in real life. If there are certain procedures or pieces of equipment that aren't used that often in your unit it can be difficult to make sure staff has enough exposure to be competant, without them having to learn in a high stakes situation. it sounds like that patient was complex and this was a great opportunity for you to get your hands dirty with a lot of different skills while on orientation. since its early in your orientation, you have time ahead of you to seek out practice with the things you had the most trouble using. Having oriented to several critical areas, my feeling is that the best way to learn is to not run away when you're uncomfortable. Keep doing it until you ARE comfortable. Even once fully oriented there will be situations that scare you silly-but if you avoid them you won't ever get more confidence. BUT...its important that through this process your preceptor is there to both ensure patient safety and also to encourage you/provide constructive feedback/help you feel comfortable. A preceptor who lets you sink or swim but is there with a lifeboat and words of encouragement can be helpful; the same assignment with a preceptor who stands back without helping while rolling her eyes at you and badmouthing you you other staff is not so helpful. Generally I'd say to look at these challenging assignments as chances to learn and as signs that your preceptor and the unit think you can hack it and want to invest in your learning. if the pulse is plummeting and the doc is shouting to turn the pacer on at rate of x and energy of y and you simply can't do it then it's your turn to call out for help- "Jane, I don't know how to set the rate, please show me." If no one is around/able to help, that's a problem. In that case i would go to your educator and discuss exactly what happened-at which points did you not know what to do and have no backup? Then go through those procedures and learn them and also find out what the plan is to ensure that in the future, you will always have someone there who can step in and do what's needed if you're over your head. As long as the patient gets what they need, I would advise you to keep accepting challenging assignments. If you feel embarrassed about learning in these situations remember that good/experienced staff were all new once, too, and the best clinicians are those who allow others to learn and improve. OTOH if there are 3 nurses, 2 interns and 5 students in the room all "learning" from just 1 doc who knows what to do, that needs to be discussed with your educator too-everyone needs to learn but not all at the same time.

Was browsing AN and came across this in a post by Stargazer Feb 2001: "This reminds me of an article on another nursing website (sorry, don't remember which one)about a year ago on how one ER had decided to have all patients fill out a "satisfaction survey" asking them to rate the "service" they received from the medical staff and the overwhelmingly negative impact this had on nurses' morale (needless to say, many of the repeat-ER abusers, drug seekers, etc. took the opportunity to rate staff poorly--all of which was taken with dead seriousness by administration). " I was in high school in 2001. Satisfaction surveys have been a given my entire 10 year career. I wonder if those working when Press Ganey first started up anticipated how big a deal these surveys are now. Obviously, nurses knew it was complete crap, right from the get-go. Schools teach to the test, and hospitals script to the surveys.

You cannot do everything all at once. You did what you could. WRT to septic patient, you noticed the AMS and reported it to all concerned parties. The patient was sick, that's why they were hospitalized (if they just needed fluids/abx they could go straight to a SNF. They are in an acute facility because it is accepted they have potential to decompensate.) Further, this one was booked to stepdown for a reason. A stepdown unit's purpose is to care for and monitor "borderline" patients at high risk for becoming critical patients. And to send those who need it to ICU. Sounds like that's what happened. I think it's great you noticed the AMS and stepdown and the MDs had warning that they might go bad. You cannot treat decompensation until it happens (you don't amputate for every case of cellulitis just to make sure they don't get osteo). You gave appropriate tx for sepsis and monitored; what were you supposed to do, start "preventative pressors?" Septic patients crump. It can't always be prevented. The diabetic wasn't there for glucose mgmt and it sounds like they weren't being admitted, at least at that point. If anything you'd expect a fever to mean high sugars. Regardless they were self-managing at that point-you didn't give details on how you noticed the low but you caught it somehow, treated it and [sounds like] no harm came to the patient. A sick diabetic will have wacky sugars at times; again you can't necessarily be expected to prevent a fundamental feature of the disease. You identified and treated it soon enough to prevent harm-you did fine! ETA: when the MD learned the septic patient was more lethargic there were no new orders. I take that as confirmation that there was nothing else to be done for them at that point (again, once standard care is in place for the problems that exist, you can't treat potential problems until/unless they happen.)

This may be petty but propofol is not a "narc." It is not on a DEA schedule. It is a legend drug. I have never worked in a facility where "every drop must be accounted for" i.e. I've never had to waste with a witness and actually have never gotten flack for not recording waste at all. It is documented that propofol is diverted and abused and i imagine that if a facility had a problem they might track it more carefully... i've never had a provider ask me to pull propofol and give it to them; i pull other legend drugs (things like lidocaine for suturing or epi for hemmorhoid injection) and give them to providers all the time without a thought-i document in the chart "lidocaine given to dr dre for administration for suturing, procedure in progress now." in my state propofol is considered an anesthetic and when pushed must be given by a LIP except in critical care areas for intubated patients who can recieve it from a trained RN under certain conditions. i have never been in this position since i work in critical care but if i were asked by a doc to pull propofol for them to give a patient i wouldn't have a problem doing it-i would document that it was pulled and given to them to administer. an actual narcotic like morphine i would not let out of my sight until in the patient or appropriately wasted. i could imagine that the "puller" in this case had a similar train of thought (since the patient wasn't intubated yet when the drug was pulled its possible that in the OPs state a LIP must give to non-intubated patients and the nurse saw nothing strange about the request. Finally, in critical areas as well as critical situations elsewhere it is common for med students and 1st year residents to be present gawking-ahem i mean learning-but not taking an active role. At times the spectators are sent to gather supplies or meds-while they wouldn't be giving orders in that case the nurse who pulled the med didn't know all the circumstances. I wouldn't find anything odd with a resident rushing out of a critical situation-and intubating a combative patient qualifies-asking whoever is in sight to pull a non-controlled drug. i would pull it and hand it to them. Again a controlled drug i would be more careful. I strongly recommend becoming familiar with the DEA classification of drugs you are handling-it will help you make sure your butt is covered and save you from unnecessary headaches tracking a med you don't have to. (for example many nurses think benzos are schedule 2 like opiates-they're actually schedule 4 which doesn't really effect handling in acute care but does have very different rules for outpatients. suboxone is schedule 3.) Obviously if your facility has stricter policies about certain drugs its important to know that too but unless you plan to stay where you are forever it will serve you well to understand whether you're witnessing wastes to satisfy DEA rules, facility policy or both. it will also keep you from refusing to facilitate administration of something like propofol in a critical situation because you erroneously believe it is a scheduled narcotic.

I agree that the danger of a physical conflict may be worse than some jewelry. But, then don't make the rule at all. Patient A's earrings are very sentimental to her, but she understands and appreciates safety efforts and turns them in. Patient B doesn't really care about his earring but is angry about being on a psych hold so argues about everything. Staff lets him keep the earring because he seems about to blow. Patient C has borderline personality disorder and self-harms. She has used her bracelet to cut herself before and is thinking about doing so again. When asked to give it up she whines and cries and swears. She's allowed to keep them because staff doesn't want to escalate her. A, B and C came at the same time and witnessed each others admits. A feels cheated. She's the only one who did what was asked and didn't fight and she is the only one who lost her jewelry. She got no reward for compliance. She feels that B and C are in charge and not the staff. She is afraid B or C could blow up and the staff wouldn't protect her from them. B feels triumphant and now threatens violence whenever he doesn't get his way. He already felt the psych program was a joke but now that feeling is stronger. His focus is now on what he can demand next to enjoy himself. He puts no effort into groups or therapy. A thinks B is in charge, not the staff. C smugly heads to her bathroom and cuts herself. She comes out and displays the cuts to another patient. She is the center of attention and gossip and calls her mother saying she kept her jewelry against the rules and used it to try to kill herself. Her focus is now on what she can do next that's bigger and better, and is silently challenging staff to stop her. During future intakes and evals she will tell how she brought sharps to the psych ward and used them in a "suicide attempt." Again I feel that consistent firm boundaries are so important in psych. If you don't want to enforce the rules by whatever means necessary then maybe the rule shouldn't exist.

If a stud there is a sharp-ish end, a hoop could be broken to create one, and either could be used to cut oneself or if swallowed has potential to cause damage much like a swallowed soda can tab. It's certainly possible, maybe even likely that they would pass without damage if swallowed and that any self-inflicted cuts with them would be superficial but that cannot be guarenteed. To me though the biggest problem is the psychological implications of successfully doing something [potentially] harmful, using something they aren't supposed to have but the rules were bent. It could encourage competition (she snuck in x and did y with it, i want attention so I'll use xx to do yy) or copycats, it sends a message to families that the hospital can't keep patients safe. The patient feels she can manipulate staff to allow self-harm. She feels the staff is incompetent and can't keep her safe. she may feel accomplished and enjoy being the center of attention/gossip and now seek to do it again but bigger. She can now say "i even cut/tried to kill myself in the psych ward." Policies exist for a reason. Psych patients can be very manipulative, and clear consistent boundaries are a must. If rules are bent for one person, the entire unit loses respect for them and other patients feel cheated. I don't necessarily agree with the methods used in OP. I do believe that at times force may be justified to prevent actual or potential harm to self/others. While the jewelry is hardly the most dangerous item a patient could ask to keep, it sets a dangerous precedent to tell someone they must turn something in for safety and then back down because they throw a fit. It's the same reason the police don't drop criminal charges because a patient tries-or pretends-to hang themself in jail. They go to a hospital or psych jail and get suicide watch but they don't get to say "if you bust me ill kill myself" and skip away. I know the two situations are very different in severity but psychologically the implications are the same.

You probably already know that spitting into the eye or mouth areas is also a body fluid exposure and should be reported immediately. And at the same time security should be called. Perhaps they can give you a panic button if you're going to be dealing with patients in areas where there may not be other staff. If the waiting room is where youre assigned you'll definitely need to develop thick skin and scripts to address the common complaints-"why did he go first?" "how long do i have to wait?" "my primary doctor/sister/mother/wikipedia said i need xyz immediately-why am i still waiting?" "can you get me a sandwich?" "i came by ambulance, why am i out here?" "why is it taking so long? I've never waited this long before" "can't you just give him a bed to lay down while he waits?" "i need something for this pain right away" "i see that nurse just sitting there doing nothing..." Some of those questions should be referred to nursing but it's okay you reiterate the rules after they've been told by triage who is aware of the patients concern/. If the triage nurse knows about their pain and has told them they can't get meds until seen for example i think its fine for a volunteer to just reinforce the policy. Sadly, it's vital that you also know how to respond to insults, threalts of complaints, demands for something that's not possible or not allowed, passive aggressive comments-especially when made to other patients-and threatd to leavee. Don't take anything personally and it helps me to have standard lines all ready for the nasty ones.

Thats what it is-frustrating. Recently had a parent come in with dizziness and feeling confused (normal Neuro exam) freely admitted having been on a 3 day crack and MDMA binge. 4yo daughter in tow. Parent couldn't/wouldn't find child care, we provided snacks and DVDs for the kid while they waited. Kid was understandably bored/restless and got whiney, and at one point parent slapped child across the face in front of an xray tech. CPS was already being called as the patient admitted doing crack while alone with the daughter. There were no signs of abuse/neglect-kid appeared healthy, appropriately dressed, no visible bruising etc-and CPS elected to take no immediate action. They said they would follow-up. Parent discharged home with child after 8 hour eval. Frustrating and also time consuming for staff trying to make sure kid was okay, and figure out and do what was required. Which didn't feel like a good option.definitely felt bad sending kid with patent but had no choice. (I don't believe one slap warrants removing a kid from a parent, but scary that parent has no issue using hard drugs in the presence of a young child they are supervising, with no other adults present, when the parent knows they become confused and hallucinate with said drugs.)

First off thanks to all who replied. I know the med surg floor had a problem like this one-elderly patients spouse brought the dog to spend the night. The patient was being made comfort measures and they do allow pet visits for dying patients but this wife and dog settled in for multiple nights. They had been dropped off by a daughter who disappeared and wife claimed she had no way to get herself or the dog home. The biggest problem (besides the obvious issues with a pet in the hospital) was the wife was old and had mobility issues. This was the 7th floor. She claimed she was physically unable to take the dog out and just let it pee on the floor if staff didn't take it. Poor dog would cry and bark-because it needed to go out-so staff often took it just to stop the disruption. Also she went to sleep in the recliner holding the dog-had a crate but never put/left dog in despite multiple requests-and when staff entered to provide care the dog would get territorial/protective. It barked loudly which was disruptive and sometimes frightening to other patients and nearly bit a tech. Wife became very manipulative/passive aggressive when the issue was raised and when all else failed played the dying husband card. Admin didn't have the guts to make her angry so never took real action to remove the dog. Very frustrating to staff who felt unsupported while this woman walked all over them. Basically I started this thread to see if other places actually draw and hold a bottom line and take action like calling animal control etc...so frustrating that it seems my job isn't the only place where this stuff is allowed to continue and nursing is expected to just deal with it.

Glad things worked out for you. I'm sure you know this already but even if you HAD given Tylenol, liked everyone else said it wouldn't have prevented the seizure most likely. While it might have looked better to the principal if you could say you'd given him something, honestly po Tylenol likely wouldn't even have changed his temp in that time period. Let's go to the extreme and say you had called 911 for him after one look. EMS certainly doesn't give Tylenol or even check temps ever; they may not have medicated for the seizure if it resolved fairly quickly. While this child would get Motrin or Tylenol once triaged in the ED he easily could have waited much longer and seized in their waiting room if taken in earlier by car. I don't think anyone can hold you to a higher standard than those folks who have way more resources!

A similar question with that would be the personality disordered individuals who come neck time and again with either non-lethal attempts or those who have many moderately lethal attempts? When all meds and therapies have been tried and they still have literally dozens of suicide attempts? How do you interact with these people? Is it just give the meds, be respectful and let them cycle through again? Or do you actually have techniques to try to help? I swear I don't believe all psych patients are hopeless...it's just felt that way lately in my ED! I have so much respect for what you guys do and I'm just looking to learn more about how you do it...

I guess that's part of my issue-that guy was honest with us, i think because he felt he had nothing to lose or didn't care. But if he had summoned the energy to try to get out i feel he would have just lied his way out so he could kill himself. In a way it feels messed up that someone's options are to either be tied down in the hospital for being honest or to lie so he can leave and kill himself. I know we have to keep him safe but it sucks to feel like we're just keeping him safe till he lies his way home. Honestly I think I feel this way because all we see where I work are the people who either make a really serious attempt or the ones who cycle in and out over and over with either psych issues or addiction (how many times can you CIWA the same person before you want to just start an alcohol instead of ativan taper/schedule? And you ask what they're going to change this time and they either say nothing or they don't know and have minimal interest in figuring it out.) The ones who do well once on meds and get discharged and then are back just as psychotic when they stop taking the meds, AGAIN. It sometimes seems like if the first detox stay or med trial doesn't make some kind of real change (even if it takes a couple tries to get it perfect) then nothing does. I'm sure its because I just don't get to see the success stories and I'm glad you guys mentioned ECT because I'd never really seen it in action but it's nice to know that some people do make turnarounds like that. I guess my question isn't so much, what to do with THAT particular patient (got transferred to another hosp for psych involuntarily and that's the last I heard..) but more him as an example to ask how you deal with taking away people's rights when it sometimes feels you really can't fix some patients? Tying someone down and jabbing needles into them is one thing if their psychosis improves and they're thankful 3 weeks later. But when you just don't have anything else to offer, how do you guys deal with that? Or maybe even just if you can share more success stories so those of us on the front end know that sometimes things do get better for these people...

In my state death in restraints is reportable with the exception of ICU patients who die in 2 point soft wrist restraints. (There may be an exception for comfort measures also but I'm not sure.) Regardless its definitely reportable if they fall and its never smart to remove restraints and leave without telling anyone. That's incident reportable in my opinion. And it's also not okay to have a patient with restraint orders and no restraints/doc not aware-so when she removed the restraints she should have discussed with MD.

16 weeks is shorter than some new grad ICU programs but the thing is youre 14 weeks in. Finding another job if you leave now will be tough and you may not be given new grad orientation at this point. Try really hard to make the best of where you are for 1-2 years MINIMUM. Remember its normal for new grads anywhere to be overwhelmed, to not feel comfortable and to struggle for months. If you feel you need to leave research the new grad posts here and try to talk to other grads at your facility to be sure its not just normal new grad jitters. And have a new position in hand before you walk unless you're independently wealthy or on the verge of suicide or a breakdown or the like. Others have given you good advice on using your resources and making the most of your situation. Try going to former new grads with 1-3 years experience, they may be more willing to teach than your preceptor who may be burned out on precepting and may not remember what its like to be brand new. Those who are semi-new can remember what was most useful to them when they were learning.

Actually this is starting to sound more plausible now. Some EMRs have different defaults for different meds which could explain why its just this med. Honestly I kind of want to believe OP even though diversion is the most logical explanation because even someone looking for suggestions to explain diversion knows that there is always some kind of record or proof to back up the truth. And no one knows whether the OP is the only one being investigated/suspended or whatever for this error. And, we don't know that it didn't happen with, say, Heparin but the employer only audited controlleds or only mentioned narcs in the write up.