AlexCCRN

How do you report a pattern of narcotic medication record irregularities without making it personal. A few specific nurses consistently remove narcotics NOT ordered, presumably administered under the pretense it would be what the MD would order but never secure an order. Or, have vague explainations for meds removed - found in the PYXIS report but no administration record entry for that med. Or, removed meds but apparently - appears as if - given much later - 6 hours later? Or, record/sign that 80 mg IV morphine given at 10mg intervals over 10 hrs but elderly narcotic naive DNR patient's clinical signs don't add up. Or, meds removed under my patient but not administered? Just a few examples of my observations. I have a record of many more. Recently faced with a narcotic "discrepency" created from a previous shift but I'm left holding the bag because my count generated the difference. I'm concerened about how the patients are being treated but also worried that I'm somehow part of the "action" - unvoluntarily :)

Is anyone else just sick and tired of arrogant self-appointed straw bosses who can't seem to stop themselves from screwing with new nurses? Managers could stop this sort of ADHD behavior if they wanted to so, I'm convinced that most managers are either too weak or too goofy themselves. In the meanwhile, I'm learning new deliveries for the time honored message of "step off" cause in the end that's all they seem to understand.

5 day orientation - unless your a seasoned ICU nurse - it's crazy and just plain bad. As for keeping up... consider a pocket sized recorder. I use my Palm PDA with digital recording to keep voice notes if I'm not able to chart. It's just the best! Once you get used to a digital device, you can be so facile with it... accuracy goes through the roof. :)

Tolerance used as a term denoting range of variability accepted - not requiring intervention ... yes, tolerance develops over time with experience - you knew this. Yet, you also know that experienced nurses may have developed a degree of informality or even slopiness that new grads are rather sensitive too. So, never hesitate to call on a higher power. Start first with ONE trusted, experienced coworker. Careful not to invite a committee. Often the oldest or loudest or most cantakerous wins out. Then escalate to nursing supervisor who should be responsible for finding the appropriate resources if they themselves are unsure. Of course, we must not bypass the so called charge nurse on the way up but, you can always invite the nursing supervisor into he picture, hopefully, quietly, as an additional resource. Yet, I never hesitate to call the on-call MD. They are the single best source. Before escalating past the road block, I try to represent my side of the argument diplomatically assuring the other that it's only a matter of differences in opinion due to knowledge and training. It's so hard navigating the sea of personalities... it makes my bones ache.

Assessing pain can also be accomplished without asking the patient - VS, nonverbals, trends, etc.. I've experienced that asking too often seems to train or encourage a yes or exagerated response when their level is actually tolerable. Ater admin, I follow up in an hour, giving the med a full opportunity to work. Then I follow up when the med is anticipated to have begun wearing off, try to intervene before pain is out of control - much easier to manage with lower doses. I don't encourage narcotics but if prescribed I certainly never withhold. I often wonder what's behind the prejudice in pain medication delivery?

I once provided an inspirometer to a patient with a trach. I was just so happy to see her off the vent :)

Don't go quietly. Establish yourself as a critical thinking, caring, safe RN who's willing to argue their case without emotion. I mean, whenever something ridiculous presents itself and you are certain about your facts - represent yourself, demonstrate that your not a push over. Challenge their *judgements* of you. Who are they to judge your passion. Good grief. Bunch of little primadonas... and they're a dime a dozen so might as well practice the art of deflating their hilarious notions with evidenced based practice and theory in a unit you may leave cause you'll be faced with this again and again. Become your own advocate without seeming arrogant. Keep to objective non-emotional responses. Don't allow them to bait and hook you. It's all fun and games for the tenured staff. So NEVER let them see you sweat :)

Depends on the facility. ER nurses should be ACLS certified and therefore have rudimentary intubation skills and are expected to be able to accomplish intubations as part of the ACLS requirements. Yes, RNs could just as easily be as competent as an RT or EMTP or MD in the skill but it might appear as an encroachment if RNs routinely did it. IMHO.

What do we use? All drug doses are determined by patient weight. Unless you're caring for gerbils, the doses you mention are insufficient. Compensating by allowing more frequent dosing is a cop out. Furthermore, Demerol is bad pharmacy except for post op rigors. Advocating for appropriate pain management can be frustrating but, it's our role. Sounds like your prescribers are following a rule that's designed to minimize their risk exposure and insurance expense.

roustan jp, valette s, aubas p, rondouin g, capdevila x. department of anesthesiology and intensive care medicine, neurological explorations laboratory, lapeyronie university hospital, 295 avenue du doyen g giraud, 34000 montpellier, france. prolonged use of sedative drugs frequently leads to oversedation of intensive care patients. clinical assessment scales are not reliable in deeply sedated patients. parameters obtained from spectral and bispectral analysis of electroencephalogram (eeg) records have been combined to create an index (bis) to monitor anesthesia depth. the role of such parameters in monitoring the depth of the sedation in intensive care unit (icu) patients has yet to be determined. we designed the present prospective study to redefine and calculate available spectral and bispectral parameters from raw eeg records and estimate their clinical relevance for the diagnosis of under- or oversedation levels in icu patients. forty adult patients receiving continuous midazolam and morphine sedation were included. we obtained 167 clinical evaluations of sedation level using ramsay and comfort scales along with an eeg record of 300 s. six spectral parameters-relative power of 4 frequency bands (beta, alpha, theta, and delta), 95th percentile of the power spectrum (sef95), and 50th percentile of the power spectrum (sef50) and four bispectral parameters, real triple product, bispectrum (bispectrum), bicoherence, and ratio 10-were calculated. the relevance of each of these parameters and combinations in predicting too light (ramsay 1 and 2) or deep (ramsay 5 and 6) sedation levels was assessed. these calculations were performed before and after exclusion of the agitated patients, whose comfort 4 score was above 2. the most relevant parameters for predicting levels of deep sedation (ramsay 5 and 6) were ratio 10 (area under the curve = 0.763; 95% confidence interval, 0.679-0.833) and sef95 (area under the curve = 0.687; 95% confidence interval, 0.597-0.767). the most relevant parameters for predicting light levels of sedation (ramsay 1 and 2) were also ratio 10 (area under the curve = 0.829; 95% confidence interval, 0.695-0.917) and sef95 (area under the curve = 0.798; 95% confidence interval, 0.650-0.898). there is a modest improvement in relevance of their linear combination in predicting sedation level. results were similar after exclusion of agitated patients. we conclude that various calculated eeg descriptive parameters exhibited large interindividual variability. there was a strong correlation between eeg spectral and bispectral parameters. bispectral analysis slightly improves the predictive power of simple spectral analysis in distinguishing too light or deep sedation levels in icu patients. implications: spectral edge frequency 95 and ratio 10 are the most relevant electroencephalogram (eeg) indexes for monitoring the level of sedation in intensive care unit patients but calculated eeg values exhibited large interindividual variability. bispectral analysis of eeg provides a slight improvement over simple spectral analysis.

Not voodoo but "oh no!" is what you'll be saying if the pt is improperly anesthetized or sedated and you chose not to use the available BIS monitor. Use ALL the tools at our disposal. I've experienced good/consistent results with careful attachment and integrating data with standard assessment. Didn't mean to speech at you. Just thinking out loud.

Topiramate label use: anti-seizure and migraine prophylaxis. Investigational use in infantile spasms, neuropathic pain, cluster HA. Teratogenic & enter breast milk. Can reduce serum HCO2 up to 67% - risk for metabolic acidosis - must be monitored. ARs > 10% include dizziness, ataxia, somnolence, psychomotor retardation, memory difficulties, fatigue. Use caution in conjunction with any anticholinergic drugs.

Pinyoy, name a responsible profession in which practical experience and measured competency isn't a prerequisite for advancement. Thankfully, reputable nursing schools rarely accept candidates for NP who have little or no RN experience.

NO and as well, they shouldn't. Period the end.

Agree that open visits have downside. Training visitors takes up much time too. I wish we would have blocked off hours and a limitted visitors list including only a few family, friend or whoever. The rest can get reports from the lounge. Then I only need to train a few key visitors who have reasonable access and can help me with some pt care. I promote family-pt-nurse team building and interaction. Develops trust and becomes very important in end-of-life.