rac1

Ahh, found this pretty quickly after asking: https://www.AANP.org/advocacy/state/state-practice-environment

Is there a resource out there that lists all states with APRN info - autonomy, DEA and prescribing requirements, etc?

Certain IV push meds need to be diluted. It's easy to look up - do you have a Davis's Drug Guide? You can look up certain ones you use often on your unit and write a little cheat sheet for yourself (or use a "notes" in your phone for all your reminders). You'll have them memorized after a month. I literally brought my guide with me to work when I first started and just looked it all up. Meds that need to be diluted are usually considered "high risk" in some way - because of patient response, or risk of extravasation, or viscosity, or just the difficulty in the size of the dose being drawn up. For example, I still always dilute morphine and push slow. It makes people sick, young and old, and especially opiate-naïve. I just like to. (Davis) states to dilute with at least 5mL sterile water or NaCl, and administer over 5 minutes (for 2.5-15mg doses). However, there is a whole push about product shortages and how it's not recommended to dilute morphine (and all opiates) "anymore." Things do change, and I am happy to do it, but I also find it safer to dilute and push slow than to draw up and push slow....it can make some people feel really awful when it isn't diluted. If the person is being administered continuous fluids you can also just draw it up straight and push it slow at the top of their line (depending on the rate of fluids), etc. A sickle-cell patient might not need it diluted or pushed super slow.... so it just depends on your experience and patient population. And also - I think nursing is an art AND a science. I like to think that when it does not change the medication properties, that I can have some leeway in how it is administered (over 2 minutes or 6..). pantoprazole/Protonix is reconstituted with 10mLs NaCl - and pushed over 2 minutes. ondansetron/Zofran is preferred to be pushed over 2-5 minutes (30 seconds min) but does not have to be diluted. However, I dilute it in a 10mL flush because I think it's easier to push 10mL slowly than 2mL...just a preference thing on my part. promethazine, pantoprazole, ephedrine, phenylephrine, phenytoin and lorazepam needs to be diluted. Just look through your drug guides, then talk to your preceptor and see what they say in comparison. And depending on your eMAR - it will give you specific instructions (some do a great job at this, and others leave a lot to be desired.) GL!

Another vote for "no," from me too. After 1 year, I don't think many nurses could say that they are confident in the management majority of obstetrical emergencies. At a year - you may know how to manage the myriad of complications that can be thrown at you, but it is most likely that you aren't as fast or safe as someone that has 2 years. Another thing is that many units that are requesting travelers is because they are VERY short staffed - they are asking for a traveler or two, but they probably need to hire 4-6 RNs permanently - which means the unit is probably going to be very busy. We recently had a few rounds with new travelers (and although I just mean "new to us" - many of us are pondering if they are fairly "new to L&D"!). They aren't quick, they ask questions they should know, they can't perform accurate SVEs, they don't know how to catch babies, some don't know how to administer baby meds, and some aren't confident in NRP (or even comfortable). We are def. teaching more of L&D than just 2 days of how to chart. And granted - many of these things can stem from being taught in teaching hospitals where SVE are done by residents 100% of the time, and there are NICU nurses to catch babies - but then maybe you shouldn't travel to a hospital where you have to do these things! Anyway, just some more food for thought.

This is one of the first actions I teach nurses, and why I teach the importance of bedside report. One of my main issues in my current situation is that I have said things 15 times and she still isn't doing it until I say "did you check if your lines are all labeled?" or whatever (and I do wait a while to ensure she really just forgot). But great advice - I love it and I do teach this.

Manager meeting check. Educator meeting check. Come to Jesus check. I think I put some things in place that will move us forward. And I now believe that at this point it is time for the "figure things out on her own." I'm feeling more positive about the outcome! Personally, I don't think she is fit for a specialty unit and she should have gone to a med/surg type floor. However, I wasn't asked my thoughts in the hiring process (har har). After some good reflection time, I think I've trained well-fit nurses. I don't think she was well-fit to come into a specialty, so the learning curve is steep. But that does not change anything about the situation because they aren't going to unhire her. So onward I plod... ? You're right - this is a hard transition and not every person does it the same. Thank you for sharing the link.

Thanks for responding. I really like this advice. I try to be cognizant of what you're talking about. I often teach "this is the right way, and this is what I do" - I explain that it is their nursing license and they have to be comfortable with their actions. I explain my reasoning and let them decide what to do. Sometimes I explain I want them to do something until they are more confident with their own skills. In my experience, some new grads believe me, and some don't care and are already lazy. I can't force their hand, but I try to teach them to be (what I think of as) a good nurse. Over this last week, I did come to the conclusion that it is going to be a sink or swim for this new grad - I think it will actually help her come to the conclusion that she needs help, and mostly that the things I am saying are real and need to be applied. And obviously, I am there and not leaving her in any way. I think I see the light for this one. ?

Yes - in close communication with management and our educator. I'm trying all the things. Just thought I'd pop in here and see what worked for others in these situations. =)

Thanks for your sweet words! I am really trying here. I think I may have to start letting her struggle in other ways - I do let her struggle with answering my critical thinking questions. I am hoping there is maybe just a tipping point she needs to get to. Hoping.

EDIT: HA - just saw the date this was asked - a day late a dollar short - sharing my response anyway - but now you know I was really late with med passes. ? I'd be starting my 9am meds at 8am with that many patients. And I would be in the room already, finished with my assessment, meds scanned and passed BY 8am. Every place I've worked allows for meds to be passed an hour early. And on busy units with 5 patients I've been passing meds at 11 still. Make sure you're doing bedside report so you can assess the situation you're walking into - we are doing 12 things at once as nurses right? Bedside report really is advantageous to you for your first assessment of the patient and the situation you're walking into. You can look at the room and see what you need to bring - does the patient have water for meds, blankets, is the continuous fluids almost empty? Ask them specifically what they need you to bring to the room when you come back - this stops them from calling you too - then write it on your report sheet and bring everything to their room at once so you aren't running for things to get them settled. This is a first look at who your needy patients are - the ones who talk a lot, or are very sick. You can tell your talky patients you'll be back soon with all their requests (they always request!), but go to their room last so you can spend the extra minute letting them talk - it'll save you time during the shift because they'll feel heard and will hopefully be less needy. I hardly ever answer my phone when I'm in a patient room - unless I'm charting and not engaging with the patient at the time. What did we do before phones? If it's an emergency you'll know. Always start earlier than you think you should. I would save total cares, wound cares and complicated patient research (chart review stuff I mean) for AFTER first med pass is complete. Just go in assess and get first med pass done. Then go back and do your major stuff. When you have 7 patients are you getting low acuity patients with minor/no meds, ready to d/c in the mix (I hope so?!) - go see them first and assess and be done, and on to the next - or at bedside report tell them since they have no meds you're going to see some other patients first, ask if they need anything before that so you can take care of them, and then see them last. If you don't have low acuity patients in your mix of 7 patients - maybe it's a charge nurse assigning issue? Or you just have really sick patients on your unit? Again - when I was on a very busy unit with 5-6 patients It was 11 and after plenty of times when I was doing first med pass. Ask for help when you need it. If you don't have it maybe you need to find a better team (it makes all the difference) to work for. Sitting down to chart really well at 3-4 was normal for us.

I'm doing this. I switched a few weeks in to asking: "What do we need to do right now? Which patient should we see first? Look at the monitor - what does this mean we have to do? What do we do if there is no u/o for one hour? How do we do this procedure?" etc...... I'm reteaching things I've taught every shift. I'm hearing "I didn't know if I did that right," and "We were so busy I didn't want to ask if that was right" when things are wrong (things that I've never had to teach this many times). I thought the cockiness would subside - I mostly ignore it and simply address what exactly needs to be done in the moment with my most professional nurse face on, because the docs are not going to put up with that and it'll definitely come out and hit NewGrad in the rear. I have check-off lists. I reiterate and teach and use teach-back. Then NewGrad walks away and does not do what was just taught back to me, then when I address that discrepancy I get a deer-in-headlights look and the "I didn't know" - I mean what? How - I just told you several times, then you told me back correctly. I don't know what gives.

Tell me what your preceptor did great that helped you learn, feel confident, and do a good job. I'd also like to know what your preceptor did poorly that frustrated you, and made you had a poor relationship which slowed down your learning. If you have any suggestions that are pearls of wisdom for teaching/precepting those that lack critical thinking/judgement - lay it on me. I am precepting a new grad - precepted plenty of nurses at this point, this one is rough. New grad is eager and willing, but slightly entitled and cocky, also not a critical thinker. Would love some ideas, fresh takes and best tips......

You got great advice (especially from @Ohm108) - just wanted to chime in with one little thing: Think of all the OB/GYNs that started out as OB's without L&D experience. Not that we want to be like OBs. My point is - being a labor and delivery nurse is something completely different than being a CNM. There are skills and experience that are all helpful, but you will learn them as a CNM just like OBs learned them without L&D experience. No one questions their lack of L&D nursing experience (maybe they should, ha - kidding).

Hey - just wanted to reply and say that Frontier is online, and you complete your clinicals wherever you choose. There are some in person requirements for Frontier (I believe all online CNM programs have this requirement) for skills checkoffs etc.

I don't understand this. You will give all sorts of controlled medications throughout your career. I've never thought that since I take Tylenol or Flexeril at home I need to disclose that to my place of work. Just because someone has a prescription for a medication, how does that make them more likely to take a medication from pyxis? Seems opposite to me. There should be no questions about where your home medication came from anyway. Do you think you're going to drop and lose a adhd pill and someone is going to suddenly accuse you of diversion?

This is crazy to hear. I have to ask how your interviews went..? Nursing interviews can be daunting, to say the least. Do you need work on your interviewing skills for nursing questions? Did you get interviews or just apply and not get called? Do you need to work on your resume? Did you ask your nursing school friends to look at your resume or look at theirs and compare..? Sometimes it really is just as simple as that.

Hi! I'll chat with you of course! Can you send me a direct message on here?

There can be more or less force.... I would say for most it isn't all that forceful. But every so often that baby is tucked deep into some narrow hips. And I would say that if you watched some online sections it's preeettty much the same as what you'll see in person. I think one thing that can help with the anxiety of the OR (or anything) is to keep yourself really busy. Whether you are asking your preceptor questions or writing stuff down - keep your brain busy. Keep asking yourself, "what can I do next? what can I do to help? what is happening now?" - keep a running dialogue in your head, and you won't think too much about being worried about anything. ?

Thanks for being an awesome nurse leader. We need MORE.

I totally agree with you here. Like I mentioned before - we all make mistakes. They have a lot of patients and could have something confused. As long as it was all documented I personally wouldn't be worried. However, I do care about my relationship with my provider, and I would want to clarify in person or over the phone just to show them hey - I did all the things I was supposed to...whats up with your charting... to clear the air and so I feel trust them, and if they DID think I did the wrong thing, I would want to correct them so that they know they can trust me.

I think that you should stick it out. I think there is a combination of things happening. First, you are learning a new job that is really completely different than what you were doing before and that is SO HARD to do when you know your previous job really well. So much routine, and normal in that - and now you have to work to think about everything you're doing because it is all new. Luckily, you have time management, charting and assessment skills already. The newborn assessment will come as you work, and the worry will go away somewhat (but those babe's can be stinkers! I never trust them!). I think that you are going to be a L&D nurse. You need the BUSY. It sounds like you need the constant change, and there is constant change in L&D. Even on "slow" days - they are just welcome because they are so few and far between! I think that you should do your year in postpartum and then try to transfer to L&D. I think you will be great. Work hard to focus on educating those moms/families. Get your lactation counselor certificate if you can. Busy your mind by focusing on educating your patient's and going above and beyond for each one. There is always something to educate on. And then go to L&D when you can. It really does sound more your speed. I say this as a former trauma floor nurse. I went to L&D and did my training, and then my second shift on the floor out of precepting, they floated me to postpartum. Gave me 5 patients (which is really 10 right!) and I was like oh ohhhh, this is going to be awful. But it was the easiest day I had had in weeks. It made me comprehend how much I really love L&D, and the crazy busy that it is. It is constantly something new. Find something you love about postpartum - like educating your patients, or learning more about breastfeeding so you can help your pt population....and learn it like a pro....put yourself into it so you can come out the other side - and then try L&D out! ?

LOL. If only AWHONN managed all the hospitals, paid the nurses, and created the policies.

Does the idea of circulating the surgery already bother you? I never thought that it would bother me when I was in school, and it did not, and still does not. I actually have an issue with looking at surgical and trauma photos online, but I am 100% fine in person, and I love trauma nursing. However, if you think it'll bother you already then you probably know yourself and trust that. I think exposure to it over time would probably help. As circulator, you don't really have to be all that close up to the surgical field. You can get away with minimal "looking" really, for most normal surgeries. However, you do have to be prepared for emergency needs....going to the OR after a normal lady partsl delivery, or crash sections - which can look quite different than the normal, calm, planned section. I have not really heard that most nurses have an issue in the OR. ?

Did you chart that you notified the provider each time you did notify? Did the MD notify you and complain or just write a note? If there is only a note I would call the MD and ask for clarification. I would assume it is a mistake on the MDs part before believing that s/he was throwing me under the bus about it because well 1 - I'm a positive person like that, 2 - because I know I took the correct nursing actions and 3 - because people make mistakes and this doc could have been looking at another chart or thinking it was a different patient and thought s/he was not notified. So I would talk to the doc and ask for clarification. Tell him/her that you saw the note and wanted to see if they had made a mistake. Remind them that of what happened, what you did, and that it is charted, etc. I have been sitting next to providers where they are charting a note and looking at another fetal heart strip when I hear them say "Oh that is not the right patient!" They have LOTS of patient's. I have charted on the wrong patient before too. Clarify first. ?

Experience/opinion for working as RN at this hospital or for Adventist HealthCare? I would love to hear!! ???