elephantlover

The Radonda Vaught trial has me wondering about my hospital’s policy on versed administration. Nurses are not allowed to administer versed unless the the patient has an airway and is on a ventilator OR if a physician with procedural sedation privileges is in the room and the patient has capnography monitoring. Yet, at my workplace we give IV lorazepam all the time without special monitoring. I’ve attempted to research the differences in pharmacokinetics. I haven’t found anything that suggests midazolam carries a greater risk for respiratory depression or cardiovascular side effects. All of the literature I’ve read supports that lorazepam is more potent than midazolam. I understand why versed is reserved at a lot of hospitals for procedural/moderate sedation (cost, onset of action, amnestic effects etc), but I don’t understand why only versed comes with extra monitoring requirements at my workplace. Any thoughts on why this is? Perhaps we reserve versed for procedural sedation because of its cost and that is the only time I’m seeing it used outside of sedation for vented patients? So maybe it isn’t that versed requires a physician to be at bedside, but the level of sedation we are trying to achieve with it does? Thanks for reading!

I am currently a RN in a med-surg adult ICU with two years of experience. I get a nice mix of medical, neuro, trauma, and other various surgical specialties on my unit. My five-year plan involves applying to nurse anesthesia programs. I plan to continue gaining experience in my current unit for a few more years before applying to schools. I have learned so much in the ICU, but I wonder if I am missing out on certain competencies. I am curious if finding a part-time position in the ED would be worth it to help round out my experience and better prepare for school. I feel like ED would give me more opportunities to start peripheral lines under pressure, learn about pediatrics and maternity, and sharpen my rapid assessment skills. I know of a few nurses who split their time between ICU and ED. I understand that ED is a very specialized department and takes a real-time commitment to become a proficient ED nurse. I am not under the impression I can just casually moonlight in emergency care-- it would really be an investment. Any thoughts on if this is feasible or worth the time commitment? Thanks for the read.

It is a rare exception when things escalate to pulling lines. With education on risks, people are more often than not willing to comply with CLABSI bundles. To my knowledge, my organization was free of CAUTIs and CLABSI in 2019.

Sometimes I am successful in encouraging reluctant patients to wash up just by saying: "you will probably feel better... you will look nice and fresh for your visitor today...." *hands patient supplies* Not going to waste my breath trying to convince or argue with an independent adult who requires no assistance with ADLs. I feel strongly that nurses need to maximize patient independence. Sometimes allowing the patient to do what they are capable of doing takes up more of my time, but it is SO important to promote independence. My organization will pull central lines and have patients sign an AMA form when they refuse regular hygiene. Why should the health care organization be liable for that CLABSI? I think it is awesome.

I think OP has a good point and did not intend to undermine the need for safe patient handling practices and equipment in the workplace. Of course, not all nurses need to be nor can be powerlifters. There IS a body of research to supports even limited resistance training as an effective measure to reduce injury risk. People develop musculoskeletal disorders just from sitting at a desk all day long. Researchers suggest that nurses are at the greatest risk among all health care workers to develop work-related injuries (Davis & Kotowski, 2015). Although I suspect EMS/ medics are up there with nursing. Although my personal experience is anecdotal, strength training has helped with lower back pain. I started working in LTC when I was 17 and knew I was too young to be waking up with back pain. Numerous coworkers on leave for back injuries, hip replacements. NOT OKAY. After a couple of years, I left this LTC facility for an acute care setting. I was tired of shortcuts and being asked to roll patients three times my weight without assistance because "other people had no problem rolling them with an assist of one." I digress. This post is a great opportunity to discuss workplace safety. It is disappointing that it takes workplace injuries for change to occur. I am happy to report that I see more mechanical lifts being used and specialty beds that reposition patients. The training and equipment matters, but I think having a culture of safety is what matters most. Does management look for solutions to reduce injury risk? Is staffing appropriate? Are people willing to take the "extra time" it requires to move patient's safety and utilize equipment that is available? Are nurses encouraged to put their foot down when something seems unsafe?

I graduated in May as well. I started right away at a large urban teaching hospital with magnet status that enrolled new grads into a mandatory "residency program." The program had watered-down content in my opinion. It involved monthly meetings where we watched videos on topics like self-care, delegation, finance, end of life care etc. Basically repeats of lectures I had in nursing school. The whole thing sounded lovely in theory, but the quality of education was poor in my opinion. Yes, please tell me more about self-care as I pinch myself to stay awake because it has been 20 hours since I last slept ?. Other than these monthly meetings (where I was half asleep after a 12 hour night shift), there was nothing more to the program. I got to a point where I felt my learning was tapering off. I was working with almost exclusively other new RNs and first-year residents. Not many seasoned folks to turn to. I decided to leave this teaching hospital, the biggest reason being I needed to be closer to my family. One month ago I started a new job at a smaller regional medical center with no formal new grad residency program. I have learned SO much more in my first month here than I did in 6 months at the teaching hospital. My orientation at my new job is TWO weeks longer than my orientation was at my former job as a brand spanking new grad. There is truly a culture of excellence where I work. I feel supported and look forward to going to work most days. For the most part, people are receptive to newcomers. I have learned a lot from doctors, respiratory therapists, care managers, and other nurses all willing to take the time to teach me new things. These informal learning opportunities have been far more valuable to me than the silly videos we watched in nurse residency meetings at my last job. I allowed titles and name recognition to sway my decision with my first job as a new grad. I made the mistake of assuming name recognition went hand in hand with quality nursing and professional development. Look at the big picture. I am a better nurse now because I am happier being closer to family working for a community hospital where I have the opportunity to build relationships with my colleagues. I did some serious investigative work before taking this position. I considered several area hospitals and talked with people I knew to get an idea of what the culture was like at each place. Long story short, bigger is not always better. It really depends on what YOU are looking for and where you are going to have balance and QOL. I think the previous posters hit the nail on the head, nurse residency is a loose term. What exactly does the program entail and how would that be any different from the orientation you would receive as a new grad elsewhere? Good luck to you!

I am a nursing student and I feel the same way as you. I excel in my theory classes and I do well enough in clinical. But I have moments where I forget things or stumble on my words when giving report. Moments like these make me question I am cut out for this profession. I would like to think this is normal to a certain extent. Maybe some of it has to do with how we process information and communicate compared to others? Keeping a detailed to-do list and "brain" sheet has helped a lot. Working as a CNA and nurse extern has helped A LOT. I think time, experience, and diligence will get us to where we want to go. Good luck from one student to the next. You aren't alone.

It is a good lesson. I am sure you will not make it again. Nursing schools have to prepare you for a real job where there would be disciplinary action. If you mind your ps and qs you should be fine. I use two alarms on my phone and an alarm on my watch. I double check the time and volume on both each night. Budget 20-30 minutes extra than you think you need and you should be fine. And ps. Have some confidence. shake it off. prove that you can grow and learn from this. We all make mistakes. It is what we do to learn from them that matters.

I am in my last semester of an accelerated BSN program. I think the hardest thing about nursing school has been balancing my priorities: work, clinical, school, staying healthy, etc. I had MANY times where I would go from clinical to work, work till midnight and leave my house the next morning for clinical at 5:15 AM. I think being in clinical adds a new layer to nursing school. Clinical is very time intensive. From the prep work to post clinical paperwork. At my school expectations were very high. I would spend 10 hours a week on clinical paperwork.

My understanding is that CAA school is the anesthesia equivalent of PA school. So with the proper prereqs you could get in with any bachelor's degree. Mier Kat is probably correct in that CNRAs are more widely used. Not sure what the outlook is for CAA

I appreciate your input everyone! I love learning from experienced nurses. In my opinion, the rise of ligation in healthcare has contributed to this protocolization of tasks as you describe JKL33. The way in which reimbursement works has also. Nursing care is not so black and white though. I digress. Thank you for your time!

I appreciate your input. You sound like a good preceptor. I am trying to learn as much as I can about clinical decision making before I am on my own this summer. I agree there aren't excuses for incompetent care. This particular nurse was precepted by an RN who is rather flippant and short with new nurses who ask questions. Management has been made aware and this woman has improved her behavior. I have enough confidence to not care how others perceive my question. I wish all nurses would provide the support that you describe.

Thanks for your feedback. I do not want to rip on this nurse. She is a new nurse figuring things out. I just wonder why the policy at my hospital is so vague about phlebitis. Perhaps a certain degree is acceptable, and simply needs to be monitored depending on the circumstances (e.g. the patient is discharging shortly etc.)?

You can get your masters in anesthesia and become a certified anesthesia assistant. Different from CRNA school. CNRA programs build off of the student's critical care experience as RNs. Not absurd. Makes them qualified, experienced, skilled.

Hi there! I think your first clinical in the acute care setting is a big step regardless of the unit you are on. Some nerves are to be expected. General advice to calm your nerves before clinical: do thorough prep work. Wake up early the morning of and give yourself plenty of time in the morning to get ready and make it safely to clinical. The time it takes to find a parking spot, walk into the hospital, and get settled on the unit might be over ten minutes. Go in early to check your patient's orders and get settled. Observe how employees interact with the patients. You will likely shadow for a day before jumping in. You likely won't be administering chemo. You need a special certification to do this as an RN. Just listen to patients. Introduce yourself to form a bond. Let the patient know it was nice to meet them. Thank them for allowing you to work with them. Follow their lead. Don't minimize their experience or tell them not to worry. Try to validate the emotion the patient is experiencing. I float to the oncology medical unit at the hospital where I work as a tech. The patients are not as intimidating as I thought they were going to be. Cancer-related pain can be difficult to manage. Be prepared to use pharmacological and non-pharmacological interventions. Ask the patient what works for them. Don't be afraid to ask difficult questions during your assessment like how have your moods been? You will likely see all sorts of patients on this unit. Hopefully an oncology nurse chimes in. I would be interested to hear from a real professional. Good luck to you! I am excited for you. It is OK to feel nervous. I often felt incompetent during my first acute care clinical. I am not suggesting you too will feel this way, but know my confidence and skills have come along way. No one expects you to know everything or to have the perfect communication skills. Be respectful, keep safety in mind, and work hard.

Interesting. I hear what you're saying! I have more limited experience with venipuncture. I will keep this in mind. The RNs on my unit do not draw labs and they rarely start IVs. I just don't think to claim someone is a difficult poke is a valid excuse to leave an IV catheter in a patient a red, rock hard vein just because it flushes.

The patient was of normal weight. Middle-aged. Visible veins. We have IV resource nurses at the hospital I work at. I just was trying to understand why this particular nurse decided not to start a new IV. But yes, thank you for your answer. If a patient complains of new pain at the IV site. Remove and start a new an IV.

THANK YOU! This seems so straightforward in my mind. This patient's vein was being irritated by the catheter and the abx. Solution. STOP and remove. Further complications could develop. I just could not understand why my hospital's policy was so vague. We have resource nurses that will use ultrasound to start IVs as well. Takes the burden off the nurse. This seems black and white. Now I know what not to do. Thank you for walking me through the big picture.

I love Ezekiel bread! Always have a loaf in the freezer. I am going to have to try your tuna salad sandwich with jalapenos and pickles. Sounds tasty. I agree rotisserie chicken is a big time saver. Always worth it. I too love egg bakes. Yum, your egg muffins sound great. I like to add sweet potatoes, spinach, jalapeños, and broccoli in mine. Basically whatever I can find in the fridge. For breakfast, I like to do steel cut oats with walnuts, PB, and blueberries. The oats take about 15 minutes to cook, I always hop in the shower and get dressed while my oats simmer. Yes, I make my own protein shakes and I buy iconic grass fed protein shakes (I love the golden milk one). In my shakes, I like frozen berries, vega protein powder, instant espresso, almond milk, and cocoa powder. Sometimes I will use peaches, greens, and use tea as my liquid. Banzo pasta is my favorite! Only ingredient is chickpeas. I use that for cold pastas. I like to add broccoli, cherry tomatoes, onions, pesto add ranch seasoning. Soba noodles are another favorite. They cook in 2-3 minutes, but are still an excellent whole grain. I eat them cold and warm. I like to add liquid aminos (or soy sauce), edamame (I buy frozen and steam), sometimes I will scramble an egg, sometimes PB for the flavor. Other stir-fry veggies sautéed. Avocado salsa salad. I add salmon or chicken. Snacks: • Cheese • Popcorn • Salsa and corn chips • Apples and PB • Yogurt • I like the healthy grains kind bars. These do have roughly 5 grams of added sugar, but it’s one of the better tasting granola bars I have found that are packed with nutrient dense ingredients. • Dark chocolate • Iconic grass-fed protein drinks • Golden-milk smoothies (turmeric, protein powder, almond or coconut milk, ginger, pepper) • I love some treats too: fig newtons, alternative chocolate chip cookies (google Chelsea’s messy apron), dark chocolate. I think we are on the same food wavelength ? Sounds like you eat some well-rounded meals

Love this story. Thank you for sharing your personal experience. Vulnerability and kindness are brave and beautiful. Nursing has really challenged me to withhold judgment- it is an ongoing process.

I have really enjoyed your posts in this discussion. Excellent food for thought. Thank you. I hope I never stop honoring patients as you describe. What do you do when you are running out of options to manage the patient's pain? Do you contact the provider to discuss something for breakthrough pain? What if they have poor renal function or their RAAS score is low, but the patient is reporting moderate to severe pain? Beyond environmental and alternative interventions, how do you have that discussion with your patient when their next available pain med is hours away? I feel that I will struggle with this as a new nurse.

Currently living the lunchbox life. On a typical day, I pack or eat 2-3 of my meals on the go. Sometimes it can be a real struggle. I have always told myself I was going to learn how to meal prep for several days, and it has not happened. Hoping to get some inspiration from others in this post. My favorite lunches are dinner leftovers. Other than that, I often make hummus sandwiches. I toast some sprouted bread. Load up all the veggies in my fridge, add a little pesto and black pepper. Yum! Salads are another go-to. I will keep hard boiled eggs in my fridge ready to go. Add some sunflower seeds, cherry tomatoes, a good dressing. Done! I also keep those flavored tuna packets in my pantry for salads and sandwiches. Some good omega-3s. I keep a few lighter frozen entrees stocked for days I am low on groceries or running late. In addition to the entree of my lunches have trail mix, a granola bar, veggies + dip (usually hummus, mustard, or ranch), a piece of fruit, a cheese stick, and carbonated water or tea. Breakfasts I like doing a smoothie with pea protein powder and piece of sprouted toast or a waffle. My biggest piece of advice to you, pack more snacks than you think you will need. You can always save them for a different day. Days I pack a good lunch I have something to look forward to. Nursing school is already challenging. Eat things you enjoy in moderation. You don't want to feel deprived or uninspired by your meals. I feel that a lot of my classmates underestimate how much food they will need when we have lecture 8 hours straight. Clinical days I am usually to busy to realize I am hungry, but a good breakfast and on-the-go snacks are important because sometimes you do not know when you have a lunch break. I also keep k-pods in my backpack because my school has a Keurig machine. I am so excited for you! Hope you have a great first week of school.

For my fundamentals clinical we were in an LTC facility as well. Yes, the main focus was on basic nursing skills and ADLs. Minor soap-box moment: these skills are so important! Yes, RNs do delegate to assistive personnel in certain settings, but they are still involved in patient care! I currently work on a medical floor at a teaching hospital and guess what? Nursing home residents make up a large part of the population that we work with. During this clinical practicum, I also practiced assessment skills, care planning, passed oral meds, and did wound care. Check out the course outcomes in your syllabus. Keep an open mind! I had been a CNA for 5 years prior to my fundamentals clinical and I had a lot to learn. Some days I had to seek out opportunities to learn. For example, if there was a patient on a different wing who had a PEG tube or trach I asked to be assigned to that patient or shadow the nurse. Overall it was a good experience. You have a great opportunity to teach your classmates who are less familiar with patient care. I know a lot of my classmates had not touched a patient prior to our first clinical. I enjoyed going into patient rooms with them to support them. I hope you have a really great experience!

I see what you're saying. This nurse did not intend to start a new IV. I work on a medical unit and our policy is that every patient needs IV access. I just don't understand why she wouldn't start a new IV for this patient who was not being discharged in the near future.

This past week at work I was working with a different RN. We had a patient receiving a dobutamine infusion through a peripheral IV. The patient complained of pain at the infusion site a few hours in. There was no redness or swelling around the site, but this RN decided to remove the catheter immediately. Both dobutamine and vancomycin are vesicant medications. Our policy isn't clear. Trying to gauge what the most appropriate course of action is.