doing stuff differently

[cvryder]

I initially posted this on the travel nurse forum but haven't had many replies, so I thought I'd bring it over here too as some of y'all seem to be travelers.

Going from one hospital to another I've run up on some interesting differences and expectations of what nurses are allowed or expected to do. The only constant seems to be a sort of "what's wrong with you?" attitude if you say you haven't done a procedure before. I've worked mostly in critical care areas and differences can be vast. For instance, in one hospital where I worked, nurses did *all* ABGs; in others, nurses got the ABGs from A-lines, but RT got the rest; where I'm just leaving, RT does all of them, A-line or stick. As far as A-lines, I just no learned that in some places nurses are allowed to insert them. Another: I'd never worked anywhere nurses were allowed to put down small-bore feeding tubes. That one earned me some *looks* here. In some hospitals assorted fecal collection systems (rectal trumpets or pouches or the flexi-seal tubes) are routinely used and don't even require an order, in others not. What differences have others encountered?

[prmenrs, RN]

I haven't traveled, but I do know that there's a right way to do some things, a wrong way, AND, most important: the way they do it HERE.

Altho a few suggestions about the way they did it in East St Elsewhere, a constant refrain (esp if said in a disapproving tone) is not particularly welcome! It sounds to me like you've already figured that out!!

[dorimar, BSN, RN]

Yes, yes, yes. I totally see what you see, and I don't travel. I just changed jobs and was shocked at how rude people are when nurses ask questions about how things are done. The rudest attitudes usually come from the nurses who have never worked anywhere else, and obviously don't realize the world is round and not flat. One of the travelers was telling me how diffiuclt it was for her because our neuro unit was so lax, and she was asking pertinent question about the hospital's protocal for steroid drips and C-spine precautions, and was then treated like an idiot. I was new to neuro and this was disheartening to me. I find that usually the new people just need help with different equipment, what the docs like, how to page, different protocals, etc., but are treated like idiots because they don't know these things. I was at my last job for 8 years, and i always considered new people and travelers to have something to offer me. I NEVER treated anyone badly or made them to feel insecure.

[Mags4711, RN]

Yes, yes, yes. I totally see what you see, and I don't travel. I just changed jobs and was shocked at how rude people are when nurses ask questions about how things are done. The rudest attitudes usually come from the nurses who have never worked anywhere else, and obviously don't realize the world is round and not flat. One of the travelers was telling me how diffiuclt it was for her because our neuro unit was so lax, and she was asking pertinent question about the hospital's protocal for steroid drips and C-spine precautions, and was then treated like an idiot. I was new to neuro and this was disheartening to me. I find that usually the new people just need help with different equipment, what the docs like, how to page, different protocals, etc., but are treated like idiots because they don't know these things. I was at my last job for 8 years, and i always considered new people and travelers to have something to offer me. I NEVER treated anyone badly or made them to feel insecure.

AMEN!!!!!

I am always amazed at how people who have never been anywhere else think their way is the only way. I love what you said about the world being round, not flat. That is it in a nutshell.

And yes, travelers have been a fantastic resource for me, too. I always love to hear what others are doing.

[JiffyGriff]

Never travelled but as far as our unit goes: The RN's do all of the blood draws and ABG's. on the med/surg floors the lab techs do the blood draws but they don't come into icu. The RT's never draw abg's or blood ever; I'm not sure if they are even allowed to do the sticks. As far as any invasive procedure goes I think the only personell allowed to start peripheral lines other than rn's is the rad's tech. er techs only draw blood and lab only draws blood. anesthesia or md is the only ppl allowed to start a-lines, and we have a dedicated nurse that travels around and starts the picc lines. subclavian sticks are only done by anesthesia and md's as well as anything in the neck. We have to have an order for any peripherals in the legs, i've seen a few thumb lines but don't know if we have to have an order for those or not. only rectal foley's we use are the flexi-seals cuz they are the only ones that work and we have to have an order for those. We do put down small bore feeding tubes but need an order and get a stat cxr directly after. only time we're justified in an ng or og without an order is when we are bagging a patient and they get very distended, or they had one in and it came out. other than that many things happen through the night without an order but it all depends on the doc that will eventually sign it and the situation, more often than not though when we do call them for orders we say...I need this, this, and this.........they say ok and go back to sleep.

[Celia M, ASN, RN]

I work in a small general ICU in a rural hospital. We love it when travellers come from the big ICUs with lots of cardiac surgery and invasive monitoring experience, we pick their brains and learn from them, heck we've changed 20 yr old policies because of them.

[Marie_LPN, RN, LPN, RN]

I am always amazed at how people who have never been anywhere else think their way is the only way.

Not to mention their way is the right way, and only an idiot would do it your way. Worked with one of those people today.

[RNforLongTime]

"when in Rome..do as the Romans do"

I try to remember that daily as where I am currently working in the ICU, nurses are allowed to draw ABG's but are NOT allowed to pull art lines, Swans and central lines. Everything is highly physician oriented where I currently work.

Now, I have never drawn ABG's before but am slowly learning. I have worked in hospitals where nurses weren't allowed to put down small bore feeding tubes, it was done in X-ray by a radiologist under fluoroscopy. Where I currently work, I am allowed to place them. On night shift there is no respiratory therapist so I do my own vent checks, nebulizer treatments and vent set-ups if needed.

[Bruce RN]

Now that's where I need to work for a while.

I've always wanted to become more vent savvy and less dependent on an RT, but I guess in the meantime I'll take advantage of always having an RT to do those things for my patients.

Now as a travel nurse, here's another crucial piece of advice not yet mentioned here:

Do not, I repeat do not, offer to perform procedures that you are trained and proficient in performing that routinely aren't done by nurses at your given assignment. You'll make enemies fast.

I was working in a PACU and had a patient just happened to need both a dobhoff and an A-line. I grew tired of waiting for anesthesia to come by so I asked the charge nurse about any policies regarding nurses doing these things.

She said that there were no policies against nurses putting in dobhoffs and A-lines and that the nurses in the ICU's at the same hospital do it all the time.

As I was setting up my A-line tubing, the charge nurse touched my arm and said "Darling, I don't think you quite understood me. I said that nurses in the ICU's put in A-lines and dobhoffs, and right now you are working in the PACU. We never did that stuff in here before and we certainly don't want to start routinely doing it in here now."

I got the hint and waited for anesthesia.

[aj1973]

hmm, i have a question - what do you guys mean by 'draw an artline'? do you mean drawing blood from an arterial line? just thought i'd ask, as i haven't heard that term before.

seriously, some of you need to come work 'down under' for a while. i'm amazed reading these forums how little you guys are allowed to do in icu's in the usa. i'm not sure if you all know, but in australia there are no such thing as rt's, icu ccrn's set up, troubleshoot and care for ventilators themselves, including interpreting abgs, and making the necessary vent changes, nebs and intrapulmonary vasoactives. we don't put in any invasive lines, but assist the doc to do so, and we remove them all. we can put in rectal tubes, or rectal management systems if we think the patient would benefit from it.

also, what is a 'dobhoff'? haven't heard of that either!

cheers from down under

mandy

[caroladybelle, BSN, RN]

A dobhoff is a small gauge nasogastric tube used for tube feeding. It is smaller than a salem sump/many other NG tubes, more flexible and has a stylet in it to aid in placement. Thus it is much easier and less traumatic to feed into place, but also much easier to pass into the wrong position (lungs). Some facilities will permit nurses pass larger guage tubes, but require an NP/PA/MD to pass the smaller one and/or get a placement CXR to ensure placement.

[aj1973]

AH I see, thanks for that. Being an aussie, it never ceases to amaze me how different the terminology is between us and the USA - I think I'd be stuffed if I ever decided to move to the USA to work!! :)