They didn't teach me this in nursing school and I could have killed someone!

ageless · Jul 28, 2005

according to my iv drug administration book by mosby, there are physical and chemical incompatibilities. these can cause precipitation and gas evolution in drug mixtures. temperature can also affect solubility and compatibility along with ph and even the rate of administration.

i take this to mean an air embolism or gas evolution can occur if incompatible chemicals are mixed in the same lumen. i have never heard of a problem if using different lumens. i flush before and after each piggyback to check for patency and maintain the integrity of the lumen. this also prevents incompatibility problems. in general, i do not piggyback drugs in tpn because of the high risk of infection along with the other incompatibility factors.

if i have a doubt, i call the pharmacy and document their instuctions.

epiphany · Jul 28, 2005

What things "didn't" you learn in nursing school or during orientation that could have resulted in a patient being harmed? ....... What would your "top three" things be that fall into this category?

Actually, as far as your original question, my experience has always been the opposite. I am finding that a lot of things I learnt in school are not being done in the hospitals, and I constantly feel like there's a blurred line between Real World nursing and a potentially dangerous negligence.

For example, just recently, it's come up that the doctors in my ICU unit do not bother to do the Allen's test before drawing arterial blood - and these patients are circulatorily(?) compromised, so it's even more important to check of their ulnar artery patency, in this newbie's opinion. Another thing - nurses are not rolling their NPH insulin to mix it before using. It's hard to question these actions without, at some stage, feeling like you're some lone ranger trying to challenge years of experience and practice. All I really want is a satisfactory rationale for why certain "text-book" techniques that made sense to me when I learnt them in school, are not be adhered to. In some cases, like when I find out that Real World nursing does not always allow you to do a head-to-toe assessment of all patients, okay, I can accept that. But in what seems like potentially life-altering measures that are not being carried out, like the two examples I mentioned, I will always feel I'm not doing the job right, unless I do it by the book.

It's exhausting. Even though I tend to be thick-skinned and willing to stick my neck out and probe for the answers, it can feel like a constant uphill climb. So, my experience is just the opposite.

epiphany · Jul 28, 2005

To address your issue of not having learnt some things in nursing school, in my opinion, a school, no matter how bad, does prepare you for the ability to make the right decisions. For example, as noted, you can never know every medication intimately, until you work with them, and the school has already introduced you to the concept of referring to your drug guides, so there should be no excuse to make that mistake. A school cannot spoonfeed you information and pamper you because we are suffering shortage of good nursing faculty. That's just the reality. I am the biggest whiner about how much my school sucked, but on the other hand, I am also aware of the need to be proactive and responsible for my own education. Now that I'm just finished with school, my education is really just beginning. There are tons of resources out there and a nurse should be responsible for acquiring researched based information herself/himself. I can see how tempting it is to say: "the school never taught me that", and because my school sucked (did I already say that?) I may even be justified to make that statement, but if I ever get into the habit of that, I'm getting into the habit of not being accountable for my own actions.

Sorry, I had to get that off my chest. I don't mean anything personal.

mysterybe · Jul 28, 2005

I wish our nursing school would have taught more about mainenance of peripheral IV sites and central lines. They taught us how to do a PICC dressing change; but we were never allowed to do a flush of any kind in clinicals. Not even a saline flush on a peripheral line. It became a catch-22 when we'd try to get experience inserting a new IV site, as they would let us attempt that...but then we'd need to have a floor nurse or clinical instructor to actually push the flush!

So I've had to play catch up after I was hired in the real world. My preceptor at the hospital (who was a great preceptor) got a kick out of the look on my face when she told me to go ahead and flush a peripheral line. It was so drilled into us to not do a flush...it was like asking me to jump off a cliff! :rotfl:

I agree one has to take personal responsibility to look meds up and hospital protocols. However, my school could have done a better job informing us about general IV maintenance other than the PICC dressing change. I wonder how common it is for schools to not allow students to do any flushes.

Roland · Jul 28, 2005

I'm just wondering what are the "obvious things that every nurse knows which could harm clients" only the thing is not every nurse and especially newer nurses necessarily know these things. Two more examples of which I am aware:

1. There was a case related to me of a resident who inserted a chest tube, but didn't verify placement with an X-ray. The patient declined and after many calls to the attending it was discovered that the resident had lacerated the liver when he inserted the chest tube . The lesson here as a nurse may be that when the doctor inserts a chest tube, but doesn't verify placement that you must either step up to the plate and "raise a stink" or at least pay extra close to the patient's vitals and labs.

2. I've noticed that many nurses "in the real world" verify placement of an NG-tube via auscultation. In nursing school we were taught that only by aspirating a small amount of stomach contents and checking PH, or an X-ray could you be satisfied with NG-tube placement (indeed our text specifically indicated that auscultation was not acceptable). Well, what's the real story?

I have no doubt that there are dozens (hundreds ?) of other similar situations involving issues not specifically taught, but which are vital to safe client care.

I wish our nursing school would have taught more about mainenance of peripheral IV sites and central lines. They taught us how to do a PICC dressing change; but we were never allowed to do a flush of any kind in clinicals. Not even a saline flush on a peripheral line. It became a catch-22 when we'd try to get experience inserting a new IV site, as they would let us attempt that...but then we'd need to have a floor nurse or clinical instructor to actually push the flush!
So I've had to play catch up after I was hired in the real world. My preceptor at the hospital (who was a great preceptor) got a kick out of the look on my face when she told me to go ahead and flush a peripheral line. It was so drilled into us to not do a flush...it was like asking me to jump off a cliff! :rotfl:
I agree one has to take personal responsibility to look meds up and hospital protocols. However, my school could have done a better job informing us about general IV maintenance other than the PICC dressing change. I wonder how common it is for schools to not allow students to do any flushes.

nicolel1182 · Jul 28, 2005

i thought in general a TPN line may cause a pulmonary embolism. at least this is what my instructor taught me in clinical. Something to do with the lipids gettings clogged and somehow and someway getting into the lung and causing an embolism. Something to this effect

suzanne4, RN · Jul 28, 2005

It is the lipids that could cause the embolus, not the TPN or the TPN line.

suzanne4, RN · Jul 28, 2005

And to add in to the mix, nursing school only gives you some of the basics, the others you will learn as you do your orienttion and then just thru working. School cannot even attempt to teach you everything. But you should know where and how to look up drugs and what your facility's policies are on these exact things. And that goes for any procedure. What you learned in school may be different from what you are expected to do when you begin work, and you need to follow those of the hospital's policies and procedures.

ageless · Jul 28, 2005

It is the lipids that could cause the embolus, not the TPN or the TPN line.

I assume you are speaking of lipids causing a foreign body embolism or more specifically a fatty embolus.

TPN can cause a gaseous embolism if combined with chemically incompatible substances.

fergus51 · Jul 28, 2005

I work NICU. We routinely give meds in the same line as the TPN. There is really no way around doing this since our PICCs are all single lumen. There are exceptions per hospital policy because some meds are incompatible (like amphotericin for instance). The only time we have the luxury of running things separately is if the baby still has a double lumen UV line in place or has 2 PICCs.

As far as NGs: We check placement by auscultation and aspiration (though no ph testing). If we had to do an Xray every time our kids would glow from the radiation by the time they got discharged.

mrdoc2005 · Jul 28, 2005

I wish our nursing school would have taught more about mainenance of peripheral IV sites and central lines. They taught us how to do a PICC dressing change; but we were never allowed to do a flush of any kind in clinicals. Not even a saline flush on a peripheral line. It became a catch-22 when we'd try to get experience inserting a new IV site, as they would let us attempt that...but then we'd need to have a floor nurse or clinical instructor to actually push the flush!
So I've had to play catch up after I was hired in the real world. My preceptor at the hospital (who was a great preceptor) got a kick out of the look on my face when she told me to go ahead and flush a peripheral line. It was so drilled into us to not do a flush...it was like asking me to jump off a cliff! :rotfl:
I agree one has to take personal responsibility to look meds up and hospital protocols. However, my school could have done a better job informing us about general IV maintenance other than the PICC dressing change. I wonder how common it is for schools to not allow students to do any flushes.

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My school changed insurance comapanies between semesters my last year. We went from doing almost anything to not even able to touch an IV med. We were not even allowed to go down to the blood bank and pick up a unit, much less give blood.

The idea that an LPN cannot give blood but an RN can (Speeking for my state) I never was allowed to start blood during my BSN program just seems wrong. My school did not even talk much about giving blood. I learned most of what I knew about blood transfusions from Kaplens NCLEX review.

Also, my school spent more time majoring on the minor things like bedmaking and bedbaths. Don't misunderstand I know we needed to know these things, but with all there is to learn these things fall short on my list.

mattsmom81 · Jul 29, 2005

"Also, my school spent more time majoring on the minor things like bedmaking and bedbaths. Don't misunderstand I know we needed to know these things, but with all there is to learn these things fall short on my list"

LOL...I still remember the hoopla surrounding the bedbath and bedmaking...it was SOOOO ridiculous how anal those instructors were. We had to do it JUST SO... :uhoh3: