5/7 (on 5/9) WILTW: ixchel is a cornflake girl

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by ixchel ixchel Member Nurse

Specializes in critical care.

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Jensmom7, BSN, RN

Specializes in Hospice. Has 36 years experience. 1,907 Posts

Almost everybody has lines at my full time job. Everybody. I would estimate less than 3/30 patients only have peripherals, and everybody and their dog has peripherals at my PRN job. I hate peripherals. Hate hate hate. Every single time I work at my PRN job I come in to at least one infiltrated peripheral.

When I still worked MedSurg, I frequently wished there was such a thing as a permanent PICC, and thought that everyone should have one placed at birth.

calivianya, BSN, RN

Specializes in ICU. 2,418 Posts

When I still worked MedSurg, I frequently wished there was such a thing as a permanent PICC, and thought that everyone should have one placed at birth.

That sounds amazing to me.

OCNRN63, RN

Specializes in Oncology; medical specialty website. 5,978 Posts

I learned this week that panic ensues when the WILTW doesn't appear ... there's panic in the streets. ;)

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WellThatsOod

WellThatsOod

897 Posts

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*flying tackle hug*

OCN!!

WellThatsOod

WellThatsOod

897 Posts

I haven't ventured far since my return...

Some classmates have received their ATTs, so I might be able to schedule my NCLEX date tomorrow!

My mom, who is super conservative and religious, has concerns about my baby brother's sexual orientation. I had to repeatedly reassure her that he does have interest in the female population.

In DKA, give fluids THEN insulin. I dislike NCLEX questions that limit you to do one thing when, realistically, you'd be doing 2-3 things at once.

When I go to MI, I'm going ring shopping with her. Her boyfriend is planning to propose sometime soon, apparently.

OrganizedChaos, LVN

Specializes in M/S, LTC, Corrections, PDN & drug rehab. Has 10 years experience. 1 Article; 6,883 Posts

Thank you everyone for your well wishes.

calivianya, BSN, RN

Specializes in ICU. 2,418 Posts

In DKA, give fluids THEN insulin. I dislike NCLEX questions that limit you to do one thing when, realistically, you'd be doing 2-3 things at once.

The NCLEX is actually right on this one for every place I've worked. The ED always royally screws everything up and turns DKA into a crapstorm every. single. time. They are supposed to be using our protocol, which puts fluids first. The order of things (for my current FT job) is:

- Make patient NPO

- Get initial labs: ABG, BMP, mag, phos, Hgb A1C, CXR, stat lab backups for any glucose >500, urinalysis, blood cultures

- 2L NS (1-2L additional if presenting MAP

- 100 mEq bicarb if initial pH under 7.10

- Initiate insulin at 1 u/kg/hr with a 1 u/kg initial bolus

- Initiate 1/2 NS w/40 KCL @ 250 with the insulin

- Initiate a 10 ml/hr NS line to run directly with the insulin (carrier)

- q4h BMP, mag, phos, ABG/VBG

- Do electrolyte replacement only, do not give maintenance while pt. on insulin drip

- Blah blah blah titrate via a table if BG dropping too fast, not dropping fast enough, etc.

- Once BG drops below 250, titrate insulin to 0.5 u/kg/hr

- Start D5 1/2 NS w/ 20 KCL @ 150 at the same time

- BMP, mag, phos, ABG/VBG can now be q6h

- Once BG hits

- BG

- Anion gap

- Then, patient can have real food

What happens in real life is usually at LEAST four of these:

- The patient was eating/drinking in the ED

- Initial labs were incompletely drawn

- Something other than 100 mEq of bicarb was given for a pH

- Bicarb was given for a pH >7.10

- The initial fluid boluses were never given

- The initial fluid boluses were not finished before the insulin was started

- The insulin bolus was never given, the drip was started by itself

- The insulin is running with anything other than 1/2 NS w/ 40 KCL at 250 and NS at 10

- The insulin is running at something other than 1u/kg/hr

- The initial insulin bolus was something other than 1u/kg

- The patient is already on a fluid with dextrose (probably not the one on the protocol) and the BG is still over 250

- The patient was in the ED more than four hours and none of the q4h labs were drawn

- The q4h labs were drawn, but the ED did not replace electrolytes and the patients had critically low K+ levels by the time they got to me (usually ED forgets the 1/2 NS w/ 40 KCL @ 250 also in these cases)

- The q4h labs were drawn, replacement was given, but maintenance was also ordered, so that has to be d/ced

- Or, worst yet, the ED forgets to check the patient's BG at all, the patient lingers in the ED for hours and hours without a BG check, and the patient ends up brain dead (happened at my first job; it was somebody in their 20s, and it was a really big lawsuit)

UGH.

I kind of wish the ED would just send the people straight up the second the first BG came back. It's easier to start from the beginning of the protocol than it is to backtrack through all the things that they missed and figure out if those orders are still appropriate hours later. I love my ED people but the DKA protocol might as well be in a different language that none of them speak because I have never had a SINGLE DKA patient whose protocol was initiated properly in the ED. It's done wrong 100% of the time.

TLDR; version - Actually, unless you want to royally screw up a DKA protocol, you really do give fluids first before insulin. NCLEX has that one right.

LadyFree28, BSN, RN

Specializes in Pediatrics, Rehab, Trauma. Has 10 years experience. 8,427 Posts

The NCLEX is actually right on this one for every place I've worked. The ED always royally screws everything up and turns DKA into a crapstorm every. single. time. They are supposed to be using our protocol, which puts fluids first. The order of things (for my current FT job) is:

- Make patient NPO

- Get initial labs: ABG, BMP, mag, phos, Hgb A1C, CXR, stat lab backups for any glucose >500, urinalysis, blood cultures

- 2L NS (1-2L additional if presenting MAP

- 100 mEq bicarb if initial pH under 7.10

- Initiate insulin at 1 u/kg/hr with a 1 u/kg initial bolus

- Initiate 1/2 NS w/40 KCL @ 250 with the insulin

- Initiate a 10 ml/hr NS line to run directly with the insulin (carrier)

- q4h BMP, mag, phos, ABG/VBG

- Do electrolyte replacement only, do not give maintenance while pt. on insulin drip

- Blah blah blah titrate via a table if BG dropping too fast, not dropping fast enough, etc.

- Once BG drops below 250, titrate insulin to 0.5 u/kg/hr

- Start D5 1/2 NS w/ 20 KCL @ 150 at the same time

- BMP, mag, phos, ABG/VBG can now be q6h

- Once BG hits

- BG

- Anion gap

- Then, patient can have real food

What happens in real life is usually at LEAST four of these:

- The patient was eating/drinking in the ED

- Initial labs were incompletely drawn

- Something other than 100 mEq of bicarb was given for a pH

- Bicarb was given for a pH >7.10

- The initial fluid boluses were never given

- The initial fluid boluses were not finished before the insulin was started

- The insulin bolus was never given, the drip was started by itself

- The insulin is running with anything other than 1/2 NS w/ 40 KCL at 250 and NS at 10

- The insulin is running at something other than 1u/kg/hr

- The initial insulin bolus was something other than 1u/kg

- The patient is already on a fluid with dextrose (probably not the one on the protocol) and the BG is still over 250

- The patient was in the ED more than four hours and none of the q4h labs were drawn

- The q4h labs were drawn, but the ED did not replace electrolytes and the patients had critically low K+ levels by the time they got to me (usually ED forgets the 1/2 NS w/ 40 KCL @ 250 also in these cases)

- The q4h labs were drawn, replacement was given, but maintenance was also ordered, so that has to be d/ced

- Or, worst yet, the ED forgets to check the patient's BG at all, the patient lingers in the ED for hours and hours without a BG check, and the patient ends up brain dead (happened at my first job; it was somebody in their 20s, and it was a really big lawsuit)

UGH.

I kind of wish the ED would just send the people straight up the second the first BG came back. It's easier to start from the beginning of the protocol than it is to backtrack through all the things that they missed and figure out if those orders are still appropriate hours later. I love my ED people but the DKA protocol might as well be in a different language that none of them speak because I have never had a SINGLE DKA patient whose protocol was initiated properly in the ED. It's done wrong 100% of the time.

TLDR; version - Actually, unless you want to royally screw up a DKA protocol, you really do give fluids first before insulin. NCLEX has that one right.

We actually do this at our hospital....you can always work here... ;)

I did some hardcore NCLEX studying today, so some relearning occurred:

Rhogam is only given by the RN because it IS a blood product.

MSAFP is done at 16-18 weeks and detects fetal abnormalities. Low levels can indicate Down's and high levels can indicate NTDs.

CVS can be done at 8-12 weeks to detect fetal genetic abnormalities.

Cultures for GBS are taken at 35-36 weeks, and, if positive, treated with penicillin IVPB q4h during labor.

High levels of hCG can indicate multiple fetuses, ectopic pregnancy, hyatidiform mole, or Down's. Low levels of hCG can indicate miscarriage or ectopic pregnancy.

aeris99

aeris99

490 Posts

Pinning was last night and it was great. My hair looked awesome, super cute dress, rocked my heels and didn't fall. Lol it's the little things.

I was totally floored though, when it was announced that I was being presented with the Nurse of the Future award.

Nursing school has been such a crazy rollercoaster!