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Posted: 10/8/2017 11:24:20 AM EST
[Last Edit: BillyDoubleU]
Well, here are somethings to keep in mind that may help you out in your first few years. Yeah, some may sound stupid but I am going to post them because I've seen them...

Foleys- Always get urine return, always. Never inflate the balloon without seeing it. Yes, I've seen a new grad inflate the balloon in the prostate. I've seen out laying hospitals also inflate do it as well. If you try to irrigate it and you can't withdrawal urine... see how much catheter is hanging out... Maybe it's clots... maybe it's not...

NG tubes- Check its depth at the start of your shift. If it ain't around 50+cm it may not be deep enough. Dobhoffs are typically 10cm or so deeper.

NG tubes- They go straight in, not up. Hit the back and twist.

NG tubes/Dobhoff- always ask or check if they've had gastric surgery. Sometimes they need to be placed under Fluro due to the anatomical changes.

Midlines- they are not PICC lines even if they are in the same spot, save the xray...

IV's- they go towards the heart. Remember that when you are starting that IV on the underside/backside of the forearm...

AC IV's- you may hit the artery one day, you'll know because it will flood the flash chamber in the blink of an eye and when you put the saline flush to it it will spurt into it. I've seen the ER do it once and I didn't realize it was in the artery. I've done it once (in the ER, HA!) but I knew immediately and removed it. That patient ended up having multiple people try and ended up with an US guided IV.

Trachs- Don't bag them over the mouth. Yes some could but if you don't know what they have etc etc just remember to bag them hooked up to the trach.

Heparin gtt's- if you are starting it above 12 MLs/HR you are fucking up. What is it, 18u/kg max does not mean start at 18mls/hr...

Sodium Bicarb- just treat it like it's NOT compatible with anything.

Hyperkalemia- giving d50 and insulin? Give the d50 first. If for some reason you lose the IV you aren't chasing 10u of insulin without access all of a sudden.

Port-A-Cath- it's never a dual lumen. Even if the IV tubing has a "Y" site. It's still a single lumen.

HD patients- if they are on continuous fluids find out why.

02- not everyone needs it

Vents- they have alarms for a reason

Tampanode- it's usually a big deal

Afib with a bundle branch- yes it may look like an odd ventricular/v tach type rhythm. It's still Afib.

If a patient says they are choking- they are not.

If they are all of a sudden hypotensive you can help by raising the legs to or just above the level of the heart.

If they are large and are desatting all of a sudden, sit them up. Sometimes that gut impedes the diaphragm.

Assessment- 90% comes just from talking to the patient

Calling the Dr- Never apologize, it's their job

Round with the Dr's then stay in the room and tell the patient what he actually said...

Don't sugar coat shit for the patient, be honest. They appreciate it. You wouldn't believe how many compliments I get just by being honest.

Oh, and don't be afraid to hurt people. You will, get over it.

That's all I can think of for now. Just looking at basics here as ARFcom seems to have lots of folks in nursing school or are New Grads.

Add to it.

Adding more:
IV’s- always try. It’s helpful to give the needle just a slight bend. It can help you from going straight through the vein if you find that happening to your IV starts often. A warm moist towel can plump the vein up as well. If the vein collapses as soon as you hit the wall or pull the tourniquet on your second try don’t use a tourniquet. You also don’t always need an 18g. 22’s will work for blood and most other things. In oncology they typically start the smallest gauge they can, think about that. Obviously certain situations require large bore IV’s but not all of them.

Elevated Troponins don’t always mean MI especially in renal patients.

Always get a baseline EKG on admission. It always comes in handy later when they inevitably has chest pain.

If your patient’s blood sugar is high (300+) always do the math to check the anion gap. If you don’t know what that is that’s ok. It’s to see if they are in DKA. If you have a BMP this is the formula. Na - (Cl + CO2). If it’s greater than 13 then think DKA though at 14 that may not get an insulin gtt. Typically values close to 20 need a gtt but be careful of potassium on initiation. Typically needs to be above 3.3. And yes, type II’s can be in a “soft” DKA regardless of what the doc might think and could benefit from an insulin gtt.

ACLS- if it’s not required get it anyways.

NIHSS- if it’s not required, get it anyways. It’s free. Being able to score a stroke is not hard and makes you smarter. NIHSS

Learn your EKG rhythms. I’ve found this to be the best online resource for learning rhythms. https://www.skillstat.com/tools/ecg-simulator
A much more advanced resource https://thephysiologist.org

At a minimum learn what normal in leads I, II and V1 look like. These leads can help you identify where a bundle branch block (bunny ears on your QRS) is coming from and most other conduction abnormalities at a starting point glance.

On your ABG’s. If your base is negative for every “3” you can expect to give 1 amp on bicarb. A base of -3 = 1 amp. -9 = 3 amps. Something you can keep an eye out for.

Learn the 300 method for quickly identifying rate in rhythms. Guess I can’t upload images anymore.
Just google it.
Find a R that falls on or right next to a thick block line. Each thick block line then corresponds to the following rates. 300, 150, 100, 75, 60, 50, 43, 37.

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All for now.
VP
Link Posted: 10/8/2017 11:35:04 AM EST
[#1]
Showing up when they are short staffed is always appreciated.

Working in the ED there was always OT available.
Link Posted: 10/8/2017 11:37:33 AM EST
[#2]
Game face.

Never lose your game face.

When the patient is freaking out at all the blood that came from X area, your ability to remain calm will in turn calm your patient.
Link Posted: 10/8/2017 12:48:27 PM EST
[Last Edit: ecgRN] [#3]
Specialize.

It'll make your twentieth+ year much easier.

Find your thing. Go after it.


Edit: excellent OP BTW
Link Posted: 10/8/2017 3:14:25 PM EST
[#4]
Discussion ForumsJump to Quoted PostQuote History
Originally Posted By ecgRN:
Specialize.

It'll make your twentieth+ year much easier.

Find your thing. Go after it.


Edit: excellent OP BTW
View Quote
I'm at 10 and am so numb I can't believe I still show up...

I'm hooked on my 5 days off...
Link Posted: 10/8/2017 4:01:10 PM EST
[#5]
Everyone will break the sternum and a few ribs doing CPR sooner or later...........usually sooner.
Link Posted: 10/8/2017 8:24:43 PM EST
[#6]
Discussion ForumsJump to Quoted PostQuote History
Originally Posted By fxntime:
Everyone will break the sternum and a few ribs doing CPR sooner or later...........usually sooner.
View Quote
Whenever I go over code status I tell them. The worst thing we can do is bring em back. They are already dead.

And yes. I use those exact words. I'm so fucking sick of Dr's afraid to say "dead". Just fucking say it! Dead. If you die, do you want us to try and bring you back. We have no idea if you'll be brain dead or impaired, all we can do is try.
Link Posted: 10/10/2017 12:47:15 AM EST
[#7]
Link Posted: 10/14/2017 12:21:07 PM EST
[#8]
Talk to the PTs

As a very new nurse myself I am very appreciative of this thread.
Link Posted: 12/3/2017 5:10:19 PM EST
[#9]
Show up
Shut up
keep up
Link Posted: 12/3/2017 5:24:27 PM EST
[#10]
Discussion ForumsJump to Quoted PostQuote History
Originally Posted By EvanWilliams:
Show up
Shut up
keep up
View Quote
That
Link Posted: 12/9/2017 4:34:34 PM EST
[#11]
Read everything you can.  Nowadays you don't need to carry a book bag full of books to work for reference.  Most likely your hospital has subscriptions to online resources like
UpToDate, Clinical Key and Lexicomp. Take advantage of those.

Or, buy a wifi only ipad and load it with all kinds of stuff

Merck Manual
Washington Manual
The ICU Book
etc.
Link Posted: 12/10/2017 1:21:56 AM EST
[#12]
A lot of good tips and advice here.

As a doctor, I'll add a few:

Yes, don't apologize for calling the doctor. It is our job. If a doctor gets mad at you for simply for calling them, they're an asshole. Plain and simple. However, we will get annoyed with you if you keep calling over and over because you don't have your shit together. Don't delay the call if the patient is actively trying to die, but have the info you need ready to go -- what happened, vitals, meds the patient is on, labs, etc.

Do round on patients with the doctor whenever possible. Have as many of the care team there as possible. It gets everybody on the same page so the same questions don't have to be answered 10 times thoughout the day. If something isn't clear during rounds, ask.

If something doesn't seem right, double check it, and ask if it still seems wrong. Doctors are human too, whether they believe it or not. Med orders get screwed up all. the. time. I've had some of my own errors caught, and possible harm prevented, because a nurse was thinking and called. I certainly appreciate that.

Lastly, go with your gut. If you think there's something wrong with your patient, you're probably right. If it looks like they're about to crash, they probably are. Call the doctor. If you're new, you could ask your charge nurse what they think, but in the end it's your call. If something feels off, assume it is. It's better to annoy a doctor with a false alarm, then to lose a patient because you didn't trust your gut.
Link Posted: 12/13/2017 11:53:07 PM EST
[#13]
Where was this knowledge when I was a fucking new RN

Good info guys

And as the doc said, go in on rounds whenever possible
If you are in a teaching hospital, ask the residents to explain stuff, they frequently will take time to teach as it’s still new and exciting for them as well
Link Posted: 7/17/2018 2:43:28 PM EST
[#14]
If a patient has COPD, its normal for their sat's to run in the high 80s low 90s. Giving them O2 will just make them retain CO2.
Link Posted: 7/17/2018 9:22:02 PM EST
[#15]
The best text book you will ever have is your patient....
Link Posted: 10/28/2018 7:26:14 AM EST
[#16]
I updated the OP some.
Link Posted: 12/20/2018 2:20:18 AM EST
[#17]
Heparin gtt's- if you are starting it above 12 MLs/HR you are fucking up.
View Quote
Not where I have worked, unless you are just referencing low range protocols.  High range heparin drips here can start at a max of 2400 units/hr (24ml/hr), and potentially go up from there (depending on the Hep XA)....I've seen rates in the low 30's on some patients.
Link Posted: 3/17/2019 2:34:00 PM EST
[Last Edit: BillyDoubleU] [#18]
Discussion ForumsJump to Quoted PostQuote History
Originally Posted By Jason280:
Not where I have worked, unless you are just referencing low range protocols.  High range heparin drips here can start at a max of 2400 units/hr (24ml/hr), and potentially go up from there (depending on the Hep XA)....I've seen rates in the low 30's on some patients.
View Quote View All Quotes
View All Quotes
Discussion ForumsJump to Quoted PostQuote History
Originally Posted By Jason280:
Heparin gtt's- if you are starting it above 12 MLs/HR you are fucking up.
Not where I have worked, unless you are just referencing low range protocols.  High range heparin drips here can start at a max of 2400 units/hr (24ml/hr), and potentially go up from there (depending on the Hep XA)....I've seen rates in the low 30's on some patients.
And I’ve given 25,000u boluses and start/run drips at 3,000u/hr (30ml/hr) to maintain ACT’s over 350. But I wasn’t a new grad and I wasn’t in a procedural unit at the time. For DVT/PE, MI/ACS, I’ve never seen someone start at 3,000u/hr... I’ve seen a few get that high but NEVER started that high. And that’s the point of the advice. Obviously their can be variations based upon where someone works. This is general advice.

It’s not a dick measuring contest. State your unit and where and why you were running your numbers. Don’t come in and try and big dick the thread. This is for NEW GRADUATE RN’s where most will go into med/surg units.
Link Posted: 11/19/2019 4:26:54 PM EST
[#19]
Glad I found this thread as I just started my first RN job. I will be in Medsurg for at least a year per my agreement, not sure after that. However, during my clinicals I by far enjoyed my pediatric and OB rotations the most. Especially OB.

I was turned down for two different OB/L&D positions. I put it down to being a new grad, but I learned today that my hospital hired three new grads for that department. Perhaps being a guy is going to be a strike against me.
Link Posted: 11/19/2019 6:15:11 PM EST
[#20]
Discussion ForumsJump to Quoted PostQuote History
Originally Posted By AirRaceFan:
Glad I found this thread as I just started my first RN job. I will be in Medsurg for at least a year per my agreement, not sure after that. However, during my clinicals I by far enjoyed my pediatric and OB rotations the most. Especially OB.

I was turned down for two different OB/L&D positions. I put it down to being a new grad, but I learned today that my hospital hired three new grads for that department. Perhaps being a guy is going to be a strike against me.
View Quote
A dude in OB as an RN.

I wouldn’t hold my breath. That’s a pretty female-centric area and understandably so. If you want to work OB you’ll need to be an NP and even then I wouldn’t even expect a job in that area as a man. Unless you are a Doctor...

Good luck though.
Link Posted: 11/19/2019 10:15:12 PM EST
[Last Edit: medicmandan] [#21]
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