Normal for med-surg?! Please advise.

[ninja-nurse]

I'm a fairly new nurse, and have been working at my (first) position for about 7 - 7 1/2 months now, and I've run into a few things that I'm really going back and forth about. Please bear with me, this is a little long.

The first thing is narcotics. Our MD's prescribe what seems like an awful lot of narcotics for little things. Come in with bronchitis? Get Demerol 50mg q 2 hours PRN. Abd pain and vomiting? Get 3-4 mg of Morphine (or 1-2 mg of Dilaudid) q 3 PRN. I've had a patient getting 6 mg of morphine q2 hours PRN plus scheduled oxycodone AND Lortab q6. More than 1 patient has had to be coded because they quit breathing after the meds they demanded. I don't remember any clinicals patient getting that much that often, and all the other nurses say that it's ridiculous. IS this normal?

I'm a little concerned about our MD's, though I don't expect them to be great. But we have one who sometimes slips out of english and into a middle eastern language when he writes (can't remember which one) and gets upset when we ask what he wrote. He tells us "If you can't read it, just cancel it out." We have another that I overheard an ICU nurse ask about her patient (I'd been called in to help hang IV meds, blood sugars, etc). The patient had had a 105-106 degree fever for 3 days, and the staff was worried that if they couldn't get it down she might get brain damage. He told her "That's not dangerous in an adult. I'm not doing anything for that."

We get peds patients, but the hospital won't carry the stuff to treat them. RT is constantly throwing fits b/c they don't have child-sized masks, and I've seen a nurse go down the street to Wal-Mart at 2 AM b/c there wasn't enough formula for the baby and the supervisor wouldn't go. We ran out of BP cuffs for them the other night.

I love the people I work with - from secretaries and security to RN's and RT, and I had the best mentor I could have asked for - but it seems to me that the hospital is going downhill. Am I just in first-timer freak-out mode, or are these some valid concerns?

I'm sorry for the rant, but I needed to get it off my chest - to someone who would understand and be unbiased. If anyone has plowed through this whole thing, thank you.

[Kdog]

Well, I've seen Md's order alot of narcotics too while on some travel assignments. It is scary, especially when the pt. can hardly wait for the next dose. As long as their vs and o2 sat are stable and they rate the pain as 7-10, we really have to give them the narcs.Just document everything and keep checking them.
As far as the Peds supplies go, that is really bad. something is going to happen someday.
As far as the Dr. and the fever etc. report him to Supervisor.
I see how concerned you are and uncomfortable. Is there another hospital that you can apply to?

[Ricu]

The nurse goes to WalMart at 2am to get formula? No pedi masks in the pedi unit? Doctor forgetting which language to use AND directs you to disregard whatever you can't read? Temp. of 105F is not too high- for an adult? For days?! This is just crazy.

Now, for those pain med orders. I'm going to come at this from a diffferent angle and throw the onus on the nurse. Because there are people out there who have significant pain and tolerance to narcotics isn't readily known, liberal dosing should be available as needed. This is all part of the PRN dosing process. The nurse is expected to be able to properly assess a patient, determine an appropriate dose from within the PRN range available and dispense as needed. This would include reviewing a particular patients' dosage history. It's always advisable to dose low at first, reassess in thirty minutes and give more if needed. Never give the maximal dose of narcotic available first especially to an unknown patient. Finally, the nurse is expected to perform a complete follow up assessment. If a patient has become obtunded especially to the point of respiratory arrest, it was because the nurse didn't control things well, NOT because the doctor wrote for too much medication. While the ultimate responsibility lies with the prescribing physician because it's that order that makes the drugs available to the patient, it's the nurse who gives them. We have been trained in how to manage this so let's be responsible for it.

R

[ninja-nurse]

Thank you both. The other nurses gripe, but they're so easy going about it that I was worried I was freaking over nothing.

I do watch my patients with the pain meds (though I've been laughed at for it) and try to start with the low dose - fortunately, the patients I've seen coded weren't mine. Not that that makes it any better, but still...

It was mostly the MD's and the peds things that worry me - and Ricu? No peds unit. We're mostly Adult Med/Surg, they just send us peds sometimes. And I'm not the only nurse who has to dig out my little book to make sure that I remember the right vitals for the age group when they do! I haven't quite gotten over the initial "oh, s*(&" reaction when I've had adult med/surg for 5 weeks, then ER tells me they're sending me a 4 month old with resp distress...

But it's really good to hear unbiased opinions, from someone who I know isn't just griping about THEIR workplace. So thank you again.

[Ricu]

Thank you both. The other nurses gripe, but they're so easy going about it that I was worried I was freaking over nothing.

I do watch my patients with the pain meds (though I've been laughed at for it) and try to start with the low dose - fortunately, the patients I've seen coded weren't mine. Not that that makes it any better, but still...

It was mostly the MD's and the peds things that worry me - and Ricu? No peds unit. We're mostly Adult Med/Surg, they just send us peds sometimes. And I'm not the only nurse who has to dig out my little book to make sure that I remember the right vitals for the age group when they do! I haven't quite gotten over the initial "oh, s*(&" reaction when I've had adult med/surg for 5 weeks, then ER tells me they're sending me a 4 month old with resp distress...

But it's really good to hear unbiased opinions, from someone who I know isn't just griping about THEIR workplace. So thank you again.

Ninja,

I'd be concerned about working on an adult med-surg unit and receiving a 4 month old in respiratory distress. Hopefully you are PALS certified. Are you in a rural area?

[ninja-nurse]

Ninja,

I'd be concerned about working on an adult med-surg unit and receiving a 4 month old in respiratory distress. Hopefully you are PALS certified. Are you in a rural area?

To be honest, it's usually pneumonia, but they still don't breathe right. Yes, we are in a rural area (mostly) - but they don't require PALS certification! I'm working on it because I feel I need to be.

ninja

[Ricu]

[QUOTE=ninja-nurse;138683]To be honest, it's usually pneumonia, but they still don't breathe right. Yes, we are in a rural area (mostly) - but they don't require PALS certification! I'm working on it because I feel I need to be.

ninja[/QUOTE

Respiratory distress including pneumonia, is the primary cause of pediatric arrest so, PALS certification is a very good idea. Good luck and be careful.

R