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thanks DocB
does anyone have anything similar to this for Peds? it would be very helpful.
does anyone have anything similar to this for Peds? it would be very helpful.
What I found interesting/confusing was your comment NOT to the "child who started throwing sand" but rather to the one who responded to being attacked.
just passing down to the clinician's forum, and I noticed this thread, and figured some nurse advice would be in here...
As a house supervisor now, and a nursing instructor, I appreciate the nice words spoken about nursing...I struggle every day w/ incompetent nurses and students. I'm working on the problem.
I like the comment about teaching...Most nurses ask because they genuinely don't know, and love to understand what you are thinking, and relish at being taught a new thing.
And the seasoned nurses will ask questions, sometimes just to be a pain in the a$$...Can't help you there...
I love students, residents, interns, and attendings, as long as there is mutual respect among us.
The good ones among us know what to ask, when to call, and when to question...Hopefully we are in the majority, but (and it goes both ways) the bad ones stick out and cloud your memories of the good ones...
Can't we all just get along??
Thanks again
wow, I'm suprised he gets off his throne to even speak w/ a nurse. jeez, funny how you focus on my alleged insecurity and gloss over your peer's arrogance.
I was nothing but complementary to all, and thankful for the nice words by all other posters, and he takes a cheap shot...
nice
whoa , i think he wasn't being insulting and i agree most people aren't worth arguing over trivial stuff ,unless it is about someone who could sue or die from not listing or the nurses not listing
You don't think calling nurses "dumb" or "clueless" or stating that talking with them is like "losing 100 brain cells per minute" is insulting? Wow...you have a really high tolerance for insults, I guess.
It may not be worth arguing over but I frankly am sick and tired of the arrogant attitude amongst physicians, especially those in the SDN forums. Am you wonder why the nurses feel they have to defend themselves with attitudes like those expressed here.
JCAHO is getting crappier and crappier about orders so check with your seniors about what's allowed at your house but here are some good starters:
Insulin slide:
FSBS q 6 hours or qac and qhs
if glucose < 70 give 1/2 amp D50 po or iv and recheck FSBS in 30 min
if glu 70 - 150 do nothing
if glu 151 - 200 give 2 units reg insulin SQ
" 201 - 250 " 4 "
" 251 - 300 " 6 "
" 301 - 350 " 8 "
" 351 - 400 " 10 "
" >400 " 12 " and call MD
Potassium slide:
If K < 3.0 call MD
If K 3.0 - 3.2 give K riders x 40 meq iv over 4 hours or KDur 40 meg po
If K 3.2 - 3.3 " x 30 meq
If K 3.3 - 3.5 " x 20 meq
If K > 6.0 call MD
Tylenol:
Tylenol 650 mg po/pr q 4 hours PRN pain/fever
*only do the fever part if you expect the patient to have a fever and you don't need to work it up
*remember to provide alternate routes. If the pt can't take it po it's gotta go pr. This goes for other stuff too. You don't want a call a 0200 to ask if the IV ativen could be given PO.
Fever:
If Temp > 100.6 obtain blood cx x 2, urine cx, sputum cx, CXR.
Pain:
Morphine 1-5 mg IV q 4 hours PRN pain
Dilaudid 1-2 mg IV q 4 hours PRN pain
Antiemetics:
Phenergan 12.5 - 25 mg IV q 6 hours PRN nausea
*write it as nausea because they technically can only give it after the patient pukes if you write "vomiting."
Resp:
Albuterol 2.5 mg Neb q 4 hours PRN wheezing
Atrovent 0.5 mg neb q 8 hours PRN wheezing
*write wheezing instead of SOB or they may keep giving Nebs to your worsening CHF patient.
Sleep:
Restoril 15 mg po qhs PRN sleeplessness
*every oldster expects a sleeper. Your covering colleagues or night float will love you if you write for the sleepers.
Anxiety:
Ativan 1 mg IV/IM/PO q 6 hours PRN agitation
Haldol 2.5 mg IV/IM/PO q 6 hours PRN agitation
*be stingy on this one. The idea is to deal with the demented sundowner patients without over sedating a patient with unrecognized delerium.
Vent:
ABG PRN vent changes
You don't want a call at 0200 asking if it's OK to get the gas just so you can get called 30 min later with the results.
Disclaimer: I'm sure there are those who want to debate dosages and so on and maybe even the use of slides and PRN altogether. Instead of doing that I'll just say that you have to use judgement and know your patients. You have to base these things on your particular patient and your labs norms.
Almost as tiring as people who get all bent out of shape over an internet message board. No doubt these are the same that can't criticism in "real life"
Most useful post EVER on SDN. Made sifting though the playground name-calling BS (does every thread about being a new resident HAVE to degnerate into a nurse vs doctor shouting match? ) actually worth it to find this.
Thanks so much.
More of the same, please!!
As for writing the actual orders, I doubt anyone is allowed to write ranges. For example, you can't order Morphine 1-5mg iv prn whatever. The nurse isn't allowed to use discretion. You can write morphine 5 mg prn pain >7/10, 2 mg prn pain > 4/10, etc.
Most useful post EVER on SDN. Made sifting though the playground name-calling BS (does every thread about being a new resident HAVE to degnerate into a nurse vs doctor shouting match? ) actually worth it to find this.
Thanks so much.
More of the same, please!!
Antiemetics:
Phenergan 12.5 - 25 mg IV q 6 hours PRN nausea
*write it as nausea because they technically can only give it after the patient pukes if you write "vomiting."
Not being a pediatrician I can't be too helpful. Hopefully some peds folks will chime in or you could start a similar thread on the Peds forum.thanks DocB
does anyone have anything similar to this for Peds? it would be very helpful.
but don't nurses destroy brain cells when you talk to them?...
but don't nurses destroy brain cells when you talk to them?
and I heard that they have no discretionary skills in discerning appropriate dosing determination...
has anyone seen those white hats and white stockings??
When IS my tee time??
Not being a pediatrician I can't be too helpful. Hopefully some peds folks will chime in or you could start a similar thread on the Peds forum.
I will say that many peds orders are a lot more house dependent. For example where I did residency all peds drips had to be calculated on these special forms. There was one for dopamine, insulin, phenobarbital and so on. Find out from your seniors if something like this exists at your house.
Some places want orders in mg/kg and others demand that you calculate it out and order in straight mgs. JCAHO is leaning toward the straight mg way. Find out what's expected for you.
but don't nurses destroy brain cells when you talk to them?
and I heard that they have no discretionary skills in discerning appropriate dosing determination...
has anyone seen those white hats and white stockings??
When IS my tee time??
Ugh. I re-refer everyone to the last paragraph of my original post.>>>>Pain:
>>>>Morphine 1-5 mg IV q 4 hours PRN pain
>>>>Dilaudid 1-2 mg IV q 4 hours PRN pain
These are significantly different equianalgeisic dosages. I encourage folks to look up morphine-dilaudid conversions and reconsider this recommendation.
I read an interesting ER paper that suggested that dilaudid was a better analgesic: the thesis -- the nurses didn't understand how much of an equianalgesic morphine dose they were administering in their PRN order and, therefore, the patient received relatively more opiate.
Mick
Now we can quibble 'til the cows come home about which antiemetic or sleeper to use and what dose of what will do what. Here are a few of the cruel facts that future interns should be aware of. What meds you can give and in what dosages will be determined a lot more by your hospital's formulary and your nursing staff's comfort level with certain drugs than your medical judgement. Good luck writing for Ambien if your house gets a deal on Restoril. They will change it without your OK. That goes double for antibiotics. See what happens the first time you try to order Zyvox.Disclaimer: I'm sure there are those who want to debate dosages and so on and maybe even the use of slides and PRN altogether. Instead of doing that I'll just say that you have to use judgement and know your patients. You have to base these things on your particular patient and your labs norms.
As for narco equivalents I can tell you from years of experience that titrating the dose to the actual patient and giving the nurse who's at the bedside all night the latitude to cover the pain is way better than memorizing an equivalent table.
QUOTE]
Why not be consistent then and rewrite your morphine for 7-14mg IV q 4hrs PRN? Sounds a bit high, but at least its the same as your hydromorphone order.
Better yet, you could give your nurse plenty of latitute with Fentanyl 1-2mg IV q 4hrs PRN (no need to memorize an equivalence table -- your patient surely won't complain of pain).
I'm not knocking your recommendations and I wish something like this existed when I was an intern. At least at my institution, there seems to be an inherent misunderstanding of Dilaudid potency and I didn't want these new physicians to think that 1-2mg of Dilaudid is the same as 1-5mg of Morphine. As such, I'll hopefully save myself at least one page in the middle of the night for the obtunded medical patient who recieved 2mg of dilaudid.
Best,
Mick
Better yet, you could give your nurse plenty of latitute with Fentanyl 1-2mg IV q 4hrs
I have no idea how the above post wound up with me being quoted as advising Fentanyl PRN. That was a misquote. I never said it and I've never written for it.That is quite a dose of fentanyl. I'm not sure you need to bother dosing it Qanything, since most patients won't be breathing after the first dose. Consider stepping it back to micrograms.
And just remember that fentanyl accumulates with a fairly long half life and initially has a short duration of action, so is a poor choice for chronic pain.
As for the equivalance issue I've never had a problem dosing Dilaudid in aliquats of 2mg. I'm sure everyone can throw out tons of cases where the pateint died from getting 0.25 mg. I concede. If you don't want to use Dilaudid don't. Most of my patients report that they only get relief from something that starts with D.
Since this thread has been hijacked more than a 1970s Air Florida jet I will say that for those of you looking for tips for intern year there are such things as PRN orders. Obviously some people have huge misgivings about them (as I said they would in my first post). Talk to your seniors. Now (hopefully) back to your regularly scheduled thread...
I have no idea how the above post wound up with me being quoted as advising Fentanyl PRN. That was a misquote. I never said it and I've never written for it.
A surgeon at my hospital told me that in surgery, you find the most competent attendings and stick to them for the first couple years so you learn the right way to do things. Then, in the last couple years, you stick with the incompetent and insecure ones because they'll let you do all their cases.
1. Show respect and gain respect - This will serve you very well when interacting with all health care professionals. Having a genuine interest and learning the names of the nurses, physical therapists, dietitians, pharmacologists, etc will benefit you greatly when you need their assistance. It benefits you in ways you'd never know b/c others wind up going the extra distance for you i.e. IV placement, transport, seeing someone first thing in the a.m. for you, etc.
Interesting, because while I agree with the first part (learn from the most competent) I would actually venture that the most secure and competent attendings are likely to allow you to do more. They realize that they can get you out of whatever mess you create - the insecure ones are not comfortable with their own skills and resources when you F-up.
how by signing out 5 minutes later can cause you to get stuck in the hospital for another hour
There is that expression 'the longer you stay, the longer you stay'
There a caveat to this that I don't think can be appreciated until you do cross-cover. The amount of work on cross-cover with new admits and honey-dos can rapidly snowball and if you stay an extra hour to take care of things yourself, you can buy cross-cover an hour of sleep (maybe the only hour they'll get that night) while you get 8 either way.
the longer you stay the longer you stay!!!!
get in, and get out.
**** hits the fan in a heartbeat (pun intended)...
That would vary by specialty and rotation...Post some book recommendations..