On the inpatient units we frequently give continuous heparin dosing. Upon the initial order received from the doctor they order a starting dose rate. The registered nurse is expected to pull up in the patient’s electronic record under orders the protocol that provides guidelines for RN’s to adjust the rate according to the patient’s heparin PTT lab levels. The doctor at times will also order a loading dose or additional loading doses depending upon the lab levels. The heparin PTT is drawn every eight hours to determine where the dosing rate should be set to determine if the level is therapeutic, sub-therapeutic or critical reading. The nurse must use the computerized electronic record that is interfaced with lab and other ancillary departments throughout the hospital in the patient’s electronic record. This makes providing care to the patient more efficient for all those involved in the patient’s care.
The nurse is able to pull the data from the computer to make a decision based on her training to make dosing corrections based on the protocol. The nurse’s wisdom also allows them to call the doctor for critical readings, the knowledge to know when to call the doctor for guidance as needed. The electronic chart also makes available other pertinent data for the nurse to research to make sound decisions based upon the patient’s diagnosis and to know what to look for if the patient has had any recent falls or surgery. In addition the nurse would also be able to complete the nursing assessment and input the data compiled into the electronic record for other medical staff . The template was recently redone with nursing input and the assistance of our informatics nurse.
I actually only see advantages to having a singled shared consensus-driven model of terminology. I feel it would be a hindrance and a disadvantage to the healthcare profession if we as nurses did not have a single consensus-driven model of terminology. I moved from Florida to California and since my move I have encountered a wide variety of culturally diverse nurses. It is at times challenging with the language barrier when they have trouble thinking of the term they want to use but will generally remember the proper term. Many completed their initial education and training in their birth countries and if we did not have a single driven terminology it would be disastrous. There are companies in the United States that have recruited nurses to come and work in the states partly due to the shortage of nurses but also many to fill very hard to fill positions such as medical surgical or acute medical units.
With the shortage of nurses in the United States and some nurses refusing to work certain areas it has become very challenging to fill these positions in hospitals. Along with this is if one were to travel abroad and required further care when they went home to obtain the chart and the terminology be basically understood would also be very important to one’s health. This also helps to integrate knowledge into one’s own routine clinical practice since all nurses started from the same basic understanding of terminology, what the problem is with the patient, with the ability to verbalize the care needed along with the implications of the disease process. The other issue to consider is if we had more than one model of terminology it would be very difficult to communicate with other medical staff, i.e.. doctors, radiologist, dentist, etc.
Currently we have on board a NIS and he is under the Title 38 classification which belongs primarily to nursing. Even though his job does not involve direct nursing care his primary job is directly related to nursing. The is computerized with computerized charting, templates created for nurses for various forms of documentation, and we also use a bar code medication administration scanner (BCMA). The NIS is involved in the development of new templates, modifications of existing templates, the BCMA’s and determining to what extent we can allow it to be fully used by nurses.
For example, the BCMA has the capability to get onto the internet from anywhere in house however, that capability had to be absolved. The ability of having an NIS available to nursing and be a go between with IT is very beneficial for nursing needs on the unit level. The NIS has the capability to understand nursing needs and resolve or find a way to intervene on our behalf. When I went to the Cochrane Collaboration and selected from the drop down list of disorders.