IV Therapy

  1. 0 New grad ER nurse here. So after only a couple weeks, they're letting me see the "clinic" type stuff on my own which is all good and I think I'm managing OK so far but I'm having trouble deciding what's going to need a bit of a workup and what's not. For example, I got a young healthy pt with c/o migraine and nausea. 8/10 pain. Vitals were stable, no hx, no meds, bit of a drama queen (sorry but true). Put her on monitors and left the room without starting an iv. Doc ends up ordering head CT, iv meds, fluids, labs.

    Because I didn't start the iv and draw labs immediately, it kinda set me back and I felt like I was moving patients like molasses. Honestly, I thought the doc would just order some PO pain meds/anti inflammatory and send her home.


    SO my question is should I just preemptively start an IV on all adults? So long as they're not there for something like suture removal of course...
  2. Visit  Ciale profile page

    About Ciale

    Joined Feb '09; Posts: 284; Likes: 147.

    22 Comments so far...

  3. Visit  RN&mom profile page
    3
    You will never get rid of a true migraine with po meds if its gotten to the point they're in the ER... Unless you've had a migraine you might want to be careful with the "drama queen" bit as well. I was in the ER myself not too long ago for a migraine and endure 31 injections of Botox every 3 months in my head & neck just to keep my migraines manageable. The pain is very much real, trust me! And maybe this girl was being dramatic (I obviously wasn't there) just be careful what you're saying because it sounded like you were dismissing migraine headaches as nothing. They are awful, I go through a lot to try to keep them away and when I get them I still only go to the ER when I feel like my head is going to explode and I can't stop vomiting (with zofran)... All I'm saying is please take migraines seriously, offer a cold cloth to cover the eyes while you start the IV
    flyingchange, poppycat, and nrsang97 like this.
  4. Visit  FL ER Nurse profile page
    3
    It depends on the pts symptoms as well as the MD working that night. Some docs work everybody up. Some are minimalists.
  5. Visit  IrishErin profile page
    0
    Quote from FL ER Nurse
    It depends on the pts symptoms as well as the MD working that night. Some docs work everybody up. Some are minimalists.
    This! We also have regulars that come in and have their own "care plans", so to speak. One might always get a litre bolus with some morphine and maxeran. Another gets an IM of morphine and gravol. One woman gets a shot of solumedrol into the joints in her neck!
    Each headache is different, and each doctor may treat them differently.
  6. Visit  Ciale profile page
    0
    Quote from RN&mom
    You will never get rid of a true migraine with po meds if its gotten to the point they're in the ER... Unless you've had a migraine you might want to be careful with the "drama queen" bit as well. I was in the ER myself not too long ago for a migraine and endure 31 injections of Botox every 3 months in my head & neck just to keep my migraines manageable. The pain is very much real, trust me! And maybe this girl was being dramatic (I obviously wasn't there) just be careful what you're saying because it sounded like you were dismissing migraine headaches as nothing. They are awful, I go through a lot to try to keep them away and when I get them I still only go to the ER when I feel like my head is going to explode and I can't stop vomiting (with zofran)... All I'm saying is please take migraines seriously, offer a cold cloth to cover the eyes while you start the IV
    No no, definitely not dismissing migraines as nothing. The lay in bed, no sound, no light and sensation of someone stepping on your head while simultaneously stabbing it. Yup. I used to get them often. There's way too many details that would prove my point regarding the "queen" comment but none of them are relevant to my actual question about when to go ahead and start an iv.

    I guess just assume the worst? Headache think aneurysm?!?! I dunno...everyone keeps saying "it will come with time" but I'm really looking for black and white answers.
  7. Visit  Ciale profile page
    0
    Quote from IrishErin
    This! We also have regulars that come in and have their own "care plans", so to speak. One might always get a litre bolus with some morphine and maxeran. Another gets an IM of morphine and gravol. One woman gets a shot of solumedrol into the joints in her neck!
    Each headache is different, and each doctor may treat them differently.
    Aaah yeah, gotcha. Thanks!
  8. Visit  SweetMelissaRN profile page
    1
    Although you may feel like being told "it will come with time" is a blow off answer, but it's the truth...

    With that said, there are certain chief complaints which will just about ALWAYS get a work up: chest pain, nausea/vomiting (in adults), ams, seizure, sob, stroke-like symptoms, flank pain in males (not women bc it's usually just a UTI).... Each hospital and doctor vary so it takes time to learn who they like to work up and what not..

    You'll get it, I promise!
    Ciale likes this.
  9. Visit  Altra profile page
    0
    For your migraine example, here are things I would have assessed:

    1. Does the patient have a hx of migraines? If s/he has never had one before, or has been well-controlled for a long time but then suddenly has a whopping migraine -- that's likely going to get worked up.
    2. Any trauma?
    3. Fever or other recent illness?
    4. PERRL?
    5. Any other neuro deficits or s/s?

    In other words ... the differential diagnosis rules out other big & bad stuff before concluding that it's "just" a migraine. The old ER adage: "prove to me that you're not sick". (in some patients, this takes only 15 seconds )

    Having said all that -- migraines are unlikely to respond to p.o. meds. If there are no red flags in the differential (see above) nearly all are going to get 500mL or 1 liter IVF and your provider's cocktail of choice such as Benadryl/Reglan/Toradol. Hoping you don't work with a provider who has been sucked into giving narcotics for migraines -- the chance of a rebound headache is very high, and it's a very problematic road to go down.

    Exceptions to the above would be: "I ran out of Maxalt and all I really want is an Rx for 5 days or so until I can get in to see my doctor."

    OR

    The "migraine" whose s/s don't really match the migraine profile. It's not for me to say whether or not you have a headache ... but if you're noisily crunching away on Cheetos or potato chips ...

    OR

    The frequent flyer migraine patient (and yes, I'll say it, there is a subset of these that include symptoms of "drama") who has not managed to follow up with neurology as previously directed.

    A strong suggestion for you, OP -- listen to the docs' assessment of patients. You'll learn a great deal about differential diagnosis that way.
  10. Visit  Adenosine6 profile page
    2
    In general for ER's you have some "standard guidelines"

    Example:
    ER (A), Line and lab all urgent patients (ESI 3,2,1)
    ER (B), Line and lab, place orders: Chem 7, CBC, Lft's, Meds: I.e Zofran (docs will then co sign)
    ER (C), Line and lab if your nursing judgement thinks your patient needs it
    ER (D), If you have an old-school doctor that rarely orders much, then wait...

    Best thing to do as a new-grad who is unfamiliar with treatment in the ER; as your fellow coworker "Hey, should I line and lab him?"
    Last edit by Adenosine6 on Jul 11, '13
    psu_213 and Ciale like this.
  11. Visit  Ciale profile page
    0
    Quote from Altra
    For your migraine example, here are things I would have assessed:

    1. Does the patient have a hx of migraines? If s/he has never had one before, or has been well-controlled for a long time but then suddenly has a whopping migraine -- that's likely going to get worked up..
    Oh yeah. Good point and thanks for all the input. Will listen to doc's differential dx. Also, I didn't know that about narcs for migraines causing rebound headaches. So far I've had mostly orders for morphine/dilaudid (+benandryl and antiemetic). Hm. I have seen Toradol as well but not as often.
  12. Visit  RN&mom profile page
    0
    Narcotics should definitely NOT be given for migraines! Anyone who has had migraines long term knows this and as a pt generally refuses them (or should). The best "cocktail" for migraines, mine and everyone I've talked to is compazine, Benadryl, toradol. I'm sure other things work but any doctor handing out morphine for a migraine is a fool and the pt is a bigger fool!! And yes lots of IV fluids, 1000mL, sometimes 2000, depending on my headaches... Thanks for understanding my previous post. I definitely wasn't trying to pick on you but I know a lot of people don't understand migraines or think sufferers are drug seekers when most migraine sufferers never touch narcotics at all...
  13. Visit  psu_213 profile page
    0
    Quote from RN&mom
    Narcotics should definitely NOT be given for migraines!
    First, let me state that I suffer from occasional migraines, but, thankfully, I have never had to go the ER for treatment. From working in the ER, I see how bad they can get and usually is relieved with a migraine cocktail (some combination of IVF, reglan, compazine, benadryl, toradol, zofran, etc...the exact mix depends on the individual doc). There are a few (definitely the minority) migraine sufferers who demand a narcotic (i.e. "dilaudid is the only thing that works for my migraine") and that is when warning sirens go off in my head. It is these individuals who give a "bad name" to the majority--those with a true migraine who want nothing more than some measure of relief.
  14. Visit  psu_213 profile page
    0
    Quote from Ciale
    SO my question is should I just preemptively start an IV on all adults? So long as they're not there for something like suture removal of course...
    There are only a few categories of CC for which I preemptively start a line: "true" chest pain (i.e. not the 20 year old with a sore chest after helping a friend move yesterday), when it appears a long bone is broken/there is a dislocation (such as a leg that is shortened and rotated), severe vomiting, HR way out of normal parameters (like HR of 32 or one of 170). Other than that I am going to wait for the doc to see them. Each time someone is "lined" is one less time you are going to get a line on them later in life. When I see what a nightmare it can be to get an IV on the most frequent of frequent fliers, I realize that I should not put an IV in everyone "just in case." Not to mention the fact that some pts. have gotten really ticked off when an IV was put in and it was never used.


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