nurse2033 26,417 Views
Joined: Jun 6, '07;
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Which environment suits your personality? If your hobbies are racing, mountain biking, rock climbing, martial arts, or first person shooter games I'd go with ER. If you like knitting, cooking, sunsets, coin collecting, or long walks on the beach I'd go with the med/surg job.
Hmmmm, let me think.... work as a nurse? I know, it's crazy. You should spend 2-3 years learning your craft. Then, you can probably answer your own question. Good luck.
Yes, nurses get assaulted every day. The odds of it happening to you are higher than ever before. Yes, the nurse should call the police and press charges. Many don't because of the hassle involved though. Yes, if the patient is mentally ill charges may not be brought, but it should always be reported to law. A patient at our facility was recently charged with attempted murder for an assault on a nurse. Deescalation and situational awareness are key skills that nurses should posses. Otherwise, you may defend yourself against an attack as any other person is allowed to do. You would not lose your license for defending yourself. High acuity areas such as ED and ICU are probably the highest risk areas by far, but floor nurses get assaulted too.
Yes, you have already opened the outer wrapper, the inside of which is sterile. It is big enough to hold both the box and tray. Once your hands are gloved, pick up the tray and set it in front of the bottom part. Another tip, instead of squeezing the lube onto the tip, pull open the lube syringe and stick the tip into the lube, that helps keep it clean, covers it with lube, and gives it some weight so it doesn't fly around. Oh the Foley fun goes on and on...
This is an excellent example of why nurses need to get involved in politics at the state level. Yes, yuck! Or at least with your state nursing association. Consider working on ratios as advocacy for patients.
This is a great opportunity to connect with them. Ask the patient their reason and you might be able to address their concern. I have had this happen very occasionally, but almost always after talking with them, they consent. I had a patient say once refuse me as a male saying "all male nurses are homosexual". I told him I wasn't and he was like, "oh, ok". More likely it is a female who is uncomfortable. If you can make them comfortable you usually will be fine. Sometimes they are adamant and I feel we should try to accommodate them. Typically you would tell them that it isn't possible to change assignments due to staffing management, but you will ask a coworker to do anything that might involve close contact.
You should address it. You don't want them wondering and filling in the blanks with their imaginations; prison, rehab, writer for the Fox network... Just say you stayed home to care for your children, this is not lame and not an excuse. It's a perfectly good reason. Good luck.
This is a med error, but your MAR system contributed to the error. This is an excellent example of how a root cause analysis would reveal that the order should not have been red. It was entered incorrectly, or the system didn't allow for delayed administration. If you report it, then the organization has an opportunity to correct the MAR.
The ALTO program (alternatives to opioids) in the ED.
Last year the Colorado Hospital Association (CHA) pioneered the ALTO program. Ten hospital emergency departments across the state participated and decreased the use of narcotics from 31-46% (CHA, 2018)!
Colorado, as well as the US, is in the grips of an opioid epidemic, as I'm sure you are aware. We have the 12th highest rate of abuse of prescription opioids in the US (CHA, 2017). According to the CHA (2017), "the vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from a doctor". This effort is to reduce the unnecessary use of opioids, and thus one of the pathways to abuse and addiction.
The key to the program was creating treatment algorithms based on pain pathways. The idea that all pain can and should be treated with narcotics is not true. All pain is not created equal. So the Colorado ACEP (American College of Emergency Physicians) developed Opioid Prescribing and Treatment Guidelines. (This can be found on the CHA web site.) This method treats pain by targeting the pathway that causes it. They identified the following;
· Headache/ Migraine
· Muscoskeletal Pain
· Renal Colic
· Chronic Abdominal Pain
· Extremity Fracture/ Joint Dislocation
For each source of pain, they prescribe a set of drugs or treatments, always starting with non-narcotics, progressing to opioids as the last resort. As previously stated, a major reduction in opioid use resulted, with no reduction in patient satisfaction scores!
The medications that are used are familiar to us, but not necessarily as pain medication. Topical as well as IV lidocaine, low dose Ketamine, Toradol, Tylenol, nitrous oxide, Haldol, Benadryl, and a number of antiemetics were all used with good results. Trigger point injection is also an intervention, in which lidocaine is injected directly into a nerve bundle, or muscle fascia. It can relieve muscle tension and spasm, and works well for the release of scalp tension headaches and other muscle pain.
As a nurse who was involved in the pilot, I can tell you this works. Not only are patients looking for alternatives, but we are providing better care with less risk. Patient satisfaction scores did not go down overall. Hopefully as providers get more experienced in using these protocols, satisfaction will go up.
Preparing a hospital for the ALTO program is a huge project. Pharmacy, purchasing, IT, and physicians and nurses all have to be on the same page. New standing orders needed to be written, new order sets generated, new dosing guideline for smart pumps, and new products, such as lidocaine patches had to be ordered.
The Colorado ENA (Emergency Nurses Association) provided nursing education that included scripting in how to explain the program to patients. Nurses explained that we are looking to make patients more comfortable, or reduce their pain. Complete pain relief is not always a realistic goal, as we know. It is also realistic to discuss with patients the risks of narcotics, and the risk of abuse and dangers of having narcotics in the home.
It will be exciting to see how far we can go. There were many lessons learned that will only serve to improve this model and how it is delivered.
CHA (2018), Colorado Hospital Association, Colorado Opioid Safety Pilot Results Report, retrieved from Opioid Safety | Colorado Hospital Association
CHA (2017), Colorado Hospital Association, Colorado Opioid Safety Collaborative
You did violate HIPAA but if no one looks you will probably not get caught. Why would you put yourself at risk?
1. Probably yes. You will be expected to use the protocols when things are busy, and that's always- in the numbers you describe.
2. That's too high. 4:1 is about right, with some patients being 1:1.
3. Not to plug my own post but try this http://allnurses.com/emergency-nursi...f-1104760.html
4. You will be pressured and rushed, get used to it. It will probably take 6 months to a year to get a really good handle on everything.
We use this book in our orientation, I highly recommend you read it. Sheehy's Manual of Emergency Care - E-Book (Newberry, Sheehy's Manual of Emergency Care) - Kindle edition by ENA, Belinda B Hammond, Polly Gerber Zimmermann. Professional & Technical Kindle eBooks @ Amazon.com.
The Schemas of Emergency Nursing: How to organize your thinking and knowledge
Chris Hendricks RN, MSN, CEN, CFN
As an ED Educator I am frequently tasked with training nurses who are new to the Emergency Room. It is true that every nursing unit has their own culture, practices, and sometimes jargon. But, it seems that the ER is just special in how we approach patient care (I'm admittedly biased). But a concept called "schemas" is one way to approach the sometimes demanding and rapid-fire workflow. Conditions in the ER can change minute by minute so nurses (and techs and providers) must be flexible in their thinking. They must also be quick to change direction when needed. This is where schemas come into play. I first utilized schemas as a paramedic early in my career, but didn't realize what they were until I learned the concept later in educational theory.
So what is a schema? Schemas have many definitions but a good one is, "A schema is a cognitive framework or concept that helps organize and interpret information" (Cherry, 2015). Piaget, a well-known psychologist, coined the term and popularized the concept (Cherry, 2015). Piaget recognized that we group information into mental packages, which are schemas. We all do this without thinking all the time. By describing schemas in this way, we can make it easier to develop them.
A nursing example of a schema would be starting an IV. This is one of the most common procedures in the ED. An experienced nurse will instantly be able to visualize all the steps and equipment needed. This is the schema. This includes (but not limited to):
· The indications
· Informing the patient
· Gathering the supplies
· Performing the procedure
· Adapting to irregularities
· Assessment/ reassessment
A new nurse will have to think about each step (in a process is called conscious competence). Over time and repetition, this schema will be strengthened and become unconscious. The key is to develop these schemas in a way that makes sense to you. You would start to build this schema by observing the procedure, studying the policy, and practicing.
There are obviously many, many, schemas in play in the course of a routine shift. The challenge for the new ED nurse, is to start to organize what you are learning as you gain experience. Since the schema is about organizing information, you clearly must have the information to start with. I recommend an excellent text, Sheehy's Manual of Emergency Care published by the Emergency Nurses Association (I am a member of ENA but have no other ties to the organization). The information is organized by problems and gives step-by-step advice on what you need to know for the pathologies you will see in the ER.
You also have many resources at your disposal such as policies and procedures published by your organization. You can study TNCC or other sources. What do you see your coworkers do? But ultimately you should be prepared to answer the question in your mind, "what do I do if my patient has X"? This will prepare you for when you have to do it. Think of the schema as a package you will open that contains everything you need to know.
All nurses know how the body works, and what wellness is. But the approach of the ED nurse is to drill down into what can go wrong. Injury and illness produce somewhat predicable patterns within the body. So based on a complaint, an experienced nurse will start their assessment and test, reject, and eventually arrive at the correct interventions using their schemas. This includes ruling out injury or illness based on the situation.
So as an example, a patient is coming in via EMS with a leg fracture. Just based on that information, the nurse can probably predict what assessment and interventions will be needed. The schema on fractures would include: mechanism of injury, physical assessment, x-ray, pain control, infection control, splinting, and education (among others). Obviously the nurse must be flexible because the information could be incorrect to start with. If the patient takes a blood thinner, for example, that would add another schema for that issue. Or if the injury was the result of domestic violence, that would add yet another schema.
Schemas can be described as a tool kit. Visualize a huge backpack with all your ER nursing knowledge. For each patient, you will take out smaller packages that contain each schema, customized for what they need. I made reference earlier to testing and rejecting schemas (you might call this ruling-out). If a patient is short of breath for example, you should "test" each schema within that problem. If during your assessment you find their lungs are clear, you could put your asthma schema back in your tool kit, but you would continue to test other schemas.
Cherry (2015) writes that there can be problems with schemas. You must be flexible and be able to incorporate new information into your schemas. You can’t accept the schema as an "end product" that is perfect and needs no revision. If you do, you will have trouble in adapting to changes that will inevitably occur.
Hopefully, you recognize the schemas that you know and use. By understanding how they work, they can be used to help you develop and improve your practice. Take a problem, investigate all the possible actions and solutions, and this is your schema.
For the new nurse, develop your schemas as you gain experience. For each patient problem, think about the care that was given and the outcomes. As I wrote earlier, use the reference materials at your disposal to war-game all the possibilities.
Cherry, K (2015). What is a Schema? Retrieved from What Is a Schema in Psychology?
You don't drive the medical care, that's the provider's job. So I don't think you did anything wrong. You did have another nurse cover in case anything changed, and guess what, it did. The patient was treated appropriately. You notified the provider about a change in mental status which puts it on them to investigate. The MD's remark that a change in mental status is to be expected seems a bit blasé. Altered mental status in the face of shock is deadly serious and needs to be addressed immediately. If not, the patient could decompensate. Oh wait, that's exactly what happened (not your fault). What you could have done differently perhaps, is to more assertively remind the MD that the patient was deteriorating. What is not here is the dynamic between you, the MD, their experience, the culture of your department and so on. This all affects how things go. I work in a small ER, we all know each other, no students, and the MD's take our concerns seriously. Take a breath. Patients will have bad outcomes sometimes even if you do everything perfectly. You can't take it personally. You did everything that nurses are expected to do. Hope this helps.
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