Latest Likes For Anna Flaxis

Anna Flaxis, ASN 25,951 Views

Joined Oct 15, '10. Posts: 2,867 (67% Liked) Likes: 8,627

Sorted By Last Like Received (Max 500)
  • Apr 15

    Depends on the clinical picture.

    Is this a new medication for the patient, or have they been taking it for a while?

    If it's new, I agree that it would be safest to have them on the monitor for at least the first few doses.

    If they've been on metoprolol for some time, and it's simply a route change due to NPO status, it is important to avoid abruptly discontinuing the medication, as this can lead to a whole host of problems, such as Acute MI. It would be of great import to make sure they get their dose. If you're not comfortable with an IV push, then mixing it in a mini-bag and infusing over 10 minutes would be a good compromise.

  • Apr 6

    Depends on the clinical picture.

    Is this a new medication for the patient, or have they been taking it for a while?

    If it's new, I agree that it would be safest to have them on the monitor for at least the first few doses.

    If they've been on metoprolol for some time, and it's simply a route change due to NPO status, it is important to avoid abruptly discontinuing the medication, as this can lead to a whole host of problems, such as Acute MI. It would be of great import to make sure they get their dose. If you're not comfortable with an IV push, then mixing it in a mini-bag and infusing over 10 minutes would be a good compromise.

  • Mar 26

    Let me first preface by stating that I do not work corrections, but I do receive inmates on occasion in the Emergency Department.

    I would think about the harm that could come from making the wrong assumption. If you determine that the patient is lying, and it turns out they really *are* having an MI, they could die.

    If you determine that the patient is being truthful, you follow protocol, send them to the ED to r/o MI, and the workup turns out negative, what is the harm that can come from this? None, that I can see.

    My advice is to follow your facility's protocol to the letter, and leave the question of whether the person is lying or not out of it.

  • Mar 21

    Quote from 35Nurse
    The rationale is if the H&H is 1/2 of what is should be but all are saturated with 02 then of course your going to get a decent sat BUT they don't have enough RBC's to adequately oxygenate the rest of their body. Is that correct?
    Correct. Which explains why the patient was dyspneic and anxious even with sats in the mid 90s. She was probably tachycardic as well.

  • Mar 21

    Quote from LalaJJB
    My question is: If a patient is in respiratory distress, what do I do especially if the MD is nowhere to be found and my RN co-workers are busy with their patients? I’m new and I don’t want people to die on my watch.

    Thankfully for this patient, she got an ICU room before her breathing got too bad. She was also perfusing fine and her O2 sats were reasonable if she wasn’t doing anything. I’m just scared for when I get a patient who is in respiratory failure and I have nobody to turn to. PLEASE HELP ME!!
    You needed a doctor, an RT, and another nurse or a tech in the room with you. That you were alone with this critically ill patient who needed interventions beyond your scope of practice and level of training and experience is really at the crux of the matter.

    Remember, airway, breathing, and circulation in that order. She had a patent airway, but was not ventilating (breathing) effectively because of the lack of red blood cells (circulation). Your priority interventions are to put her on NRB and get that blood transfusion going *yesterday*!

    Do you guys have lab techs/phlebotomy services? If so, get a lab tech in there to get your type and cross. If not, get a tech or another nurse in there to help you get the sample and get it to the blood bank as quickly as possible. If you can get the sample with an IV start, great, but you've already got a patent IV, so hang a liter and keep that line open! Use what you've got! Getting some more fluid in her might help find a vein for better peripheral access, and it will help if the doctor decides to place a central line. Warm her up with some blankets to help those veins pop up. Gather your supplies for the blood transfusion; blood tubing, a pump, a mini bag of saline, any consent forms you need, so that you can start the transfusion the moment the blood is ready.

    While you're doing these things, continue to monitor for s/s of deterioration and be ready for RSI.

    Edited to add: Sats in the mid 90s on 4L NC, HOB at 90 degrees, anxiety and feeling of dyspnea, does not paint a picture of someone who is perfusing just fine! Do not be afraid to put the NRB on someone like this. If she is a retainer, you can fix that later. She needs more O2 now. It's no different from someone with a cardiac history who is in septic shock. You will still aggressively fluid resuscitate, and worry about fluid overload later.

  • Mar 20

    Thank you for sharing your story, HoneyMagnolia.

    I have never cared for a pediatric patient with CVS, and I wonder if there might be some key differences between childhood and adult onset of CVS, as far as causes and contributing factors and so on?

    Unlike some of the other posters here, the patients who have cannabis induced CVS (Cannabinoid Hyperemesis Syndrome) that I have taken care of are in the minority, but the nice thing about it is that there is an identified cause (whether the patient will ever stop using cannabis even though it makes them so sick is another story).

    The adult patients with CVS that I have cared for have typically also displayed some really challenging behaviors that point to, as another poster stated, unmet psycho-social needs, which makes me highly suspicious for psychologically/emotionally induced symptoms. Of course, correlation does not equal causation, but it's interesting to me that for so many of the adult patients with CVS that I encounter, behavioral issues seem to go hand in hand with it.

    Of course, this is very much distinct from some people who have other health problems that affect their GI motility- when their system is thrown out of whack by some insult, such as ineffective blood sugar control, viral infections, or even emotional stressors, you can see the connections between other body systems and their GI function. You can see it reflected in lab studies and diagnostic imaging.

    I think what is so frustrating for so many of us is the former group, the adult onset CVS with no discernible lab abnormalities and nothing out of the ordinary on any imaging studies to explain the symptoms (which is why it's referred to as a "syndrome"), who act out in ways that are difficult to manage in an Emergency Department setting. After you've taken care of enough people who present this way, you begin to develop an opinion of what CVS is and what people with CVS are like- and, since this is a nursing forum, our discussions tend to be from the perspective of the nurse. :-)

    I just wanted to thank you for not taking a defensive tone in your post. It was very informative.

    Anyway, best of luck to you and yours.

  • Mar 20

    I think that, while CVS may have psychogenic causes in many of its sufferers, it is very real and an awful thing to have. Imagine feeling sick as a dog for days and days, unable to participate in your normal daily life. It's easy to lump patients into categories and decide how you're going to feel about them based upon their illness- for instance, "cyclic vomiters" are a certain type of person to you. What helps me is to see the individual person, not the diagnosis- for instance, I think of them as a "person with cyclic vomiting syndrome".

    It's true that there are some common threads and we can make some generalizations, but I try to get away from that and look at the individual person. I've taken care of some people with CVS who, from all appearances, do nothing to manage their condition- they don't follow up or establish care with a primary or gastroenterologist, they don't get their scripts filled, they don't make efforts to identify triggers and make lifestyle changes- they just keep coming back again and again and it can be irritating- sometimes it seems like they'd rather just live at the hospital and be taken care of all the time. But then there are others who truly don't understand why this is happening to them, and they are hungry for answers and they do seem open to what you have to suggest. They don't WANT to keep coming back and would rather do what they can to stay OUT of the ED.

    Not to say that I'm a saint and that no patients ever step on my last nerve, and I won't lecture you on how you should have compassion for these poor people or you're a terrible nurse and an even worse human being. The fact is, we're all human and we all have our own individual life experiences and biases that contribute to our attitudes toward individual patients. R.N. does NOT equal sainthood.

    For me though, it stinks to be stuck taking care of someone that I really don't like for hours on end, so out of self interest, I try to just put myself in their shoes and see the individual human in the picture. It makes my time with them a little less yucky and more bearable if I can dredge up some semblance of being able to identify with them even just a little.

  • Mar 18

    Quote from Curious1alwys
    It's a group home so not sure they do anything with sterile gloves. We did mask however. So I think I have the first part down....flush 10-20 cc, pull sample, flush 5 cc hep, flush 10 cc NS, all push pause. As far as hub caps, this line is being accessed every AM for a blood draw, sometimes more frequent within 24 hrs. The line is definitely being opened as we are pulling off the hub and putting a new one on. Even the hub was equipment I hadn't seen and we had a very tough time getting the hub off for some reason.
    Okay, your flushing procedure is incorrect.

    Confirm blood return.
    Flush with 10cc NS.
    Waste 10cc.
    Draw sample.
    Flush with 20cc NS.
    Flush with heparinized NS, 5cc or per policy.

    The rationale for wasting between your flush and your draw is that when you flush, there will still be NS in the catheter and the dwell (part of the port), and this will dilute your sample, altering the results.

    You flush with 20cc NS after blood draws to remove blood components from the inside of the lumen that want to build up and cause occlusion and/or provide a hospitable environment for bacterial colonization. Flushing with the heparin last means that the heparin will be inside the dwell and the lumen of the line. If you do your heparin, then your NS, then you're just flushing out the heparin with NS, which makes it completely pointless to use heparin.

    Also, just a terminology issue: The "hub" refers to the end of the line, which you attach the injection caps to. You should not be changing the hub.

    You can draw blood through the caps, but if you do so, the caps should be changed. The rationale is that blood components can remain inside the cap, providing a hospitable environment for bacterial colonization.

  • Mar 2

    I've been a CNA, LPN, and RN, and I've worked in Home Health, Skilled Nursing, and Acute Care. Across this entire spectrum, communication is what it frequently boils down to. HOW you communicate, not WHAT you communicate, is often the key. You can say just about anything to just about anyone, if you say it just right.

    On the surface, I don't see anything wrong with what or how this RN communicated with you. As you know, in the ED, we are often less concerned with people's feelings than we are with getting the job done. It's part of our "tough" ED personas- a survival mechanism that most of us who have spent any time in the ED are familiar with. Sometimes we are brusque with one another, or we snap at one another- but we cut each other slack because we understand. Sometimes we might talk it out, other times we just let it be and move on. In the end, we have each other's backs.

    I know the kind of nurse you're talking about- the "tech hog", or "needy nurse" who delegates to the tech more than their fair share, while the other nurses just do things they could be asking the tech to do, and just suck it up. When these nurses ask for your help, you know they really need it. And then, when you have to say no because you're doing something the "needy nurse" has asked you to do, they are crestfallen.

    Every ED has them. You are not alone.

  • Feb 18

    I find that often, especially for new grads, it's not a "safety" issue so much as a confidence issue. You just don't THINK you can handle what you really CAN handle.

    At the same time, new grads do need a lot of hand-holding that a lot of departments can't afford, because they need bodies out on the floor NOW.

    As a result, these "sink or swim" situations are exceedingly common.

    Personally, I do well with sink or swim. But I recognize that one size does not fit all.

    My personal opinion, based on what you have posted, is that you should try to find a more supportive environment to first learn how to be a nurse- then, once you have your feet on the ground, transfer to something more specialized. I hate to tell new grads to cut their nursing teeth in Med/Surg, because IMO, Med/Surg *IS* a specialty- and it's not fair to that specialty to use them as a stepping stone or training ground for people that don't really want to be there.

    And yet, at the same time, Med/Surg units are really fertile learning grounds from which to step off into something more specialized once you've learned the basics of nursing, such as head to toe assessment, pathophysiology and pharmacology, the "soft" skills of therapeutic communication, and of course, prioritization and time management.

    There is absolutely no shame in admitting that you need more nursing experience before starting in the ED, and while I respect M/S nursing for its role as a specialty, there is no better learning ground for those who want a solid foundation before they make the leap into an area such a ED or ICU.

  • Feb 12

    Yes, the catheter itself is touching the urinary meatus. That is unavoidable. However, it is possible to avoid touching the skin with the sterile hand. Would I stop and start all over again if my hand accidentally touched the skin? Probably not. But I would make every effort to avoid doing so.

  • Feb 12

    You are correct that Betadine reduces microbial burden, it does not truly sterilize the skin. Catheter associated UTIs are a huge problem, and although prolonged dwell times are the most significant contributing factor, I would advocate for avoiding contact with the peri-urethral skin with the sterile gloved hand during insertion, simply as a matter of doing all you can to minimize risk to your patient.

    That being said, one thing I have learned in nursing and life in general is to pick your battles wisely.

  • Jan 31

    Under my state's Nurse Practice Act, I am not authorized to diagnose medical conditions.

    The radiologist's impression and the assigned provider's diagnosis may differ because the radiologist simply gives their impression of what they're seeing without very much context, but the assigned provider does the clinical correlation, which is a synthesis of the "big picture"- i.e. the patient's age, past medical history, familial history, signs and symptoms, etc., and actually makes the diagnosis.

    If it is a new diagnosis, then I defer to the licensed independent practitioner who is authorized to diagnose and treat medical conditions, stating something like "I'm not qualified to interpret (blank), and I don't want to misinform you, so I'm going to let the doctor come and talk to you about that." But, if it's part of a continuum, where the patient already has been given a diagnosis and we're monitoring progression of illness or response to treatment, then it is within my scope to discuss radiology reports in more detail- again, with the caveat that I'm only repeating what the radiologist said, but that the person's doctor needs to put it all together.

    If it's a new diagnosis of heart failure, I defer it to the doctor. But if it's an existing diagnosis, and the patient wants to know their EF, I'll tell them.

    It's really important not to be evasive, because people pick up on that, and it increases their anxiety as they imagine all the worst case scenarios. Avoiding disclosing results can easily come off as evasive, but when you verbalize a concern for not wanting to misinform, people tend to understand and appreciate that, at least in my experience.

    Clear as mud?

  • Jan 30

    Yes, you are allowed to disclose laboratory values to patients. As a licensed nurse, you should have a basic understanding of common lab values and what they mean, and keeping the patient informed of their health status is a basic function of nursing.

    When you give supplemental potassium, do you not inform the patient that their K+ was low? When you give a blood transfusion, do you not inform the patient of their H&H? If you're monitoring serial troponins, do you not keep the patient informed of the results?

  • Jan 10

    Lots and lots of practice exams. :-)


close