Content That Anna Flaxis Likes

Content That Anna Flaxis Likes

Anna Flaxis, ASN 22,268 Views

Joined Oct 15, '10. Posts: 2,857 (67% Liked) Likes: 8,555

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  • Aug 25

    Quote from Been there,done that
    Per NIH "no compelling evidence for routine cultures or empiric treatment with antibiotics. Further research is required." This is my kid we are talking about. Use sterile procedure, culture that green and yellow stuff, determine if and what antibiotics are necessary. I would expect the same for my patients.
    I don't have time right now to research it, so I can only offer anecdotal "evidence." We had a male in his late teens who had an abscess in a sensitive area. Surgery was called to I&D it. After the procedure the ER doc asked the surgeon "what antibiotic should I discharge him on?" Surgeon replied "I just drained the abscess. Why would he need antibiotics?" No culture was sent. In the absence of cellulitis, I see almost no one from the ER sent home with ABX (or having had a C&S done) with an abscess I&D.

    FWIW, the surgeon did use sterile technique.

  • Aug 25

    I do I&D's as a clean procedure. I do not culture or script abx unless there is a complication.

  • Aug 25

    It is a clean procedure where I work. Instruments are sterile but sterile gloves are not used. I don't routinely culture unless the patient has recurrent abscesses. Antibiotics are not necessary unless this is a recurrent problem or the patient has systemic symptoms. This is per our health system's protocol.

  • Aug 25

    Quote from BCgradnurse
    I use a disposable scalpel, which is sterile. I only touch the handle and never touch the site after it's cleaned. The sterile blade is the only thing that touches the abscess.
    Same. Alcohol prep, local anesthesia, povidone-iodine prep, drape, disposable scalpel, and clean gloves. Once the abscess is opened its non-sterile anyways.

  • Aug 25

    I certainly hope not.

  • Aug 25

    Quote from Anna Flaxis
    What about experience; how many veteran nurses and new grads are there?
    This seems to be the biggest factor that our facility has identified in regards to patients deteriorating without being noted. We had a relatively high proportion of new grads (about a year ago we had somebody that had been a nurse for 5 months doing charge on a med-surg floor). There has been significant improvement as our facility wide level of experience has increased.

    We've recently instituted a family initiated rapid response to help reduce the number of code that occur outside of ED & ICU. It has not been implemented long enough to garner any data.

  • Aug 22

    Great thread with lots of thoughtful responses.

    A couple of thoughts for OP

    Its unwise to "jump to solutions" until you actually know what the problem is. In my consulting years, a lot of work involved reversing the superficial "improvements" that were implemented to solve problems - AKA, it seemed like a good idea at the time. My mantra became "Today's problems were yesterday's solutions". Don't fall into that trap.

    Look at the research being done on "missed nursing care", "failure to rescue" and "nursing surveillance".... there's a ton of evidence out there to inform your decisions. Better yet, start analyzing those near misses or nursing failures using a system like HFACS or a rigorous root cause analysis process to determine the systemic problems that may actually be the causative factors.

  • Aug 22

    I'm sorry if I don't belong here, or if I angered some of you. I just wanted some insight, and THANK YOU, I think I got it. I never gave any thought to the fact that my straining might cause me to pass out. That IS a piece of the puzzle that was lacking.
    To explain further, yes I was a fall risk, for more reasons than one. I am diligent about NOT moving without staff present. I had also gotten permission from both the Doctor on staff and the PT department to use the toilet for BMs.
    In reply to the harassment comment: I surely WOULD NOT call it that. They were doing their job and I better understand why now. Yes, it was more than one nurse, more than once, but again, I GET IT NOW.
    And as for laxatives, stool softeners, and enemas. I have to take some responsibility for the fact that its just NOT that simple. I have a neurological condition that renders my abdominal muscles all but useless in the act of defecation. I can't bear down. I manage the situation quite well on my own at home by using my elbows, jammed into my lower abdomen, to facilitate bowel evacuation. When that fails I use a warm water enema with enough volume to literally flush out my lower colon. Unfortunately this information was not in my records and no one seemed willing to believe it or seek it out. I was given laxatives, stool softeners, and enemas (Fleets) all of which fail to solve the problem. Thus I was left with the intense need to strain, fortunately SOME of my nurses were willing to manually disimpact me.
    I assure you all that next time (and I'm expecting to have the other hip replaced soon) I will be more considerate of my nurses' dilemma
    and there need for more information.
    Thank you for your help!!

  • Aug 21

    Quote from robynnel
    I recently started working in a LTC memory care/dementia/alzheimer's unit and last week we had an inservice on caring for patients/residents and during that inservice we were told that our facility encourages you to say the patient/residents' name regularly and also tell them that you love them every day because it brings them joy. Would you feel comfortable telling a resident/patient you love them? I am just trying to get other opinions because others I work with said it sounds odd. (I should add: I am one of three people who work full-time on my unit, everyone else is part-time or PRN so I am usually on the unit 5-6 days a week and have very strong bonds with my residents, so telling them I love them isn't really an issue for me).
    I've never worked in memory care, and I would never want to. Trying to take care of my mother at home was an exercise in frustration -- I was so grateful for the memory care unit that took such good care of her.

    Mom's caregivers frequently gave her hugs and told her they loved her. She would brighten up every single time. It made her stay in "an institution" brighter. To me, it seemed absolutely false and strange -- bordering on inappropriate. But Mom loved it, and that's what matters.

    That said, I don't think I could do it myself.

  • Aug 21

    I don't have a problem with this as long as it is just a suggestion and not a requirement. I understand the objections voiced in this thread by most of the other posters. However, I have worked in a memory care unit before and believe that this type of emotional validation goes a long way with residents severely affected by dementia. Many of them live in a perpetual state of anxiety and confusion due to their disease. Trying to re-orient them to reality is usually impossible and sometimes even harmful.

    This happens to me less often as a nurse now, but when I was a CNA it wasn't unusual for one of these residents to say "I love you" to me as I was assisting them into bed at night. They had no idea who I was. In their mind I was just someone who had cared for their personal needs and shown them kindness. I could have been a friend, relative or complete stranger. They just couldn't remember but believed that I must care about them in order to be providing them with such personal care.

    When they said "I love you", I could have tried to side step the issue or remind them that I was just their nurse or CNA but why? It would have served no real purpose. They still wouldn't have remembered who I was and I would have missed an opportunity to quell their insecurities and reassure them that someone in their world does indeed care about them.

    I admit that I'm not completely comfortable saying to "I love you" to residents since I would normally reserve such a statement for family members. However, I believe that a moment of awkwardness or discomfort is a small price to pay for another person's sense of peace and happiness.

  • Aug 21

    Three to consult:
    1. Hospital pharmacist
    2. Occupational/employee health
    3. Your obstetrician.

  • Aug 21

    Give the lasix. Labs will be back before she starts peeing. Correct k as needed.

  • Aug 21

    But an automatic foley isn't called for any longer. Foley's cause UTI's which lengthen hospital stays and make the bean counters angry. If they are able to get on the bedside commode then they need to do this unless they are too medically fragile to do so.

    Quote from edmia
    Fun!

    In the ED, I would place a Foley for accurate I&Os and given her edema, it must not be easy to move quickly to the commode.

    I wouldn't hold the Lasix. So #3.

    As a side note, I would not order a drug screen unless the patient agreed to it. I'd never do one without patient consent unless we're talking about an OD for example and we don't know what they took.


    Sent from my iPhone -- blame all errors on spellcheck

  • Aug 21

    Quote from Emergent
    Without going into potentially revealing detail, care was assumed, pt was heartily diuresed as per physician intent, and released from ER with script and attempts at pt education.
    I'm kind of bummed it wasn't a trick question... I was hoping it was going to be a tropical illness, or three different things happening all at once (CHF exac, CKD, and PNA at the same time!).

    In practice I do the "when you hear hoof beats, think horses not zebras" thing. Online I'm totally looking for zebras.

  • Aug 21

    Quote from Emergent
    Multiple choice here, and, hopefully a discussion. If you are a know it all, please let us all know (so we can try to set you straight, and you can tell us why you are right )

    A pt comes into the ER C/O SOB, well known to you as a drug abusing CHF pt with very poor coping skills, on very high doses of home Lasix. States she is out of Lasix. Lower extremities with 4 plus pitting edema, crackles in lungs, sats in low to mid 90s, RR 24. You've established IV access and have obtained blood, and Dr has ordered IV lasix and labs.

    What should be your first action?

    1)Order a urine drug screen

    2)Monitor pt while awaiting lab results

    3)Give Lasix and bring BSC

    4) Counsel pt on better adherence to home medication routine.
    Well, 1 and 4 can be ruled out, as they are silly. What is going to come up on a u-tox that is going to change anything? Counseling at this point? Well that's just goofy.

    2 can pretty well be ruled out, as labs can take an hour, and the pt needs diuresis. So- the labs come back with a K of 2.7 after I gave the lasix. As luck would have it, we happen to have potassium,

    So, gonna go with actually doing my job and following dr orders on this one.

    As far as all the folks who were going to wait for something or order something: Do you not trust your docs? How about you ask them if you have concerns about the orders?

    Not sure why people are scared to give the lasix- people call there pcp during an exacerbation and get their lasix doubled over the phone.

    And- I am not putting a foley in. I am perfectly capable of measuring from a hat or a commode, and don't care if it's off by 67 ml.

    This seems pretty straigh forward here. Maybe I missed something. Can somebody give some good rationale for not following these orders?


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