Anna Flaxis, ASN 22,317 Views
Joined Oct 15, '10.
Posts: 2,857 (67% Liked)
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.
This should be an incident report. Don't let doc get away with it. He is supposed to know more than you do.
I work PRN exclusively. My orientation was as brief as I could possibly make it, as I am an experienced RN and have little tolerance for having my hand held.
I&D is a clean procedure. C&S is unnecessary for simple abscesses, as most abscesses heal without antibiotics.
Hmmm, I've gone as far as I wanted with my ADN. I've worked in cardiopulmonary/post-interventional/telemetry, emergency, infusion services, and administration. I've been approached for peri-operative services, but declined because I don't want to take call. I value my free time too much for that.
Is it bigger than a bread box?
Yes, my managers sided with me on the out of scope of practice, but did still choose the preceptor over me and it makes perfect sense, they've invested a lot of time, money and energy into them more than me and human nature tends to value the those opinions we've built a relationship with over a newer relationship, just part of our nature. Also I would be the most expendible due to being the most new and less skilled of the two. While it may not add up to you, that is okay. It is what it is, and I do need to move on. While I do feel that I would have thrived with a different preceptors whom I worked with side by side in different situations and they taught me well on certain skills, that doesn't really matter either since doesn't change the outcome now. The reason I had written the original post is more due to trying to figure out how to move on, and figure out how to pursue my next job since it was already difficult to get a job as a new grad, let alone someone who was let go.
I do not wish to complain I have found most nurses the most kind, sensitive, caring, people I have ever known. I want to know if I'm being overly sensitive or if my nurses (this time) were a bit out of line? I was in a rehab hospital for a hip replacement. Getting from bed to commode to toilet was an issue, but once there I had grab bars and felt myself quite safe. I assured the nurses that I would obey the rules and not get up on my own. I was extremely constipated and wanted some time and privacy to force a bowel movement. Time and again I had to specifically ask that the nurses leave and close the door. Often I was popped in on and asked how I was making out. Quite frankly the interruptions stopped the process in its tracks, I had to ask the nurse to leave, to close the door and begin my efforts all over again.
Am I being an overly sensitive prude or did I deserve a little more consideration?
The preceptor delegated medication administration to a PCA, and also used medication from a different patient on their current patient, also it was not prescribed yet either.
So Yes, I am CERTAIN the preceptor went outside her scope.
also it was not prescribed yet either.
That she is on "high doses" of Lasix at home tells me she most likely has severe CHF, that she is out of her home Lasix tells me she didn't go to the pharmacy for her refill, that she is "well known" to this ER tells me that she probably does this kind of thing on a fairly regular basis, which means that where her labs tend to run, what her VS typically look like, and what her EKG typically looks like are well known also.
From the sounds of it, she probably could have simply been given her regular PO dose of Lasix, except it would take longer. IV administration is fast, it's going to get her feeling better much quicker, and get her out of your ER and free up a bed that much sooner.
Although, on the down side, this also just enables her to continue to make poor choices because she knows the ER is there to save her behind. Is she at least polite? If you're going to abuse the ER in this fashion, you might as well be nice about it.
Since all lab work in the ER is STAT, the results will be back soon, and any abnormalities of concern can be addressed promptly.
And, I might be a "know-it-all", but I certainly do not know it all!
I think that the failure to recognize early signs of deterioration is a worthwhile issue to explore, but before you implement process improvement measures, it is important to find out what is at the root cause. Many different variables can factor in. What is the staffing matrix for the unit? What is the skill mix (RNs, LPNs, CNAs, Techs, ancillary staff, etc.)? What about experience; how many veteran nurses and new grads are there? How many RNs hold certification in their area of practice? What about education; does the facility provide inservices on a regular basis or offer classes either on the company intranet or in a live format? What about relations between nursing staff and physicians; what is the typical communication process and what, if any, barriers or glitches occur? At what percentage are core measures being met? And lastly, you should compare the rates of sentinel events/poor outcomes/code blues etc. at your facility with that of a few other facilities similar to yours. Is this really a problem, or are you doing better than you think?
The filter was above the place that I connected the piggyback of lasix and the line had been flushed with NS (although there was a small amount still hanging out in the line).
What is really the science behind it?
So, I work on a fabulous unit, with mostly very nice people who respect each other and work well together. But, there is one nurse who is just plain mean. She says nasty things and complains about whoever happens to be not around. Her nasty things range from complaining about their work habits, to personal attacks about people's hair or shoes being ugly. When I was orienting, I was told by my preceptor, "That's just her personality". I guess, my feeling is that it's ok for her to be her not-nice self on her own time, but at work, she should tone it down and act like a professional. What do you all think?
Since the purpose of the Emergency Department is to rule out/stabilize life threatening injury/illness, we are concerned primarily with acute pain.
The numeric pain scale is one dimensional. It only evaluates the patient's verbal report of the intensity of their pain. Since the goal in the ED is to determine the cause of the acute pain in order to treat the cause (i.e. appendicitis, myocardial infarction, bowel obstruction, long bone fracture, etc.), a multidimensional pain assessment is appropriate.
A multidimensional pain assessment includes the patient's subjective report of the intensity of their pain, but also the quality, the clinical progression, any alleviating or exacerbating factors, as well as objective observations such as splinting, grimacing, moaning, crying, etc. as well as abnormal vital signs.
It is the multidimensional assessment that should be guiding the prescriber's decision making regarding appropriate analgesia, not simply a number from 1-10.
Treating pain related to a long bone fracture is different than treating pain from renal colic. Treating a migraine is different from treating a small bowel obstruction.
There is no one-size-fits-all pain management strategy.
When you triage a patient who presents to the ED for a pain related complaint, it only takes a few minutes to perform a comprehensive, multidimensional pain assessment. Part of this means that when you ask the patient to rate the intensity of their pain on a 0 (no pain at all) to 10 (the worst possible) scale, it is completely appropriate to explain the scale to assist them in selecting the appropriate number to represent their experience. For example, 1-3 is mild pain that can be ignored and doesn't interfere with their activities of daily living. 4-6 is moderate pain that is difficult to ignore and interferes with concentration. 7-9 is severe pain that interferes with activities of daily living. 10 is the worst possible pain that requires bedrest. Obviously, if they drove themselves in and are calmly sitting in an upright position with no grimacing, splinting, tearfulness, and with normal vital signs, then they cannot be a 10.
Keep in mind that I am speaking of acute pain only. I'm perfectly aware that chronic pain is different. But again, in the ED, we are not in the business of treating chronic pain. If a person with chronic pain at baseline presents, it is appropriate to ask about their chronic pain, but also to explain that we're concerned here today with what is new or different from their baseline. We are not going to adjust their oxycontin dose or prescribe a fentanyl patch- that is for their primary care provider or pain specialist to do.
Having said all of this, I would say, Emergent, that if the providers in your ED are prescribing analgesia based only on the unidimensional, subjective, verbal report of the intensity of pain and not taking into account the physical exam, objective signs, differential diagnosis, etc, to select the most clinically relevant pain management strategy, then it's probably due to a host of factors such as pressure from administration to speed up throughput and increase patient satisfaction.
Honestly, it might feel like what number you plug into the computer under the pain score really matters, but in the end, that's not what the bean counters are auditing. They're looking at things like how long it took for the physician to order pain medication for a long bone fracture, or how long it took to give antibiotics to a person who met sepsis criteria, or whether a repeat lactate was drawn within six hours, or how long it took from the time the decision to admit was made until the person finally got to the floor, or how many patients a provider saw in their shift. Providers are under so much pressure to meet these demands, that they just click the boxes and give the patients what they want because they don't have time to actually practice medicine- i.e. dilaudid for a pinky toe sprain.
In other words, it's bigger than you or me or the stupid 0-10 pain scale.
Does that answer your question...sort of?
It sounds to me like you hit the median nerve which caused the patient's pain, and the clear fluid could have been lymph fluid.
I would highly recommend avoiding the wrist area for IV starts due to the risk of nerve damage.
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