Double-Helix, BSN 25,816 Views
Joined Apr 5, '11 - from 'New Jersey'.
Double-Helix is a Nurse, Children's Hospital.
Posts: 2,695 (50% Liked)
Just take it as practice for the endless useless continuing ed requirements you'll face throughout your career.
Now, breathe deeply, in and out. Imagine your peaceful center, that calm, happy place, free from discord and strife. Nothing can disturb your peace of mind.
Have you taken the time to review your Candidate Performance Report? This report can provide information about what areas are strengths, what areas are near passing, and what areas are weaknesses. That can help you with developing a study plan.
You're certainly not going to see people at their best in the ED, so if they are a jerk on their best day... I try to keep in mind that they are in pain, or that they're having to watch their loved one in pain, and getting inadequate treatment. I usually will explain that the fewer things on my list that I have to do, the quicker I can get to getting them pain medication, and having to deal with a disruptive patient and husband isn't making my list any shorter.
What sticks out to me though is that the doc is only giving one time pain med orders for a patient with a known kidney stone, I've never known an ED doc to do that and is pretty much guaranteed to inadequately treat the pain. I'd tell the Doc that the patient in bay 12 wants to talk to them about their poor prescribing habits.
You never know though some docs are odd about stuff, it may he a rule he really put in place for his own peace of mind
A question was posted
The nursing student was given a zero on the assignment, after being reported to faculty, for a hipaa violation/ division policy violation ("posting anything related to clinic on social media") and is facing the possibility of not being allowed to participate in patient care/ have limited access to patient information, during future clinical rotations... pretty stiff penalties, for asking for help.
I was assigned a patient tonight in clinical that was getting prepared for emergency surgery. He was in extreme pain and his nurse gave him dilaudid for the first time. I was asked to stay with him while she called the doctor to update him on the status of the patient's condition. He was panting and shaking and kept repeating "I can't breathe."
I started out by trying to reassure him that he was breathing and his O2 stats were perfect. But no change in his condition. I was frustrated (not with him) because I felt like there was nothing I could do to make him feel better and wondered what in the world would convince the nurse to leave me alone with him???? So, out of desperation I sat on the side of his bed, grabbed his hands, made sure he looked in my eyes and had him breathe in and out with me and tried to keep the both of us from panicking (To be honest I needed the breathing as much as he did ). He calmed almost immediately. He squeezed my hands and said simply thank you. He asked me to stay with him until his family got there...... And then it hit me.... He was scared. He was alone. He thought he might be dying. I only held his hand but I helped him feel less afraid. I helped the person, not the assignment. I made a difference. I felt like a nurse.
It was amazing
As has been pointed out previously, a confused patient who pulls his indwelling foley out is not likely to leave a condom catheter alone either.
You can try a skin prep which helps it to "stick" to the skin of the penis somewhat, however, you DO NOT want to promote any shearing or tearing injuries to that skin.
Why does this fellow require a catheter? Why is the team focusing on a POC that is irritating, agitating, and annoying the patient?
When the caregiver told him I was removing the foley this morning, he looked at me and said "God bless you!"
AWW.. give him a little kiss from me.
Forget the condom cath.. will never work. He is refusing the treatment,, and that's ok. He will continue to pull off the condom cath until the cows come home.Develop a toileting regimen.. use adult briefs as needed.
This is not about condom cath techniques.. this is about solving a problem.
With some surgeries that are expected air leaks. A gentle intermittent bubble indicating that there is air leaking would be expected in this kind of surgery and in a pneumothorax...which is trapped air in the pleural space. As long as the patient is not in distress and subq emphysema isn't present everything is fine.
In the case of open hearts it might be different. Air leaks aren't expected as the lung was not operated on so no leak should be there. The pleural chest tubes are placed for drainage if the internal mammary was used and if the lung was deflated during the operation. The mediastinal chest tubes will also not have air leaks, if the do they will be minor and brief because of course there is mediastinal air when the opened the pericardial sac to perform the bypass.
I was going to type an answer but I remembered GrnTea had a great explanation
When you breathe in, you're not actually pulling air into your lungs with your muscles. You're actually making a suction inside your chest with them (I know this may seem like a distinction without a difference, but stay with me), and the air enters the lungs thru the route provided for it to do so-- your trachea, via your nose or mouth (or trach tube, if you aren’t so lucky).
Your lungs are covered with a slippery membrane called the visceral pleura. The inside of your chest wall has one too, the parietal pleura. They allow the lungs to slip around with chest wall motion, like you can slip two wet glass plates around that are stuck together. Like the two glass plates, they're hard to pry apart due to the surface tension of the wet between them, and that's why the lungs fill the chest cavity and stay there. But just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.
How does the air get in the pleural space where it doesn’t belong? Well, you can do it two ways. One is to play rough with the bad boys (or have surgery, which is, after all, only expensive trauma) and have a sharp object puncture your chest wall and admit air into the pleural space. How does it get in there? Well, you make suction in your chest when you breathe in, and now air has TWO routes to get inside your chest-- down the trachea into the lungs, and thru the hole in the chest wall into the pleural space. This is called a pneumothorax, air in the chest that is outside of the lung. The lung will tend to collapse because the surface tension between the wet layers is now interrupted (remember how the pieces of wet glass can be separated by introducing air between them?) and the lungs are naturally elastic.
The other way to get air into your pleural space is from having blebs/bullae on your lung surfaces, and pop one (or more), or have some other hole in your lung (sharp things again, including a WEDGE RESECTION, which leaves holes that can't be sealed until they heal by themselves). Then air gets out of your lungs thru the hole(s) and disrupts that pleural side-to-side thing, and there you go again, a pneumothorax. This, however, is called a TENSION pneumothorax, because that air increases with every exhalation (the lung now having two routes to exhale air out of, the trachea and the hole in the lung itself). This allows the lung to collapse on that side, and soon enough pressure (tension) will develop in that half of the chest to push the chest contents over to the other side, compromising blood flow and air exchange in the other lung & heart when it does so. (This is when you see the "tracheal shift.") This is also a bad thing.
So: now both of these fine folks have bought themselves chest tubes. The guy with the chest wall trauma has had his trauma hole sewed up, so when he takes a deep breath air enters his trachea only. He has a water seal on his chest tube so he can't pull air into his chest thru the tube-- the water seal acts like the bend in your sink drain and prevents continuity of the inside and outside places. The suction on the chest tube setup has done its job of removing the air from the pleural space where it didn't belong--it was seen bubbling out thru the water seal and then couldn't get back in. (When all the air is gone from his pleural space, there will be no more airleak in the water seal compartment.) Now, if he disconnects his Pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. THEREFORE, when this guy disconnects his tube, you clamp it IMMEDIATELY, to prevent air from entering the pleural space. He should ALWAYS have those two big old chest tube clamps taped to his Pleurevac (so they go with him to xray and all), just in case he does this.
However, the other guy, with the ruptured blebs or wedge resection and the intact chest wall? Well, his chest tube is pulling air out of the pleural space, but more is still getting in there since he still has a hole(s) in his lung. The idea of the CT is to pull it out faster than he can put it in, and allow the hole to heal up, at which point he will no longer collect air in his pleural space and be all better. Meanwhile, though, you see air bubbling in the waterseal chamber, showing you that there is still air being pulled out of his pleural space. He has “an air leak.” What happens to him if his chest tube gets disconnected?
Well, remember, he still puts air into his pleural space, because there's still a hole in his lung. You put a tube in there to take it out, remember? OK, so what happens if you clamp his tube? Bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket. This guy should NEVER have clamps at his bedside, because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in trouble all over again. If he pulls his tubing setup apart, have him breathe slowly and shallowly (to minimize the air leaving the hole in his lung and getting trapped in his pleural space) while you quick-like-a-bunny hook him up again to a shiny new sterile setup. But do NOT clamp his tube while your assistant gets it set up for you.
Good way to remember for the tests:
Primary - Prevent
Secondary - Screen
Tertiary - Treat
I'm a first semester student in an accelerated 2nd degree program.
I just generally feel soooo slow!
The first sim, the "doctor" told us to give our "patient" a 30mg IV dose or morphine. I thought it was high but was prepared to administer it, and then another peer of mine brought it up and we discussed it. She thought it was high too, so we called back and the doc said oops, 10mg not 30mg. So it was a good catch except it wasn't really my catch, since had it not been for my peer I probably would have administered the erroneous dose
Second sim, the "patient" was a type 1 diabetic and had just received humalog. It was lunch time and we were also prepping him for a blood transfusion. He kept complaining of being cold, tired and had chills/shakes... For some reason my whole group got hung up on the mind set that he just really needed the transfusion to make him "perk up" rather than the fact that he was experiencing symptoms of hypoglycemia from his rapid acting insulin and having refused his lunch! We eventually figured it out and pushed sugars but again, I just felt so slow and stupid. I know the symptoms of hypoglycemia perfectly well and yet I did not connect them, clinically, to my patient.
Should I be concerned that I am being slow and missing something
is it supposed to take awhile to make clinical connections like this?
i feel like I also get nervous because of the one way mirrors and the professors watching us
I have a countdown app on my Android phone that includes a home page widget you can set to display however many days until a date of your choosing. My widget has a picture of me with my significant other, David, and it is finally down to double digits for days remaining here in our little corner of Afghanistan!
I can recall when I first put it on my phone, and it was well over 240 days. My original orders for deployment in support of Operation Enduring Freedom (OEF) were "not to exceed 284." Ugh.
Every day when I wake up (or after midnight when my widget changes digits, haha), I divide the total by seven to calculate how many weeks I have left here. We're at less than 14 weeks currently (double digits in days!), so my brain automatically rounds down to 13-ish (conveniently for me). I think of it in terms of 13-ish more "civvy Sundays" (days we get to wear civilian clothes), 13-ish more days off (Saturdays for me, once I come off of night shift-there are no days off for night-shifters), 26-ish more Tuesday/Thursday classes taught by my unit peeps, 13-ish more weeks to work out in our amazingly dusty but much beloved gym.
Leaving this place has become a looming reality, and I feel a little bit sad at the prospect. I love what I do here, and I adore my unit (most of them, anyway; you can't love everyone!). One of the sad parts about being PROFIS (i.e., temporarily assigned to the unit only for the deployment) is that once we leave here, I won't see these peeps at home.
I used to think that I would give my eyeteeth to go home early. We used to hope for news that we'd get to leave early; I remember summertime musings of maybe being home before 2014 arrived.
Those were just the idle speculations of people who were trying to get used to an unfamiliar place, who were acutely missing our families and loved ones stateside. We accepted our reality and embraced our role. As odd as this place is, it's become our "home" for now. How strange.
I recently had a very good friend (truly my "sister from another mister," haha) who was inadvertently and unfortunately injured here in country, and she's going home early. Thankfully she's fine, and will heal without a problem.
She and I came into country at the same time, so I know just where she is in her deployment. She is understandably upset about leaving her team. I can completely grasp the complex emotions: the excitement of being back stateside, of seeing our loved ones again, of doing all those things we miss (brushing teeth with tap water, showering barefoot, ordering pizza, etc.), coupled with the longing for the team with which we've endured so much. I'm sure her team has grown and bonded, as has ours, and it's going to be tough to leave the comfort of our brothers and sisters who get it, and get us.
We hear so much about PTSD and what happens when we go home. I wonder if I'll startle easily at loud noises, or if crowded places will overwhelm me, or if the colors and textures of home will just be too much for me at first. I think of the adjustment of getting back to my life, and I crave it and I dread it. I envision it will be similar to adjusting to daylight after being in the dark for so long, and I eagerly anticipate having to squint and shield my eyes against the brightness.
Of course that comatose person is at risk for pneumonia, from stasis alone even c turning q2h. I like the way you think; do what your professor tells you, but keep thinking it out and I think you'll do well.
Ashley: Perfect example. You might be right that the professor wants to discourage the rote "airway is always first" answer; I wish the professor had then gone on to explain why in the way you did. Critical thinking!
I think your instructor is trying to get you to think more deeply about the scenarios. She doesn't want you to just see the word "airway" and automatically choose that option because it's the "A". Yes, airway is absolutely a priority, and assessing it will always be correct (in real life). But in the context of the question, is it your MOST correct response?
Let's see if I can think of an example...
Your 6 year old pediatric patient was admitted for observation after being stung on the neck by a bee while riding her bike 6 hours ago. The patient suffered a broken right radius after falling from the bike. A plaster cast was placed on the right lower arm. Upon assessment, the nurse notes swelling and redness of the neck in the area of the bee sting. The patient reports that her neck "hurts a little" but her arm "hurts a lot". She says it "feels like there are lots of needles poking her fingers and hand". She appears scared, is crying and having a hard time catching her breath. Vital signs are as follows: HR 113 BP 110/69 RR 36 SpO2 95% Ax Temp 98.3 What is the nurse's priority?
1. Administer prescribed pain medication
2. Assess for a patent airway
3. Instruct the patient in relaxation techniques to slow respiratory rate
4. Assess circulation of the extremities
In this example, all of the ABC's are addressed, as well as the 6th vital sign- pain. Every option is correct, but one is the MOST correct, and it's NOT the airway option OR the breathing option. Yes, airway is important. The neck has some swelling, the patient is having a hard time catching her breath. Yes, anaphylaxis is possible with bee stings, but remember it's been 6 hours since the sting. Anaphylaxis onset at this point is extremely unlikely.
Breathing- yes, the respiratory rate is high, and the breathing pattern is labored. Oxygen saturation is slightly decreased for an otherwise healthy child. But WHY are you seeing these symptoms? The patient is in pain and scared. All are expected findings in this situation.
Which brings us to our C- circulation. There's a few clues in this question. 1. The patient is reporting severe pain in the casted extremity. 2. The patient reports a pins and needles sensation in the hands and fingers (not just in the area of the break). These things are suggestive of compartment syndrome- a dangerous complication with serious consequences if left untreated. Assessing the circulation of this extremity compared to other extremities is definitely your priority.
I hope I helped explain why the ABC's aren't always the correct answer, and why it's important to evaluate your options in the context of the question. That being said, with the information provided about the facial trauma and swelling, I probably would have chosen airway as well.
About 4 or 5 months ago I (the PCT, the hired help, that young guy, the guy that looks like he's new, the Per Diem staff) was floated to the Cardiac Care Unit (CCU) for half of a shift. About 3 hours into the shift, the Nurse went into a patient's room to find the pt in cardiac arrest. He came to the doorway and exclaimed ''we're calling a code here people!"
I was directly across the hall and was second in the room as the nurse started the first few compressions. I said "I got compressions", and he moved over and went to grab code cart.
This person was alive just minutes ago. It was surreal. For a few seconds it was just me and this Patient. Alone. I'm doing chest compressions,her ribs weren't cracking or grinding. Everyone tells you that you can feel ribs breaking. At that moment it was just me pushing down with my hands together on the center of this woman's chest. Her body slightly jerking with each compression.
This person was alive just minutes ago. It was surreal. The patient was on a ventilator so we only had to do chest compressions, the breathing was taken care of. In what seemed like ten seconds, there was seven or eight of people in the room.
I see the hand of a nurse sneaking up to place the two electrodes on the patients chest. I remember my CPR instructor telling us, "DO NOT STOP COMPRESSIONS- Let them work around you" so I just kept going, I remember the nurse going to push epinephrine. After two electrical shocks, her heart was now beating again. She had a second chance.
About 20 minutes later I was re-floated back to my normal unit (physical rehab) and finished my shift. I didn't work again for two weeks, during that time I had dreams about this patient, the code, and doing chest compressions.
I knew that we had saved the patient at that time, but after I finished my shift, I had no idea what happened to the patient. This patient may have died the next morning, and I had no way of knowing.
It is fairly common that when someone goes into cardiac arrest once, they are likely to arrest again, and again until their body has nothing left, and then they have died.
The next time I worked, I was on the Progressive Care Unit (PCU), which happens to be right down the hall from CCU. I did a little snooping around to see if this patient was still in the hospital (alive).
I got wind from a CCU nurse that the patient was on PCU (where I was floated to!), so I probed some of the nurses and found out which room the Pt was in. I looked into the room and the patient was in the bed, still on a mechanical ventilator, but skinny as a rail. The patient I remember was big (swollen with fluid). This Patient was in restraints and wasn't coherent. If she patient didn't have a very unique condition / wound wouldn't have believed it was really her.
I thought ''Oh well''. I finished my shift. I have seen countless people on ventilators that will likely never be themselves again, out doing what they love with those they love. It's a part of our profession.
Five months pass and the memory of this patient is gone, sent off to my brain's filing department to be entered into the "Patient's I'll never forget Folder".
My life continues as normal.
Last Monday I'm back on my Physical Rehab unit and am looking through my 4 or 5 Patients' Charts and I see a patient's history with this same unique diagnosis / wound!
I'm thinking ''no Freaking way"
I go into the room and see my Patient, months later is doing well (alive is better than dead right?). The tracheotomy is healed up, the wound has healed, that one amputated toe is still....amputated...
The Patient has no idea who I am, but I know all to much about her. I considered telling her about our history, but I chose not to.
Everyday Nurses help people feel better, get better, deal with their biggest fears and how their life may never be the same. This becomes routine. At the end of the day we know that we have helped people, but we don't FEEL like we've helped people
It wasn't until I saw this patient's progression from being on the cusp of death, to the edge of moving on with her life, that I really understood how we can really make a difference.
And she'll never even know who I am. I don't want special recognition, I don't want hero status or an award. I know in my heart that what we did matters, and that's all a part of nursing.
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