All Ye Shall Benefit...

MAISY, RN-ER, BSN, RN · Oct 26, 2007

Hi welcome to the ER!

Monitoring is used on anyone with electrolyte imbalances, weakness, extreme gi issues-lots of vomiting/diarrhea, bleeds, dizzy, loc, elderly, and just in anyone that doesn't look well in our ER-this is beside the usual cp. Our 12 lead ekg's are done by order or at any change in monitoring, or condition. Our 5 lead is in every monitored room and used during transport with patients on drips or on the way to telemetry, ccu, or icu-critical patients.

IV contrast is not used in patients with shellfish allergies, severe asthma, or poor renal function. Asthmatics will be premedicated (20 minutes) with 125mg solumedrol. Our ER has baseline creatinine numbers. We need to have large line at least a 20 g in an AC or large vein for spiral CT to r/o PE.

PO contrast usually is used with abdominal/pelvic cts -patient waits 2-3 hours for contrast to go throught system.

As a nurse you shouldn't have to anticipate-it is always physician ordered, but will not happen without labs(in our ER).

Using ancillary staff in ER is no different than delegating anywhere. Ask for task completion, and advise that results need to be delivered right afterwards. Understanding that they are part of your team, and not your slave will come across. You must be willing to lend a hand, if you want a hand lent to you. They are not the nurse, but they are there to help-that being said. They may gather the facts, but you must be responisble for acting on them and making sure the patient outcome is good.

My ER is in a teaching hospital. We are always learning, and to my knowledge-no one has seen it all.

Maisy;)

lela186 · Oct 26, 2007

1. Most of our patients get 12 lead EKG's. These include people with syncopal episodes, CP or other cardiac problems, OD's, trauma's, codes, drunks/druggies, SOA, Abd pain/NV (esp if over 40 y.o.), hx of cardiac problems or irregular heart beat, hypoglycemia, plus a variety of others. I will put the pt on a 5 lead monitor depending on thier symptoms as well and age. I generally don't really trust a 5 lead b/c you can't see as much. I much more prefer to see a 12 lead when trying to dx any cardiac abnormalties. 5 leads are good to monitor and watch your patient while your running around busy, but if you see anything unusual on that or a rythm change, you had better get a 12 lead.

2. For CT, usually we do non-contrast on heads unless there is a mass or something we are wanting to see bette. Just to rule out bleeds though or acute changes such as stroke, it's just non-contrast. We use contrast for CT's of chest for PE protocol, on our abd/pelvis as well. Make sure you get a consent signed for contrast use. Usually if your scanning an abd pain then you will also have them drink the PO contrast before they go to CT. I'm not sure what kind of contrast you use at your facility, but we use the Omnipaque that you mix in 1 liter of juice, coke, whatever as long as they are not allergic to the dye. If they are allergic to the dye, we have them drink 2 bottles of the regular barium contrast over 1 hour and then send them up 1 to 1 1/2 hours after they have completed it. This is so that it can get all the way through the bowels. Also, before you use IV contrast, check the BUN and creatinine and make sure they are okay. If they are elevated, then they may do it without or with a smaller more dilute amount. If they are allergic to it, they may have you pre-medicate with Benadryl first. If they are of child bearing age, check an HCG before sending them to CT unless it is an emergent situation.

3. As far a using PCT's I just ask them to do what I need done nicely and always say thankyou. If I'm not busy then I do it myself.

4. Any ER is a learning enviroment. Utilize your experienced nurses and always ask questions. If you don't understand why a MD/PA/ARNP is doing something, ask them to explain why. People appreciate others who ask questions to learn, esp new people. It is the ones who think that they know everthing that can be scary!

Hope this helps!

bill4745, RN · Oct 26, 2007

5 Lead vs. 12 Lead EKG analysis/monitoring...

Also, drug OD. When in doubt, monitor. Leave 12 lead on (if you can keep the machine) for unstable tachy, evolving MI, etc.

PO/IV contrast.

No anticipation, don't give until ordered. Only anticipation is 20g IV might be needed for contrast injection for certain CTs.

utilizing PCTs/CNAs in delegating tasks without being rude or being seen as overdemanding?

Only use when needed, do their job on your pts when you haave the time. That way,they know that when you ask them to do something, you really need them.

Is your ER department a learning type of environment.

After ten years of ICU and four of ER, I still learn something every day, from the docs, techs and other nurses. And there are times when we teach the docs!

andhow5, BSN, RN · Nov 3, 2007

Besides patients with trauma, difficulty breathing, chest pain, and cardiac related/hx...what other kinds of patients do you hook them up 12-lead to? And when would 5-lead monitoring be incorporated?

We hook tele to our CP, SOB (CHF and Resp Distress), OD, Trauma, bad GI, Stroke sx, anytime something just doesn't "feel" right. We don't have to have an order to put tele on a patient.

Our tele is only 3 leads. We do 12-lead ekg's on CP, OD, Stroke sx, Trauma, bad GI, and as ordered by the MD.

PO/IV contrast. MDs are always ordering different CTs depending on the patients presenting problem. With which CTs do you give patients PO/IV contrast to, and which CT scans require no contrast? It's been difficult in trying to anticipate this.

The only CT's we do without contrast are: Head, cervical, facial bones, and abd for stone. The majority of our other scans are with IV contrast, and at our facility the CT Techs give the IV contrast. It's rare that we have to use oral, but if we do, the CT Techs come over to do the teaching on it, and get them started on it.

If we suspect the patient might get a scan with IV contrast then we always get a saline lock size 20g or bigger (of course when we start locks we always go for 20g or bigger anyway - if they're "sick" enough to be there, then they "need" the lock). But I'd estimate that about 95% of our patients get locks regardless...

How did any of you ER nurses get better in utilizing PCTs/CNAs in delegating tasks without being rude or being seen as overdemanding?

I usually say, "Hey Fred (whatever the name is) - when you're finished with what you're currently doing, would you be able to do me a HUGE favor and do 'X' for me? Thank you."

They are very quick to pick up on rudeness or pick out what nurse is being just plain lazy (I know - I went from tech to nurse)! Most of them (but not all), have the basics down and can also anticipate what you might need on your patient so they won't be surprised by the requests.

A question to all of you. Is your ER department a learning type of environment.

Ours is a teaching hospital so we have students of all kinds at all hours. It gets kind of interesting trying to meld all these different approaches, patient needs, and helping the students (of all disciplines) get in the tasks they need to get done.