Well, once again I've been sent a patient that is just a complete mess and I have no idea what is going on with him. This seems to happen more than a lot lately.
This patient came in because his wife found him on the floor and when he came to he was confused and weak. He had chest pain in the ambulance that was relieved by nitro.
When he got to the ER they did a lumbar puncture, EKG, CT of chest, abd, and head that were all negative except the LP. They were unable to get that because of bone spurs apparently. His vitals were stable, but white count was 23.9 and he had some respiratory acidosis. The man wears oxygen at home due to copd and smoking 3 ppd. He has sleep apnea but will not wear a cpap, so they sent him up on 2L. I ended up having to get him a mask due to him breathing through his mouth and being knocked out cold from morphine he got in the ER.
So anyways, I talk to the wife and she says he has been throwing up every morning and sometimes through out the day for 9 months, also having malaise, fevers, urinary retention, and just not feeling well. Apparently he had been confused more over the last three days. Turns out he had a pretty significant cardiac history with stents and was a recovered alcoholic. There was no mention of this by the ER nurse.
I soike to the MD and she said he was over sedated from meds he takes at home and possibly had gastroenteritis. She said she was going to order a repeat LP for the am.
First of all, I was only told that he came in confused for 3 days and had an elevated white count and unsuccessful LP. The nurse said he had no other tests done, did not mention any of his history other than HTN and COPD, and didn't say anything about fevers or vomiting. Second, he had been in the ED for 12 hours and didn't even have his EMS stick replaced, had no temperatures recorded except right before coming to the floor, and hadn't been given any fluids, just 1 dose of vanc and ceftin.
Im very confused as to how they can get away with not recording vitals. I figured she had only given me his last set because he just got there. She could've given me a range if he'd been there an entire shift already!
I had to call that nurse back when I got the patient to ask why there were orders for fluid boluses and to get the results of tests that she said he had never had. She denied he ever had a fever or that there were orders for a bolus when she had him. She was very rude and acted as if I was overreacting, but the Dr told me the patient needed to be in ICU. There were just no beds. Then the nurse finally said she thought he had meningitis and to just wear a mask. Ugh!
Also, in the doctors h/p it said nothing about any of his symptoms except for chest pain and elevated white count. I'm so confused and probably too exhausted to be thinking about this right now. All I know is this patient is sick and would be better off going somewhere else if the ER doesn't even have a clue what's wrong with him after he's been there for that long.
I know the other day I spent about 40 minutes in CT with my vented patient because our MD dropped a surprise CTA in the order list. We had to make sure nothing was pulling, change her arm positioning because it was blocking her heads, try to find some way to limit the odds of her yanking her tubes out, make sure that we were following policy regarding the PICC lines, etc.
Like ED Nurse said, if you're feeling overwhelmed, find a mentor. Use a mentor. Learn their tricks and see if you can make them into your own.
In the ED, patients and their families are also of the opinion that they are the only ones that matter; it's not just the inpatient units that get that. So it's up to us, the nursing staff, to make them feel like they are important, even if we can't respond immediately to them. Do you do hourly rounding? Just sticking your head into the room and asking how they're doing makes patients and families much, much happier, and it takes less than 30 seconds.
Communicating with patients and their families. "Sorry about the wait. I've paged the doctor and am waiting on him to call. As soon as I know something, I'll tell you." Boom. Patient feels empowered and involved in their care. They also feel like the hospital cares about them. I have to find the research, but I heard an anecdote. Patient satisfaction went through the roof when the only change made was people apologizing for extended wait times. Nothing else changed, people were still sitting around for much longer than they wanted to, but the staff started acknowledging the time and the patients felt like they were more than a number.
Warning patients about timing. "Let me go get that for you - it might take a few minutes, however. I'll be back as soon as I can." "The test results should be back in about two hours. In the meantime, here's the remote, here's the call bell. Nothing to eat or drink yet, but as soon as the doctor tells me you can I'll let you know."
Any time RT or lab refuses to do something or blows you off, tell your charge nurse. Passing it up the line means that they'll soon learn that their inactions have consequences. Will they be unhappy? Of course. But we've made enough noise at my current facility that people have been retrained, gotten enough warnings that they're one step away from being fired...Yeah, otherwise good people have left, but they had some amazingly bad attitudes and work ethics.
This may be anecdotal, but frankly, I've worked in some places that had things held together with duct tape. But the patients were happy and would return, because even though there wasn't enough staff, the few staff there were focused on their patients and their families. It's tough, yes, because you'll be starving, your feet will be sore because you haven't sat down in 6 hours, and you feel like your bladder is about to burst. I've worked in places that had the top-of-the-line equipment and way more staff than needed, but patients were miserable because they were being treated like a dummy in a simulation lab.
A lot of this is not taught in nursing school, and rarely during orientation. Mostly because it's hard to teach attitudes. But as my boss says..."If you're in this for the money, than you're in the WRONG field."
I have not read each post in this thread, but wanted to quote you because I really like what you've said. I am a med-surg nurse, and I cringed at your examples of the petty things you have been called about. Thank you for being calm and patient in how you responded. You have a great attitude.
Specializes in Care Coordination, Care Management.
So, what about the confused/unconscious/whatever pt. coming into the ED without family/friends AND without their med list? In the middle of the night? How exactly would you like the ED staff to reconcile those meds?
I also think that certain things like home meds should be reviewed one ER, they're supposed to. It never gets done though. And then my patient comes and has no list because it was lost downstairs and they don't know their meds. Once a patient stayed a whole day in the ER and meds weren't reviewed. They ended up having s seizure and the family sued because the nurse didn't go over the meds, she just took the list and said she did. Maybe she got busy, forgot, lost the list by accident with all the chaos around her. I don't know, but I wish every patient I got didn't have a list that was lost. It makes things very difficult.
I have read virtually every comment and have some suggestions.
First, to the OP and others who complained about the ER as a whole: I work in the ER and have taken report at shift change from other ER nurses that I soon discovered have clearly dumped on me, so I totally believe it can and does happen sometimes with these same nurses when giving report to the floor. But I, and others like me, tend to get a little defensive when people blame bad nursing on an entire department or group instead of where it rightly belongs--with the individual(s) in question. So when you feel the need to vent, or have questions about what is or is not appropriate care, remember that there are bad nurses in EVERY area of the hospital and make your comments or questions about the individual, not the entire department for the most effective responses.
Second, there have been differing opinions on whether or not the patient in the OP should have gone to the ICU. None of us were there and it is impossible to relay every necessary piece of information as it actually happened. Also, although unintentional, the OP necessarily has a bias in this situation, so I think we should all be careful of making absolute judgements about what should or should not have been done in a situation like this when it comes to slamming another nurse.
Third, I have worked in most other departments at one time or another, so I know what it's like from that perspective. I try to relate to the receiving RN on a personal level for just a moment before giving report by asking how his/her night is going and commiserate with them briefly if necessary. I find it that it sets the tone for report if they know that I understand that I am not the only one who needs consideration and support in this situation. I also try really hard to give everyone the benefit of the doubt if someone can't take report right away, and I try to always be polite and respectful.
Lastly, make a formal complaint if you feel that it is warranted, but do not get into an argument with the nurse on the other end. If there are truly things that need to be addressed, either with an individual or a process, then it needs to be corrected or it will only get worse. If I think that there is the possibility that the nurse on the other end did something wrong, I ask the nursing supervisor (or someone in a position to know) what the situation is on that unit/floor so I can make an informed decision about whether or not I need to make a formal complaint. More often than not, however, I find that there are extenuating circumstances and no complaint is needed.
So, what about the confused/unconscious/whatever pt. coming into the ED without family/friends AND without their med list? In the middle of the night? How exactly would you like the ED staff to reconcile those meds?
I think it's a given that we all understand that there are going to be situations where home med lists cannot be verified. My hospital allows for such situations and I'd be surprised if all hospitals did not do the same.
Just as many other have stated, there is no time to go over every detail in the ED. And depending on what type of system you have, you may miss orders that MDs have placed maybe a minute after you checked for new orders. You will never get a full complete report from the ED no matter how thourough any nurse can be.
What I do is I get the name/account# etc of the patient, look him/her up on the ED tracker and print out the labs and ED progress notes. I then look at the orders and take quick notes on the printed progress notes like the following: diet orders, consults, procedures (2D Echo, dialysis, KUB, etc).
Now that you have a pretty picture of your patient, all you have to do now is to confirm with the ED nurse about the above. Believe me when I tell you that half the time they don't know the vent settings, they don't know the consults, they don't know a 2D echo was ordered, etc but they did one hell of a job in keeping that patient in 1 piece.
You can also look up in your system if the patient has been previously admitted to get a full medical history and look up previous consults just in case you need to consult them on this current admission.
I would absolutely love it if I could do this where I work! Matter of fact, I always attempt to look at everything before they call to give me report for that exact reason...so I can know more, know what to ask, help them out on not having to tell me every little thing, etc. For whatever reason they made it unavailable to view a patient in the ERs info unless you have worked in the ER before and been put in their system or something like that. Sometimes registration will transfer them in the computer before they call for report, but hardly ever. It's very frustrating and leaves a lot of room for confusion when I do get to view their stuff. I always have questions for the ER nurse, but hardly ever bother to call and ask because most of the time they're too busy to look up everything.
The main issue I have been having lately is they will be in a hurry to get off the phone (because they're slammed...I know) so they may forget to tell me what they've given and not given (they don't always scan the meds) and so when I see a med that was due at say 1500 and its still in red when I get them at 2300 I don't know whether they've had it or not and neither do these patients lol so I have called before to ask and can never get in touch with the nurse who had the patient. Or the nurse says she did give it but doesn't sound confident and it's just scary.
GM2RN
1,850 Posts
What, you never take a break and have another nurse watch your 1 or 2 other patients for 5-10 minutes???