An exciting ER day with REAL nursing interventions

[libran1984, ASN, RN]

I'm an LPN in a non-trauma ER. I get to take my own patient load as long as an RN performs the assessment/agrees with my assessment and discharge teachings. I also act as a float / supplemental nurse starting IV's, catheters, etc when the time is needed. I perform most IVP medications except for cardiac meds and conscious sedation medication. I wish to share some of my more exciting experiences of this week and hope to receive input.

---- TRIP TO THE ICU ----

Earlier this week a morbidly obese pt was brought in d/t pneumonia. Oxygen levels on RA 72%. Suffering altered mental status, severe dyspnea, and was immediately intubated at which point O2 was brought up to 84%-88%. Pt was febrile and profusely diaphoretic. Myself, an RN, an RT, and an RT student began transporting the pt to ICU. While moving the pt to ICU he began to buck at the ET tube. Upon arriving to ICU I slipped on a wet substance and realized the pt had sweated all the adhesive off and the IVs in bilateral arms had slipped completely out, draining abx and sedatives on the floor. The ICU nurse immediately calls IV for IV team and becomes strangely obsessed with the pt's body odor and starts ordering everyone in the room to grab a wash cloth and deodorant and begin washing the pt.

I'm somewhat in shock that our primary focus isnt restarting the line and propofol drip. I begin asking, "Where do you guys keep ur IVs and IV start kits." Someone points me in the right direction and while everyone is hustling to clean this pt up, myself and the ER RN that I'm transporting with are looking for veins, instead of waiting for IV team. The pt's skin is so damp and moist. There is certainly a lot of tissue to go through. I think I see something in the R FA, its superficial and the 20G I have in my hand may be too big. I exchange it out for a 22G. The RN pulls the skin taught and I stabilize the vein and BAM, I score access. 22G RFA. Propofol restarted. Yah. It was an awesome situation that I got a huge rush from. The RN I was assisting explained that a lot of nurses outside of IV team and ER don't get enough experience with starting IV's to be proficient.

I hope I made a good name for LPNs since techs and LPNs are not utilized in ICU at my hospital.

------ Awesome Nursing interventions -----

An elderly lady came to the ER from a rehab center via ambulance. She was being admitted for hypotensive and Altered Mental Status and uncontrollable, exaggerated bodily movements. The pt had a Hx of Parkinsons, but this was beyond the typical Parkinson's display. The pt was alert enough to say one word at a time and respond to the best of her ability to commands. Pt also exhibited spontaneous eye movement when her name was used. Upon triage we attempted multiple times to gain an accurate BP using automatic and manual means. Finally, I obtained a sketchy manual BP of 82/40.

Nursing Intervention #1:

I placed the pt in a Trendelenburg position.

The blood pressure was sketchy and unreliable but always best to be safe if it happened to be accurate. Further attempts to obtain a blood Pressure was unsuccessful and unreliable.

An I&O cath was performed and IV access established in R wrist. Pt attached to the monitor - afib.

The physician ordered CT and Xrays to be performed. Sadly, as time progressed the pt's exaggerated and uncontrolled motions became worse and the pt is found to be unable to sit still for CT or X-ray. In addition, we still needed an accurate blood pressure. As it turned out the physician believed she was being medically overdosed by her PCP on her Parkinson's medication and the result was flailing of the limbs banging into the bed rails.

Nursing Intervention #2

I padded the bedrails with seizure pads

I thought that was thinking outside the box. Recognizing a need and utilizing what is normally used for the case of seizures for and OD'd Parkinsons med.

An order for 1 mg ativan was administered IVP by myself. I watched the patient. There was no reduction in movement, but pt no longer roused with spontaneous eye movent in response to her name. Pt still seemed to make attempts at obeying commands but seemd to quickly forget. I was worried the pt may bottom out if she truly was as hypotensive as we all believed. However, her motions and HR proved that she would be just fine.

30 minutes later I was ordered to administer another 1mg Ativan IVP. Pt began to calm slightly but no longer seemed to acknowledge commands. Movements and jerking was mildly reduced enough for Xray but still not CT nor an appropriate BP.

15 minutes later, I was ordered to administer another 1mg of Ativan since CT was at the door wanting to transport the pt. I administered the ativan and the pt became jsut as wild as if no ativan had been administered, period. I felt hopeless and began to use Guided Imagery to help calm the pt.

Nursing Intervention #3

Guided Imagery of a small spotted got chasing a fluffy squirrel around a Red Oak tree.

The dew drops sparkled in the midsummer day sun while the deer sprinted in the open fields looking for shelter. The yaps of the spotted dog echoed through the wooded forest as he fervently chased after the fluffy squirrel who eventually eluded the dog by climbing up a tree.

The pt seemed to listen intently. I hit the BP button on the monitor and SUCCESS my first blood pressure of 128/84.

Not long after the pt fell fast asleep. Respirations were monitored closesly and pt was admitted by a hospitalist.

I just wanted to show off some of these skills and interventions I never really thought much of until I began working in the ER.

[Double-Helix, BSN, RN]

Good for you! I think you did a great job in some tough situations. You really make a difference for that elderly lady. Congratulations! You should be proud of that shift. (On a side note, I think the ICU nurse wanted the patient cleaned up because she was concerned he was so sweaty and without cleaning any further IV's would not be able to be secured. Deodorant kind of makes sense if it was anti-perspirant.)