Anna Flaxis, ASN 29,302 Views
Joined: Oct 15, '10;
Posts: 2,886 (67% Liked)
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Well, color me disappointed. I was expecting to read all about your addiction to prescription pain pills and how you're having an extramarital affair with the pharmacist to get them. Dang.
Did you have orders for oxygen? What did the orders say?
In someone with a history of sleep apnea and mild lung disease, I would expect that he probably drops down below 88% in his sleep on a regular basis at home. It sounds like during the day, when he's awake, 94-95% is his normal. I agree with your preceptor, except that I would accept anything above 90% in this fellow.
Remember also, to assess the whole patient, not the monitor, and that the SpO2 should not be used in isolation, or regardless of other assessment data. Of interest would be his respiratory rate and effort, heart rate, skin signs, mentation, and airway status.
Your instincts were correct that the Xanax could relax him enough to diminish his respiratory effort as well as relax his airway protective mechanisms. In addition to considering supplemental oxygen to keep him above 90%, I'd suggest stimulation (i.e. waking him up) and positioning (i.e. turning him on his side) to prevent airway obstruction.
But I think your preceptor is correct - he probably lives with lower than normal SpO2 levels, and you should titrate down once he's above 92%. Also, this is information that should be passed along to the physician. This patient would benefit from a sleep study and a pulmonology consult.
I'm one of those bleeding heart lefties that believes that access to health care is a right, not a privilege. I don't mind my hard earned tax dollars going to help those less fortunate than I am. And honestly, I don't think we have a problem with access to health care, what we have is a problem with access to PRIMARY care.
When you can't get in to see a doctor, because they're not taking new patients, or they won't see you without payment up front, and you have no money to spare or you work a cruddy minimum wage job and can't get the time off to go to a doctor without an act of congress, I can see why people get desperate and go the the ED for primary care, or put off taking care of chronic health problems until they reach a point where they need urgent medical attention.
There are people that truly do not have a support system to get them home, or have any money to spare for cab fare. Poverty is a real problem, and not easy to overcome. Poverty should not be equated to character flaws, IMO.
I have walked a mile in those shoes, where I needed help to keep a roof over my head and food in my childrens' bellies. It is demoralizing and humiliating, and it is NOT easy to lift oneself up out of it.
When I was on public assistance, I was urged to get a minimum wage job in order to "get off the dole" and be "self sufficient". I did the math. A full time minimum wage job would bring in exactly what it would cost me in day care to work outside the home. I would have been working in order to put my kids in day care. One cannot pay rent, utilities, buy food, pay for daycare, let alone have anything left over for unexpected expenses on minimum wage. My case worker told me not to worry, the State would continue to subsidize day care, housing, and food for me and my family. So in other words, I would have a job and STILL be dependent on public assistance. The idea of having a minimum wage job and no longer being dependent on public assistance was a lie.
When I told my case worker that I wanted to finish my high school education and earn an Associate's degree (in a field unrelated to nursing) so that I could become truly self sufficient and no longer need any public assistance at all, he told me that if I did go to college, I would be "cut off" from all benefits. In other words, the system was set up for me to remain dependent.
Well, I hate being told I can't do something, or threatened with hardship if I make my own choices, so of course I went to college. I got Pell grants for my first degree, and my case worker's threat turned out to be empty. I was able to attend college and earn a degree and still receive public assistance. Once I graduated, I was able to obtain a family wage job and leave public assistance behind permanently.
In my case, public assistance worked like it was supposed to (despite the efforts of my case worker to scare me into remaining dependent). It was a safety net for me until I was able to get back on my feet again.
So, as you can imagine, I can really identify with those who are at the very bottom rungs of the socioeconomic ladder, and I make a practice of treating *everyone*, no matter their socioeconomic status, with basic human dignity. That pregnant teenager, that unwed mother of five, that unemployed high school dropout, each one of them could be someone who could, with help and support, change their lives and become self-supporting, if they just know it's possible.
The thing about poverty is that it can feel like a trap. It can feel hopeless, like there is no escape, so why even bother trying? Everywhere you turn is another obstacle. It's easy to become cynical and embittered, especially when others look down on you with disdain.
I do get irked by the "work the system" mentality. When I feel like I'm being used, scammed, or manipulated, I get irritated. It's especially irksome when it's by someone who is not emergently ill attempting to monopolize my time while I'm taking care of others who ARE emergently ill.
But, I can understand how a person might need to use the ED for something as minor as a sore throat, and not have any resources or funds to get themselves back home. I can empathize with what it must be like to be in that situation.
What makes the difference to me is the person's attitude. There are some people who, no matter how down on their luck they are, still treat others with basic respect, who still know how to say please and thank you, who would still rather give something to their community and not just take.
Still, I don't get to decide who "deserves" a taxi voucher based on their attitude or whether they rub me the wrong way. If a person has no resources, no money, no support system, I'll at least try to get them a bus token.
I try to remember that just one bad lift, one stupid mistake by me or the other driver, one bad genetic link in my family history, and I too, could be once again dependent on the taxpayers.
I often liken working in the ED to the Stanford Prison Experiment. It's really easy to develop biases, to become irked by certain "types", and to adopt certain attitudes as one adopts the role of ED Nurse. I'm no angel. My absolute least favorite patients are the ones with Borderline Personality Disorder. They irritate the living bejeezus out of me with all the manipulation and drama. I have to remind myself that BPD is an illness brought on by emotional trauma and lack of nurturing in childhood, and the behaviors are symptoms of the illness. I work to remain aware of my bias and temper it with objectivity.
And yes, if they really need a taxi voucher, I'll get them a stinkin taxi voucher whether I like them or not.
Sorry about the novel!
My secret? Per diem status.
I don't have to provide health insurance for a family, and I rent out my house so my mortgage gets paid. I love the freedom of not having a regular FT work schedule! If I don't want to work, I don't work. I have to work enough to pay the few bills I have and to be able to go out to dinner, see concerts or plays, and travel, but I'm not tied in to a regular schedule. I don't have to ask for vacation time. I just tell my employer I'm not available. It's the best kept secret in nursing, IMO.
I recently took a new job where I was just amazed by the teamwork displayed by the entire staff. I was just in awe. But now, the honeymoon is over. I'm starting to see the chinks in the armor. Like Neo in "The Matrix", catching glimpses of the true reality, I am beginning to "wake up".
Don't get me wrong- the teamwork really is outstanding. Nobody ever utters the words "That's not my patient.", or when a physician asks who is taking care of Patient X, we might respond "Joe has been, but what can I help you with?". If there are orders to be transcribed, IVs to be started, meds to be given, EKG/Radiology/CT techs to be paged, whoever is not doing something at the moment just does it. Well, mostly.....
I work with one particular nurse who has....habits, shall we say...that I struggle with. It has made me see the value of zone nursing, where each nurse is assigned a set of rooms, or primary nursing, where each nurse has a set of patients, and those are their patients that they are responsible for. This is the background I come from, where I cut my teeth in ED nursing, and I have really enjoyed the team nursing approach in comparison. But, I've been seeing the value in zone or primary nursing lately.
What are these habits, you may ask?
Well, disappearing for one. Not just for a few minutes to go to the bathroom or something, but anywhere from 15 to 30 minutes, where I do not know where my partner in nursing is. I tell my partners where I'm going, even if I'm just going to the bathroom. That way they know, if something happens and they need me, where I am. Not this nurse. This nurse seems to feel it's okay to be gone without saying anything. To be fair, sometimes this nurse does tell me where they're going- for instance they will clock in and then tell me they need to go deliver a book they're lending to another nurse over in OB- and of course they're gone for no less than 30 minutes.
Another thing is cherry picking. This is where the other nurse picks the patients they really want, sometimes even taking a patient right out from under me, and is conveniently busy when patients they don't want show up, leaving the other nurses to take them. This nurse tends to cherry pick the traumas and critically ill one on one patients, leaving the other nurses to manage the rest of the department.
Lastly, the "going the extra mile" thing. This is where the nurse will spend a good 30 to 45 minutes on the phone with a patient that was seen in our ED last week but still has some questions. This wonderful, caring nurse will spend as much time on the phone with the poor hapless soul as it takes to solve all their problems, while we're getting hammered with real patients who need real care in our ED right now.
I won't mention the personal phone calls. Oh, well I guess I just did.
So, what is my plan to address this, you may ask? Well, I considered talking to my supervisor. But this nurse has been around for a long time and has pretty close bonds with my supervisor. I don't want to have to watch my back. I was happy when I found this job and thought those days were over, and I want to maintain that illusion as long as possible.
So then I thought maybe whenever I work with this nurse, I'll just take care of my own patients and spend as much time in my patients' rooms as possible, sticking to a more primary or zone nursing model. But, this can be really inefficient, and not helpful to the patients.
Ah, I know what I must do. I must address these habits as they happen in the moment. I have to actually communicate with this other nurse about these habits. I'm not sure exactly how to do this- interpersonal communication is not my strong point, especially where conflict might be involved. It's something I work on regularly. Maybe that's what I'm supposed to gain from all of this- more practice in this area of weakness of mine. It's not really what I want. I'd rather practice difficult IV starts or hone my respiratory assessment skills.
Sometimes, however, getting outside of one's comfort zone, outside of that bubble of safety, is how we grow....and so, I will look at this as another one of those unsolicited opportunities for growth.
And maybe, just maybe, the teamwork will be enhanced as a result.
Also I think there is a difference between cataloguing (as in, do you have any dentures, hearing aids, or eye glasses, etc.) and searching, as in checking for any weapons or substances of abuse. Cataloguing belongings is important because it creates a paper trail so that if something is lost or missing, you know where it was last seen. Searching is important if there are questions of safety, but again, we are not law enforcement and searching someone's belongings should only be done with good reason.
Once, I was asked by a patient to check in his bag to see if his wallet was there, since his health insurance card was in his wallet. In the process I found a small amount of marijuana for personal use. He became visibly worried, and I just reassured him that I am not the cops and it's none of my business and continued looking for the wallet.
The plural of "deer" is "deer", unless you are referring to different species of deers.
In general, deer are not aggressive and avoid humans. When it comes to personal safety, deer would be extremely low on my list of potential threats.
Walking is good exercise. I'd suggest a flashlight and some good walking shoes.
who should take it, the day shift or night shift nurse? im curious about all your opinions. i think it could go either way. where i work, nurses work 6:45 am to 6:45 pm, and then 6:45 pm to 6:45 am. if a pt comes at 6:30, who do you think should do the entire admission? because if day shift takes it, they end up staying WAY past their time. and if night shift takes it, they get piled with work before they even stepped in the door. what do you think is the right thing?
159?? Fasting glucose? That is high for a fasting glucose.
1. What does the orders say? If the physician orders state to give 2 units for 159 you should give it. YOU ARE CORRECT! Sliding scales are designed to treat hypoglycemia despite diet. Sliding scales are not to treat for future food intake. It is to bring a person BG back to a normal range. ITs FOR CORRECTION. We will never know how much a person will eat!
Think of it like this. Say normal fasting BG range is from 70- 110. Anything above 150 is abnormal. THAT'S A MINIMUM 40 POINT BUFFER RANGE! (150-110=40) 2 units of insulin given at 110 or less may cause hypoglycemia. With that being said, your preceptor and charge nurse are implying that 2 units will make someone with 159 BG hypoglycemic? That means they will drop more than 89 pts to get below 70 (159-70=89). Also many ppl are not symptomatic until their BG level is about 50 (average). My fasting BG was 59 when my PCP checked me. (I was NPO for cholesterol studies) I was hungry and had hunger pains but I was driving, walking conversing just fine. So considering that, it's no way 2 units of regular insulin with drop a BG by 100 pts to cause symptoms where you would have to return and treat.
I've work in an CVICU for 6+yrs. We use sliding scales for diabetics and non diabetics who are having stress hyperglycemia. We give 2 units if they are 150-170. I've never seen anyone get hypoglycemic getting 2 units when starting out >150. NEVER.
2. Why do we treat hyperglycemia? It places them at higher risk for infection in addition to increasing the risk of damage to blood vessels end organs. Maybe you should provide some research to your preceptor and charge nurse about treating stress hyperglycemia and the use of sliding scales. Furthermore they are telling you to go against physician orders based off of ignorance and fears. So the patient suffers from hyperglycemia because of it.
Did the physician orders state, "Hold if pt has no appetite"? If they want you to hold it, you should have the preceptor/charge nurse call the physician to obtain and order to not give the medication to cover yourself. They have to have a better reason to go against a physician order than a low appetite. That's for holding ANY MEDICATION. Any nurse who feels the need to hold should call the physician and clarify the order or get orders to hold.
Let me first preface by stating that I do not work corrections, but I do receive inmates on occasion in the Emergency Department.
I would think about the harm that could come from making the wrong assumption. If you determine that the patient is lying, and it turns out they really *are* having an MI, they could die.
If you determine that the patient is being truthful, you follow protocol, send them to the ED to r/o MI, and the workup turns out negative, what is the harm that can come from this? None, that I can see.
My advice is to follow your facility's protocol to the letter, and leave the question of whether the person is lying or not out of it.
Health doesn't have to be that impaired for a prescription. My Dr told me if it were legal in our state she'd rx it for me due to my stress induced anorexia as well as dull but constant back pain.... there are many other cases where it could be helpful that are not a contraindication to working.
It's called "Hospital Induced Paralysis". Onset is sudden, and coincides with crossing the hospital threshold. It's not limited to the patient, either. Often, any family members within the vicinity also contract this condition.
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