GermPhobe

I have a patient who has been 100% afebrile during the day. At HS he says he's chilled (but has no temp). So I bring him a warm blanket, which he hides under. Several hours later, he has a 102-103 degree temp. He's done this two nights in a row. Normally, I wouldn't question this--but this particular patient has a long, sordid history (including MANY years in a federal prison). I really wonder if he's learned some tricks to make it appear that he's sicker than he is. Or am I just paranoid????????

I used to lose my "brain" (report sheet) constantly, until I started carrying a clip-board. Everyone else just folded up their sheets and stuffed them in their pockets, but it just didn't work for me. I also lost my pen constantly, until I made a rubber-band tether and attached the darn thing to the clip board!! I also made my own, customized brain. I'm good at word-processing software, so I created a table in which to write virtually everything I need to know about each patient. I have 4-patient assignments, so my sheet has four separate tables. At the bottom of each patient's table is a time-line. I make sure to SCHEDULE EVERYTHING at the beginning of my shift, write it on the timeline, and cross it off as I go along. I often use a highlighter for important tasks. And make sure you DELEGATE anything you can. I used to try to be friends with my techs. It's much more important to have their respect than their friendship. Make sure they're working as hard as you are!

Thank you again! I knew that the end of the tube was in the pleural space (and even the anatomy of the pleural space), but I just wasn't getting the fact that the visceral pleura was damaged--allowing leakage from the LUNGS into the tube. DUH! I feel so dense. Thank you for enlightening me. This has been bugging me for quite some time, and I've never gotten a satisfactory answer from any of the nurses on my floor.

Thank you, Dinith. I like the milkshake analogy. I guess I should have asked where the most likely place for an air leak would be. The cases I remember where docs were really upset about leaks were thoracotomies. In this case, the pleurevac would be draining blood from the pleural space, right? And a leak would probably be due to the "straw" not being dipped deep enough into the "milkshake," right? I guess what throws me is that I don't picture "free air" in the body. I was wondering where the pleurevace was drawing the air from. Am I still way off base?

Yes, he had a known murmur. But, being a new nurse, I'd only heard very quiet murmurs. HOLY COW that one was loud--and sounded like the bruit that was diagnosed on another patient I'd dealt with. Putting two and two together, I concluded this murmur must be "more" than just a murmur. Perhaps I should put the math book away, LOL.

A bit too basic, LOL. I know the physiological difference between the two--but I'm wondering how they sound different. In one case, the "murmur" was so loud it could be heard while I was auscultating bowel sounds! Of course it was INCREDIBLY loud over the heart. But it was NOT a softening of lub-dub. It was simply a very LOUD, pulsatile "hmm, hmm, hmm." I was thinking it could be an aortic aneurysm? How LOUD can a murmur get?

When you've got bubbling going on in a Pluerevac, WHERE exactly might the leak be? Some people have said it's at the dressing site, but this doesn't make sense to me. The open end of the tube is in the pleural space, right? If the Pleurevac is emptying blood from the pleural space, and air is entering the system, where is it coming from??? Forever confused, GermPhobe

Can someone explain the difference in sound between a murmur and a bruit? I've had two patients recently who I thought had bruits. But other nurses had charted murmurs. I thought a murmur was a kind of "soft" heart sound--a blurring of the "lub" and "dub." The two patients in question a had distinct, high-pitched, rhythmic "hmmm, hummm, hummm." So what was I hearing???? THANKS!

A friend told me a good way to remember which test is for which anticoagulant therapy: the correct test/therapy combo adds up to 10 letters PTT (3) + heparin (7) = 10 PT (2) + coumadin (or warfarin) (8) = 10 It's impossible to get it mixed up now!

Take your time. Listen for lung sounds first, since they often obscure heart tones. Then listen "under" the lung sounds, and you'll hear the heart. I used to think patients knew I was incompetent when I did things slowly. I now know that they appreciate my "thoroughness."

Well, I'm not a NE, but I am a new nurse. I'm also over 40 years old, with a large and varied resume behind me. Here's what I can tell you. I have NEVER felt so ill-prepared for a job as I did when I graduated with my BSN and finished my 3-month orientation on a cardiovascular surgical step-down unit. My orientation was USELESS. All I did was follow another nurse around. There was no rhyme or reason, and no organization to the orientation process. In my case, I had done my leadership/management in critical care. So I had NO experience caring for multiple patients. I never even SAW an admission or a discharge. That was a huge part of the learning curve for me. Believe it or not, I also graduated from nursing school without ever being taught how to look at a chart, where orders came from, what the unit secretary's function was, or what the charge nurse function was. AND none of this was covered in orientation, either. My orientation focused on things like "this is where we keep the meds." As I like to say, I got "all trees and no forest." What I really needed was the BIG PICTURE. There was so much to learn, and no EMPHASIS on anything. Somebody needed to put things in persective, and to have some checks in place to make sure I was aware of all the IMPORTANT things. A friend of mine started at a different hospital. She spent the first entire day with the charge nurse; the second entire day with the secretary. I think that experience would have been invaluable. When you work TOGETHER with other people, it's important to understand THEIR jobs, and how YOUR job influences, and is influenced by others. Another thing that would have been invaluable would be to follow a patient from admission to (in my case) surgery, and then up to the floor. I think the RN should understand the PROCESSES involved in patient care. And she should be able to understand things from the patient's perspective. When I was done with orientation I "didn't even know what I didn't know." I really wish the NE had known for me!!

That's what I was thinking. Poor man. He had some major abrasions on his upper arms, but was treated and released. The newspaper said his wife was a passenger on the motorcycle, and that the man had "lost control" of the bike. My thought was that the wife flew off the bike first, at high speed, and that he was able to regain some contol before stopping and coming to her aid. Please forgive my insistence on this part of the question. But it's something I need to know. What I witnessed was rather wet and formless. I wonder if brain tissue would have been more solid. I'm sorry this is so graphic, but I really would like to be certain what I'm seeing if, God forbid, something like this ever happens again.

Agreed and understood. But I also understood from the other RN that the patient WAS breathing and pulsatile. I still think I probably should have done my own assessment, though.

On the way into work on Sunday, I came upon an accident scene before the paramedics arrived. I'm a new RN, with less than a year of experience (no trauma experience), and I'm still a bit shaken by the whole thing. A woman had been thrown from a motorcycle, and was lying face-down on the pavement. She was unconscious, had a compound fracture of the femur, blood coming from her mouth and nose (helmet was intact), and her spine was twisted in such a manner to indicate that a spinal cord injury was likely. There was also some tan matter coming from either the mouth or nose. My first thought was OMG, that's brain tissue. But now I wonder if it was just vomit. There was another RN on the scene (we were just a couple blocks from the hospital). She supposedly worked in ER. She claimed the victim had a pulse and respirations, and was phoning into work to tell them she'd be late, and that the victim would be arriving soon. She told me they were not going to move the victim, due to the potential SCI. The victim's husband was holding pressure on the leg wound. I only had a minute or so before the paramedics arrived, but it felt like an eternity. The woman looked dead. The only thing I did was offer to hold pressure for the husband, who was trembling almost uncontrollably (he rufused). I felt the victim's rib cage for respirations, and felt none. I read in the newspaper on Monday that the woman died "of her injuries" at the hospital. I keep wondering if I should/could have done more. The other RN acted confident, but she wasn't doing anything for the patient. I wonder if she knew the patient was hopeless or dead, and just didn't want to traumatize the husband by performing CPR in the field. I have so many questions. I feel like I was completely useless, and I never want to feel that way again. I don't know who else to ask these questions, so I'm hoping those of you with trauma experience can help: * Did the other RN recognize this as a hopeless case? If so, Is it ever appropriate to do nothing? * Should I have reassessed the patient myself? I'm thinking that even if the victim had a pulse when initially assessed, in such a horrific trauma, she could have arrested at any time. * In general, is an unconscious/unresponsive patient more likely to have a pulse/respirations? Or more likely not to? * Is it likely that was brain tissue? (Not to be gruesome, but what would I expect brain tissue to look like? I've only ever seen it "preserved.") * If it was brain tissue, is there any point in resuscitation efforts? * Should I have remained on the scene after the paramedics arrived? If so, what would my role have been? My first task on Monday was to put together a kit to keep in my car, in case this type of thing ever happens again. I want to be as prepared as possible, so please tell me what I should keep in the car. So far, I have a small backpack with: CPR mask, stethoscope, tourniquet, disposable gloves, ABD pads, and VetWrap (had it in the barn!). I'm thinking I should have some Emergency notecards, too, with instructions for care. Thanks for listening. I really need to talk this out.

I'm trying to do my taxes, and I can deduct the cost of licensure and NCLEX, but I can't remember how much I paid. Does anybody know?? THANKS!