outlierrn

One new question that's come up is how people enter surgical history? In Medhost, it's bundled in the triage history group that includes allergies, current meds, and medical history, but it seems to be buried in the bedside nurses assessment in Firstnet, as far as I can tell. I've brought this up to my manager and the chief doc, but don't have an answer yet, so, how are people doing it elsewhere? thanks,

Ah thanks for this (and everyone else), I'll have to talk to my informatics nurse and see about this.

So, after 10 years with Medhost, we're finally going to Firstnet at my hospital. We've had Cerner power chart on the floor for awhile, but I've never really gotten the hang of it, so I come to you for your: Tips Tricks and Shortcuts Thanks in advance.

It was not my intention to be rude or condescending.

I had a 44 y/o guy come in full CPR in progress. We never got him back, but the story we got from the family was that he had started a new job about a week ago, and c/o of vague shoulder pain since he began (left, of course). If he had presented to me in triage and said 'I hurt my shoulder on my new job last week, I might have not taken it too seriously. Depending on which doc got him they might not have either.Enthused rn, this stuff happens, it will probably happen to you. You may want to spend some time thinking about how you're going to handle a child's death, a stupid accident, the patient you could save, not how I'm going to stop it from happening, but how I'm going to live with not having stopped it.

Paraphrased for simplicity: Pt. I think I have a kidney stone. Me. Describe your pain. Pt. Vague, diffuse, mild. Me. ?? Have you ever had a kidney stone before? Pt. No. Me. What makes you think you have one now? Pt. I have a diagnosed staph infection in my ear, and I read on the internet that staph infections can cause kidney stones. Me. (to myself) If your ear infection caused a kidney stone, you must have a Eustation tube longer than my..., well, it'd be pretty long.

It's usually institution specific, since, with the exception of what's covered by yout ACLS card, the medical staff has to sign off on any standing orders done by RNs. Where I work I can do accuchecks, 12 lead ekg, initiate o2, ua/ucg, and plain films. Although I limit myself to extremities and shoulder/clavicles without checking in. Anything else, I would turf to the bedside nurse.

Rather than saying think on your feet I would say reprioritize on your feet. You were going to clean that pt up before admitting then? Well not now, there's a multiple casualty inbound. Your pt was a stable abd complaint? Not now, the wife tells you she hears him stepping out of the room to use his nitro spray (the one he didn't tell you about). You were cleaning up the shallow hesitation 'cuts' on the drama-teens wrist? Not now, you're pulling the drug of choice for TCA overdose when her ingestion declares itself. You were going to resume chest compressions on the gas station attendant you just defibrillated? Not now, he had enough petrol fumes trapped in his chest hair to ignite. You can keep a neutral face and say something that doesn't erode theraputic rapport when a man tells you he tried to unclog his wifes nephrostomy tube with a piece of wire, 'but it didn't work.' Those are all true stories BTW, I love this job You're a little bit ADD, you understand that ICU nurses are a little bit OCD You're only half kidding when you say it isn't a good day unless you have blood on one shoe and vomit on the other.

I've worked PICU, general peds floor, and peds ER, sometimes with other guys sometimes not. If that's something you're interested in there is no reason not to for try it. Now I work in general ER, but it's a rare week when a parent doesn't compliment me for finessing their kid through a potentially traumatic experience.

10 years in, never looked back. Some days suck, but's that's true of every job I ever had.

I agree that C is the correct answer. It's poorly worded so as not to lead you to the right answer. Look at it this way; what's the worse case scenario? Compartment syndrome. If so then A actively harms you pt, B&D delay care for no gain, that leaves you with the only answer that addresses the potential emergent situation. Sure IRL you get a full assesment, but it's not an option, there's only one option that prevents harm to your pt.

When I worked peds ER we had lots of kids with ortho pain come in. We often gave subQ morphine, got the films, decided if they needed an IV and proceeded with definitive care. Now I work adult ER and find the docs resistent to this; usually I hear that we should only stick them once. Well, if you figure that it might take 3 tries to get a line on a wrestling kid with an unstabilized fracture or a kid that won't need a line in the long run all the while delaying the X-ray, I miss the old way. I'm wondering if anyone else has had this experience and if you can direct me to any research supporting or criticizing subQ morphine for acute pain in peds. All I can find is research for subQ infusions for oncology pts, which is cool, but not useful for me, thanks Larry

Lots of variation obviously, I've pushed brevitol and propofol before, and for some strange reason out facility doesn't require wasting ketamine, brevitol yes, go figure.

Back in one of my other lives I observed that you could ask two farmers about the best way to cultivate tomatos, get two diametrically opposed answers, get reasonable, rational explanations for each, and damned if you could tell them apart come harvest. Try not to let it nut you up.

I given it a number of times for procedural sedation (we don't call it conscious anymore, go figure). Usu for peds, IM or IV, sometimes with an atropine chaser. I'm an ASRN in California with plenty of experience in ER. We don't consider it a big deal, routine sedation precautions of course.

Lets see, Pressure on the bleeders is fine, be careful about making injuries worse. Can't remember the last time I saw a pair of MAST trouser let alone used them. You're right about the abbreviations. I can't believe no one, myself included, mentioned oxygen. Even if your pt's o2 sats are good and they're not dyspneac; you want every single red cell you have left carrying o2 Larry

Good question, Allow me to suggest calling the ER nurse if they're still on to see if this happened there. I take questions from floor nurses all the time. Sometimes the ER doc wrote holding orders that we can clarify, sometimes I tell them they have to call the admitting for that. If the pt has a history of this ectopy you SHOULD have gotten this in report, but it's worth checking before you make the call. Let me add that in addition to checking your most recent labs and ekg, you should check to see when they're next due, I would expect to be supported if I got my routine am labs at 2-3:00 so I had the results when I called.

hypovolemic shock is a question of degrees, B/P and C/O are maintained in compensated shock by tachycardia and peripheral vasoconstriction, when these mechanisms fail, B/P and C/O fall as uncompesated shock begins, a very slippery slope, best avoided. Volume replacement is the treatment, I would not hesitate to give isotonic saline while I wait for blood products to arrive. Hypertonic fluids are only used in special cases such as hyponatremic or head trauma induced cerebral edema, Larry

you boast about starting an IV on a pt that hasn't had a pulse for 20 min.

Although it varies from place to place, the exact meaning varies most importantly from CASE to CASE. Understand that ALL of your pts are going to die, allowing them to pass easily is not killing them. Facilitating a comfortable, peacefull experience for the pt and their family is as real as nursing gets, good luck to you, Larry

In my ER we have a dedicated peds crash cart, each drawer is a different color and corresponds to a color on the Braslow tape. Within each drawer are the supplies that are right size for that pt. We have several cheat sheets, peds micro blood tubes, and sealed intubation and drug trays. Try and eliminate every step possible from the actual code, your brain just won't work right unless you get lots of practice, Larry

Depends on where you work. When I was in PICU I liked it, it was very helpful in keeping 30 doses per shift organized. OTOH, in the ER it would suck, things are changing too rapidly, Larry

you absolutely did the right thing for the pt, virtually everybody is grumpy at 3 in the morning. But I would have asked my charge nurse to come in and confirm my obsevations to the on call doc who came in. Better to convince him now in case the pt does it again, and establish your credibility, same the with the conversation you overheard, get in there and refer him to "experienced nurse." Larry

I have done a lot of central line draws but have never heard of mixing it with heparin before replacing it. I would draw at least 5ml for a CBC, 10 ml for chemistry or coags if the line had heparin or TPN in it. Your hospital should have a written policy, but I know they often don't address 7 m/o, so I would contact the primary MD who handles the deep line and TPN orders for clarification Larry

I think Topher has it right on both problems, but I think the problems poorly worded. Never did like dimensional analysis, I always go with dose desired/dose on hand X volume on hand Larry