kmoonshine

Try reading through this case presentation (I found it interesting): http://www.flightweb.com/forums/index.php?showtopic=618&hl=takotsubo&st=0

There is a topical cream with lidocaine that works wonders, but as other have said, it takes quite a long time to work (I put the cream on thick over the potential IV site and cover the cream with a transparent dressing; I then put a warm compress over the site to increase absorption...but even with this it can take more than 20 minutes to get the site nice and numb). I use this topical cream for pediatric patients when I anticipate that they'll need an IV. I have never used lidocaine injections to numb an IV site, but I hear that it can burn (as others have stated, you can mix it with bicarb to lessen the discomfort). When you inject the lidocaine into the skin above the IV site it forms a bump called a welt, which can make it harder to see the vein when you are ready to start the IV. A nurse that knows what they are doing and who can start an IV quickly tends to cause very little pain. I avoid starting an IV in the patient's hand since it tends to be more painful.

I've never heard or seen this practice. I would think that it would cause more discomfort by increasing leakage into subcutaneous tissue (but that's just my opinion). I use an infant heel warmer to increase absorption of some meds, such as morphine or valium (they're those little packs that you squeeze to activate the warming gel and they cool off pretty quickly). I don't use them for vaccine injections. I'm interested in seeing what others have to say about this.

Try relating it to something that the patient understands. Perhaps say something like "TSH levels go up because the pituitary gland is sending out more horomone to get the thyroid gland to respond. Kinda like trying to call someone by phone but they don't answer - so you continue to call again and again until someone picks up the phone. Basically, the pituitary gland is trying to get an answer from the thyroid gland, so it continues to try to "call" by sending out more TSH."

I can't say much for policies...but, you need to beef up the security to protect staff and other patients. Discuss the use of panic buttons in all rooms, having a locked unit, and implementing a 2-visitor/patient rule (visitors must check in at triage and must wear a pass before they are allowed to go through locked doors to the main ED area; obviously this rule can be modified, especially if there's a PNB or critical patient). Discuss the importance of documenting exactly what the patient says (ie "I'm going to come back and kill you all"). On patients who are a threat to themselves or others, we have security 1:1 with them and all belongings are removed and they are searched with a metal detector.

I give metoprolol 5mg IV push over 5 minutes and I wait around 2 minutes before administering another dose.

We have 4, 8, 10, and 12 hr shifts in our ED. I've seen people pull 16+ hrs before. Personally, I think 12-hr shifts would be safe if staff were given a decent lunch break (at least 30 minutes) and at least two 15-min breaks to step away from pt care. We rarely get breaks in the ED. I just finished a 12-hr day with a 10-minute "break" to grab a bite to eat; didn't even use the bathroom during my shift. I had 4-6 pts during my whole shift, most of who were admitted. At times, I am exhausted; but yet, another ambu is coming in 5 minutes so you gotta find the energy to make it through the night. There needs to be mandated breaks for people providing pt care - you NEED to have a chance to sit down and eat a little something, especially when you are making patient-care decisions that may have disasterous outcomes. Hospitals will push you right until the edge - and things should not be this way. How can you care for someone if your employer won't even allow you to take care of yourself at work?

Here's some info: http://doctors.shorehealth.org/nursing/iv/DECLOT%20ACCESS%20DEVICE-3-WAY.pdf Obviously, follow the P&P at the facility you work at.

From the moment you punch in to the moment you punch out - you are working (hence, getting paid). Ms. Ramona needs to punch out when she is done doing her share of work (if she wants to sit in the break room at 2310 until the end of her shift at 2330, then she should punch out at 2310 if there is work to do and she doesn't want to do it). However, she won't do this because it's a red flag for management (where I work, we get "talked to" if we punch out 5 minutes before the end of shift). Usually I am stuck working past the end of my shift, but today was the exception; I was caught up and report was given by 1510. So, did I sit in the break room? Nope! I made sure all my vitals were up-to-date; my shift relief just got a new pt so I popped my head into the room to see if he needed any help. Then, I asked my fellow first-shift co-workers "what can I help you out with?" After all was said and done, I punched out at 1528 (yay, I finally got out on time today)! Try to delegate some things to keep her busy until the end of her shift, assuming you need the help getting caught up and familiarized with the pts. If she says no, I'd address this with someone who could mediate the situation. There's a reason for shift-overlap: to give report and work together to meet the pts needs. Its nice to have an extra set of hands to get caught up and wind-down at the end of a shift. Sure, it would be nice to fly through report and give the bare minimum so I could get out early - but its not safe for the pts and its not fair for the next nurse taking my report. So, lets work together, get familiarized with the pts and what is ordered, ask questions that arise during the 30 minutes of shift-overlap, and help each other out so we're not constantly working to catch up! IMHO, Ramona is stealing from the hospital and is cheating the pts and nurses who take her report. Dont let it continue... There's a difference between punching out at 2310 one time, "because I stayed late to cover since we were short second shift, and I gotta leave and pick up my daughter"; its a whole other story to give a crappy report and sit in the break room for the remainder of the shift, still punched in on the clock.

Before I access a PICC, I ask the pt why they have a PICC in the first place. If they can tell me why they have it and what is capped in the line, then I will access it (however, I am hesitant to access PICC lines if it's used for chemo, since it is necessary for medication treatment and accessing their PICC puts them at increased risk of infection). But if the pt has no clue about their PICC or what solution is used to cap it, then I hesitate to access the line. I had a CHF pt come to the ED who could not tell me why he had a PICC line; "so they could give me medication, cause my veins are bad". And as I look down, I could see veins that could take an 18g anyday. I ask "what medication?"; he responded "I dunno." (I looked it up on the computer - and he's on natrecor for CHF). I asked him "do they put medicine in the PICC when they are finished with it, so it doesn't clot off?"; he says "I don't know." The caps of his PICC were covered in adhesive; the dressing was not transparent and was basically tape wound around his upper arm. I initially called lab to draw peripheral labs, but the charge nurse stepped in stating "we access all PICC lines - you must access his PICC." I don't like touching a PICC in the ED if the pt can't give me a good history on why they have it. I think it is a pt's responsibility to know a little SOMETHING about the tube hanging out of their arm; and I don't feel that it is best to access a device which has an unknown purpose (kinda like jumping without looking). Obviously, in an emergency situation (ie code), the rules change; but if someone comes in with no knowledge of their PICC, then I hesitate to access it. Now, if someone has a PICC because they have sickle cell and they come to the ED because they are having a sickle cell crisis, by all means I will access it. I use a chloroprep to cleanse the cap (I usually just change it out and give them a nice fresh cap), I use a 10mL syringe and draw off 8-10mL for discard (or use it for cultures, if indicated), then I draw labs using a 10-20mL syringe, and then I flush well with 10-20mL saline (using push/pulse technique) and hook their PICC up to normal saline on a pump at 75mL/hr during their ED stay to keep it open for meds and fluid administration. If I can't draw blood off their PICC line, I ask them to raise their arm up, lean forward, cough, turn on their side, etc. This may or may not work. I am amazed at how many people come to the ED with PICC lines, who cannot tell me why they have it. Seriously...

The cost of emergency services is high due to the need to staff 24/7 (lab, nurses, docs, radiology, etc). UA and preg, with CBC/BMP, RH, serum Hcg; abd. ultrasound to rule out ectopic - all finished in 3 hrs isn't too bad. I've delegeted things before to ED techs because I can't get into a pts room right away ("Beth, can you start a line in room 14 and draw labs for me?"). Its better than making a pt wait longer than they have to. Personally, I like to start all my IV's but when I'm strapped with resources and time, I need to prioritize (ie level 2 chest pain, level 2 overdose, level 1 SOB, level 2 head injury - so I definately need to delegate because I can't be everywhere at once). Coupled with people who don't pay their bills, and state-funded programs that pay pennies on the dollar - the cost gets passed on to people who have private insurance and who pay their bills.

Just a thought: would these new "rules and regulations" be applied to our president, senators, congressmen/congresswomen etc? I doubt it. We (the American people) should receive the same quality of health care as our elected officials. Afterall, we put them in office... As far as futile treatment - yes, we need to rethink this and focus on future "prevention" rather than fixing problems as they arise (ie HTN, kidney failure, etc). In my opinion, non-compliant pts are not entitled to treatment and should pay out-of-pocket should they continue their health-destructive ways (ie non-compliant diabetic eating cake and drinking beer prior to drs appt with blood sugars running well over 300 and on dialysis and natrecor infusions for chf; etc). We also need to re-examine the amount of money medicare pays out for ICU care at the end-of-life, and "futile" treatments. It would be better for the pt to receive hospice and to die with dignity rather than to undergo aggressive and painful treatments with no hope of recovery only to die in ICU on a vent with skin breakdown. We do have amazing medical treatments, but they should be used under appropriate circumstances. Its difficult for a young person to receive quality preventitive care, and its even harder to receive specialized care for a young adult. However, as we get older there seems to be an army of specialists ready and willing to write prescriptions for pills and perform surgeries when there is little chance of full recovery. So, as our children lack basic health care and our young adults forgo basic physicals due to lack of finances, grandma who is 89 yrs old is getting prepped for a CABG and can barely consent due to her progressing dementia...

I don't give back rubs in the ED - sorry! When I was nursing student on a med-surg floor, I had a 28 yo post-op hyst pt in severe pain. She looked very uncomfortable, was on Dilaudid PCA (which should have been increased by the primary RN per MD orders, IMO; I couldn't mess with the PCA pump as a student). I dimmed the lights, got some warm washcloths, pulled up a chair at the pts bedside, and I gave the lady a hand massage with the warmed towels. It seemed to help her anxiety and help her relax a bit - it was the least I could do, as I had little control over anything else. I did this 3-4 yrs ago and haven't had the need to do anything similar in the ED setting. I'd be afraid of being accused of "inappropriate touching", or "exaccerbating" someone's chronic back condition (I can just hear it now; "that nurse was rubbing my back and she pulled one of my back muscles - and now my back is killing me"). I am not trained in massage therapy and therefore, I do not provide that service. However, I am trained to administer meds so here's some valium and dilaudid!

:smiley_abNope, no fight-picking here! I totally see where you are coming from, as it seems silly for me to be upset because I want to go home but the floor nurse won't take report, since she is going home too. However, I went out of my way to do as much as possible for the pt so the floor wouldn't have to worry about feeding the pt, toileting him, doing his med rec, medicating his pain, changing soiled linens, etc. We have a "float" nurse who even did ALL the admission paperwork for the pt too. My charting is very thorough and organized, and I make a point to highlight all the meds I give in my copy of the chart that goes to the floor (no one else does this). This pt was very stable, received only meclizine po and his BP med (norvasc, I think) po during his ED stay. We waited quite some time to get a bed. I just wanted to give report so the pt could go to a room, as the ED beds are very uncomfortable. Additionally, the nurse relieving me already had his hands tied with new pts, plus an ambu coming in (and so calling report was the least of his priorities, and thus the pt would continue to wait in the ED). The ED charge nurse was upset because the floor wouldn't take report (which has become a big problem lately and is being tracked; the floor isn't supposed to refuse report due to change of shift per hospital policy). The pt wouldn't have gone up to a room until at least 1545 - enough time for second shift to start. There actually wasn't much report go give (labs & radiology all WNL). The pt was old and being kept overnight for observation; I was irked that I couldn't give report because there wasn't much to give! The pt would probably be the easiest pt that the floor nurse would have all night. I was just trying to make life easier for my shift relief and make the pt more comfortable. We've been slammed in the ED lately, and I wanted to to all I could for the next shift (both in the ED and on the floor). Our ED census has been up and our staffing has been cut as well, so its a struggle to maintain flow in the ED when we're holding floor admits with assigned beds because floor won't take report; meanwhile, there's pts on stretchers in the hallway and the charge nurse is trying to figure out why it took over 90 minutes to get a bed assigned - and now that a bed is assigned, why can't report be called since this pt is tying up one of our major trauma rooms? If the nurse can't care for the pt at that time, then I'd rather not have the house supervisor assign a bed. We had put a bed in and the house supervisor assigned a bed 90+ minutes later (which is approved by the assigned floor's charge nurse - so according to them, "we can now take the pt"). Sorry, just had to vent...

BTW: In the past 6 months I havent had a pt in the ED go for PICC placement. The other pt I spoke of (vomiting, needing antiemetics and IV fluids) was being taken care of by another nurse and is the only pt that I've seen go for PICC placement in the past 6 months during my work shifts. Most of the nurses I work with are pretty skilled at IV access and we'll try to get at least something until a more reliable line can get placed. For example, we had a pt come to the ED for "seizures" by ambulance, and the pt had a witnessed seizure while in the ED. She had NO veins, and 4 other nurses had tried to get a line. I was the 5th nurse to attempt IV access and after 2 tries, I got a 24g in her upper forearm. Not ideal, by any means; but it was patent and worked just fine. We'd be able to use it to give ativan (or something similar) should the pt seize again, but I told the primary nurse "I woudn't give fosphenytoin through it". It was a temporary fix until something more permanent could be placed - the pt would probably need a PICC eventually, but not STAT. We don't have an IV team at our facility. Difficult IV sticks on the floor call the ED for help. I love putting IV's in and I'm glad that I've had experience with hard sticks on a regular basis (I used to work at a facility where pts with ESRD on dialysis would come to the ED daily, or sickle-cell pts that had little veins left, etc). I love the challenge of putting in IV's!!! The only time I struggle with IV access is in peds pts; but for the most part, we (nurses) are self-sufficient with IV access in our ED.