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HermioneG BSN, RN

Emergency Nursing
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HermioneG has 1 years experience as a BSN, RN and specializes in Emergency Nursing.

HermioneG's Latest Activity

  1. HermioneG

    ER nurse to patient ratio

    I work in a level 1 trauma center and we work in both adult and peds. We have a 2:1 ratio in the trauma rooms and then 3:1 for the rest of the department. During very rare situations we have done 4:1 but that's typically if one is a hall patient waiting for transportation back to a SNF but is otherwise discharged, etc. Our leadership is very careful not to do 4:1 and our managers, educators, and even director have been known to come out to the floor and lend a hand when things get rough. It does happen, though, when we are really short staffed and I've noticed how much harder it is when I have had a true 4:1 list.
  2. HermioneG

    Tips to survive ER

    I've found that taking an initial two minutes to show empathy, kindness, and overall sweetness on initially meeting my patients goes a long way. Wrapping them in warm blankets, providing an extra blanket for a family member, tucking them in and fluffing up their pillow all while fussing over them and buttering them up takes very little time and I've noticed that it sets an excellent working relationship between myself and patient/family/etc. From my experience they're typically less demanding, kinder, and more understanding when I try extra hard to make a good first impression because the nurse is so "nice" and they see that you're working hard and the unit is busy. Whenever I'm caught up I will first make sure the nurses around me don't need help and then I will update my patients on what they are waiting for and the ER flow. I will also do a round to make sure that my patients and beds are clean, that their ice packs/warm packs are fresh, that their blankets aren't wadded up, that family doesn't need a glass of water etc then after that I will sit down and take a breather myself. Its helped me a lot when I've had a notoriously "difficult" patient or "frequent flyer" who has been known to give staff grief. I've only had one truly mean and frustrating patient and I've been working for 10 months now (knock on wood). Just be careful to set clear boundaries so you can still get your work done (ie barring a life or limb situation, I will help you after I am done with my other patient). Also always ask questions if you're not sure. ALWAYS. And tell the patients what you are doing and why. If your patient is crumping or you have a concern tell those around you so that no-one is caught off guard if/when things go south. Communication is key. Make sure you ALWAYS have 3 things when you walk into your room (1: suction, 2: O2 on the wall and in a tank under the gurney, 3: ambu bags at my facility every bed has adult peds and neonatal sizes). Aside from that, everything else just takes time. Ask the nurses around you for tips. Once I established great working relationships with the residents I've also sometimes even asked them which is most important or what they want first when I'm not sure (ie I only have one line and have X, Y, and Z infusions, X and Y are compatible, Z isn't, so while I'm working on a second line for this hard stick patient do you want X and Y, or Z running? Do you care?). I don't do it often, but when I do I've received nothing but "thank you for asking" followed up with recommendations. Edit: also be diligent in placing your patients into gowns. I've had multiple situations where I found something very concerning that the patient didn't mention while getting them into a gown. Know that clothes, home blankets, and even hospital blankets can hide some very important things if you're not careful and diligent on assessing your patient fully.
  3. HermioneG

    Getting urines quicker

    I bring it up immediately as I meet the patient. It goes something like this: "Hi, my name is HermioneG and I'm going to be your nurse today. What brought you into our ER today? (pt explains) Ok so I took a look at your chart and I see that we have done (A, B, C) already and are waiting for results for (X, Y, Z). Something important that you can do to help get results for the docs and answers for you faster, is to pee in this cup here." (hands patient urine cup and biohazard bag). "Now, I know you might not feel the urge to go, but lets at least try. The lab only needs a little bit." Then I will usually do a quick assessment and then we try for urine. Even if I don't have an active order yet, I still ask them to try since I've gotten to the point where I can start to anticipate when it will be ordered. Usually when I explain to the patient/parent/family that the quicker we get urine the quicker we can get results and expedite their stay they're able to provide urine quite quickly. I've personally found that when I get a hugeeeee delay with the urine often times the patient just didn't understand that I wanted it sooner rather than later and will wait for a completely full bladder to give the urine sample. I also find that unless I have a truly urgent or emergent situation going on its easier to help the patient get into a gown, get them in socks, help them get settled, and help them with getting set up to go pee early on (for non ambulatory pt) so that way I don't get the "NURSE I NEED A BEDPAN RIGHT NOW" routine when I'm swamped juggling a million things. Its not foolproof, but it at least helps a bit.
  4. HermioneG

    Medical Assistant vent

    My view on life is that you can learn something from every single person out there, and sometimes you learn from them how not to act. This person sounds insecure and seems to lack perspective. This is not your problem. Move on and don't let it rattle you up. I know it sounds cliche but they really aren't worth the stress.
  5. HermioneG

    Should nurses be able to listen to music at work?

    I usually don't mind it, but I did become very frustrated the other day with it. A dear coworker of mine who I love a lot was blasting (yes... blasting) music. It was difficult to concentrate, but most importantly it was so loud that you couldn't hear the alarms on the patient monitors. Consequently, patients were left to lay next to aggravating alarms for very long periods of time for something simple like a cardiac lead sticking to their gown rather than their chest. Not to mention, of course, how bad it would've been had it been a critical situation and we didn't hear the monitor alarm. I usually don't mind it, but it really bothers me if its presence decreases patient care. To me, it's unacceptable to let a patient lay there for hours on end next to a beeping machine.. and that is something I've seen before, music or not. It's unfair to the patient, and to others around them. It's also something that is such a simple fix, you just have to be diligent about it. Basically, if the nurse can hear the monitors and is on top of it then fine. But if it's presence means the nurse can't hear the monitors, or if the nurse is using it to tune out when their patient goes to CT and everything is blaring because the nurse doesn't want get up and put the monitor on standby, then yes it bothers me a lot.
  6. HermioneG

    Was I wrong?

    I just want to echo what everyone else said and say great job. If I or any of my loved ones was ever in pain or needed help, I would feel so fortunate if they had a nurse like you. And in our profession, I can't really think of any higher compliment. You were your patient's advocate and 100% did the right thing. I'm sure that your (YOUR.. NOT your coworker's) patient is very thankful for it, and don't let your coworker's reaction make you question yourself for even a second. PS maybe I'm a weirdo but I'm kind of worried about this nurse taking care of this patient again? I don't know how things work on in-patient units (I'm from ER) but can she get the doctor to d/c the PCA pump? Can we be certain the patient's pain will continue to be controlled once she reassumes responsibility? Is her bias against this patient going to cause her to let the patient suffer with inadequate pain control? Or is this patient covered now that the PCA pulp had been initiated?
  7. HermioneG

    Hypothetical situation, thoughts?

    Well, at least I can now be at ease knowing that if the OP ever comes across me and I'm in dire need of a needle decompression, they will hopefully remember to use the mid-hemithorax as opposed to mid-clavicular line for the needle decompression site to help mitigate the risk of iatrogenic bleeding and my subsequent death :) Kidding. I barely even understand what I just said But thats the point, isn't it? Its complicated. The point of referencing the detailed surgical procedures is to show exactly how risky and complicated it is. Its not just "poking a hole in the lung" its something that is serious, and should be done only by people with the right training (ie, definitely not me, and probably not the OP). This is also one of the many reasons why we have a scope of practice. Perhaps people who think its as simple as poking a hole in a person's lung need a good dose of detailed surgical info to hopefully wake them up, and help them understand how badly it could turn out if done improperly. People who underestimate stuff like this scare me, because you can really hurt someone. And its not just about this one particular off the wall scenario, its everything about providing medical care in general. If you're not trained in it or don't know how, then just don't do it! Stay in your scope (not you, dear Mavrick. I'm just piggy backing on what you're saying and throwing my opinion out to everyone in a general sense :) )
  8. HermioneG

    Hypothetical situation, thoughts?

    Also, here's a great article on the topic of needle decompression that I want to put here to really drive my point home. In these "what would you do" situations, its important to look at the big picture. Diagnosis can be complicated and the procedure can be difficult and come with risks. There are other supportive interventions that we can do that are within our scope. One study showed that only 60% of a sample of 25 emergency physicians were able to correctly identify the second intercostal space (which is where someone would do the needle decompression). At first thought one might say "oh, but if this patient was CLEARLY DYING to try is better than to not try." I don't necessarily agree with that because based on the situation we may have our adrenaline pumping and misunderstand just how bad the patient's status is. We also may be misunderstanding what we are seeing based on complicated co injuries and cause unintentional harm to the patient through our misunderstanding. We have to see it as the serious business that it is: "Rawlins et al.,[3] and Butler et al.,[2] described life-threatening injuries, including hemothoraces, that complicated the placement of NT. Management included postprocedural resuscitation and surgeries in two cases. However, surgery could not confirm which vascular structures were injured.[3] In another case,[2] a young woman who had a NT placement in the left anterior second intercostal space at midclavicular line was noted to have an immediate sanguineous output of >300 mL. She became hypotensive, requiring immediate fluid resuscitation. A portable chest radiograph showed no residual hemothorax or PTX, but a chest CT demonstrated a large pericardial effusion and fluid in the mediastinum with the catheter tip near the pulmonary artery. The patient was subsequently taken to the operating room, where a 3-mm perforation of the main pulmonary artery was noted in close proximity to the right ventricle.[2] Potential mechanism of major vascular injury has been outlined in Figure 4. Riwoe and Poncia[25] reported a case of subclavian artery laceration following NT placement in a young female patient. Her initial chest radiography suggested a left tPTX, and a 14-G NT using the "catheter-over-needle" technique was used for decompression in the second intercostal space at the midclavicular line. Repeat radiograph showed resolution of the tPTX. She was then transferred to another facility and arrived with ongoing left-sided pleuritic chest pain, dyspnea, pallor, and hypotension of 95/59 mmHg. A second decompression was performed with a 20-Fr tube placed into approximately the third/fourth intercostal space in the midaxillary line, yielding 1,100 mL of blood. The patient was resuscitated with blood products and underwent video-assisted thoracoscopy that revealed hemorrhage from a perforated left subclavian artery. Some authors advocate the use of the mid-hemithorax line instead of the midclavicular line [Figure 3], as well as using the sternal notch as a point of reference for the intercostal level, in order to minimize the risk of major vascular injury.[25,32] Consequently, close attention to surface anatomy and key landmarks, as well as using the mid-hemithorax as opposed to mid-clavicular line may help mitigate the risk of iatrogenic bleeding. At times, a better alternative may be the use of the fifth midaxillary line as the NT placement site [Figure 1]." (Complications of needle thoracostomy: A comprehensive clinical review)
  9. HermioneG

    Hypothetical situation, thoughts?

    In order to be protected from legal liability (and, in my personal opinion, to practice with integrity) you must work within your scope of practice in the manner that you have been trained. In the hypothetical situation you presented, you are making a diagnosis and doing an invasive intervention that could potentially cause serious harm to the person if you are wrong, or do the intervention improperly. "Potential complications of NT include cardiac tamponade, life-threatening bleeding due to pulmonary artery or intercostal vessel injury, nontherapeutic (i.e., ineffective) NT insertion, and nerve injury/neuralgia at the insertion site" (Complications of needle thoracostomy: A comprehensive clinical review). Or, if the patient doesn't have a true tension pneumo and while inserting the needle you cause a laceration to the lung, the patient can develop an air embolus. Additionally, it can be difficult to properly diagnose the condition without ultrasonography. One study I ready on the subject said that approximately 30% of patients who were treated for tension pneumo in the prehospital setting actually didn't have it. Also keep in mind that the signs/symptoms of tension pneumo are not always going to be textbook, and that given the mechanism of injury there can be significant comorbidities that could make the accurate diagnosis in the prehospital setting very difficult without the proper resources and training. As far as your reference to the trachea: "Late and unreliable signs: Increasing tension may include tracheal deviation (or tracheal "tugging") and jugular vein distension (JVD). Simple visual inspection is unreliable in detecting tracheal deviation. Bates' guide to physical examination recommends placing your fingers on either side of the trachea to determine if the distance between the trachea and the sternocleidomastoid muscle is equal bilaterally. Prehospital Trauma Life Support (PHTLS) indicates the trachea is bound to the cervical spine and fascia, and deviation would be detected lower, at the sternal notch" (Tension Pneumothorax | EMS Reference). "In this case, providers would simply feel the deficiency of the trachea if it has shifted to one side. These authors also point out that JVD might not be present either. If tension pneumothorax results in decreased cardiac output with hypotension, it is not likely to cause JVD. Note that although tracheal deviation is rare, it is primarily a sign of tension pneumothorax. In contrast, JVD can be present in multiple conditions, such as cardiac tamponade, so it is not necessarily an obvious tension pneumothorax finding" (Tension Pneumothorax | EMS Reference) The point of both of those quotes from the same article is to show you how detailed and specific diagnosing it can be. Without extensive training I don't think it would be appropriate for a nurse do that on a patient. Additionally, I don't think its ethical to have the patient decide if they want you to do it or not by asking them to nod their head. You are the medical professional, you know the limits of your training and the patient may not or may not be in a position to make an informed and rational decision, especially while scared and in pain. What would I do in this situation? I like the idea in the end of the article "EMS providers should maintain good situational awareness and not fixate on one problem. If mechanism existed to create a tension pneumothorax, then other traumatic injuries may also be present. Thorough assessment and monitoring of the patient's condition is also essential. Look for other causes, injuries and co-morbidities" (Tension Pneumothorax | EMS Reference). I would do everything within my training and ability, and do everything in my power to get them to help. Anything outside of that seems to be reckless and you'd be putting them, as well as your license, at risk. But, hey, thats just my opinion.
  10. HermioneG

    Starting out in ER?

    I'm a New Grad at a teaching hospital and level 1 trauma center. We are also cross trained in both the adult and pediatric ERs. I think that starting out in the ER is great, but you need to be in the right ER and you have to go in with the right mindset. The ER you start in should have a solid new grad program (from my experience and what I've read, about 4 months with consistent preceptors), and preferably be a hospital that has a culture that accepts new people/students/etc. If you can find a hospital and program like that, then you will find your transition so much easier. As far as the right mindset to thrive as a new nurse you need to be a self starter, be quick on your toes, and also be okay with man/womaning up and admitting when you need help or don't know your head from your tail. Some people might disagree with me, but I don't think that the ER is a good place to start if you insist on having a "fake it until you make it" attitude. Especially starting out, you need to be mature enough and wise enough to admit when you need help or are overwhelmed, since the flow of the unit and also patient status can change so rapidly in the ER. In short, if you're up for the challenge and find a place that is a good fit for you, do it!! :) Good luck with everything, and I hope to read about your success as an ER nurse in the future! :) :)
  11. I just got off orientation and there are three very solid pieces of advice that stand out: First is that in all kinds of nursing, but ER especially, its important to be tuned in to what one of my preceptors calls the "steps to an emergency." Example: you have a patient who has an increased work of breathing and a SpO2 on the low side. Its easy to get overwhelmed with the history, physical, meds, treatment, plan, etc etc and in getting swamped under everything ultimately missing the bigger picture (especially as a new grad). What is critical in these situations is identifying way before hand how many steps of interventions can occur until a true emergency happens. Back to the patient who is short of breath. What level is this patient at, what can we do right now, and what is the next step for when this current level of intervention doesn't work? How many steps does our team have before this patient reaches a fatal level? This would be my line of thinking (again I just got off orientation so I'm sure more seasoned nurses might have a different opinion and I'm always eager to learn) for a patient who presented with shortness of breath. In the case scenario with the increased work of breathing and low SpO2 patient. While there are many variables, treating this particular problem has a basic skeleton ladder of steps in which you can escalate treatment until this patient is dead, or the patient can travel back down a level if the intervention works and the patient's condition improves. No intervention: room air Level 1 of intervention: sit the patient up and put them on a nasal cannula. If that doesn't work and the patient is still tachypnic with low O2 sats then notify the physician and escalate to: Level 2: simple mask (our facility usually skips this step) Level 3: non rebreather at 15 L/min Level 4: BiPap Level 5: Intubation Sure, there might be other steps we could throw in there but that is a pretty basic skeleton of how you could escalate if needed. So, when your patient is tachypnic and short of breath instead of freaking out, ask yourself how many steps there are to an emergency and/or patient death. Look for your resources and communicate. Let the nurses around you know of the situation "hey heads up my SOB patient over here is not looking too great this is whats going on right now, and I'm going to let the Dr, Charge, and RT know." That way if your current level of intervention doesn't work and you have to escalate quickly your team and those around you know what is going on. This same preceptor told me that ER nursing is about communication and utilizing your resources. Know how to access policies online, the online drug library, etc etc. Also, don't just look at a patient problem and see it as stagnant. Understand that things can escalate quickly and so its critical to know what resources you have on hand and steps you can take before/during/after the situation turns critical. My other preceptor, when I was talking about how overwhelmed I was all the time, told me that ER nursing is like playing a sport. I like to personally compare it to baseball. In the beginning the game is going to move incredibly fast. You're going to mess up, strike out, and things are going to blow past you sometimes. But, as you learn the game and get more practice you're going to start actually seeing the ball as it passes in front of you. Instead of striking out constantly and just swinging and wondering where the ball went you're going to start making contact. The game will slow down, and you're going to start feeling better about it and it gets fun. It will get better, you just need to get through this phase and make sure you don't hurt anyone and have a good team to back you up. The third thing I want to share that BOTH of my preceptors told me is that nursing is a 24 hour job. There will be days where the opposite shift nurse is going to hand you a mess. There will be other days that you get swamped at shift change and you hand the other nurse a mess. Forgive yourself for it and just try your best. Help out whenever and wherever you can. You'll do great just keep pushing through!
  12. HermioneG

    Uhhhh, That's Kinda Personal

    Do you have any children? -No Well, you had better hurry up, your eggs are getting old Do you have any children? -No Thats a shame because that's a woman's purpose in life. You won't know true happiness or fulfilled your duty until you have children Do you have any children? -No An empty uterus is a wasted uterus Those are my top three ones that come to mind. They were all said by old creepy men. It made me want to take my expiring uterus and get the heck out of there. lol. I was in complete disbelief for a few minutes and then just walked away and laughed really hard. Better to just let it roll off, I think lol.
  13. HermioneG

    What is harder- nursing school or first year working?

    For me, nursing school was much harder. Instead of stressing about exams, all nighters, and busy work, my free time is my own. Although I use my free time to study, my studying is based off of real life scenarios instead of random nursing models. There's a lot of responsibility and a healthy level of stress that comes with the adjustment process in your first year of nursing, but I've found it to be very manageable. A big part of me thinks, though, that its because of my solid support system. In my unit culture, you're never truly on your own. Even on our first day off orientation, multiple supervisors were rounding on us new grads constantly to check in, see if we needed help, and cheer us on. Experienced nurses who have been precepting for years were assigned as team leaders in our assignment areas or given an assignment right next to us to keep a watchful eye. Everyone watches out for each other (nurses, techs, RTs, PCAs, etc) and that takes away so much of the anxiety. My coworkers have my back and I have theirs. Aside from the stress of being responsible for someone's life (I consider this a healthy stress that better never go away) most of the other stresses are just growing pains. They'll pass and you'll hopefully acclimate quickly. TLDR: nursing school by far. The first year of nursing is awesome and I love being on my own.
  14. HermioneG

    New grad RN

    Be open minded. Put effort into studying the culture of the unit. Be teachable. Smile often and learn how to laugh at yourself because you're going to be a hot mess your first year. You might as well own it lol.
  15. HermioneG

    Nursing Medical Symbol: What is it about?

    I think that's great! If I was you, though, I would first do thorough research on the caduceus (also known as the staff of Hermes) vs the Staff/Rod of Asclepius before you buy one. I've personally thought of finding a Staff of Asclepius necklace to wear!! :) Caduceus as a symbol of medicine - Wikipedia
  16. HermioneG

    What's your best 'Nurse Hack'?

    I learned this one the other day!! The trauma junior (?) asked me if I had some lube for my patient's face. I must've looked really confused because he laughed and quickly clarified that it helps to remove the dried blood! hahaha I love reading all of these awesome hacks! Great thread.

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