janine3&5

I use the HL to draw labs whenever I can in the ER. When we first put in the IV, I attach the HL to a vacutainer to draw blood. After the HL's been used for meds, fluids, whatever, then I use a syringe for any blood draws ( waste the first 5 ccs) However, you aren't always able to draw blood from the existing site- probably about 40% of the time the HL will be patent, but you still can't get any blood from it. I'm not sure why this is? In my experience, repeated draws from the HL work best with at least a 20 guage (18 is even better) in a big vein (AC).

I also had the chance to remove one as a nursing student. I was in clinicals on a surgical floor, the nurse I was working with talked me through it. I was under the impression that this is a nursing skill.

We have a few paramedics working in our ER; they function in the same position as nurses with their own pt assignments. However, they can't give any meds! I'm not sure of the rationale behind that. Our ER rooms are staffed by acuity levels, i.e. LPNs/medics work ortho/suture/OB/gyn intermediate care rooms. They team with an RN to staff critical care rooms. But they're awesome- do a great job!

I work in a very busy ER: 100,000 visits/year. Once a pt is seen by the doc, it takes another 1-3 hrs for labs and so forth to come back. They're usually admitted after 2-3 hrs. And that's when the real wait starts. Pts are usually with us AT LEAST 3-4 hrs for a non monitored med/surg bed. I've seen pts stay over 24 hours waiting for a critical care bed. And that's just what it is....waiting for a bed to open up. Our charge nurse is very big on getting pts transferred out of the ER as soon as possible. I know that if I don't have report called and transport notified within 15 minutes of getting a bed, she's going to be on my phone, asking why the pt's still here. Which is fine with me, I hate sitting on pts who have been admitted for hours and hours. It's very frustrating....about half of the time, the admitting doc doesn't even see the pt in the ER, there are no floor orders to help with even if we have the time to do so. The pts don't understand why they're waiting so long, they're uncomfortable and hungry. When we do have floor orders, we're responsible for doing any stat orders. Beyond that, policy is that we need to start looking at orders when the pt has had them for 2 hrs. I do always try to hang the antibiotics asap. Just to touch on a few other topics here that I can relate to. IV access, I can't imagine any admitted pt being sent up from the ER without IV access. They ALL get IVs. And yes, most times we put them in the AC when the pt has something acute going on. Yes, it may be inconvenient, but it's the easiest site to access and get blood from in one shot without the lab calling to say our specs are hemolyzed (which I think they LOVE to do!). In the ER, there is so much to do at once, and there is a need to get it done fast, searching for other veins is not a big concern of mine. But if the pt is not too bad off, or has veins jumping out at me, I use the FA. I quite often have nurses who can't take report, say they'll call me back for report and never do, etc. I understand that these nurses are busy too, but feel like they don't understand that I already have a pt literally waiting outside my room on a stretcher with EMS, along with my charge nurse wanting to know why I'm taking so long to move my pt out. Pts going to the unit or cardiac floor are ALWAYS transported by an RN with a life pack to the floor. I have yet to see that rule be broken. There are just NOT ENOUGH beds or TOO MANY pts, bottom line. Yes, it's frustrating, BOTH to floor nurses and ER nurses; I don't think either type of nurse has a clue of what the other one is trying to do and balance. There are different priorities.

I was surprised too with the Dx with that BS. I asked another nurse about it, who said it was DKA because of the ketones and ABGs. The patient was oriented, but lethargic, sleeping most of the time and slow with responses. As far as the dehydration, pt was not able to urinate until after the second L of fluid. The ABGs, I only really glanced at the first set and saw the abnormals. I'm a new grad, so it takes me a little while to analyze the results to understand what I'm seeing, and now I couldn't even tell you what they were! Its very frustrating to me when things need to move so quickly that I don't have the time to understand the physiology and rationales, but I try to go home each night and research the things I've seen during the day that I didn't quite get. The nurses and docs are very supportive for the most part and are great at answering my many questions, but there's not always time to ask everything I want to know while at work. But despite this, I love the ER and I can definitely saying that I'm learning everyday.

I'm so glad to hear these replies; I got the same response from a nurse at work today that I talked it over with. My understanding of the pathophys was a little off, but glad to hear I didn't screw up. The pt was a 36 yr old F, Hx of DM (admittedly very non compliant, had been in a few weeks earlier with same problem), no other significant medical Hx. VS okay. Denied Hx of Etoh. Initial blood sugar wasn't that high; 303. So the Dx came from the other lab values; ketones in urine and ABGs out of whack. Honestly, I couldn't tell you much about the rest of the lab values except that nothing jumped out at me as being way out of range. I ran the first L of NS in wide open and had an insulin drip going at 7 U/hr. After 30 min the BS was 169, so I switched to D5NS. Kept the drip going at 7U. Then BS were to be done hourly. In better circumstances, I would know more about the labs on my pt. This was my second day on my own on the floor, and wasn't supposed to be my pt. I (along with a tech) already had 5 pts on our critical care side, but then the nurse working next to me got pulled to a trauma, so I got his 2 beds as well for about 7 hrs. We were slammed all day, so after I checked labs or orders, I dealt with them and then moved on. I kind of feel like I didn't really have time to critically think things through to really understand the big picture of what was going on with this pt, so when I had to deal with this doctor, I did doubt myself. Also, I literally did not have time to deal with her! She's someone who loves to make a scene and belittle the nurses, so to an extent, I wanted to just let it go. But as I said earlier, I want to learn, and I want to understand why I'm doing orders, that was the reason for my post. Although I could go on and on about this doctor and my crappy day! So thank you so much for your replies, that's what I wanted to know, and now I better understand the rationale for the treatment. You guys are good!

Okay, long story short: Had a pt today with DKA in the ER, and our ER doc ordered a 2 L bolus of IV fluids (NS, then changed to d5ns after blood glucose was less than 250) along with insulin drip. Keep in mind that I'm a brand new nurse, but to me this made sense, the fluids would dilute the blood glucose, restore fluid losses from polyuria, increase circulating volume, and so increase tissue perfusion. So the pt gets admitted, and the admitting doctor comes down to see the pt and absolutely flips out on me when she sees that the pt has over 3-4 hours had 2 L of fluid. "I can't believe you would have that wide open on a pt with DKA, what are you thinking? and on and on and on" First of all, the ER doc ordered the bolus! I didn't question the order because it made sense to me. I can handle being told when I'm wrong, but I want to know why so I can learn from my mistakes. So tell me, why shouldn't DKA pts get rapid infusion therapy? What is the normal first line treatment in the ER?

I don't think you're being too critical at all, would you want someone like that taking care of you? Especially in the healthcare field, where hygiene is so important! I have to agree with every thing you said; if someone is not concerned with their own cleanliness, are they really going to care about the condition of the residents? I don't know if in general, a person's appearance is related to how well they perform their job. We have some nurses on the other side of the spectrum, who wear too much makeup, jewelry, long nails, tight clothes, etc. While these nurses may be dressed inappropriately, I wouldn't say that it reflects their performance ability. But lack of hygiene and dirty clothes are a different story, definitely posing a health risk to already sick pts.

Hey! That Springhouse book is great, I also used it to help prepare. I just took my boards a few weeks ago, and the test really focused on prioritizing care. For example, questions like, "You're just starting your shift, these are your four patients, who do you need to see first?" Then you choose from the four descriptions of pt conditions. Or, "There's a disaster situation, and you need to open up beds......." Then you decide which patients are stable enough to be d/c. Also, delegating care; deciding pt assignments for an LPN vs an RN. Quite a few questions on growth and development, too. From what I understand, there's no guarantee that your test will focus on these areas as each test is different. However, many people that I graduated with agreed that these areas were hit pretty hard. Just remember your ABCs and the steps of the nursing process, and you'll be fine. My test cut off at 75 questions, and from what I've read on this board as well as what my classmates have told me, the majority shut off somewhere around this point. Keep in mind, though, that you may answer all the way up to 265 questions and pass as well. A lot of people hit that 75 question mark and then start to panic, thinking they're not doing well, but that's not the case. Stay focused on the questions and don't worry about how many questions you have to answer. Good luck to you and keep us posted ! Janine

We used "Go Light Your Candle", and one of our class members sang it. I'm not sure where you would get the lyrics or music, maybe just do a search on the internet. It's a pretty well known song, and so pretty; everyone was in tears at the end.

Blood, poop, vomit, and even phlegm don't get to me, but that unwashed body odor stench does it everytime. Yesterday, I had a lady, about 300 lbs., who obviously is not able to reach all those little crevices to wash really well, anyway, I got her into the shower first thing. So I'm walking BEHIND her, dry heaving the whole way, and she starts passing an unbelievable amount of gas aimed right at me. Those combined smells just about killed me--I managed to get her into the BR, then ran gagging out of the room.

Beautiful poem, thank you.

Most of the hospitals in our area offer review courses to employees. The hospital that I work at offers a week long NCLEX-RN review free of charge (I think we also get paid regular wages for attendance). I don't know if you already work at a hospital, but it would be worth looking into if you do. I've been using Springhouse's "NCLEX-RN Questions and Answers made Incredibly Easy", which is great. As a class, we have also taken Mosby's Assess test, which is supposed to be a pretty good indicator of how you'll do on boards. The results are broken down to show you which areas you're weakest in. I'm sure you'll do fine- GOOD LUCK! [This message has been edited by janine3&5 (edited April 15, 2001).]

WOW, those are quite a few questions! Did you check in your textbooks? I remember that my Fundamental Nursing text discussed all of these right in the beginning of the book. Good luck.

Quick question- what does the DO stand for; what's the difference between an DO and an MD? (Have noticed alot of our ER docs are DOs, just curious) Thanks!