10/31 What I learned this week: Walking Dead anatomy lesson, herpes EVERYWHERE

[ixchel]

I'm having my annual struggle to decide what I want to be when I grow up. Thankfully, things are feeling a bit narrowed down this year. At the very least, I think it's time to start the typical core NP classes.

Every level of care provider at my facility is frustrated by our current lack of psychiatric specialty care, psychiatric consulting provider, and poor staffing for acute psychiatric needs, but no one knows what to do about it. Why aren't we diverting some of these patients?

Huh. Perhaps becoming a PMHNP would knock out both those birds with one stone. (Honestly, though, I'd burn out faster than The Donald's political dreams should have. Hey, Dogen, come to the mid Atlantic when you graduate. We have crab cakes and they are amazing.)

A terminal DNR patient will become full code if they are admitted from an incomplete suicide attempt. I have a serious problem with this.

If you only see one piece stitched in on a central line (IJ, SC, or femoral), you should get in touch with the MD to get the second piece stitched in. That is a lot easier than having to pull a line and reinsert a whole new line. If you only see one piece capable of being stitched in, the other piece wasn't put on, and it needs to be. You'll have someone irritatedly inform you that that will require wasting an entire central line kit just for that little thing, but again, this is better than requiring a whole new line insertion. If you notice this is a trend, consider incident reports. Seriously, it's not okay to increase infection risks and invasive procedures to patients just because the ED doc or intensivist just didn't feel like sewing in a couple more stitches. (See picture) [/rant]

The Fitbit charge HR is my favorite toy right now.

Every time I open the AN app on my iPad, I want to get the eye booger off the right eye of the nurse in the front.

Herpes can literally get in and on every part of the body. I'm glad my innocence was already shattered by sidepockets because for real, people. EVERYWHERE.

My fellow Walking Dead community - blood does not pour like that from the second intercostal space lateral to the midclavicular line, and there are no intestines at approximately the fifth or sixth intercostal space, even if that was somewhat midline. I'm just saying.

I hate to admit this (because I'm in love with, and rather loyal to my hospital), but lately, some ED shifts have been a little scary. I really hope they get their act together quickly.

One of my floor's charge nurses has advanced so highly on my "you are an amazing nurse and charge nurse" scale, that I think she broke the meter. During some of the hardest shifts I have ever had, she has put herself right at my side, battling through the thick of it with me. She has truly made me realize the value of a charge nurse you can TRUST.

That does, unfortunately, make it suck to realize how much harder a shift can be with a charge you can't trust. My understanding is that a previous manager made it a habit of promoting the slower, lazier nurses to charge. Look, if you are a manager and you think it's easier to promote them than it is to fire them when it is obvious the bedside isn't a good fit, you're doing it WRONG.

I have heard that in the last two years, my unit has gone from "fend for yourself" to a cooperative team that has each other's back. It's sad to hear that it was that way, but I'm proud to be part of the change.

This makes me laugh every time I see it:

Apparently my screenname is a planet name in A Wrinkle In Time where Aunt Beast lives. How did I not remember this?! Charles Wallace knows!

After the last two fresh off residency new hires we got (who are absolutely terrible to work with), I never expected to feel the massive amount of relief I felt when we just got a new hire who has a decent background and enough experience to realize nurses are a valuable resource, not competitors in an ego pissing match.

What have you learned this week?

As a friendly reminder, it is important to keep our WILTW threads mostly related to nursing. It's okay to throw in personal life observations, as long as the main focus of discussion remains nursing. Be safe on this All Hallows' Eve, my friends. :) And all you ED peeps - I'm hoping for some really good lessons from you on Sunday!

[Jensmom7, BSN, RN]

Okay, I had to look it up for the terminology. It's "ring avulsion".

Yep, they're both right.

And they both make me throw up in my mouth a little bit. [emoji33]

[cracklingkraken, ASN, RN]

Yep, they're both right.

And they both make me throw up in my mouth a little bit. [emoji33]

Is it weird that I was actually fascinated by it?

I find those things sickening, yet intriguing. I just can't look away.

[NotAllWhoWandeRN, ASN, RN]

This week I learned that How to Get Away with Murder literally strings together random medical words when a character gets shot.

BP is 70/palp, patient has JVD

Chest clear with "equal" breath sounds, so prepare for a thoracotomy!

[ixchel]

And when you ask "Is this your first time?", I will just shake my head and pretend like I've done it before.

You can't just say it. You have to look like it. Practice this until you look like you know what you're doing. The second you sit down and don't set yourself up with finesse, they will see right through your white lie.

If you have skills lab access, go visit your mannequin arm. If you do not, grab a box of tissues, roll them longways really tight, using scotch or masking tape wrapped tightly around it. This will simulate the feeling of poking through layers of skin, SQ fat and/or muscle, and the lumen of a vein.

Get IV start materials together - IV catheter, hub or pig tail, chlorhexadine, flush, tape, tourniquet, tegaderm, 2x2s

Now, set up your workspace.

1. Open the catheter wrapper, set the catheter right by your working area.

2. Open your hub/pig tail. Which one to use is a preference thing. I find inpatient management of IVs is far easier when I'm not pinching them to get a good grip on a hub. Others like hubs better, I just really like pigtails.

3. Open your flush wrapper, pull out your flush, hook it up to your hub/pigtail, flush fluids through. Leave them connected, because you'll use the rest of the saline to check your IV site for patency.

4. Open your tegaderm. Now, whether you pull the back off and expose the sticky side at this point is a matter of set up space cleanliness and preserved levelness. If you're setting up on a patient's bed, leave the back on. You will be able to secure it with tape before using tegaderm.

5. Rip off one 3" piece of tape, then rip that in half lengthwise. Stick it on a convenient surface (this will probably be the bed rail or tray table with a patient) with most of it hanging free for easy access. Rip another 3" piece of tape off the roll, stick it on the surface next to the thin tape strips.

6. Open your 2x2s, without touching them, and leave them on their open wrappers.

(I should say here - I never go into a room without extra of everything. If you only go into a room with one of everything, you WILL NOT get a usable line in. Murphy's Law was created for nurses.)

Now that you have yourself set up to start the IV, go through the steps. Do not skip a single step in practice. Wrap that tourniquet around those tissues. You'll feel silly, but you'll be practiced when it comes time to do this with a human patient. Repeat these steps over and over. Once you feel like you're not awkwardly trying to remember your routine, do it like, 5 more times to know you e cemented it, if you have enough materials. If you DON'T have enough materials, everything you have will be reusable except the tape (which you can get at any pharmacy) and the IV catheter. If you can get two catheters, keep one that you never retract to the point that the safety device locks you out of practicing it again, and have one you retract the needle out of so you can switch between the two while you practice going in for the stick, and hooking the hub/pigtail, taping it down and adding the tegaderm.

Believe me when I say, if you don't do this up front enough times to have your own routine comfortably down, you will look awkward and unpracticed. You're already going to be nervous with your first handful of sticks. If you make the process of it more routine, you'll know you can hide your nervousness from the patient, who is already scared you're a newbie.

[cracklingkraken, ASN, RN]

You can't just say it. You have to look like it. Practice this until you look like you know what you're doing. The second you sit down and don't set yourself up with finesse, they will see right through your white lie.

If you have skills lab access, go visit your mannequin arm. If you do not, grab a box of tissues, roll them longways really tight, using scotch or masking tape wrapped tightly around it. This will simulate the feeling of poking through layers of skin, SQ fat and/or muscle, and the lumen of a vein.

Get IV start materials together - IV catheter, hub or pig tail, chlorhexadine, flush, tape, tourniquet, tegaderm, 2x2s

Now, set up your workspace.

1. Open the catheter wrapper, set the catheter right by your working area.

2. Open your hub/pig tail. Which one to use is a preference thing. I find inpatient management of IVs is far easier when I'm not pinching them to get a good grip on a hub. Others like hubs better, I just really like pigtails.

3. Open your flush wrapper, pull out your flush, hook it up to your hub/pigtail, flush fluids through. Leave them connected, because you'll use the rest of the saline to check your IV site for patency.

4. Open your tegaderm. Now, whether you pull the back off and expose the sticky side at this point is a matter of set up space cleanliness and preserved levelness. If you're setting up on a patient's bed, leave the back on. You will be able to secure it with tape before using tegaderm.

5. Rip off one 3" piece of tape, then rip that in half lengthwise. Stick it on a convenient surface (this will probably be the bed rail or tray table with a patient) with most of it hanging free for easy access. Rip another 3" piece of tape off the roll, stick it on the surface next to the thin tape strips.

6. Open your 2x2s, without touching them, and leave them on their open wrappers.

(I should say here - I never go into a room without extra of everything. If you only go into a room with one of everything, you WILL NOT get a usable line in. Murphy's Law was created for nurses.)

Now that you have yourself set up to start the IV, go through the steps. Do not skip a single step in practice. Wrap that tourniquet around those tissues. You'll feel silly, but you'll be practiced when it comes time to do this with a human patient. Repeat these steps over and over. Once you feel like you're not awkwardly trying to remember your routine, do it like, 5 more times to know you e cemented it, if you have enough materials. If you DON'T have enough materials, everything you have will be reusable except the tape (which you can get at any pharmacy) and the IV catheter. If you can get two catheters, keep one that you never retract to the point that the safety device locks you out of practicing it again, and have one you retract the needle out of so you can switch between the two while you practice going in for the stick, and hooking the hub/pigtail, taping it down and adding the tegaderm.

Believe me when I say, if you don't do this up front enough times to have your own routine comfortably down, you will look awkward and unpracticed. You're already going to be nervous with your first handful of sticks. If you make the process of it more routine, you'll know you can hide your nervousness from the patient, who is already scared you're a newbie.

I was joking. And we haven't learned how to do IVs in lab. It is not a skill that we are taught in the program, unfortunately.

[Farawyn]

This is probably really bad but I'm a one glover when I draw blood. I need the ungloved finger for the bounceback. A lot of older school nurses do this, and that's who taught me. Don't learn from me!

I also lay (lie? Grrr.) the patient down, whenever possible. I used to work in OBGYN where fainting was a "thing". The DON who taught me to do IV's told me "ALWAYS lie (lay? Grrr.) them down- that way YOU have the power."

She was a goddess, and I've never forgotten that.

[cracklingkraken, ASN, RN]

This is probably really bad but I'm a one glover when I draw blood. I need the ungloved finger for the bounceback. A lot of older school nurses do this, and that's who taught me. Don't learn from me!

I also lay (lie? Grrr.) the patient down, whenever possible. I used to work in OBGYN where fainting was a "thing". The DON who taught me to do IV's told me "ALWAYS lie (lay? Grrr.) them down- that way YOU have the power."

She was a goddess, and I've never forgotten that.

I think you use lie when it's 3rd person and lay when 1st person. It's been a while since I've taken English, though...

[ixchel]

Yes, yes you were...[emoji41]

Ok, how does one get more than one quote per post?? Tried everything I can think of, but I'm not doing it right. [emoji35]

On app:

Click more to get this:

Click multi-quote. Now, every post you tap will go in your multi-quote. Tap it a second time, you will I select that post from your multi-quote. Downside is while multi-quote is on, you won't be able to "like".

On that last image, after you've added all the posts you want to respond to, you tap that top right thingy, and it will open the reply box thing.

[Farawyn]

I think you use lie when it's 3rd person and lay when 1st person. It's been a while since I've taken English, though...

My Achilles heel is lay/lie.

I do other stuff wrong, but I'm halfway aware.

Lay/ lie flummoxes me every time.

[ixchel]

Perhaps those were not HIS intestines and blood we saw!!

Exactly!

[ixchel]

BP is 70/palp, patient has JVD

That takes some talent, huh?

Kid was watching X Files yesterday and they gave Mulder a massive dose of phenytoin and he immediately went into a tonic-clonic. :\

[la_chica_suerte85, BSN, RN]

I've worked 24 hours straight (in another job) before, but I learned this week when you work on Halloween and it happens to be time to go back to Standard Time from Daylight Savings, that extra hour is surprisingly soul-searing. I felt like a giant baby but when you have an easy assignment and are trying to get into some kind of mess just to make the time pass, the moment 2AM becomes 1AM for the second time, it just hurt my heart.

I learned that some people can suffer through waiting on a fracture repair with only Tylenol (and repeatedly refusing morphine) for over 36 hours because they are that terrified of becoming addicted to pain medication. Once you get over the age of 85, IMHO, you are allowed to become addicted to whatever you please. Hmph

I learned that 45 years ago nursing students were allowed to place chest tubes.....

lol....

Just kidding. That pt was just...confused....?