October, 2005 Archive

October 29, 2005, 8:26 pm

Ask the Great Pumpkin….

Lucy thinks this is bad? She should try working in an ER. I’ll take dog germs any day. In recognition of Halloween, I have compiled a list of questions I would ask The Great Pumpkin, who, as we all know, rises out of the pumpkin patch once a year to answer rhetorical questions such as:

Did Dixie McCall ever leave the nurses’ station on “Emergency”?

Why is it easier to stay up until 0700 than to get up at 0700?

Why is it that when you have a child requiring transport to a pediatric facility, the patient is well enough to be throwing a football to his nurse when the transport team arrives?

Why would my husband even remotely suggest that I want to watch “Trauma In the ER” on my days off?

Why is it when a law enforcement officer seeks medical attention in the ER, the entire force on duty at that time comes in to say hi? Ditto with the fire guys?

How can they say we don’t have universal access to health care when anyone at anytime can walk into any ER for any reason and by law cannot be turned away because of lack of funds?

Why are they always defibrillating patients in asystole on TV?

Have you ever noticed that if the wait is too long, patients will “self-triage” themselves out of the emergency department?

What is it about “No Cell Phones” that is so hard to comprehend?

Why is it that a person will stand in line for three hours for a flu shot and then gripe if their entire ER visit takes the same amount of time?

Ever notice how a warm blanket will soothe the cranky patient?

Why would county dispatch send four ambulances to one ER within 15 minutes when none of the other hospitals are on ambulance diversion?

Ever feel like Sally Brown when you are trying to work and it seems like the entire world is trick-or-treating?

How did the nurse on “ER” auscultate a sys-
tolic BP of 40 without a sphygmomano-
meter or a stethoscope?

Why would a facility feed into the “instant gratification” culture by placing this ad in the local paper: “It takes longer to walk to your mailbox than it does to be seen in our ER”?

And finally, how much candy will be on the break table at work tomorrow?

Happy Halloween! Here’s to no tricks and a ton of treats!

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2:28 pm

Critical Mass….of Nurses

I’m sure we all remember our Wheatena lecture! Why, it was the highlight of my nursing education! Today we have drug reps, back then they must have had Wheatena reps…

I’m a Cream of Wheat fanatic, myself. Freakin’ nectar of the gods, it is! Trust me, when you’ve been NPO for 36 hours and you are status-post intubation, that first swallow is absolute heaven. A little sugar, a little milk…..ahhhh…..the epitome down-home comfort food! I never will figure out how it qualifies as a full liquid, though.

I realize that it has been a long time since I’ve worked anywhere in a hospital but the emergency department. I realize that life on the telemetry and med/surg units has changed in the last 16 years.
But…

Why on earth does an entire floor have to shut down because one patient goes critical?

Let me give a hypothetical example. Say there is a telemetry floor that holds 50 patients, but the census is at 45. There are nine nurses (5:1 at night), a unit clerk and a charge nurse. A patient at one end of the unit goes critical. At this point:

  • The ER cannot obtain a room number for the new admission because
    • the charge nurse is busy assisting the nurse whose patient is crashing
    • only the charge nurse can assign a room number
  • If a room number has already been assigned, no nurse on the unit will take report
    • because a “patient is crashing” on the unit.
    • they are busy
  • The new admission happens to be assigned to the nurse whose patient is now critical.

Now it doesn’t take the logic of Mr. Spock to figure out that:

  • The charge nurse
    • knows which rooms are available for an admit
    • knows which nurses are open for the admit
      • doesn’t need an hour to figure this out
      • can delegate the assigning of the room
      • can make a decision and revise prn
  • The nurse taking the new admit with room assignment
    • has an open room ready and assigned
    • is not involved with the critical patient
    • has no reason not to take report or accept the patient after report has been given
      • hectic activity in one room does not preclude giving care in any other room
      • is able to assess his/her patients without the charge nurse
      • can hold paperwork if necessary until unit clerk is available to process orders
  • The nurse of the critical patient, if assigned the new admit, should have the admit given to another nurse and be open for the next admit after they have transferred their patient to ICU.

Am I missing something here?

In the ED we have critical patients on a continuous basis along with a rotating census in every other bed, but the unit does not come to a halt because there is a code going on. Patients keep getting triaged, orders keep getting written and carried out, nurses multitask and take over for each other where necessary.

Two nurses, a doctor and a respiratory therapist (or two) can run a critical patient and get them transferred to ICU. It does not take an army….or an entire unit of nurses.

Can someone shed some light on this?

I just don’t get it.

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October 28, 2005, 12:16 am

One Child/Multiple Patients: Parents in the ED

I bought this book as part of a Sesame Street series for my first daughter back in the early ’80s and now I find it on a “review of antique books” site! Good grief! If this is an antique then I’m a pre-historic relic.

Being a nurse never helped me as a parent. When my first baby ran a temperature of 104.8 I ran to the ER as fast as I could get my old VW bug to fly. When I found my 2-year-old son blue and drooling on the side of my bed after a febrile seizure, we went 911 all the way. Of course by the time I had #3, I was an ER nurse and an experienced parent. She never even saw the inside of an ER until she was 14 and that was only because she was having an allergic reaction.

I know what it is like to be absolutely terrified because your child is sick.

In the ED, the child may be ill but you are caring for the parents as well. I find parents fall into three categories:

  • The Newbie: a parent who is dealing with a sick child for the first time. They have no clue about what to do for the fever and they are frantic because the child vomited once and has not stopped crying/fussing. They truly feel this is an emergency. They did not call the pediatrician, having rushed to the ER after the first emesis. They usually have at least one grandmother with them for support. The child is dressed in a diaper, a onesie, a second onesie, a one piece sleeper with footsies, a sweater, a jacket with hood and a thick flannel blanket. They are scared to death.
  • The Walking Worried: They’ve been through this before, only the fever keeps coming back when the Tylenol wears off and the vomiting has been going on “all day”. They called the pediatrician and have an appointment for tomorrow but they are too worried to wait that long. There may be new symptoms with this illness or it may have come on very suddenly. They’ve gone through all the treatments they can do at home (ie nebulizer treatments) but their gut tells them something is not quite right or the child is no better. They aren’t panicky, but they are anxious.
  • The Veterans: They’ve seen it all. The kids are older, or the child is the youngest in the family. They can handle the usual stuff at home, so the child will be in with asthma exacerbation, an orthopedic injury or a laceration. They’re concerned, but not anxious.

So how do we help the parents while we care for the child?

  • Acknowledge that the parents are concerned/worried/anxious.
  • Begin treatment at triage. If appropriate, give the medications for fever allowed by the triage protocol. If the child will need to wait to be seen, let the parents know that the fever is being addressed while they are waiting.
  • Tell the parents that if they become worried about their child while waiting, you (the triage nurse) are available. This will help allieviate some of their anxiety about waiting.
  • Reassure the parents that although the patient seemed deathly ill at home but is now playing peek-a-boo with the respiratory therapist and trying to stand on their head on the gurney, this is not unusual for children and we do believe their story…
  • Discuss the care for the illness as you care for the child. For example, talk about the need for minimal clothing in the presence of a fever as you undress the child for a weight. Go over what a clear liquid diet consists of when offering the child Pedialyte.
  • Encourage the parents to ask questions if they are concerned about an aspect of care.
  • Be sure to reinforce aspects of care that the parents did right. This is especially important for new parents who may not be confident in their ability to care for a sick child.
  • If the parents are very anxious, they may not retain a lot of what is discussed. Let the parents know that everything will be written in the discharge instructions given at the end of the visit.
  • Discuss options for care of future illnesses at discharge. The parents may not realize that there is a doctor on call for their pediatrician 24 hours a day and they are able to give out telephone advice. They may utilize an advice line after hours. During office hours, their pediatrician may be able to fit them in to a same-day appointment. It is important that the parents are not made to feel that bringing their child to the emergency department was wrong.

In the beginning of my career in ED nursing, pediatric patients were not my strong suit. Adult intensive care skills did not transfer over to caring for children. I took a PALS class and told my co-workers I wanted every pediatric patient that came through the door for two months. I became comfortable with pediatric assessments and treatments. Now, after 16 years of ED experience I don’t think twice when my patient is a child. I learned early on that when you care for a child, you are caring for a family and that the needs of both the child and the parents must be addressed for a successful outcome.

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About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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