I am not sure how it works in other areas of nursing, but in the emergency department, we run several back office tests like rapid strep, urinalysis (UA) and pregnancy tests. I have had a few UA’s which were positive for urinary tract infections, but otherwise, all of my back office tests have been negative until yesterday.
Last night I had a positive pregnancy test. I really wasn’t expecting it to be positive. The patient was a 12 year old girl with hip pain. Usually, a pregnancy test on a teenage girl is just a formality. You don’t really expect it, but you have to rule it out. Maybe a positive test on an older teen, but a 12 year old? I had to confirm that I was seeing what I was seeing. Were there really two lines? Maybe I should repeat it. Apparently the family had the same thought. We collected another sample, and indeed, it was positive again.
It was difficult to gauge the family’s reaction. They seemed happy enough, but there was just the slightest under current of tension. As the nurse in the situation, I had a difficult line to tread. It was obvious I knew the score, but I needed to remain unbiased and neutral in my reaction and interaction. I tried to strike a balance. I did not want to get too serious, but yet a joking manner did not seem appropriate. I tried to engage the patient in light conversation while gathering the needed information. Trying to let her know that I was on her side and not judging.
I guess this case was just a much more dramatic presentation of what I strive for as a nurse with every patient. My patients need to know that I am on their side and that I do not judge the situation they find themselves in. My job is to care for my patients. Not just physically. Yes, I apply bandages, but I would hope that I also apply emotional bandages. I believe healing involves more than the physical. By expressing my concern for all of my patients and their families, maybe I am sowing the seeds of healing.
Monday, March 17, 2008
Friday, March 7, 2008
Should you visit me? Or "What is an emergency?"
What is an emergency? It seems that there are many people out there who don’t know the answer to this question. Can the patient breathe? Are they bleeding? Is there a bone broken? Are they awake and alert? These are the questions we attempt to answer in triage. Remember your ABC’s? In all first aid and CPR classes, the first thing they teach you is ABC, or Airway, Breathing, and Circulation. Additionally, we have added D for “Da brain”. Chances are, if all your ABC’s are in order and functioning, you do not need to go to the emergency department.
Let’s start with A and B since they go together. Is the patient moving air? If so, they are good! Even if they are coughing or have a stuffy nose, chances are they are going to be fine without any intervention. If they are breathing really fast and seem to be working hard at getting air in, they might need to be seen. One way to tell they are working hard is to look at the belly and neck. If the muscles in these areas are getting a workout, that is not so good. By all means, come see me in the ED.
How about C? Amazingly, children rarely have trouble with their heart. How about the other circulation issue, bleeding? How long, deep and where is the cut? If it is small, not on the face, not deep, and can be easily cleaned out, you are good! If not, come see me…
Da brain. Is the child lethargic? What the heck does a lethargic child look like? Can they answer questions appropriate to their developmental level? Think about how you feel when you are sick. Don’t want to eat? Want to sleep all day? When a kid is sick, they can feel the same way! Kids can get dehydrated much quicker than big people, so here are some easy ways to determine the hydration status: tears, diapers or trips to the bathroom, and moist mouth. If they have these things, they are probably ok. If not, come see me…
Do not come visit when your child has a nightmare. Do not come see me when they have a cold. Does their tummy hurt? Go to the doctor in the morning. The emergency department is not the best place to hang out when you are bored in the middle of the night. The other night, we had a family who brought their child for a cold and then, after waiting an hour, the parent asked, “Why did I come to the emergency department any way?” It was all I could do to refrain from replying, “I don’t know. Why did you come to the emergency department?”
Another issue; why do parents end up in the ED without the supplies needed for the general care and feeding of their child? I do understand that in an actual emergency, there is often no time to grab these items. However, when a family is coming for less urgent care, why do they leave this stuff home? If you were going to the mall, would you expect the shop keeper to supply a diaper, wipes and cream for changing the baby? It will likely be a long wait, maybe some books and or small comfort toys would help the cranky child who is usually asleep at this hour and now is in desperate need of a nap. I had a father the other night who demanded immediately after being placed in the room, “I need a diaper, baby wipes, and cream and a bottle with formula.” This was for an older child with special needs who required a diaper size which we do not usually stock in the ED. Fortunately; there were some in the store room.
To sum this up, if there is an issue that truly needs immediate care, come see me. If not, consider staying home and calling you doctor in the morning. Generally speaking, the doctor is less expensive and the wait will be shorter. If you do decide to come see me, bring whatever supplies you might need as the wait times can be quite long at this time of the year. When in doubt as to staying home or coming to the ED, call your pediatrician or a nurse advice line. Children’s has just such a resource which can be found online at http://www.thechildrenshospital.org/wellness/at_home/index.aspx, or by calling 720-777-6543.
Let’s start with A and B since they go together. Is the patient moving air? If so, they are good! Even if they are coughing or have a stuffy nose, chances are they are going to be fine without any intervention. If they are breathing really fast and seem to be working hard at getting air in, they might need to be seen. One way to tell they are working hard is to look at the belly and neck. If the muscles in these areas are getting a workout, that is not so good. By all means, come see me in the ED.
How about C? Amazingly, children rarely have trouble with their heart. How about the other circulation issue, bleeding? How long, deep and where is the cut? If it is small, not on the face, not deep, and can be easily cleaned out, you are good! If not, come see me…
Da brain. Is the child lethargic? What the heck does a lethargic child look like? Can they answer questions appropriate to their developmental level? Think about how you feel when you are sick. Don’t want to eat? Want to sleep all day? When a kid is sick, they can feel the same way! Kids can get dehydrated much quicker than big people, so here are some easy ways to determine the hydration status: tears, diapers or trips to the bathroom, and moist mouth. If they have these things, they are probably ok. If not, come see me…
Do not come visit when your child has a nightmare. Do not come see me when they have a cold. Does their tummy hurt? Go to the doctor in the morning. The emergency department is not the best place to hang out when you are bored in the middle of the night. The other night, we had a family who brought their child for a cold and then, after waiting an hour, the parent asked, “Why did I come to the emergency department any way?” It was all I could do to refrain from replying, “I don’t know. Why did you come to the emergency department?”
Another issue; why do parents end up in the ED without the supplies needed for the general care and feeding of their child? I do understand that in an actual emergency, there is often no time to grab these items. However, when a family is coming for less urgent care, why do they leave this stuff home? If you were going to the mall, would you expect the shop keeper to supply a diaper, wipes and cream for changing the baby? It will likely be a long wait, maybe some books and or small comfort toys would help the cranky child who is usually asleep at this hour and now is in desperate need of a nap. I had a father the other night who demanded immediately after being placed in the room, “I need a diaper, baby wipes, and cream and a bottle with formula.” This was for an older child with special needs who required a diaper size which we do not usually stock in the ED. Fortunately; there were some in the store room.
To sum this up, if there is an issue that truly needs immediate care, come see me. If not, consider staying home and calling you doctor in the morning. Generally speaking, the doctor is less expensive and the wait will be shorter. If you do decide to come see me, bring whatever supplies you might need as the wait times can be quite long at this time of the year. When in doubt as to staying home or coming to the ED, call your pediatrician or a nurse advice line. Children’s has just such a resource which can be found online at http://www.thechildrenshospital.org/wellness/at_home/index.aspx, or by calling 720-777-6543.
Saturday, March 1, 2008
The training wheels are off!
Look Ma! No training wheels. I (and all of my patients) survived my first week off of orientation. I was in the observation (OBS) unit the first night. The OBS unit is intended to house patients who need to be observed for a few hours (less than 24) to make sure they are indeed getting better and ready to go home. With the high level of occupancy in the hospital at this time, the OBS unit often ends up being a holding pen for patients waiting to go upstairs to a regular room. I had several patients (about four at a time), some went upstairs, some went home, and a few stayed the night. It was busy, but not too bad. The biggest problem with OBS is that you feel a bit like you have been sent to outer Siberia. It is a bit cold and lonely.
The next two nights were out in the main ED with a regular hallway. Taking a hallway means you have 4 rooms, and you care for the patients who rotate through. You see a wide variety of patients and conditions, although you see mostly respiratory patients at this time of the year. I did get two items accomplished.
My first day on a hallway saw my first infiltration. My patient was a five year old with no muscle tone. Her veins were difficult. I was quite pleased with myself when I got the IV on the first try. It seemed like a good one with excellent blood return and it flushed easily as well. The patient needed fluid bolus, so I hooked it up. After the first bolus, she needed another. I checked the IV site, which looked good, and started the second bolus. Near the end of the second bolus, the doctor asked for another bolus and more lab tests. Being the ever dutiful nurse, I unwrapped the IV site, hoping to draw blood from the line already in place. Imagine my surprise when I noticed that my patient’s arm was bout twice the diameter it had been prior to my intervention! Amazingly, because of the lack of muscle tone, the arm was still soft and not painful to the patient. The estimate was about 100 ml of fluid in the tissue surrounding the IV site. For those of you who have never experienced this, just know that any extra fluid in the tissues usually caused a hard swollen area which is usually painful. So, I had to remove the IV and start another. The patient’s mom was very understanding, telling me what a good job I was doing and how glad she was to have me for a nurse. I suppose this should have made me feel good, but I was really wishing she would get a little upset, because her kindness was making me feel even worse…
The other item I got out of the way happened on my second day on a hallway. I was helping another nurse hold a patient for a nasal wash. In this procedure, saline drops are placed into each nostril, and then a suction tube is inserted into the nose to the back of the throat and mucous is collected. We often refer to this as a “booger-ectomy”. You might imagine that the kids do not care for this procedure, and can put up a bit of a fight. So, as the “helper nurse” I was in charge of holding the hands and head still. This is usually done in the “touch-down” position, with the hands above the head near the ears. All was going well, the patient was old enough to cooperate a bit, and then she gave a good cough. The cough is actually not an uncommon occurrence, but this one was quite moist, and a bit of it managed to hook around my glasses and land directly on my eye-ball. I had on gloves and a mask, but no further eye protection. My glasses should have been enough… And to make matters more interesting, the patient was positive for strep throat and influenza B! Fortunately, I had antibiotic eye-drops in my locker for my last round of pink-eye.
So, lessons learned:
- Wear eye protection, even if you have glasses.
- Check, check, and triple check all IV sites
- Don’t get too sure of yourself
- I can ride without the training-wheels!
The next two nights were out in the main ED with a regular hallway. Taking a hallway means you have 4 rooms, and you care for the patients who rotate through. You see a wide variety of patients and conditions, although you see mostly respiratory patients at this time of the year. I did get two items accomplished.
My first day on a hallway saw my first infiltration. My patient was a five year old with no muscle tone. Her veins were difficult. I was quite pleased with myself when I got the IV on the first try. It seemed like a good one with excellent blood return and it flushed easily as well. The patient needed fluid bolus, so I hooked it up. After the first bolus, she needed another. I checked the IV site, which looked good, and started the second bolus. Near the end of the second bolus, the doctor asked for another bolus and more lab tests. Being the ever dutiful nurse, I unwrapped the IV site, hoping to draw blood from the line already in place. Imagine my surprise when I noticed that my patient’s arm was bout twice the diameter it had been prior to my intervention! Amazingly, because of the lack of muscle tone, the arm was still soft and not painful to the patient. The estimate was about 100 ml of fluid in the tissue surrounding the IV site. For those of you who have never experienced this, just know that any extra fluid in the tissues usually caused a hard swollen area which is usually painful. So, I had to remove the IV and start another. The patient’s mom was very understanding, telling me what a good job I was doing and how glad she was to have me for a nurse. I suppose this should have made me feel good, but I was really wishing she would get a little upset, because her kindness was making me feel even worse…
The other item I got out of the way happened on my second day on a hallway. I was helping another nurse hold a patient for a nasal wash. In this procedure, saline drops are placed into each nostril, and then a suction tube is inserted into the nose to the back of the throat and mucous is collected. We often refer to this as a “booger-ectomy”. You might imagine that the kids do not care for this procedure, and can put up a bit of a fight. So, as the “helper nurse” I was in charge of holding the hands and head still. This is usually done in the “touch-down” position, with the hands above the head near the ears. All was going well, the patient was old enough to cooperate a bit, and then she gave a good cough. The cough is actually not an uncommon occurrence, but this one was quite moist, and a bit of it managed to hook around my glasses and land directly on my eye-ball. I had on gloves and a mask, but no further eye protection. My glasses should have been enough… And to make matters more interesting, the patient was positive for strep throat and influenza B! Fortunately, I had antibiotic eye-drops in my locker for my last round of pink-eye.
So, lessons learned:
- Wear eye protection, even if you have glasses.
- Check, check, and triple check all IV sites
- Don’t get too sure of yourself
- I can ride without the training-wheels!
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