Archive | October, 2007

The phone

15 Oct

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What do you think this nurse is thinking about?

Doesn’t she look so calm and cheerful?

She is not rushed or hurried. She is calm cool and collected.  That must of been great in those days; that is the olden days before…cell phones.

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Anasarca

12 Oct

Ok. It is extreme generalized edema. The patient was just fluffy, and puffy. It was a strange feeling this fluffy edema. No pitting. Just fluff.

Also impossible to draw blood on or start an IV.

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It was just impossible.  And the House MD just laughed at me because he did not want to do it either, after my bizillion sticks. (no just kidding not that many)

No Burn Out

12 Oct

Do not let yourself burn out.

Read these great words, get inspired by Kim over at Emergiblog.

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Just click on over and put out those burn out flames–and dry your eyes when you are done reading!

AV Fistula

12 Oct

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Look at this picture here at OverMyMedBody–This is a picture of an aneurysmal arteriovenous fistula. A snake in the arm or camel humps.

To create these fistulas which is the most preferred access for hemodialysis a surgeon will attach an artery and a vein together. By doing this the capillaries are avoided and the blood flows from artery to vein rapidly. The turbulence causes a vibration known as a thrill. 

I will never forget the first time I accidentally felt a thrill for the first time.  I was participating in an externship for the summer right before my last semester of nursing school. (I did not want to go back to school after that). I gently rested my hand on the patients forearm.  I felt a cat purring. I doubled checked and yes: it was an arm…no cat.  I saw the sign above the bed that read: no blood pressure left arm. I am startled. Everything is intact. I see 2 camel humps on this patients arm and they are purring! Vibrating! Pulsating! I felt sick!

I go to my papers. I took report surely there must be something on my paper about this freaky pulsating vibrating, purring camel hump arm. There it was in my own hand writing. Brachiocephalic fistula, +bruit, +thrill: Hemodialyis M-W-F.

I just did not know what it was or what it meant! I was figuring it was access for HD that did not really concern me. Well..it surely did concern me. I nearly lost my skin color feeling that thrill. It was Buzzing.

The complications of AV fistulas are somewhat less as compared to sepsis from a central venous catheter and clotting associated with grafts. One of the complications of fistulas are aneurysms–the vessel wall gets weak from needle sticking as can be seen by the link above!

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Anyway I will not forget that first thrill, that frightened me so much!

Tele Nurse

6 Oct

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So what are we? We crazed tele nurses with the glazed look in our eyes running from: The med room →to the patients→to the monitor station (patient is alarming)→to the chart→Now orders (rate control)→vitals signs q 4 hours (more for those prudent nurses with patients on gtts or that unstable feeling or post procedures) →Alarm reviews→the phone is ringing→your patient is taching out on the monitor→ more IV now orders→accuchecks(where are the techs?)→ ok you can be capped at 5 patients since one is on gtt:amio(but only for the first 24 hours) How generous of the admin→See the board–ER room # 1313→you take report via phone from ER nurse immediately(why beat around the bush? they are busy too! )→Check charts and found “transfer patient to regular medical floor”→You call to give report but they sound mad and want to call you back→They never call back→More medications→ IV Cardiac Meds→ Cardiac Heparin protocol gtts on all the A fibrillators→TEEs and cardioversions.→Heart Rate of 35–the order reads: put an external pacer on and set to shock at  Heart Rate 25 (I am afraid can the patient please go to ICU? Charge nurse please call)→ OK that one is out to the unit→ER calls→you took report –on the way out of the ER the patient coded and died of massive PE→You see the board a transfer for you from the ICU→You swap reports I give you one of mine and I will take one of yours(maybe tomorow we can switch back).→Check PTT for this one, check Vanco trough for that one and Dig level for the other one→Dig level 11.7! What that is so high→More Now orders Digibind and the pharmacy wants a weight because the MD based the order on 150pound and the patient is 100 pounds wet→fix the order→Finally the newly consulted cardiologist looks at the patient, the chart, and asks what drugs were given at night? I look– 11pm 0.125mg of Dig given– At 1130 the Dig level was drawn! DUH! It is not rocket science, it just takes someone to stop with plain common sense! →No digibind. → All morning medications are given.→your 4 hours since you last vitals are over it is now time to start over again. →reveiw alarms→Your only real stable patient wants to go home–you call the attending he says “If it is ok with neuro” You call neuro, this one says “if ok with cardio” Cardio says sure follow up in a week!–Discharge nurse is available she is called and comes for the patient→Hurry up and chart on this patient! →You see the board it is a transfer from med/surg for a SBP of 89! She needs fluids! What (I just do not understand) But they want to monitor. → Vitals done with highs and lows→your 91 year patient who is nonverbal (or one word) answers is contracted on one side and was sent for a bronchoscopy to maybe suck out the secretions she is drowning in from aspiration pneumonia post CVA who is also uncontrolled A fib, and leaning towards infection maybe sepsis. Go in to reposition as you do q 2 hours and the daughter with the red lipstick on her teeth says: “she sounds so much better since the bronch.” New nurse Jane surprised by her calm answer stated: “She does sound less gurgly, but I have to tell you that your mother is very sick right now and I am not sure if she is going to be the same person as she was before the stroke.” The daughter says: I want everything done for my mother. I nurse Jane understand completely what she means as 3 physicians have spoken with her about her status →full Code it is but hopefully it will not happen here, hopefully she will go peacefully at home because I can not imaging breaking the contracted arms to get the chest for compressions. → Have to leave the floor to transfer my external pacer to the unit with the clinical→My low blood pressure transfer arrives and is stable only needed some fluids.→ Go medicate my 25 year old with severe pneumonia that almost caused the kidneys to shut down from sepsis→Sputum sample→blood cultures→lactate→urine samples→pedal pulses→stool samples→Consents signed→ Tele strips→Heparin up and down (when will it always be therapeutic once) →New IVs→Check charts for orders–charts are gone because there are a billion people in  here→Patients pooping→ No helpers→Need a boost→Vital again→try to chart→finally give report to the nurse for the med surg transfering out→look up labs/results and make those calls→ Vitals again→more meds→pull tele strips review alarms→Antibiotics not renewed–make call. And everyone thinks we are “short, abrubt and mean.”

The next shift is here. Give report. You can not imagine what you did for the last 12 hours, but you know you worked, and all are mostly stable. Good bye. Go home like nurse Taylor up there.

In your lungs.

6 Oct

Pneumo Vaccine: It always seemed to annoy me that in the acute  care setting I was worrying and spending lots of time making sure that all my patients were given a Pneumoccal vaccine. It seemed whether they liked it or not: if they fell into the category they got the shot. It is like a crazed mission to eradicate this type of pneumonia. Of course Pneumococcus has 80 different strains but the vaccine does cover 23 strains! 🙂

Well… as Karma, and Murphy’s law do work. I received a very sick young man with lobar pneumonia. The patient was very sick under the age of 25 and presented with chest pain, cough, pleuritic pain. Chest x ray revealed the pneumonia, and the patient was admitted to a general medical floor. The patient was assessed by the nurse to be tachypnic, tachycardic, and hypotensive, febrile. His BUN and creatine were elevated–the patient was becoming septic and going into mild renal failure. They transfered him to the ICU where he received close monitoring, fluids, antibiotics and aggressive treatments. One day after that the patient was transfered to my tele floor–stable, less tachy, still hypotensive and in alot of pain.  And the cough! IT was harsh. IT hurt me to listen to it.

The patient of course wanted to know when he was going home, back to his life, his job, not really knowing or understanding that it was not palm trees mountains or apples in his lungs. That he was seriously ill, and could not go anywhere anytime soon.

 The most common cause of bacterial pneumonia is Streptococcus pneumoniae or pneumococcus. Pneumococcus usually causes lobar pneumonia, attacking an entire lobe or portion of a lobe of the lung. The signs are usually: shaking chill pain in the chest while breathing, a cough, and blood-streaked sputum. This usually happens after a viral respiratory infection→ than bacteria get in.

I guess I do not mind so much injected those huge needles anymore into muscles–if it really helps knock out some pneumonias.

angioseal

5 Oct

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This next scenario did not happen to me, I only observed a nurse on my floor highly upset, extremely concerned, and well… mad, and worried.

*Remember that no names, gender, location etc will be disclosed and this may even be a fictitious made up story to make all nurses, new or not, remember certain aspects of care under our watch.*

The patient is scheduled for a cardiac catheterization. This is a test to see if a patient has a blockage of some sort in the coronary arteries or Coronary Artery Disease. A catheter is inserted into the groin or the arm–that will travel to the arteries of the heart. Dye is injected to block the rays of the x-ray so that the vessels can be visualized. Interventions to unblock the arteries will usually be implemented if possible.

The nurse assess the patient–the patient is stable, the patient has both pedal pulses present and marked with little -x- marks.

The cath lab nurses pick up the patient and escort the patient to the the cath lab.

The patient has the procedure and the floor nurse is getting report from the cath lab nurse in which the cath lab nurse explains, what happened, what were the blockages, any stents placed, etc.  The cath lab nurse tells the floor nurse that the angioseal was not sealed “it broke free.”  Assessment wise the patient is stable with positive pedal pulses, no hematoma, no bleeding and a pressure dressing applied.

What? Red flag here. What broke free? The whole thing? Is that real? Is it possible? Will it travel? Is there a chance that it will travel? To the brain? The heart? The lungs?

So the patient is received by the floor nurse. The cath lab nurses leave. Floor nurse starts with vital signs, puncture site and then on to the feet.

The feet.

The foot is cold and there is no pedal pulse to be palpated.

There is no audible doppler pulse.

The vascular surgeon was consulted immediately.

Here is a nice site with step by step instructions how to insert and anchorthe angioseal.