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emergency nursing unscrewed
no fluff | no guff | no duff
Copyright Ian Miller 2008.
Introduction from a screwup nurse........................................................................3 How to handle the workload..................................................................................4 How to nurse the machines. .................................................................................4 How not to make a medication error. ....................................................................6 How to manage a needle stick injury. ...................................................................7 How to catheterize a male. ...................................................................................9 How to catheterize a female. ..............................................................................11 How to remove a penis that is stuck in a zipper..................................................13 What is mean arterial pressure? .........................................................................15 Where to place that cannula. ..............................................................................16 How to place a cannula.......................................................................................18 How to secure a cannula. ...................................................................................19 How to tell if your patient is playing possum. ......................................................21 How to manage a patient having a CAT scan.....................................................23 Tip: lip balm and oxygen. ....................................................................................25 How to use nitrous oxide.....................................................................................25 Minimizing Violence with STAMP AID.................................................................27 How to use the rectal trumpet. ............................................................................29 How to handle the smell of poo...........................................................................30 How to immobilize a suspected spinal injury.......................................................32 How to manage hypothermia. .............................................................................34 How safe are air bubbles in the IV line?..............................................................36 How to manage paediatric fever. ........................................................................37 How to keep ‘eyes on’ your patients. ..................................................................39 How to assess a child: Respiration. ....................................................................41 How to assess a child: Circulation. .....................................................................43 How to remove a stuck ring. ...............................................................................44 10 tips for staying sharp in the Emergency Department. ....................................45 How to cure persistent hiccups. ..........................................................................48
Copyright Ian Miller 2008.
Introduction from a screwup nurse.
A nurse is the most profound of fulcrums between the patient and the care they require. And it is the intimacy of the bedside nurse that effects the most powerful leverage of all.
– ian miller.
I am the first to admit it. I am a screwup nurse. I am the reason they print handle with care on life suport equipment. I constantly bump into catastrophies and trip over delicacies. My brain always seems to run a lot slower than the events unravelling around it. It’s sorta like nursing inside a jar of molasses. So I have to work pretty hard to unscrew my practice. To meet the level of care that is demanded from the speciality of emergency nursing. To do justice to my colleagues. To strive to deliver my care from a container of integrity and competence. So here I present some of the lessons I have learnt from my own litany of sagacious screw-up’s in the hope it might help you unscrew your own nursing practice. Remember: righty tighty….lefty loosey.
This manual is by no means intended as a textbook or reference to best practice or evidence based nursing. Oh no, that would be up to you to explore for yourself (after all it’s free….and you get what you pay for…no?) Think of it more as some advice from an experienced ( but far from an expert) friend. Listen to my stories and pointers, and then go and cross-check against your hospital policies, textbooks and latest journal publications.
Copyright Ian Miller 2008.
How to handle the workload.
The ED is a wild and stressful environment that constantly bombards each of our senses with a storm of demanding stimuli. And every nurse who works out on the floor for longer than 30 seconds will begin to feel the slip and the suck.
The slip is that uneasy sensation that the workload is getting away from you. There are just too many tasks that need to be done. As they pile up in your arms you begin to loose traction and slip downhill. The further you slip the more momentum you build, and the harder it is to get back on top. The sicker your patients, the greater the slope. The trick in not slipping is to constantly re-prioritize or Triage your tasks. Keeping the high value tasks ( ie attending to tasks that will have a direct impact on patient outcome) under control will give you an anchor. Constantly asking yourself what is the next important thing I need to do? And realizing that sometimes you will need to let some things just slide on past you. And of course, the best way to avoid the slip is to rope up with your colleagues. The suck
is that insatiable neediness that you experience from your patients. These needs can generate suction ranging from the urgent, such as a patient needing de-fibrillation; to the important, such as someone needing to talk; to the mundane, such as somebody needing a cup of tea. All patients in the emergency department will suck. The suck can quickly drain your batteries, and the trick is letting the suck pull you in the right direction at the right time. Sometimes you will find yourself completely immersed in your patients needs. At other times it is actually more therapeutic to work against the suck. The important thing to remember is the suck cannot hurt you. It is easy to imagine that with all this neediness around, it will suck you dry. It is easy to develop compassion fatigue and mental exhaustion and to begin to resent the suck. But the skill of nursing is to realize you are only a conduit for the care you deliver. Your patients cannot actually suck anything out of you unless you let them. It takes a long time to learn this.
How to nurse the machines.
Health-care is becoming more and more complex. Increasingly nurses are having to manage a patient that is encapsulated by a multiplex of highly technical life support equipment. A labyrinth of ventilators, monitors, infusion pumps, defibrillators, patient controlled analgesia devices, automated CPR machines, Glucometers, blood gas analysis machines, CPAP, BiPaP. Machinery entangles our work.
Copyright Ian Miller 2008.
-5- . In our acute care ward. In most instances you can learn far more from spending your time fiddling with the patient rather than the machine they are attached to. for unlike other complex computer systems. Begin with: Airway. Your patient is the center. the more their monitoring equipment will try to compete for your attention. It almost seems as if there are more people in the health system interested in the data than the patients. and enter vast oceans of data. warnings and legal disclaimers. Copyright Ian Miller 2008. So. Take time to distill some of the key operating functions out of those voluminous instruction manuals laying around gathering dust as they prop up a computer monitor. I just want to know where the batteries go! Most staff are only familiar with only a small portion of the full capabilities of most monitoring and interventional equipment. Ask yourself: what level of monitoring does this person actually require? Does that lady with a fractured hip waiting for a ward bed still need full cardiac monitoring? Does that man with the tendon laceration really need 30 minute blood pressures? If in doubt.www. Start troubleshooting from the ABC’s and from there work your way back out to the equipment. And the sicker they are. read the manual. From studies to audits to records to key performance indicators. there are the peripheral data gathering programs. Not every patient you care for will need to be plugged into a monitor. Don’t send in a machine to do a nurses job. not the machine. Have you seen the manuals that come with these things? Five hundred and twenty six pages of technical specs. Many patients in the ED get hooked up to monitoring equipment they really don’t need. Become a super user. And if all that hardware wasn’t enough. Make sure you understand how to change basic parameters and trouble-shoot simple problems with your equipment. Start at the center and work out. When the ventilator or the monitor is alarming. Try to get to know the machines. and patient tracking programs. Breathing. Remember: KISS ME (Keep It Simple but Show Me Everything) Alarm silence is the devils button. each of the 20 beds has its own monitoring equipment and it is pretty easy to get caught up walking around silencing all the alarms only to have the first alarm start up again. There has become an almost insatiable thirst for the collection of data and statistics. Circulation. Most monitoring equipment will have some form of alarm silence that will cut the klaxons for 60 or 90 seconds. nurses must collect. Patients in the emergency department are sick. How do we break free from the robots steely grip? How do we manage all this technology without loosing the human touch? Here are some quick thoughts on how to nurse in the machine: Focus on the patient.impactednurse. first look at your patient. when life support equipment crashes you are about to lose more than just data.com Equipment that needs to be maintained and operated with a high degree of precision. and rostering software programs that all must be appeased.
Have you ever been hooking your patient up to some piece of equipment only to discover the cables slash sensors slash tubes are smeared with gobs of blood slash sputum slash unidentified gross particulate matter.www. There is no doubt that all this technology can be beneficial in improving the quality of patient care. error-producing condition. It can be pretty embarrassing to you.com Instead of hitting the silence button as a reflex action. It can be pretty harmful to your patient. or palpating a pulse. -6- . Don’t ever misplace the art of taking a manual blood pressure. take a moment to try and correct the cause of the alarm. How not to make a medication error. Changeover in staff seemed important in four cases. Don’t become a robot.5%) reported one or more personal factors having an influence at the time of the error. Copyright Ian Miller 2008. show me the machine that will help me remove a bedpan topped with a shimmering meniscus of diarrhoea from the sweaty buttocks of an obese demented patient……. Hey. feeling the blood pulse under their touch. and eight staff were unfamiliar with the patient at the time of the error. cannot do without piece of technology to the hospitals. The human body is a much more complex and reliable piece of monitoring equipment than anything you will find hanging on the walls of the ED. 16 subjects (61. and usually more than one. staff were working after hours (eight instances) or in unfamiliar hospital areas (five instances) or attending a patient who was not their prime responsibility (eight instances). Study published in the Medical Journal of Australia. or (heaven forbid) actually counting the patients actual respirations. Commonly. Overall. and. usually because of the heavy workload. Don’t let your patient catch a computer virus. interviewed medical staff to explore some of the causes and conditions that led to medication errors in a busy Emergency Department in Western Australia. tired and/or engaged in multiple tasks. Keep the surfaces of the equipment clean. and hence being potentially distracted. Multi-national companies and start-up businesses are all queued up behind those big pharma drug reps to peddle that next whiz bang. And the future will hold far greater injections of technology into our profession.impactednurse. Refer to those voluminous manuals for acceptable cleaning protocols. Every medication error was associated with one. in two cases. Traditional Tibetan doctors spend years learning how to diagnose a multitude of patient conditions by simply concentrating on the qualities and characteristics of their patients radial pulse and examining their oral mucosa.and I will be all ears. including staff being busy. Know where the silicone ends and the flesh begins. Several admitted to feeling stressed. Imagine if todays doctors and nurses were to take the time to sit down and spend 3-4 minutes quietly holding the wrist of their patients. personal issues were thought to be contributory.
What are the most important things you can do to protect yourself against medication errors? Nurse with aggressive defensiveness: the compressed and pressured zeitgeist of the emergency department is skewed to siphon potentially catastrophic errors straight into your underpants. Nobody gets out of a career in nursing without a medication error or two sagging in their underpants.impactednurse. Slow down and turn on your lights. In the case of nurses. Be accountable: When you do make an error (not if. Incredibly. Another Saturday night. Advocate for developing an information rich environment. You have just completed a venipuncture and as you begin to withdraw metal from flesh the patient executes a flailing crocodile roll. Meditation. it is definitely an awful moment for any nurse or doctor. drug guidelines and relevant information at the point of medication dispensing. -7- . Medication. the patients doctor and the patient know. It is the worst feeling in the world. sometimes resulting from junior doctors’ reluctance to bother a busy colleague or their low expectation of receiving a helpful response to a request for advice. And encourage a culture of pro-tection (yourself) and co-tection (your colleagues). The sharp sting of the needle is accompanied by the sensation of your bowel squirting out your rectum like silly-string. Junior medical staff also reported lack of guidance from senior colleagues (seven reports). three of those were during the resuscitation of a single patient. I have had eight. At some stage in our career many of us will receive a needle-stick injury. Over the twenty years that I have been working in the emergency department.www. communication problems occurred mainly within the nursing team. Nearly the same word. How to manage a needle stick injury. (*not his real name. His arm slaps against yours and the needle slices through latex and deep into your finger.) Copyright Ian Miller 2008. In the case of doctors. Thank-you very much Dr Zhivago*. another rather intoxicated and uncooperative assault *victim*. When handling medications try to punch a little space in your multi-exponentialtasking of urgent things that need to be done hours ago. Easy access to current hospital medication policies. It is more like a shock than a stick. Be attentive. the worse thing you can do is to ignore it or try to cover it up. Two doctors felt pressured by nursing staff to increase sedation in older patients. but when). this was generally between teams at the time of handing over care.com Problems with communication were reported by 10/15 doctors and 6/7 nurses. Immediately let your supervisor. Be supportive. Even worse than getting a needle stick injury. Be vigilant always. Yes.
-8- . 200% attention when handling butterfly needles.8%. You should then activate your own hospitals policy for post occupational exposure management. Syphilis. Squeezing or milking the site is of little benefit. is oozing with Hepatitis. If a significant exposure to HIV has occurred. Needles should go directly from patient into sharps bin in one motion. Never leave a sharp lying around to take care of *in just a second*. Use of such post exposure prophylaxis is not to be treated lightly and expert guidance should be sought. Use safety needles and cannulas. The most commonly transmissible diseases of concern to nurses are the human immunodeficiency virus (HIV). retroviral drug prophylaxis should be offered promptly. Copyright Ian Miller 2008. If your hospital is not using some form of safety cannula. Once bitten: If you do experience a needle stick injury. Gloves. Sharps bins should be in abundance in the work environment ensuring rapid and safe disposal of contaminated equipment. practice this: every single patient you look after is HIV positive. and HIV as soon as possible. Of course the chance of transmission occurring is dependent of several factors including: The viral load of the source person at the time of transmission.) Hepatitis C: Infection from HCV following a needle-stick is around 1. insert cannulas. 100% attention when handling sharps. Got that? Now protect yourself accordingly: Wash your hands. immediately wash the site well with water. we still need to puncture our way through the skin to take blood. and crawling with MRSA.3%.www.impactednurse. and eye protection. you should definitely throw a big tantrum. Read up on your own hospitals policy. Remember. Standard precautions: Always observe standard precautions. Unfortunately. without exception. Depending on your immunization status you may need to have a course of HBV vaccine and a dose of hep B immunoglobulin. (Staff that have achieved immunity after being covered with the hepatitis B vaccine are practically immune.com These days needle-stick injuries are much more easily preventable. Never. the risk of transmission is determined by the type of exposure rather than the patient’s risk factors. with a risk of infection following exposure of around 6-30%. The volume of infected blood transferred. They are springy little buggers and will flick around and bite you given half a chance. deliver intramuscular injections and access a multitude of bodily cavities. risk of infection. HIV: Risk of becoming infected with HIV is a mere 0. hepatitis C virus (HCV) and hepatitis B virus (HBV). Many needle-less systems have been developed to eliminate the need for sharps in activities such as drawing up antibiotics and administering IV medications. If you practice nothing else. In most cases the actual risk of transmission of a blood borne pathogen following a needle-stick is extremely low. You and your patient will probably both need blood taken for serological testing for hepatitis B surface antigen (HBsAg). ever try to re-sheath or re-cap a needle. Hepatitis B: Of these HBV is the most transmissible. Before and after any intervention.
it’s just all so complicated. First. Everything turned out OK. But all is not as it seems…. This is just the way of the world. But whatever you encounter. If this is the case you should seek professional counseling. How to catheterize a male. Sleek and functional. In the condition known as hypospadias. and I’ve seen strutting young dudes with Percys’ that look more like vaginas. But not always. the urethral meatus can open anywhere along the ventral aspect of the shaft of the penis giving it the descriptive nickname of a “whistle dick”. You can then remove the outer pair once you have swabbed the site. Do not catheterize these patients. Most catheterization kits contain a second pair of sterile gloves to place over the first pair. At that time we had an HIV positive patient on the ward who had recently been cannulated. No one knew if this was the needle used on him. Copyright Ian Miller 2008.www. privacy and professionalism. Both signs of a possible urethral rupture. Make sure you explain the procedure and provide reassurance. No matter how low-risk the needle stick injury may have been it may still cause you significant distress. the doctor should have performed a PR exam to check for a high riding prostate. Its sort of like Mac and Windows. I may be biased. It then passes through the prostate. Perform a thorough hand wash and then don sterile gloves. I remember several years ago (before we had safety cannula’s) a member of our staff was stabbed in the palm with a large trocar needle as she was collecting up a pile of rubbish left on an IV trolley. Seek assistance from a medical officer.com The needle and the damage done: Having the statistics on your side does not lessen the anguish of sustaining a needle-stick injury. burrows its way down the length of the penis and emerges at the tip of the glans. Note: There are some important signs to look for in an acute trauma patient before you attempt a catheterization. Second there must be no bleeding from the urethra. but the mental stress placed on this nurse was significant. -9- . Penis and vagina. The normal male urethra leaves the bladder at the trigone.impactednurse. Penises on the other hand seem much more user friendly. I’ve seen little old men with members requiring a stepladder and safety harness to catheterize. the preparation: Once you have assembled your equipment as per your hospital policy you can position the patient laying comfortably on his back with legs slightly apart. Of course as a penis owner.even they are not without their own perils and pitfalls. remember that your patient is probably feeling pretty uncomfortable with the thought of you stretching them into an anatomically erect position before ramming a garden hose down their dangly bit. Catheterizing female patients can be exasperatingly tricky. heads up: Peni come in all shapes and sizes. I’ve seen dicks decorated with studs and rings and distracting tattoos.
Using the applicator syringe slowly squirt the entire contents of Xylocaine jelly (around 10 mls) into the urethra. Grasp the penis just below the glans with the thumb and first finger of your non-dominant hand.10 - . Be sure you roll the foreskin back over the glans if you pulled it back during swabbing.com Swab the shaft of the penis. Copyright Ian Miller 2008. causing the patient to tense-up and increase resistance to the passage of the catheter. you can gently apply a little more traction to the penis and push a little harder…. ask the patient to try and relax as if he were having a pee. Do not be alarmed if there is not an immediate flow of urine from the catheter. if left untreated. Take the penis in your non-dominant hand and gently retract the foreskin (around 1 in 6 males worldwide are circumcised). You want to make sure that you are not about to blow the balloon up in your patients urethra (You will know if this happens because his fist will rapidly fill your entire visual field). If resistance is felt. All that anaesthetic jelly tends to clog the end of the catheter and it may take a minute or so before it ‘melts’. Once the catheter advances smoothly. Once the balloon is inflated. Rather than having the Willy poking through the hole in the towel. and lay it on the sterile field. Swab the glans… and swab around the urethral meatus. lift across the catheter in its tray. try again with a slightly larger size or notify the medical officer.but that’s about it. . Lift it upwards. This straightens out the urethra. So at least wait a bit. Local takes around 3 minutes to work properly. I prefer to fold it in half ( the towel. All the way up to the hilt. This is painful. which normally follows a sort of ‘S’ trajectory in a flaccid penis. although that is a long time to be discussing the latest sports results with a bloke whilst holding his penis in your hand. Discard used swabs into the bin you have placed close by. continue to feed it in. If there is still resistance. not the Willy ) forming a slot that can then be slid onto the penis from below. Let us proceed.impactednurse. Carefully remove your outer gloves. squeeze the urethra closed between your thumb and finger (to stop the gel oozing out) and make a little polite conversation. lead to gangrene of the penis. you can gently pull the catheter back until it stops. Once the urethra has been filled with anaesthetic jelly.www. There are 2 potential roadblocks to a smooth catheterization. Pick up the catheter with your dominant hand while your other hand re-applies gentle traction. Now. perpendicular (or should that be perpen-dick-ular? ) to the abdomen. Insert the tip of the catheter into the urethral meatus and advance it cautiously down the urethra. If the catheter will still not advance you should remove it. Do not pick up the syringe and say “I am just going to inject some local anaesthetic into your penis!” Most males will think you are about to stick a giant needle into their privates and have a cardiac arrest. feeding it from the tray so as not to contaminate it. rocket science: OK. Pick up the fenestrated towel or drape. And cold. Inform the patient that this next bit is going to feel a little weird. Inflate the balloon with 10mls of sterile water and connect the catheter to the drainage bag. lifting the penis back to attention. to prevent a swelling and constriction known as paraphimosis which could. Most nurses rush ahead ramming the catheter home before the anaesthetic has had a chance to work. The penis then flops down onto the sterile field. Secure the catheter to the patient as per your hospital policy and clean up. The first is the external sphincter and the second is the prostate.
swab in a downwards motion between the clitoris and the vagina. and then relax and let her knees drop to either side. preparation and positioning: Preparation is the key. With your dominant hand pick up the catheter.com Not a pretty sight. Next. .) At times patients will be unable to co-operate or unable to comply due to injury and you will have to improvise on the best way to obtain an access trajectory. Once again with your non dominant hand separate the labia. separate the labia majora and clean the labia minora in the same way. The urethral opening or meatus is usually located in the superior fornix of the vulva. pink. Position the patient by asking her to draw her knees up with ankles together.in a soggy.impactednurse. OK.11 - . Copyright Ian Miller 2008. You can then remove the outer pair once you have swabbed the site. pass the catheter: In females the urethra is relatively short (around 4cm). Take time to position a good light source. It’s showtime. mushy. haystack. Clean along the length of each of the labia majora. studies have found that Lignocaine gel substantially reduces the procedural pain of female urethral catheterization by comparison with use of a water-based lubricating gel. (Make sure the patient remains covered whilst you are scrubbing up to guard against this. Remember. Using your non dominant hand. Now cautiously remove your outer gloves and discard. Good luck. The other nurse can assist with maintaining comfortable positioning. If you are a male nurse always have a female nurse present during the procedure. Pick up the fenestrated towel and drape the patient. scrub up: Perform a thorough hand wash and then don sterile gloves. How to catheterize a female.www. between the clitoris and the vagina. Most catheterization kits contain a second pair of sterile gloves to place over the first pair. Use a new swab for each pass.and sometimes it looks more like a needle…. Quality lighting of the area will show you what is what and where is where. Discard used swabs into bin which you have placed close by. And realize that having a strange male nurse swan diving into your privates will probably be quite traumatic for most female patients. Sometimes it is easy to spot. Assemble catheterization equipment as per your hospital policy. Obtain consent from your patient and inform her of what she should expect to experience. in a smooth front to rear action to minimize risk of contaminating your work with bowel flora. looking like a small stoma or a dimple or a slit….
The index finger of the non dominant hand is inserted into the vagina. This may cause some discomfort to the patient so take care. Connect the catheter to the urinary drainage bag. and end up in the vagina. Copyright Ian Miller 2008.12 - . and the finger can be held there to both block the vagina and guide the catheter in to the correct position. Now I have never tried this. TIP: Difficulty locating the urethra? here is a tip from the British Journal of Urology. When you hit a bull’s-eye ( and try not to yell out “bull’s-eye!”) you will get a return of urine. and sticking a finger into a patient’s vagina is extremely invasive.com Once you think you have the meatus in your sights hold the catheter in your dominant hand and gently introduce it into the urethra. so take time to prepare and clean the area as well as developing a sound aseptic technique. Advance the catheter a further 4cm just to make sure you are well within the bladder before inflating the balloon. It is not uncommon for the catheter to slide off some mysterious bit of anatomy that was not the meatus after all.impactednurse. Leave the catheter in situ and try again with a new one. Clean up the whole area. and document your procedure in the nursing notes including size and type of catheter… and don’t forget to remove that bundle of 4 or 5 *missed attempts* splaying out of her vagina.www.). following explanation to the patient it may prove helpful if absolutely all else fails. At this point you can ask her to take a deep breath in and relax as if she was having a nice pee. Tape the catheter as per your hospital policy. . Good grief! It looks like the back of my stereo down there. The urethral orifice can then be palpated on the anterior vaginal wall. The whole art of urinary catheterization is to minimize the risk of introducing a urinary tract infection. Make sure that there is enough slack in the system that any movement of the patients legs does not put traction on the catheter. Inflate the balloon with sterile water (check the catheter pack for correct amount. Never mind. Usually 10mls) and then apply gentle traction to bring the balloon up snug against the trigone ( the area where the urethra leaves the bladder. But.
call the priest.impactednurse. .13 - .www. It involves using a wire-cutter or pair of heavy duty trauma scissors to make two transverse cuts along the margin of the zipper (figure 1) and then attaching a pair of pliers carefully over the faceplate of the zip fastener. call the rescue helicopter. Hopefully still connected to the rest of the penis. and compressing firmly(figure 2). And it often leads to medical staff swooping in with an armada of local anesthetics. And I am talking from personal experience here. Copyright Ian Miller 2008. lubricants and surgically sharp objects. There is no pain like the pain of having your Willy caught in the gnashing talons of your zipper. Call the police.com How to remove a penis that is stuck in a zipper. So how exactly do you get a penis extracted from those interlocking mechanical incisors of death? Entrapment of the penile foreskin in a zipper occurs far more often than you might imagine. Well here are two tried and tested methods: The Chomp and Squeeze Method: The first method was reported in Indian Paediatrics. The pliers squeeze open the two faceplates “loosening the interdigitation of the teeth” allowing the prepuce to fall away.
. Simple.www. The screwdriver is then twisted firmly to open up the faceplates and… Free Willy. Most ED’s have a screwdriver laying around and they are certainly far less intimidating. the procedure could be carried out at home. Thats what I like. Copyright Ian Miller 2008. The Screw-This Method: Reported in Pediatric Emergency Care.impactednurse. I dunno…move in on my John Thomas with heavy duty cutting implements and pincing tools.com The authors assure us that this method results in “instant-aneously” solving the problem. and your problems might just be beginning…aneously or otherwise. DIY penis extraction. In fact. The prepuce is usually only trapped on one side of the zipper so insert the screwdriver in the opposite side. this method involves a common flat-head screwdriver inserted between the outer and inner faceplates of the zipper.14 - .
or as the timeweighted integral of the instantaneous pressures derived from the area under the curve of the pressure-time. recording it in our observation charts…but do we pay enough attention to the mean arterial pressure (MAP)? That innocent little number placed in brackets or hiding off to one side of the monitor screen.www. if you must know… it is obtained via Fourier analysis of the arterial waveform. Copyright Ian Miller 2008. When using non-invasive BP monitoring (BP cuff around the patients arm) the monitor uses this formula to determine the MAP.15 - . The reason that it is so important is that it reflects the haemodynamic perfusion pressure of the vital organs. so it is less accurate in the unstable patient. . at a normal resting heart-rate.110 mmHg. Cardiac patients on vasodilator (GTN) infusion.impactednurse. do I need to watch it? Definitely. Some examples (and there are many more) might include: • • • a patient with septic shock on vasopressors. and the formula is not as accurate. Whatever. Normal range is around 70 . how is it calculated? The simple way to calculate the patients MAP is to use the following formula: MAP = [ (2 x diastolic) + systolic ] divided by 3. What the heck is that number? Is it important? Should I record it? MAP is defined as the average arterial blood pressure during a single cardiac cycle.. and kidneys. OK. head injured patients. The reason that the diastolic value is multiplied by 2. It is a vital sign to monitor anytime the patient has a potential problem with perfusion of his organs. A MAP of at least 60 is necessary to perfuse the coronary arteries. brain. is that the diastolic portion of the cardiac cycle is twice as long as the systolic. it takes twice as long for the ventricles to fill with blood as it takes for them to pump it out…. I guess a rough analogy would be that the MAP is the oil gauge for your patients motor. Or you could say.com What is mean arterial pressure? We all diligently watch our patients blood pressure. During invasive monitoring of BP (using an arterial line) a complex formula is used that is way beyond my understanding to attain a much more accurate and real time value. In a bradycardic or tachycardic patient this relationship between systolic and diastolic values changes.
Selection: • • Long and Large: You want to pick a large vein and then put a large cannula into it. The larger the vein and the larger the cannula. .impactednurse. I think 80% of the trick in performing a successful cannulation is in taking time to prepare your equipment and selecting the best available site. You may well disagree with them. In a head injured patient. The target area should be well perfused. You should avoid attempting to cannulate over a bony prominence.16 - . a MAP above 160 reflects excess cerebral blood flow and may result in raised intercrainial pressures. It should not be in a zone of acute burns. is it true that women are worse than men at reading a MAP? Now. a cannula placed in the back of the hand is also likely to kink with movement of the hand. or you may have some better ideas of your own. In the emergency department setting we often need to deliver large volumes of fluid over short times. if you think I am brave enough to tackle that question you must be crazy! Where to place that cannula. A cannula placed at the cubital fossa is likely to kink off every time the patient bends their arm.com • Patient with a dissecting abdominal aneurysm who needs to have his BP controlled within a narrow range so as not to cause increased bleeding. For some reason placing cannulas in the back of a patients dominant hand seems to be a favourite site for junior doctors. the less resistance to rapid flows. On the other hand. It can also be quite uncomfortable. Before we begin machete-ing our way into the circulation. • scope the lay of the land. Other tricks used to get a little vein-o-erection include Copyright Ian Miller 2008.www. Pure and Pink: There should be no evidence of thrombosis or damage to the valves from previous attempts at cannulation. the brain is at risk of ischemic injury due to insufficient blood flow if the MAP falls below 50. Some people swear by using an inflated BP cuff instead of a tourniquet to really buff up those veins. wounds or infection. Similarly. let us tighten up the tourniquet and give the veins a little time to fill. Here are some tips based on my own personal experience. Let’s have a look. OK. Safe and secure: You should also consider both the security of the cannula and the comfort of the patient when considering placement. Preparation.
Advance the needle slowly to avoid skewering right through the vein. and even using vasodilatory creams such as Nitrobid paste ( this sounds a little dicey to me). check the other arm. Approach from the side whilst at the same time stabilizing the vein with your other hand by applying gentle traction to the skin. More experienced cannulators will probably tell you that they rely more on feel than on sight when searching for a vein. Start by inspecting the non-dominant arm. Particularly in older patients with more.17 - . Quite a few times I have battled to get a line in only to find veins the size of a garden hose on the underside of their arm. Known as pranging the vein. briskly tapping or slapping the area. Once through the skin the needle will advance easily until you feel a subtle ‘pop’ as you enter the vein.impactednurse. Never underestimate the importance of palpating. The skin will often require some force to pierce. Copyright Ian Miller 2008. These veins are simply begging to be cannulated. Don’t forget to inspect the entire surface of the arm. and its a simple matter of inserting your needle through the bifurcation and up into the root vein. well.com placing warm towels over the area. Sweet. letting the arm hang down over the edge of the bed (before applying tourniquet) . Once the veins are on show… look to see if you have one that bifurcates ( like the inverted Y pictured). . but don’t push too hard.www. ground zero. older connective tissues. Over time you can develop quite a sensitivity to the actual layers of resistance. but if you cant find anything jumping out at you. More often than not the vein will *roll* away from the needle. One mistake many people make when attempting to access a straight vein is to approach from above.
A 20g in the back of the hand can be a pain in the anus for the patient. . Step 1. and there is nothing as embarrassing as putting up the bed-side to find the railing covered in blood from a previous patient. Size does matter. The ability to place a cannula is indeed an art. focus. Select a good insertion site. The tapes will adhere better and remove easier. you will probably be right.Next. A big blob of blood left on the patient’s sheets is poor form. and always always observe universal precautions.its better to do this silently to yourself). blood tubes. Be the cannula. And while you’re about it.impactednurse. Copyright Ian Miller 2008. Put some sort of protective surface down under the site to catch the spillage. Set up properly using the provided trolleys. unhygienic and produces bad karma. Use your non dominant hand to stabalize the patients arm. Open a cannulation pack and assemble jelco. Make sure you shave the area with a surgical shaver if he/she is a hairy fellow. Select the largest cannula you can confidently insert into the selected vein. Apply gloves and eye protection. Preparation: Take a few moments to gather all the equipment that you might need.18 - . If I ever see you put a cannula in without personal protective equipment. especially if it is in his dominant hand. It sometimes helps to slowly chant the ancient Australian Zen mantra: gowin-yabugger gowin-yabugger (…. never hurry a cannulation. a spanking will be imminent. The more cannulations you do the more you will learn to feel whats going on through the cannula rather than by sight. There are usually plenty of veins on the forearm…. And don’t forget the basilic veins hiding under the forearm. And like all art it should be elegant. culture bottles.com How to place a cannula. it’s kinda embarrassing when you forget the cap.well at least have a look. how about explaining exactly why you need 20mls of his blood (not just “to run some tests”). Slow down. take a slow breath. Try to enter the vein from the side rather than from above as it will tend to roll away from the needle.www. Bounding over to the bed like a Jedi Knight on heat with only a Jelco in one hand and a cap in the other is unprofessional. You see. Make sure you inform the patient of your intentions. prepare the person. Think of this as a sort of Japanese tea ceremony. beautiful thoughts. Step 2.” If the patient is diaphoretic. Insertion: …… now Grasshopper. Remember: the larger the lumen the larger the flow rate that may be achieved. if you think you might prang the vein. and think positive.. Aplying gentle traction to the skin will help steady a rolling vein. a bit of Tinc Benz around the insertion site before taping and covering the cannula will ensure security. unhurried and appreciated. Confucius say. tape etc…. “pulling out arm hairs of big man sure way to hear sound of one hand slapping. Don’t use a disposable razor that might damage skin integrity. It’s fiddly and frequently occludes with dorsiflexion.oh yes. dangerous.
com Look for a flashback of blood in the trocar hub. This is a risky proceedure and believe me. Many people make the mistake of switching off once the line is in and slaphazardly sticking it down with a little tape.www.impactednurse. How many times have you come across a canula that has fallen out. thank the patient and disappear like a Ninja into the night. First things first: The first point is to slow down and take a little time to secure the cannula. But what if you don’t have such things available? What if you only have the basics? Let’s look at my way.19 - . just to illustrate the taping technique). Step 3. There is no point in getting it in unless you can keep it in. For extra bonus points write the date of insertion in pen on a steri-strip and stick it over the dressing. Use a vacuette or similar system to collect blood safely. Once you have enough blood. smoothly slide the cannula into the vein. or has become kinked. Copyright Ian Miller 2008. advance it just slightly to ensure the cannula is in the lumen of the vein. you will not forget your first needle stick injury. Believe me you will be saving yourself a whole lotta extra work by making sure the line is secure in the first place. the nurse. And for goodness sake pay attention. Cleanup: Dispose of your sharps. Remember the cannula tip sits a couple of millimeters behind the point of the trocar. or is half out. Here we have our freshly inserted cannula (it is sticking out of the skin a little further than we would like. inevitably earn a certain respect amongst their peers. . Immediately dispose of the trocar into a sharps bin and cap the cannula. How to secure a cannula. Obtaining IV access if a pretty important skill to be mastered in the Emergency Department.it’s time to take some blood. inject a few mls of saline into the cannula to ‘lock’ it. the bed. Or is at risk of becoming infected. And there are many commercially available devices that do a great job. But IV security is often given little attention. And those with sharpshooter IV insertion under pressure. Apply the dressing as per your department’s policy. the walls). Make it elegant. so once you have a flash back. cleanup your mess (including blood spilt on the trolley. Now holding the trocar stationary. There are a hundred different ways to secure an IV cannula. Once you have it in….
You want it sticky side up which I have shown in green. Remember.www. Nearly there: Now. you can apply some Tinc Benz or Friars Balsam to the skin. this should all be done aseptically…. Make sure it does not obstruct or stick to the IV bung or IV tubing. This is an antiseptic solution that dries very tacky and guarantees a secure dressing even with profusely sweaty patients. Once again. .so good: Next you want to fold up both corners of the Steristrip to form a ‘U’ around the insertion site. Next: Take another Steri-strip and place it (sticky side down) over the top of the cannula. It is this 360 degree contact around the cannula that makes it so secure. press it down firmly and gently pinch around the cannula to secure it good and proper. Slide it up nice and snugly where the cannula enters the skin. Gently ‘pinch’ around the cannula with forefinger and thumb to bond the two sticky surfaces. So far…. Copyright Ian Miller 2008. place a piece of Op-site or Tegaderm or similar adhesive dressing over the top of the whole thing. Make sure you leave a little sticky surface exposed on either side of the cannula. and manipulating sticky tapes with latex gloves on is definitely an art.impactednurse.20 - . This surface will stick to the sticky surface the next Steri-strip providing 360 degrees of *grippage* around the cannula.com The first step is to place a Steri-strip (or similar sterile tape) under the cannula. If the patient is very diaphoretic (or as we say in the ED…. sweaty).
you are probably right.” And he left to look after sick people. the doctor actually maneuvered him completely off the bed and into a chair. If the patient is restless or confused. For extra security and to stop the bung from catching on bedsheets and ripping out. For bonus points. Make sure you dont tape the IV line directly to the dressing as it will pull the whole thing apart when you are trying to change the line. Ranging from withdrawing into themselves after a traumatic event. via remote nipple control. If your gut feeling is that your patient is feigning it. I quickly notified the senior doctor on duty who wandered over. . Copyright Ian Miller 2008. I was a virginal student nurse looking after this young dude. write the size of the cannula and the insertion date on a sticky label and attach to the Op-site.impactednurse. to attention avoiding behaviours. to attention seeking behaviors. There are many reasons why people who present to the ED play possum. place another Steri-strip over the top of the bung. After leaning over and examining the patient for a few moments he glanced over at me. and I was worried.21 - . I remember looking after a young girl that I was convinced was a total hyperventilating. How to tell if your patient is playing possum.www. If you are connecting the IV line apply this last strip after the connection. But you are not definitely right. “I think he was faking it. to psychiatric illness. took hold of the mans left nipple and twisted it up to volume level 11. He had been dropped off at the ED by a *friend* after an afternoon of drinking that culminated in a ding dong argument. you may need further IV security by using wide Elastoplast and/or bandages.com Another cannula secured: Finally. Wide eyed the man sprang up in bed and. Loop the IV so it is travelling back towards the patient and secure it with some tape. He was not responding to my attempts to rouse him. hysterical.
If they are bogus. Here is a mnemonic to help you remember them: A. Any resistance to eye opening is a tell.epilepsy. a patient playing possum should still be managed as an unconscious patient until a definitive diagnosis of pseudogenic coma can be made. Once you have stabalized the ABC’s there are a few tips you can use to determine if your patient is a possum: the sternal rub: Vigorously grind your knuckles against the patients sternum.overdose U.impactednurse. tumors I . There are many potential causes of a decreased level of consciousness in your patient. A patient pretending to be unconscious will invariably readjust the trajectory so the hand falls away from their face. In fact she had a large brain tumor. This causes what is known in the business as noxious stimuli.insulin (diabetes) O .psychiatric disorders S .22 - .www. the hand drop: With the patient lying supine. the finger press: Take your pen and press it hard against one of the patients nail beds.alcohol. Circulation requirements must be anticipated.trauma. the eye flicker: Gently run your finger along the patients eye lashes. the possum may roll his eyes back up into his head until you can only see sclera Copyright Ian Miller 2008.uremia (metabolic). environment I . underdose T . the reveal: Gently open the patents eyes. . They should have a full neurological assessment (Glasgow Coma Score) and Airway. Breathing. their eyelids will tend to flicker. anoxia E . And let it drop.com attention seeking brat. Once open. Lift their hand above their face at a distance of about 20-30 cm. This really hurts. toxins.infection (sepsis) P . acidosis. and will usually rouse the pretenders.stroke (CVA) So the short of it is.
passive eyelid opening is easy and is followed by slow eyelid closure. From the recourse rich. it will probably happen half way through their abdominal CT scan. Trick them out.23 - .www. With patients who have a true decreased level of conciousness. . One paper I read suggests holding a mirror up in front of the patients open eye and observing for a pupil constriction when they look at themselves. to them. I’m kidding. It looks as though a meatballs and tomato soup truck has crashed through an office supply shop and into a telephone exchange. the ignore: Once you have finished evaluating your patient. controlled environment of the resuscitation room… up the corridor. And so they are off to scan-land. They lay amongst a distillery of tubes and infusions. Intubated and ventilated with full spinal precautions. The patient is behaving in a way that. and over to another food chain altogether. The eyes of patients who are unconscious may have a neutral position or exhibit a roving gaze where the eyes slowly scan back and forth across the visual field. skewered with chest tubes and plugged with combines. seems totally appropriate or necessary within their current situational experience. or the lack of attention overwhelms them and they *wake up* in order to get a little interaction. The ability to maintain a compassionate and professional attitude towards their care will often result in a patient that ends up responding in a therapeutic way. You are not going to score a bonus point for tricking them or catching them out. cat as in catastrophe: You have just spent the last 30 minutes working to stabilize this multi-trauma patient. But at least the patient is now stable. If anything is going to go wrong with your patient. The room is a mess. Blinking also increases in possum patients.com (known as Bell’s phenomenon) or move around in short well defined (geotropic) tracking movements. the wasabi woo-woo: Save up those small packets of wasabi next time you have Japanese take away. it is important not to be judgmental or to ridicule these possum patients. How to manage a patient having a CAT scan. and you may simply end up with a bed full of trouble. Actually. Lack of interaction either drives possums crazy and they just have to take a peek to see what is going on. Here are some tips to help you prepare for any impending CAT-astrophe: Copyright Ian Miller 2008. I’m kidding.impactednurse. but decreases in true coma. place them in the recovery position and go about your business. Open the patients mouth and squirt.
impactednurse. Draw up some non-depolarizing muscle relaxant such as Vecuronium to take with you. Drugs. Take time transferring the patient form bed to CT table. Before clearing out of the room and beginning the scan. Oh… and one piece of advice (from personal experience). check to make sure the patients catheter bag is not still attached to his bed before sliding him across. Take some extra fluids. CT staff are always in a hurry.www. Portable monitoring equipment (check the batteries). You know. ABC comes way before X-ray. Its a pretty good idea to try and untangle that macramé cocoon of IV tubing from around your patient before you leave. Dont forget an Airviva. tackle the tubes. a dedicated saline line). They have plenty of ward scans to attend to and you have just messed up their schedule. for some reason the control room of the CT scan is like a kitchen at a party. Adequate ventilation is being delivered. check: • • • • Airway is secure and patent. Identify a line that will be suitable for CT staff to use for administering any IV contrast (ie.com pack before you go. Often you cant even swing a CAT in there. Try not to get distracted by the party and keep your eyes on the prize. . If he is unconscious this will need to be administered via a Naso-Gastric tube. Some staff refer to this as the Keep’em down Kit. At the very least make sure all lines are securely anchored to your patient. Make sure you have clear sight of the monitoring equipment. Make sure you take time to assemble all the equipment you might need: • • • • ACLS equipment. But. I’m just saying.24 - . don’t join the party. Ditto the IV tubing. Find out if your patient requires oral contrast prior to an abdominal CT. Copyright Ian Miller 2008. It always seems to fill up with people who haven’t seen each other for a long time and have a lot of catching up on gossip to do. If your patient is paralized they will inevitably wake up half-way through their scan. make sure you have an experienced doctor along for the ride. If you are taking an unwell / unstable patient to CAT scan. Observations are all stable. invite the boss. Check all ventilation tubing is secure with enough slack to cover the expected range of movement of the patient through the scanner. Continue to document the patients observations.
com Watch for any disconnections or pulling of lines as the patient moves through the scanner. Here is a quick tip. Although commonly known as laughing gas. Adjunct to lignocaine in laceration repair. Middle ear infection / recent middle ear surgery PE Decreased level of conciousness (LOC). the pleural space.25 - . Migraine. (CAR) assessment. Remember… your patient has now entered the tunnel of death. Child at risk. smear a little flavored lip balm into the inside of the mask to provide a *juicy* pleasant smell. How to use nitrous oxide. It was discovered by Joseph Priestly in 1772 and was first used to provide relief during dental extractions. If you are having trouble getting a child to tolerate an oxygen mask. or you need to deliver nitrous oxide via a mask.www.impactednurse. Nitrous oxide is a tasteless colourless gas that is rapidly absorbed into the bloodstream where it acts on areas of the brain and spinal cord that are rich in morphine sensitive cells. Reduction of joint dislocations. Indications: • • • • • • • Relief of pain from muscular-skeletal injuries. the sinuses and the GI tract so it should not be used if there is any risk of: Intracranial air Bowel obstruction. Nitrous oxide ( N2O ) is the oldest known anesthetic agent. If you purchase a selection of different flavors you can then ask the child to help you decide which flavored oxygen they will get to breathe. Contra-indications: • Pressure effects: N2O Does increase the volume of gas in body cavities such as the middle ear. • Copyright Ian Miller 2008. . When you finally do leave the CT room. the use of N2O for procedural sedation is no laughing matter and should only be instigated by staff members experienced in its management. Adjunct to other analgesia in wound care and dressing. Adjunct to analgesia during child birth. Anything that is going to go wrong will now do so. you should have left this greasy mark where your nose has been pressed up against the glass (really). Tip: lip balm and oxygen.
impactednurse. The blender permits the user to titrate the N2O to oxygen ratio. Effectiveness Complications Copyright Ian Miller 2008. and to adjust the flow rate. Recovery: Following the procedure. any leakage will tend to settle on the floor. Early pregnancy.www. N2O may cause desaturation. N 2 O causes nausea and vomiting in about 10% of cases. IV sedation or narcotic in the last hour. Immunosuppression. and as mentioned. As above. . the patient should be observed until they can safely mobilize. Observations should be obtained every 5min during the procedure. Fasting < 90 minutes. In some animal studies N2O has been proved to be directly teratogenic due it inactivation of Vit. airway obstruction or even apnoea. B12 B12 deficiency. A scavenger tube placed on the floor will collect this residue and remove it via wall suction. it may be teratogenic. The procedure: A baseline set of observations should be obtained prior to commencing.com • • • • • • • Child < 5 yrs. Remember: one of the causes of inadequate sedation may be a leak in the circuit or poor seal of the face mask. If at that time sufficient sedation has not been achieved it can be slowly ramped up to a maximum of 70%. The machine consists of a facemask that attaches via tubing to reservoir bag and blender. and one to perform the procedure.) Most N2O machines also have some form of scavenger system. The patient should be placed on a cardiac monitor. As the patient will be drowsy. one to administer the N2O and to manage the patient’s airway. the patient should be placed on high flow oxygen and observed closely until baseline LOC returns. Set-up: Make sure you have an informed consent from the patient prior to beginning the procedure.26 - . Duration of procedure. it is important to use a clear mask on the circuit so you can keep a close eye on the airway. Suctioning should be also be available and at close hand. As N2O is a heavier than air gas. Psychiatric disturbance. There must be a minimum of 2 experienced staff. N2O may cause desaturation. (Administering as little as 40% N2O is usually enough to produce confusion and sedation. paying careful attention to the patient’s airway status and level of consciousness (LOC). If being discharged home. airway obstruction or even apnoea. A significant amount can quickly accumulate in a poorly ventilated area. Assemble your Nitrous oxide machine as per ward policy. Document the procedure in the patient’s notes including: • • • • Max % of N2O administered. pulse oxymetery and have full ACLS equipment available. The doctor should begin the N2O at 50% for no less than 3 minutes.
Mumbling. That prolonged. Staring was flagged as an important indicator of violence potential.com Tips: Prior to administering N2O to young children you might give them the mask to play with whilst you are setting up. When combined with other negative cues. Anxiety.27 - . Pain. Copyright Ian Miller 2008. especially when composed of aggressive. eye contact we have all experienced drilling into our backs as we go about our work. or it may manifest as aggressive. family members or friends. alcohol or drugs can all induce an internal environment fueled by acute anxiety.www. Staring. This gives the gas a pleasant smell and allows the child to choose which flavour gas he would like to have. Pacing. It has been well documented that violence in our emergency departments is on the rise. flushed face and hyperventilation were identified as predicting trouble ahead. Indicators such as rapid speech. intent. pacing. The large number of emotional and physical stressors poking into the patient. anxiety.impactednurse. threatening or intimidating behavior. I have added my own tool to help you defuse such a situation: predicting violence with STAMP: Stamp stands for staring. loss of control. mumbling or slurred and incoherent speech. fear. It may come from the young man high on amphetamines or from the elderly female office worker. The study lead by Lauretta Luck has developed the acronym STAMP to help nurses categorize behavior sets that may point to a raised potential for violent behavior. A recent doctoral study completed in an Australian emergency department has developed a tool to help nurses predict potential for imminent violence directed toward staff by patients. is a good predictor of increasing anger. Patients pacing around the waiting room or visitors pacing around patients beds was found to be indicative of mounting agitation. Violence may be an actual assault. We also keep a variety of flavoured lip balms that we apply to the inside of the mask. negative statements about the waiting times or service was another good predictor. . can easily push them into a space where their behaviour is not in character or control. Minimizing Violence with STAMP AID. mumbling.
Copyright Ian Miller 2008. Agitated or aggressive patients are enveloped in a no-go bubble that extends the distance of their outstretched arms. keep them informed of the expected delays and any changes to their position in the queue. defence. Remember all this anger is not yours unless you choose to react to it. Imagine yourself stepping *outside* the situation looking on dispassionately. Avoid prolonged eye contact if patient is agitated or paranoid. it is much harder to predict how that violence might be expressed. What can you do? Well here is a tool I have come up with to minimize a situation of escalating violence. The fact is we should be promoting a zero tolerance for aggressive or violent behavior. Never enter their bubble unless absolutely necessary. Listen to any questions they may have. This simple act of attentiveness is often enough to de-escalate any anger and will often prove a far easier interaction than trying to manage a later situation of overt hostile aggression.com Averting violence with AID: So you have a pretty sure feeling that you and your patient are headed for conflict. This is a bad thing. Attend. defence. try not to avoid a patient that is beginning to show signs of STAMP. Make sure all your patients have an opportunity to access this information. Stay safe. Make any instructions short and unambiguous. AID stands for attend. patients often perceive that they are not receiving the level of attention they need. When patients are waiting to be seen. One of the big generators of anxiety amongst patients and relatives is the feelings of *abandonment* they experience in the ED. Talk in a calm.www. With a sustained exposure many ED nurses have desensitized themselves to low-level violence and have a much higher threshold of acceptance than most people. inform. Inform. even. Never let an aggressive person come between you and your exit strategy. or waiting for test results. Communication breakdown is another major cause of increasing aggression and contributes to feelings of abandonment and loss of control. Many emergency departments now have hand-outs or notices explaining both the Triage process as well as preparing them to spend an extended time as they are treated in the ED. Though it may not be an easy task. Tell them what has happened what is happening and what will happen. . Never mind if it’s the waiting room or a treatment area. Never forget that even though we may be able to predict an escalation of emotions that may lead to violence. Patients should also be informed with signage and handouts that aggressive behavior will not be tolerated. or waiting for a ward bed to become available.impactednurse. As I have advised before: When interacting with a potentially volatile patient it may be helpful to try and see your self as an observer of the scene. Watch how the relationship between the other you and the patient is evolving. Even if we cannot meet all their perceived needs the very act of exercising authentic concern may be enough. By making an effort give attention to these patients we can often diminish these feelings.28 - . period. clear voice.
29 - . Forget the shift coordinator begging you to work yet another double shift. ahem. From loss of dignity. the trumpet should cause only a transient discomfort for the patient. it is simply held in place by the resistance of the flange against the anal sphincter tone.com It’s not easy.impactednurse. Take a size 7 or 8 nasopharyngeal airway and connect the tapered / beveled end to a urinary drainage bag. Profuse… watery… diarrhoea. It should be part of your ongoing professional development to establish a set of skills and strategies for dealing with these sorts of scenarios. Forget intoxicated teenagers. From personal embarrassment to painful skin erosion around the buttocks and perineum. Forget gaping lacerations with arterial bleeds squirting like out of control garden hoses. Profuse… watery… diarrhoea. (Taping the tubing to the patients leg may prevent this.www. it is surely a miserable and demeaning experience. Temporarily clamp the drainage tube and use a syringe to pour olive oil through the airway into the tubing taking care not to spill any onto the distal flange of the airway. Copyright Ian Miller 2008. excessive straining or forceful valsalva maneuvers may expunge the trumpet. but for the poor patient inflicted with this liquid catharsis. Perhaps the three most terrifying words ever to be uttered during handover. There is no doubt that it is an onerous and odorous business for the attending nurses. position the patient on their side with knees drawn up to chest.the Rectal Trumpet. likewise. By adding the rectal trumpet to your kitbag of tricks. Release the clamp allowing the oil to drain into the urine bag. Debra Jackson. Make sure it is all positioned so as not to produce any tension on the tubing. If the patient has severe abdominal distension the resulting pressure on the rectum may dislodge the trumpet.) There is no need for any other taping or securing of this system. to sepsis resulting from wound exposure to nasty organisms.. Enter stage right with a fanfare…. The tubing is now well lubricated. but otherwise it should usually remain in-situ. If practical. the words profuse watery diarrhoea will be. but using this technique may help you from getting caught in the emotional wash from an abusive patient and feeding the escalation with your own reactions. butt music to your ears. Reference: STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. Pull back gently until a slight resistance is felt. Kim Usher Journal of Advanced Nursing Vol. Carefully pass the flange end of the airway into the rectum. Many hospitals offer courses on dealing with cases of professional assault which offer a combination of de-escalation strategies as well as simple self defence techniques. Lauretta Luck. Warn the patient that the next step may be temporarily uncomfortable. projectile vomiting McDonalds with extreme prejudice. . Attach the urinary drainage bag to the bedside. Once passed. 59 Issue 1 Page 11 July 2007 How to use the rectal trumpet. No…it is these three words that will drain the blood from the face of the most hardened ED nurse.
Hey scientist people…. . each has its own particular signature odor. Some seem to stimulate the gag more than others.30 - . green bubbling steamy poo. this smell that threatens to release our lunch back into the wild. skatole. Scientists have postulated that it is to deter people from eating it. and now you and your colleagues will need summon your full concentration to engage in that ancient nursing art of suppressing the gag reflex. you roll your semi-conscious patient over only to discover a steaming lumpy broth of diarrhoea that. Copyright Ian Miller 2008. I don’t know why poo makes you gag. septic poo. I once was helping to undress this drunken teenager when something fell out of her tracksuit trousers onto the floor. And I don’t certainly don’t know why evolution could not have given nurses a break and made it smell like lavender. and hydrogen sulphide.www. Nurses tend to become the wine connoisseurs of the fecal world. Malaena.. thanks to the physics of capillary action. indole.com How to handle the smell of poo. On closer inspection it proved to be a chunk of *petrified* poo. It mus have been in there for months! And it had absolutely no smell. gastro diarrhoea. constipation. Its way too late for the rectal trumpet.I got news for you. But there you go. I picked it up and thought it was a piece of wood. Just as there are many types of poo. Here are some practical tips to help you through your next code brown. You all know the scenario. is caused by bacterial action in the intestine which produces sulfur containing compounds.impactednurse. poo pointers: OK. has oozed and squittered its way into every fold and fossa betwixt and between. Incidentally.
. On our own ED we have disposable full face shields as part of our personal protective equipment. you sort of taste it…… Urrch. These work quite well as you get a relatively fresh chunk of atmosphere trapped between the shield and your nose. Also protects against cleanup spatter.com surgical mask and peppermint. face shield. Flavoured lip balm or “Vicks Vaporub” are also quite effective options and easily carried in your kit. too much peppermint and you will think you have been capsicum sprayed. oxygen mask. It does take the edge off the smell but doesn’t really take the gagerosity out of the whiff. Just take care. A couple of drops of peppermint oil on a surgical mask and you are *good to go* into even the most malodorous mess.. In fact I suspect that rather than smell it. Copyright Ian Miller 2008. desensitization. Its a tradition.uucGGAWWW……urrch!!! And loose not only my lunch. Smear inside a mask or directly under your nose. When we were both student nurses. breathe through your mouth. On the other hand. The more poo you do the better for you. He told me he found a Hudson mask running at 10 liters/min to be most effective. Personally. delegate. lip balm.impactednurse.31 - . a good friend of mine got himself in a world of trouble when he was sprung by the senior nurse cleaning up a patient whilst wearing an oxygen mask. but any last modicum of professional credibility that I may have left.www. This is only vaguely effective. I give him an A+ for ingenuity. stand next to me during a clean-up and you will see beads of sweat on my pale forehead as clench my jaw and concentrate with Herculean effort on not going: bburrWAGGHHHHhhh…. The charge nurse was not impressed. Veteran bedside nurses can scoop up handfuls of the stuff whilst deeply inhaling to discuss the Beef Vindaloo they ate for dinner last night. Sometimes the only option you will have. This is perhaps the most effective method of odor eradication. Student nurses and new-grads.
www. tongue studs and anything else that will interfere with x-ray views. Thrown over handlebars of a bike. Remove any jewellery above the clavicles including necklaces. carefully assist them to the supine position. The Fitting. is not an option. Kicked by or thrown by a horse. Usually a couple of sandbags on either side of the head accompanied by appropriate analgesia and thorough explanation will be sufficient.32 - .com How to immobilize a suspected spinal injury. After fitting. Obvious history of neck trauma . Any significant trauma above the level of the clavicles. There are quite a few rigid collars available with slightly different sizing techniques. Midline tenderness or reluctance to move the neck. Severe electric shock. . Every year we see hundreds of patients with suspected spinal injuries or who require precautionary spinal immobilization. Inform the patient of your concerns and that in all likelihood this will only be a precautionary intervention that will be removed as soon as a more thorough assessment can be made. Remember. He had an unstable C2 fracture. fidgety. Tie me down. nose studs. Tie me up. Copyright Ian Miller 2008. A tiny weeny percentage of these are proven to have any actual lasting damage. This only made the patient more anxious and uncomfortable leading to increased movement. Unexplained hypotension following trauma. If the patient has walked in to the department you might find it easier to fit the collar whilst they are sitting on the edge of a bed. Fit a rigid immobilizing collar. We used to use medieval lashings of tapes and bindings to immobilize the rest of the body to the bed or spinal board. earrings. Follow manufacturer’s instructions to obtain a snug symmetrical and effective fit. Backed over by a car. Occupant of motor vehicle involved in a collision greater than 60km/hr. Neurological deficit. We use special slide sheets to minimize friction as we swivel them into position. human beings are innately jiggly.impactednurse. Fall more than 3 meters. I once triaged an 11 year old who presented with persistent neck pain 3 days after a fall in Judo class. Some mechanisms of injury that should be ringing your bells include: • • • • • • • • • • • • A pedestrian or cyclist hit with an impact speed greater than 30km/hr. You will need an assistant to immobilize the c-spine whilst you fit the collar. Complacency however.
Make sure you have suction equipment at the bedside in case this does occur. less intervention is best in achieving some balance of spinal stability in these people. so be prepared. ensure they have a call bell handy. Who to X-ray. seriously. sedation. the management of a drunk or aggressive patient with a suspected spinal injury is a complex problem. Once again explanation of your management plan is important. Consider the use of an anti-emetic to manage nausea and vomiting. the catastrophic sequalae of a spinal injury. If you are going to leave the bedside. During transfer to x-ray etc. Reassess their neurological status after any interventions. • Any patient who has a suspected spinal injury with an altered conscious state. You will also need to have a plan to initiate a rapid log roll of the patient onto their side if they are vomiting. the things we do that interfere with the process of natural selection. As I have mentioned appropriate and adequate pain relief is mandatory. the patient must have a medical escort. one to maintain spinal alignment of the head and 3 to roll the body. I’m going to be sick. but if at high risk of spinal injury. and the collar should be substituted with a two-piece hard collar such as the Philadelphia collar if it is to be utilized for longer than 6 hours. paralysis and intubation may need to be considered. You will need a minimum of 3 people to do this. Staring up at the ceiling and not knowing what is going on will promote isolation and anxiety.impactednurse. Pressure area care should be attended every 2 hours whilst the patient is immobilized (especially in the elderly). I tell you.33 - . Sedation may be contraindicated if they have an accompanying head injury. in the nicest possible way. No. . Usually though.www. Attempting to maintain spinal immobilization in these cases will often only lead to increased movement of the neck.com headwagging animals so gently emphasize. Once your patient is properly immobilized you must remain vigilant and attentive. The drunk or aggressive patient. Copyright Ian Miller 2008.
Neck tenderness and/or pain.com • • • Adequate assessment is difficult due to distracting injury or intoxication/sedation.34 - . This time of the year. Abnormal neurological signs. . A jogger out for a Sunday morning run notices an unusual lump in the frostcovered field and discovers a frozen teenager who had gotten drunk during the night and fallen asleep on the grass. How to manage hypothermia. And would it be too crass to bring up the topic of snowballs? I thought so. Moderate Hypothermia ( 27-32 C): The body gives up trying to shiver and becomes unable to rewarm itself.impactednurse. For an accurate temperature. The central nervous system becomes depressed and apathy. Decreased level of consciousness ensues. Now that’s an icy-pole. The ECG may show a Copyright Ian Miller 2008. Temperatures had been around minus eight overnight. many of our patients present with a low core temperature.www. ataxia and drowsiness may develop. A patient is becoming hypothermic once their core body temperature drops below 35 C. But be careful…we once spent quite some time unsuccessfully attempting to re-warm a patient only to find out that he had expunged the rectal probe in a frozen poop-cicle that was now laying in hibernation on the bed. • • Mild hypothermia (32-35 C ): The body begins to shiver in an attempt to generate heat. and on arrival in the ED he was so cold he had icicles on the end of his penis. a rectal probe is the preferred method. It is mid winter.
Patients that have severe hypothermia may be refractory to many drugs as well as defibrillation due to their glacial metabolism. ( It may also be used in the elderly or pts with cardiovascular instability). Actually. Don’t forget to place warm blankets around the patients head. so be particularly careful when transferring the patient across onto the resuscitation bed when they arrive. Don’t give up until they warm up: Icicles on his penis and balls of snow? If he is not dead he’ll sure wish he was. warm blankets and devices such as the Bair Hugger that blow warmed air over the patient. handle with care: As I have mentioned. You should also be using warmed IV fluids in this situation. Passive re-warming is used with mild hypothermia. Try to minimize moving the patient whilst re-warming.impactednurse.www. many people presenting to emergency departments have made a full recovery from severe hypothermia. Options for active re-warming include: • • • Administering warmed. Pt is comatose. Afterdrop can also be precipitated by a patient moving around excessively as they begin to rewarm. humidified oxygen (preferably via endotracheal tube).com prolonged QT interval and a J wave may be seen between the QRS complex and the ST segment. afterdrop: Once re-warming has begun. Take care during any intubation too. . Cardiopulmonary bypass with re-warming of the extracorporeal blood. The aim is to warm up the patients environment. This is a continued drop in temperature as circulation improves and cold blood is washed in from the extremities. Estimates of the percentage of body heat lost through the head vary between 7 to 50%. So CPR may need to be prolonged. Severe Hypothermia (27 C or less): Vital signs are depressed. Passive rewarming involves the use of overhead heaters.35 - . the patient may experience afterdrop. The patient is quite likely to develop arrhythmias (particularly with stimulation such as intubation or movement). any sudden movement or jolting may trigger ventricular fibrillation. Remember: “A patient is not dead until they are warm and dead” Copyright Ian Miller 2008. Active re-warming: Active re-warming is considered with temperatures less than 32 C. • Passive re-warming: The doctors will decide if the patient requires passive or active re-warming. so aggressive resuscitative efforts should be considered in this situation (that is unless they are frozen solid or have catastrophic injuries). Peritoneal lavage with warmed fluids. Once the patients temperature has been re-warmed to 32°C an assessment to terminate resuscitative efforts can be made by the team.
Small amounts of air are probably absorbed by the plasma and haemoglobin. This in turn. . rapidly-entrained bolus of air can fill the right atrium with air and cause an air lock. and decreased cardiac output.com How safe are air bubbles in the IV line? We’ve all seen it. Laying the drip chamber down on its side only encourages air to enter the tubing. But how much is safe? The online site www.emedicine. spinal cord and the skin. decreased venous return. Do not place IV fluids down on the bed when transferring patients etc.impactednurse. But never-the-less. When hanging a new bag on an existing line. • • • Dont forget to prime the IV line! Sounds stupid. Large amounts (of between 100 to 300 mls) have allegedly been fatal. it would be wise to take steps to minimize the risk of larger amounts of air entering the system. but it happens more often than you think. “Don’t worry”.30 mL/kg per minute A large. may trigger an inflammatory response resulting in noncardiogenic pulmonary oedema and bronchoconstriction. Copyright Ian Miller 2008. we assure them… “its far too small to cause any problems”. In animal studies. it can potentially make its way through to the Right Atrium and Ventricle. So those pesky little bubbles travelling down the tubing are probably not going to do any damage. So exactly how dangerous are those little air bubbles? And how much air would be needed to cause an adverse event? Or to put it simply: would 10mls of air injected into the IV line by the evil ninja assassin disguised as Dr Singer (who has been tied up and thrown in a linen skip). So now you’ve really scared me.36 - . Myocardial and cerebral ischaemia soon follow. the ability of the lung to filter air micro-bubbles fails when air enters the circulatory system at a rate greater than 0. Patients looking wide eyed and worried at a small bubble of air as it travels down the IV line and off into the mystery of their arm.www. Although it states that as little as 20 mls (around the amount of air in an unprimed IV line) has been reported to cause some problems. Here air may occlude the microvasculature increasing dead space and damaging the vessels endothelial lining. but larger amounts have been associated with interfering with pulmonary gas exchange. OK.com states that more than 5mls per kg is needed to cause significant complications. be enough to kill our sleeping hero and stop him getting the girl? Once a volume of air is introduced into a peripheral vein. and causing cardiac arrhythmias. and then on into the pulmonary vasculature. Air bubbles may also occlude the micro circulation of other organs such as the brain. which leads to obstruction of the right ventricular outflow tract. check to make sure the previous fluid hasn’t run down the line leaving a large airspace.
It may be a hospital. Fever can be defined as a rectal temperature greater than 38. Now. Do not let the patient end of the IV tubing drag around on the ground while you are spiking the bag. How to manage paediatric fever.www. when your patients IV fluids are finished they will stop at the level of the bottom of the flask. Invert the bag back into its normal position and continue to prime the IV line. . first invert the bag of fluids so you are spiking it from above. and another thing: Never pull the cap off the spike with your teeth like they do on TV.impactednurse. As soon as little Miss Molly presents with even a slightly elevated temperature.0C. (rectal Copyright Ian Miller 2008. ALL neonates less than 4 months old who present with fever should have expert assessment without delay. priming tip: Heres a quick tip. but its still pretty dirty down there. Do not let fluid squirt out onto the floor as you prime your line . There will be no air in the bag to run down into the giving set necessitating a re-priming of your line. Keep squeezing until the fluid from the bag is pushed up into the drip chamber. but you run the risk of contaminating the IV fluids with your oral flora (and. One of the things we could probably manage a little better as ED nurses is the management of children presenting with fever. but a normal temperature is usually less than 37. Incompatible fluids may crystallize or form a sediment that will cause similar problems. fauna). analgesia etc that you are about to administer.37 - . Someone carrying a brimming bedpan is sure to slip arse over nipples on your mess. When priming a new IV line. It looks cool. how hot is hot? The first thing to say is that any paediatric patient presenting to the ED should not be discharged home without a thorough assessment and review by a senior ED doctor. many of us react by immediately dousing it with doses of antipyretics or perhaps even tepid sponging in the belief that this will fix the problem or prevent possible febrile convulsions. And of course always check to make sure any drugs or fluids being injected into the line are compatible with the fluid.com • • Expel any air from syringes of IV antibiotics. Is this evidence based? Should we be aiming to have a dosed up department full of afebrile children? Lets see. Children’s temperatures are in a constant state of flux. Once you have inserted the giving set into bag of fluids open the roller clamp and gently squeeze the bag expelling all the air from the top of the IV bag into the giving set.5C. no doubt.
” The most serious reported risk of administering paracetamol is hepatotoxicity. In a systematic review of the management of fever in children conducted by the Joanna Briggs Institute it was noted that: Of the total sample of 821 only one febrile convulsion (0.38 - . activity and alertness. based on the parents observations. mood and eating improved but not significantly. appetite. but taking tympanic. while drinking was worse. conclusion? If the infant or child has a low grade fever and is not dehydrated or unduly distressed I would consider their fever as part of their treatment. But studies seem to suggest that bringing the fever down has limited benefit in preventing recurrence or onset of seizures. Although in one well known study (Kramer et al.). It can also be quite uncomfortable. What about those febrile convulsions? It is true that febrile convulsions are caused buy…well. Antipyretics: yea or nay? In most cases the primary purpose of administering antipyretics is to increase the comfort of the child. 0. the more likely it is that they will have a serious bacterial infection. analysed 225 febrile children’s mood. “In the paracetamol treated group. The review concludes that there is a lack of evidence in the literature to support the notion that paracetamol reduces the incidence of febrile convulsions. it makes a pretty hostile environment for the enemy combatants. oral or per auxilla is common practice. The double-blind trial. Most causes of infection (bacteria and viruses) are quite fragile and only able to survive in a very narrow temperature range. Our immune systems are pretty clued on to this. fluid intake.www. But not always. febrile-ness. Seriously septic children may be afebrile or have low grade fevers.7°C higher than when admitted. With the proviso that the parents are both informed (there is a parent information sheet here) and supportive with this strategy.impactednurse. The parents’ descriptions of comfort were equal in both groups. activity and alertness significantly improved by one grade. why hot is hot.7°C. This can occur if too large a dose is given or too many doses are given (doses greater than 90mg/kg/day). parents were unable to tell the difference between panadol and placebo in improving the behaviour of their child. comfort. . The down side of this is that it takes a lot of energy to fire up out furnace which may lead to dehydration. As long as you are aware of the relative accuracies of these methods. and by raising the bodies temperature. The duration of fever was the same in both groups.12%) was reported as occurring during a study. She had no history of febrile convulsions. This 12 month old child was in a “tepid sponging only” group and convulsed 90 minutes after commencing treatment when her temperature was 39.) The higher a child’s temperature.com temperatures are the gold standard. Children under the age of two. or who have pre existing liver disease are at greater risk. Copyright Ian Miller 2008.
But as I have said they must be reviewed by a senior ED doctor.20mg/kg could be given. falling and fracturing her hip. McDougall A. Lancet 1991. They occurred because nobody was watching.impactednurse. followed by three doses of 15 mg/kg over the next 24 hours if irritability continues. During the night she becomes disoriented and climbs over the bed rails. cannot reach his call bell or his urinal. Risks and benefits of paracetamol antipyresis in young children with fever of presumed viral origin. Case 1: Mrs Pepper is a seventy year old lady with slight dementia. Kramer MS. overused in childhood fever. ] How to keep ‘eyes on’ your patients. Case 3: Mr Smith has an unwitnessed seizure lasting 5 minutes. Australian prescriber: Paracetamol. Each bed area has a pull around curtain to ensure privacy during examinations and procedures. He aspirates his hospital jelly and develops aspiration pneumonia. blocking not only our view of that patient. but also obstructing the visibility of other patients along the row. Leduc DG. Roberts-Brauer R. Case 2: Mr Haas. A large room is bordered with patient beds and some form of staff station sits at one end or perhaps in the center. Most emergency departments these days are open plan affairs. . on a busy shift it is amazing how few patients can be seen at any one time. Naimark LE.337:591-4. All three incidents have one thing in common. eventually he can hold on no longer and is incontinent.com Very high fevers should be managed based on the clinical situation. [References: NSW Department of Health Clinical practice guidelines. If paracetamol is to be administered: An initial paracetamol dose of 15.www. But even in an open plan setting. One common problem arises when curtains are left pulled around a bed area. Copyright Ian Miller 2008. Eventually he dies from respiratory complications. Joanna Briggs Institute: Management of the child with fever.39 - .
to give a few examples. When privacy is not required ensure that the curtains are pulled back. Noise in the ED should be minimized (good luck with this one) so that alarms are not masked by the background din. The bottom line is there is no place for visual privacy in the ED. it is very important that they can be observed at all times. Explain that even though it is inconvenient. Of course there are instances when patients will need to be made *in-visible*. Remember: There is only ever a few seconds between resting comfortably in bed and laying unconscious on the floor in a pool of blood. just have a discrete peek to see if in fact they need to be. Not only does this block them from view. blocking visibility. Just try walking around the unit during your next shift and opening up all the curtains. When the curtains are drawn around.com visual visibility. When patients are grieving or dying or being interviewed by police. Give your patients half an opportunity and they will get up to no end of mischief. Overcrowding of our emergency departments often necessitates cramming patients into any available nook or cranny. Copyright Ian Miller 2008. You can draw them a meter or so from the wall on each side. Never assume someone else will check on that alarm. Alarm parameters should always be correctly set to minimize unnecessary or false alarms. Just enough to *blinker* the patients from being able to see each other. Many doctors and nurses seem to have this habit of walking out after a patient examination without opening the curtains. Patients will sometimes ask to have the curtains pulled around for privacy. Sorry. Acquiring a supply of earplugs and eye masks (like the ones they give out on aircraft) may help with undisturbed rest. but it can make the patient feel isolated and ignored. Patients should always have access to a call bell or buzzer. If patients are located “around a corner” or “out in a corridor” they must be checked on frequently. I shit thee not. Limiting the amount of visitors in the room may help patients feel less like they are on public display. audio visibility.40 - .impactednurse. there should be a low signal to noise ratio. Never assume that someone else will respond to that feint “nurse…nurse” coming form the other side of the room. See what a difference that simple act makes? Out of sight is not out of mind. Ideally these sort of things should take place in a separate area with a high level of attentiveness.www. Not only do patients need to be visible to the eye. . This is fraught with danger. But most of the time it is vital that you can see that your patients are behaving. At night the lights from other areas may be disturbing them. That is. they need to be visible to the ear.
wheeze will subside as the patient becomes exhausted. these recessions will decrease. It indicates an upper airway obstruction. Recession: as paediatric patients have a more compliant chest wall (that is.com How to assess a child: Respiration. Pulse oximetry will give you a good indicator of the efficacy of breathing. as children will tire from an increased effort of breathing much faster than adults. • • • • • • • efficacy of breathing. Get help. It is a sign of severe respiratory distress. Use of accessory muscles: the child may begin using the sternomastoid muscle to assist with breathing.41 - . Looks cute. Grunting may also be seen in children with raised intercrainial pressure. but isn’t. Here then to help you out. . Increased wheeze does not = increased respiratory distress. Always consider the possibility of an inhaled foreign body if you can hear stridor. It is an attempt to keep the distal airways open by generating a grunted positive end-expiratory pressure. a slow respiratory rate can be an ominous sign indicating breathing fatigue. And while you’re there. But be careful. is a brief guide in making a rapid paediatric respiratory assessment. It takes only a moment to recognise an increase in a child’s effort of breathing • Respiratory rate: an increase in respiratory rate indicates possible airway disease or metabolic acidosis. it is not as rigid as an adults) any increased negative pressures generated in the thorax will result in intercostal. sub-costal or sternal recession.impactednurse. Auscultate for decreased or asymmetrical breath sounds. they tend to do so quickly without much warning. listen for any adventitious (out of place) noises. Even so. Lucky for us that they build children as tough as Tonka Trucks. Look for the degree of chest excursion (or in infants abdominal excursion) which will give you some idea of how much air is going in and out. And once again. In infants this may lead to bobbing of the head. Next we need to assess how effectual all this increased work of breathing is. cerebral depression or a pre-terminal state. Gasping: a gasping child is really really bad. We want it to be between 97-100% on room air. Grunting: a grunting child is a bad thing. Conversely. and as they do. Wheeze: Indicates lower airway narrowing and us usually more pronounced during expiration. Greater recession = greater respiratory distress. If it Copyright Ian Miller 2008. and in the emergency department.www. effort of breathing. Stridor: is usually more pronounced in inspiration but may also occur during expiration. when they do crash and burn.
the child is probably getting close to respiratory arrest. Pulse oximetry is not very accurate if the patient is shocked or below readings of 70%. Which leads us seamlessly to the golden rule of paediatric assessment: always. As the child’s respiratory distress evolves. or anxiety. Hypoxia will lead to peripheral vasoconstriction and eventually cyanosis. Cardiac compressions will need to be commenced in infants with HR<60 and poor perfusion. begin oxygen therapy ASAP. Copyright Ian Miller 2008.impactednurse. just do it. bad.42 - . or fever. The other thing to remember is children with elevated carboxyhaemaglobin levels (smoke inhalation from a house fire. And the best way to assess mentation is to ask the parents. Once the cyanosis is evident centrally (think Smurf). mentation. heart rate. A child with congenital heart abnormalities may remain cyanosed despite oxygen therapy.com drops below 95%. always listen to the parents. they will become distressed and anxious. If they are concerned about their child’s condition so should you be. Bradycardia is defined as a heart rate less than 60 or a rapidly falling heart rate with poor systemic perfusion. . Increased heart rate may indicate shock. You will probably be experiencing a holy crap moment at this time and be hesitant to begin CPR. for example) may have a falsely normal SaO2 and yet be significantly hypoxic. *Unnecessary* chest compressions are almost never damaging. Bad. This will be followed by increasing drowsiness as fatigue grows.www. or hypoxia. but by the time the saturation is dropping this low you will be too busy kaking your uniform to worry about equipment accuracy. bad. If in doubt. skin colour.
You can estimate the expected systolic blood pressure with the following formula: BP= 80+(age in years * 2). Other effects: Decreased perfusion will lead to an inability of the cells to *take out the trash*. Capillary refill time is not a useful indicator in the hypothermic patient. ( alternatively you can use the nail bed or soles of the feet. bad. Cardiac compressions will need to be commenced in infants with HR<60 and poor perfusion. The width of the cuff should cover no less than 80% the length of the upper arm. The skin may appear mottled or marbled and cold to touch. get busy! capillary refill: A slow capillary refill time indicates poor skin perfusion. *Unnecessary* chest compressions are almost never damaging. A poor central pulse with absent peripheral pulses is a sign of significant shock.com How to assess a child: Circulation. or fever. or hypoxia.impactednurse. Circulatory assessment is therefore a very important skill to develop in order to recognise the early signs of a shocked child. With circulatory function failing. You will probably be experiencing a holy crap moment at this time and be hesitant to begin CPR. . The child’s blood pressure is a much less sensitive indicator. Press down firmly with your finger on the sternum for 5 seconds and release. Copyright Ian Miller 2008. heart rate: Increased heart rate may indicate shock.43 - . Bad.) A normal capillary refill should occur within 2-3 seconds. as it may remain *compensated* until circulatory collapse is imminent. The resulting metabolic acidosis will result in an increased respiratory rate and tidal volumes (without other signs of respiratory distress such as recession) as the lungs try and blow off carbonic acid.www. Remember: when fitting a blood pressure cuff to a childs arm it is vital to select the correct cuff size. bad. or anxiety. At about 80mls/kg it doesn’t take much loss before you have a significantly shocked baby on your hands. A very low BP is a warning of imminent cardiac arrest. The total circulating volume of a 1 year old is roughly the same as the amount of water you pour on your indoor pot plant. If in doubt. just do it. pulse volume and blood pressure: A good indicator of general perfusion can be made by palpating peripheral and central pulses. oxygen and nutrients are not reaching the cells and cellular waste products are not being cleared. Bradycardia is defined as a heart rate less than 60 or a rapidly falling heart rate with poor systemic perfusion.
Once again ask the parents for any history of decreased output.www. She has no obvious deformity and no neurovascular compromise but her hand is quite swollen so we better get that ring off whilst we still can. Copyright Ian Miller 2008. and will make a big difference in outcome.com Decreased level of consciousness. so try to do this smoothly and quickly. This method should never be considered if you suspect a fracture of the finger. Let them know it might hurt a bit but will probably save their ring from a costly trip to the jewellers. step 1. step 2.impactednurse. First pass a decent length of strong suture material (we actually have some thick fishing line set aside for just this purpose) under the ring.. As babies and infants develop significant circulatory compromise it is not exactly rocket science to pick that they are sick. Drowsiness and/or agitation may increase as cellular perfusion decreases. another trick of the trade. spiralling over the knuckle and down the finger. Less than 2ml/kg/hour in infants and 1 ml/kg/hour in children is a red flag. Today we have a patient presenting with a very painful wrist after slipping on the icy driveway as she was retrieving her Sunday paper.44 - . But the sensitivity to pick up on early signs of shock is more of an art. The most sensitive indicator of changes in mental state is of course the parents. ….so before we reach for the ring cutter let us offer them this option. Another day. Take this distal end of the string and begin wrapping it snugly around the finger. Have the longer end on the distal side of the ring.but curses! It doesn’t seem to want to slip over her knuckle. even after an obscene lathering of KY jelly. . This can become a little uncomfortable (nurses code for painful) for the patient.. Continue wrapping around and around. Decreased urine output due to decreased perfusion of the kidneys. Now it transpires that this ring has a lot of sentimental as well as monetary value….…. As they begin to die they begin to look dead. How to remove a stuck ring.
“just doing my job ma’am …. (Keep the ring cutters handy in case it becomes too uncomfortable or fails to budge.. . If it isn’t documented it didn’t happen. and this requires a little practice. quickly reassess the neurovascular status of the finger and calmly proclaim.com step 3.” Walk a way with a barely perceptible swagger in your step. Documentation must demonstrate accountability of practice. Remember: The Clinical Record provides proof of the quality of care given to a patient and is admissible in court as a legal document.) ONE: always document the care you deliver. moving around the finger. grab the proximal end. Continue pulling on the string and unwinding it ‘over’ and ‘around’ the ring….www. Unwind the string. but I hand it over to you for any suggested modifications.. whilst pulling firmly and maintaining tension. 10 tips for staying sharp in the Emergency Department. Now.impactednurse. they must be dated. (Hmm…The management of narcotic seeking patients might be worth discussing. step 4. The Process Clinical notes must meet the following criteria: • • they must be legible. timed and followed by author’s signature and designation. hold the distal end of the string against their finger.45 - . (KY Jelly brings jewellery up a treat. Copyright Ian Miller 2008.with a little luck the ring will slowly slide down and off the patient’s finger earning you some rightful admiration. Legal Requirements Your documentation must reflect the patient’s care status (condition/treatment) and include nursing interventions and outcomes of care.. disagreements or additions.) We have an electric ring cutter that will slice through most rings if we need to get them off in a hurry.give it a quick polish. Next.just doing my job. What do you think are the 10 most important guidelines for a nurse working in the ED? Here is one set of commandments I found on the mountaintop.) Present the intact ring to her.
If your signature looks like spaghetti. print your name in brackets afterwards. Evaluation. Diagnosis. TWO: listen to parents. each page must be labelled correctly. Planning. THREE: reassess your patient after giving treatment. After performing a quick assessment of the child listen closely to the parents story. SIX: never deviate from safe and ethical nursing practice. Nurses promote and uphold the provision of quality nursing care for all people. culture and vulnerability in the provision of nursing care. Nurses accept the rights of individuals to make informed choices in relation to their care. Thorough and appropriate documentation of haemodynamic observations including pain score. you must use only approved abbreviations as per hospital protocols. this can be a tough one. . Implementation. most do not. FOUR: never assume a patient who is behaving erratically is drunk. Nurses respect individual’s needs. a conglomeration of nurses from the Australian Nursing Council.com • • • they must be a clearly identified signature. Its all part of the nursing process. Oh boy.impactednurse. time and mode of arrival. • • • • • Assessment. Record arrival date. the Royal College of Nursing and the Australian Nursing Federation stayed up late for quite a few nights nutting out the current code: 1. FIVE: never ever ignore your gut feelings.www. ignore it and the outcome will be the same.46 - . 3. Here are some examples of acceptable medical abbreviations …not Precisely document any information reported to a medical officer that relates specifically to a change in a patient’s condition. While it is true that some parents completely loose the plot over a microscopic splinter in the little toe. You can think of it as A Delicious PIE. Copyright Ian Miller 2008. values. Obtain a thorough history and nursing assessment. In 2000. 2. Document any pre-existing conditions including allergies and their reactions. Always reassess to gauge the efficacy of your current treatment. Is it an impending calamity? Or is it last nights vegetable vindaloo? Either way. The Code of Ethics for nurses in Australia was first developed in 1993.
Ensure you have oxygen. Just like us. 6. documented history of repeated narcotic seeking behaviours. If pain remains uncontrolled consider patient controlled analgesia. 3. Our hospital’s Health Child Protection Policy requires all its staff to make a mandatory report to Care and Protection Services should they suspect non-accidental injury.) There are many different strategies for effective pain management (which I will leave for another post. There is. 5. Get rid of it. the doctor would not be able to properly assess them. No patient should be left in pain.www. I remember in the bad old days we used to leave our patients rolling around in agony until a doctor could get to them under the pretence that if we got rid of the pain. TEN: pain is a four letter word. .impactednurse. Observe them closely. 2. spouse or elder abuse. There is no “I” in: emergency department. Keep giving aloquats of narcotic analgesia as per your hospital protocol until A) the pain score approaches zero OR B) they are too drowsy to give you a pain score. however. they should have a management plan developed in co-operation with drug and alcohol. How much should I give? In cases of severe pain. There are more than enough “I”s in: I’m in deep shit again. Many nurses are hesitant to give large accumulated doses of narcotic analgesia in case they kill their patient or get them addicted. EIGHT: work as a team. emotional abuse or neglect in the course of their work. Nurses hold in conﬁdence any information obtained in a professional capacity. What a load of bollocks. economic and ecologically sustainable environment that promotes health and well being. Use a visual or numeric analogue scale (VAS) to obtain a subjective rating of the pain from the patient. a “team”. Copyright Ian Miller 2008. airway adjuncts and Naloxone available. 1. Doctors are sometimes dumb as stumps. Nurses value environmental ethics and a social.47 - .(PCA) 4. 2.) and a wide spectrum of interventions that can be implemented. NINE: filter for suspicions of child. Think they are narcotic seeking? Makes no nevermind. It happens more than you would wish.com 4. Try not to be judgemental of their response. (if the patient has known. Control the patients subjective discomfort and then you can sort out the rest. sexual abuse. and pain management specialities. Here is a quick guide as to a safe analgesia regime: 1. use professional judgement where there is a need to share information for the therapeutic beneﬁt and safety of a person and ensure that privacy is safeguarded. SEVEN: do not accept a doctors orders without question if you have a problem with them. Nurses fulﬁl the accountability and responsibility inherent in their roles.
Dr Fesmire’s latest research evidence now concludes that the overwhelming stimulation of the vagus nerve during orgasm is even more effective in the treatment of intractable hiccups. Removal of the latter did not terminate the hiccups which had also been treated with different drugs. a specialist in emergency medicine who works from the University of Tennessee College of Medicine famously published a paper titled: “Termination of intractable hiccups with digital rectal massage” in Annals of Emergency Medicine (vol 17. all with little effect. Digital rectal massage was then performed resulting in abrupt cessation of the hiccups. and digital eyeball compression. Importantly. So next time your patient presents with a severe case of hiccups you should inform them that they need a little sex. Copyright Ian Miller 2008. The list of possible cures for hiccups is long and embroidered.impactednurse. Then in one of those moments of dazzling lateral inspiration he attempted a “slow circumferential” rectal massage. Stat.48 - . This is the second reported case associating cessation of intractable hiccups with digital rectal massage. Hiccups result from a mysterious reflex stimulus generated within the spinal cord between C3 and C5. carotid sinus massage. The danger being that if hiccups and anti-hiccups were to collide a catastrophic explosion could result. Other than causing episodes of acute paroxismal social awkwardness.www. Dr Fesmire attempted the usual vagal manuvers including valsalva . And they then only need come into the emergency department should they explode. p 872) By stimulating the vagus nerve. But as emergency department nurses we need to ask the pressing question: what are the evidence based options? Francis Fesmire. this intrusion into the vagal back passage produced an immediate and lasting effect. A few years later a second paper was published in the Journal of Internal medicine to wit: A 60-year-old man with acute pancreatitis developed persistent hiccups after insertion of a nasogastric tube. Recurrence of the hiccups occurred several hours later. . Back in the emergency department. they were terminated immediately with digital rectal massage. No other recurrences were observed. We suggest that this manoeuvre should be considered in cases of intractable hiccups before proceeding with pharmacological agents. This in turn triggers a sudden spasm of the diaphragm and accessory inspiratory muscles followed by an abrupt glottic closure. and several manoeuvres were attempted.com How to cure persistent hiccups. no one knows what purpose this reflex serves. and again. With one important caveat: the combination of rectal stimulation and orgasm may be so powerful as to lead to the production of anti-hiccups. but with no success. Fesimire successfully blocked the stimulus that had been causing a 27 year old man to suffer persistent hiccups for over 72 hrs.
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