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What to do? A real life scenario – Updates Complete!

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All right nurses, here is a scenario for you. You walk into the room. The patient seems a bit “off” but he’s sick, (DM, HTN, etc.) and a bit older at 74 y/o.  The second time you head into the room, his wife and adult daughter are there.  They tell you he’s NEVER like this.  What’s the first thing you do?

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Thanks for the responses!  Melzie said to check vitals, blood glucose, and neuro status.  I love that she included to do a neuro check. You don’t want to spend a long-time doing this. I’d stick to orientation questions only (who are you, where are you, what date it is). Maybe ask them the name of the family in the room with him.  You want to be sure to do this neuro check because you want objective data.  How confused is he?  How will we know when he’s better?  It’s important to listen to the family’s feeling about the patient, but it’s just as important to convert that information from a statement of opinion to objective medical data we can do something with.

Sheila also said to consider the possibility that the patient has a UTI.  This is a great point, especially since the patient is 74. The older the patient, the more confusion a UTI could cause, even without a fever present.  Of course, a root cause like this is a secondary concern for now.

So, I’d get the vitals and blood glucose and neuro check as quickly as possible.   The patient is oriented only to self.  He has no clue where he is, the date, or who is President.  His vital signs are within normal limits except for his blood pressure which is 74/50.  A quick glance at his charge reveals he is on blood pressure medicine and his BP is usually closer to 140/80, even when on meds.

You page the doc.

What do you do while you wait?

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Wow.  See TaraRRT’s comment below.  I’m guessing she’s a Rapid Response nurse (based on her username) and did an amazing job of saying what she’d do next!  Here’s what I did:

I put the patient in trendelenberg and started running saline at 150 ml/hr.  The docs called me back immediately and arrived immediately so I did not, in this instance, call the rapid response team.  However, a call to the Rapid Response Team was definitely warranted given the situation.

The patient’s vitals recovered quickly.  The family was really grateful for my help–they felt very listened to and cared for.  This situation was actually a really good one for me as it was really early in my career and I felt like I made some good, quick decisions.

Nursing Lingo Part 6: Walkie/Talkie

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For our latest installment of Nursing Lingo, we turn to another one of my favorites, “Walkie/Talkie.”  This phrase is darn near poetry.  It efficiently packs a whole lot of punch into just 4 syllables.

You might hear this while getting report.  I think my best definition of “Walking/Talkie” would be:

Noun person
1.  A patient who is alert and oriented x3, ambulatory, at very low risk for falls, and independent in activities of daily living.
2. A cake walk.

So, when you hear this phrase, you’re in luck!!  Would other nurses out there agree with the definition or modify it? Let me know!

Other Nursing Lingo Posts:

Part 5: CYA

Part 4: FLK

Part 3: Frequent Flyers

Part 2: DFO

Part 1: Circling the Drain

Not dead yet?

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I had a dying patient.  She had been on comfort care for several days and was nearing the end.  She was a sweet lady and was surrounded by her sweet family.  If you’ve been reading my blog long, you may know that, if a patient is dying, they will undoubtedly die on my shift.  I don’t know why.

I had tended to the patient and her family throughout the shift.  At some point in the afternoon, the adult daughter came to the nursing station to tell me that she believed her mother had passed.  I paged the doctor and headed into the room.  I felt no carotid pulse.  I auscultated her chest and airway and heard neither heart nor breath sounds.

I tell the family that I think she has passed but that the doctor has to come to declare the time of death. I head out and the doctor (who looks twelve) walks in.  As I ask a co-worker to help me with post-mortem care, the doctor walks up to me.

Doc: “She’s not dead.”

Me:  “What?”

Doc: “She has a carotid pulse.”

Me: “I didn’t feel a pulse and she doesn’t have a heartbeat.”

Doc: “She has a carotid pulse.”

Me: “Okay. Can you stay around for a little bit and go check again because I was pretty sure she’s passed.  I must not be checking right.”

The doc returns to the room and comes back out.

Doc: “I think I felt a fasciculation.”

Me: “I don’t know what that is.  Has she passed?”

Doc: “Yes, she’s passed.”

A medical school education is a terrible thing to waste.

Nursing Lingo Part 5: CYA

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“CYA” is a term you hear all the time in health care.  It’s a great piece of nursing lingo but also a great piece of advice.  It means “Cover Your @$$.”

Perfect example: you have a patient whose potassium is high.  You page the doctor and suggest he intervene (give the patient kayexalate and a heart monitor, review their meds, etc.)  The doc decides to just wait it out.  What should you do?!?  CYA.  Chart what time you told the doc AND which doc you told.  Maybe the doc has a legitimate reason to wait and is making the right call.  However, you never know.  When in doubt, chart it.

Sadly, every nurse gets called to the mat eventually.  It could be a patient complaint, co-worker complaint, or even a lawsuit.  In the end, the only one who will protect your license is you.  So, follow policy, and chart, chart, chart!  It will save your butt in the end.

Nursing Lingo Part 4: FLK

Nursing Lingo Part 3: Frequent Flyers

Nursing Lingo Part 2: DFO

Nursing Lingo Part 1: Circling the Drain

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I had a great moment Friday.  I was talking with a group of physicians.   We were talking about diagnoses of children.  A doc that takes care of adults said to the Peds doc, “John, you can put the diagnosis as ‘FLK.’  Do you know what an ‘FLK’ is?”   John is a pediatric plastic surgeon which means he’s the one operating on children born with craniofacial abnormalities like cleft palates.   My mind immediately went to my FLK post from just a few days prior.

John’s facial expression and tone grew firm.  He made eye contact with the other doc and replied, “None of my patients are FLKs.  They’re not funny-looking.”

You, go!  I was proud of him.

Nursing Lingo Part 4: FLK

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Today’s bit of nursing lingo is not without controversy: FLK.  Let me start by saying that I disapprove of this term.  However, you still hear people use it and, while the term isn’t appropriate, the concept is.

“FLK” means “Funny Looking Kid.”  You hear this most on Labor and Delivery but sometimes also on Peds.  FLK is a catchphrase to mean a child whose physical appearance is not quite right.  If a child is born with irregular ears, a flat bridge of the nose, an abnormally small head or chin, abnormal hands, or other physical differences, there is a chance that child has a congenital disorder.  The child could have one of many differences including Fragile X, Down Syndrome, even Dwarfism.

In the end, I chose to include this term because does it demonstrate an important concept in nursing.  When a baby is born, if there is something that does not quite look or seem right, that difference needs to be noticed, the parents need to be informed, and a geneticist should be called for a consult.  Whether the baby is two days or two years old, it’s important to know what exactly is wrong with the child in order to know how best to care for him.

Here’ s a partial list of disorders that have a physical difference.  Some of these would have been diagnosed by Ultrasound before birth.

  • Achondroplasia or other dwarfism
  • Fragile X
  • Treacher-Collins Syndrome (Mandibulofacial Dysostosis)
  • Fetal Alcohol Syndrome
  • Down Syndrome (Trisomy 21)
  • Noonan Syndrome
  • Cornelia de Lange Syndrome
  • Crouzon Syndrome
  • Other trisomies: Trisomy 8 mosaicism, Trisomy 9, Patau Syndrome (Trisomy 13), Edward’s Synrdome (Trisomy 18), Trisomy 22, Triple X Syndrome

See also: http://www.ucdmc.ucdavis.edu/children/clinical_services/cleft_craniofacial/anomalies/

 

While it’s not okay to call these children “FLKs,” noticing a difference in physical appearance can help the child and family, so keep your eyes open!  Be sure not to saying anything in front of the parents!  One of the beauties of being a nurse is letting the doctor be the bearer of difficult news.

Nursing Lingo Part 3: Frequent Flyers

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“Frequent Flyers” is a favorite nursing term of mine.  I suppose the definition is rather self-evident.  These are the patients that you take care of repeatedly.  Inpatient medicine floors are chock-full of frequent flyers. This could be a young person with Cystic Fibrosis or Sickle Cell or perhaps an elderly patient with COPD* or ESRD.**  On a surgical floor this could be a patient with non-healing wounds.

I like this term because it’s a pretty benign “label.”  The patients are not “the chronically ill” or “sick.”  They are just normal people that happen to frequent the hospital.

Personally, I like taking care of frequent flyers.  They know the ropes.  They also know that they will be seeing a lot of the nursing staff so it makes sense to treat us respectfully.  You just have to be careful that the familiarity doesn’t destroy the professionalism of the relationship.  I had one nursing friend who “fell in love” with a frequent flyer.  Four months later they broke up but he continued to receive his care on our floor.  Awkward all around.   However, caring, lasting relationships with pleasant frequent flyers can really bring joy to your day, and your career.

The down side to frequent flyers is also that they know the ropes.  While the vast majority of my patients are wonderful people, there are always a few bad eggs. The naughty frequent flyers know how to play the staff against one another so stay on your toes!   As soon as you hear, “But last time the nurse let me …” or “But the docs always give me more pain medicine than…”  you can be pretty sure you have a naughty frequent flyer!  As always, treat them respectfully but draw boundaries and stick to your guns!

I enjoy a challenge so if a particularly difficult frequent flyer shows up, I often offer to take the patient.  With the right mix of warmth and boundaries you can convert a naughty frequent flyer to a satisfied and pleasant frequent flyer.   And the icing on the cake? Now your co-workers owe you one!

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*Chronic Obstructive Pulmonary Disease (emphysema or chronic bronchitis)

** End Stage Renal Disease (kidney failure)

Nursing Lingo Part 2: DFO

Nursing Lingo Part 1: Circling the Drain