Monday, November 26, 2007

Woo doggies.

I do brains. Brains and spines. It's what I do. It's why I titled my blog "Head Nurse." Because I do brains. And spines.

Except lately I've been doing a lot more than brains and spines. Kidneys, for instance, and intestines. And weird plastic surgery dealios that involve, like, seven incisions in somebody's head, all intended to rebuild bits that have been lost to gunshots or cancer or accident.

So I've found myself having to do things that I'm not exactly comfortable with lately, and I've come up with some new tips and tricks. They're old news for those of you who handle a lot of bizarre surgery patients ("bizarre" in this case modifying "surgery"), but they're new to me.

Tip the First: Label IV drips in more than two places.

The rule is to label your pump and your IV line if you're running, say, chemotherapy or total parenteral nutrition, two things that should not be combined with anything else. Normally those lines are labelled on the IV pump itself and then below the IV pump in one spot, using fabric tape and permanent marker or a pre-printed label in yellow or red.

I've found over the last couple of months that that is not enough labelling for somebody like me. I now label TPN and Weird NonMixable Drips in four or five places, running those labels straight down the line. It's not such a big deal if you're infusing, say, normal saline and IV immunoglobulin, but if you've got a four-channel pump with four fluids plus piggybacks, it helps.

Tip the Second: Label the drains coming out of your patient.

Again, I'm used to three or four drains at the most, and those well-spaced: maybe one at the head, one in the belly, and one coming out of the person's lumbar spine. I was confronted late last month with a patient who had ten (10) drains coming out of her belly alone. I'm not counting the ones coming out of her back, or the ones attached to the Wound-Vac.

None of the drains were labelled, yet there was an order that said, "Flush PAD with 30 ccs NS q 8 hrs, dwell for one hr, drain." Um. Lessee...three PADs there and no clue which one to flush. Flush 'em all? Flush one every eight hours? Or ask the resident? I went with door number three, then labelled the drain we were supposed to be flushing. I also labelled the lines with where they went (JP, Jvac, Hemovac, Wound-Vac) so there'd be less tracing back. It also helped differentiate the two drains that had exactly the same tubing but different uses when the only distinguishing marks were covered by tape and connectors.

Tip the Third: Warn the next shift about that abscess.

If you know your opposite number on the night shift will have to irrigate and re-dress an abscess or undermining decubitus, have the Vicks Vaporub right there at the door when they walk in. This is one of those "do unto others" things I wish somebody had done for me. There's nothing quite like encountering a fist-sized hole in somebody's belly or a stage IV undermining bedsore without proper preparation.

Tip the Fourth: Warn the next shift about that resident.

We have our residents trained well. The same can't be said for the residents who are, for our unit, off-service. It's only politic to warn the oncoming shift about the resident who's paranoid, suspicious, and has a God complex. I was the first person to encounter him and thought he was being ironic. Wups.

And, finally, Tip the Fifth: Iodoform, Aquacel, and various other specialty dressings never go as far as you think they will.

Let's say you've got a wound that's just about big enough to swing a cat in. Let's further assume you have to pack that sucker with some sort of wound-packing material. If you already have three containers of that packing in the room, take in a fourth. If there are already four in there, take in a fifth. Have an extra in your pocket just in case. This is especially important if your patient has a live flap from, say, their shoulder to where an ear used to be that has to be wrapped with petrolatum gauze, as that stuff's a beast to work with.

It's been an interesting couple of months. Things'll probably start getting back to normal soon, as the construction that's sent Bizarre Surgery Patients to our unit is almost done. I'll miss the variety. I think I've grown a third hand through dealing with all this new stuff, and I'm hoping that sticks around. What I *won't* miss is seeing patients with half a face, or faces that are attached to arms or shoulders or chests.

Who knew that a subtotal lobotomy patient could seem so peaceful and normal?


GingerJar said...

Know what ya mean about all the packing stuff. And talk about confusing orders. Had order to repack incision on next day following surgury...however had to use own judgement on redressing the copiously draining external dressing...over and over and over ... then the patient got confused, came out of the room and threw his wet pad on the counter...and asked "what is this s**t"! "Well sir, we sure hope it isn't MRSA since you just flung your germs all over our counters, phones, and anything else in a 6-10 foot radius. Some people just don't use any common sense whatsoever!

RehabNurse said...

Xeroform gauze IMHO is just about as bad as Aquacel.

My favorite is going into the room to inspect for dressing supplies, etc. and having to come out because there aren't any, and an old nurse tells you "you don't know how to prioritize." So nice. (BTW I try to restock the room at the end of my shift for the next nurse).

I need a backpack somedays to carry all my dressing supplies and I don't have one!

Anonymous said...

Pre-printed labels do make things so much easier. I have my pre-printed labels with my address and details on printed by a british labels company. Their prices are really reasonable and they saved me the time and hassle of trying to print them of myself.