http://allnurses.com Medical intensive care units and Surgical intensive care units where there is information about nursing the critically ill patient. A huge specialty covering differing modes of ventilatory support, invasive monitoring, resuscitation, and emergency management of the critically ill patient. en Sat, 21 Nov 2009 00:00:07 GMT vBulletin 60 http://img.an-file.info/misc/rss.jpg http://allnurses.com http://allnurses.com/micu-sicu-nursing/getting-into-icu-439955-new.html Thu, 19 Nov 2009 08:33:48 GMT hello everyone, I was wondering, in order to become a ICU nurse, do you have to generally work in a... hello everyone, I was wondering, in order to become a ICU nurse, do you have to generally work in a particular ward (eg. med-surg.) before getting into ICU, or can you directly enter ICU right after getting your BSN?
:confused:
Thanks for future responses... ]]> MICU and SICU Nursing Forum Canadian eh? http://allnurses.com/micu-sicu-nursing/getting-into-icu-439955.html http://allnurses.com/micu-sicu-nursing/prbc-transfusion-question-439947-new.html Thu, 19 Nov 2009 06:21:09 GMT Assumed care of my patient (ETOH, end stage liver disease, new hepatorenal syndrome, GIB with... Assumed care of my patient (ETOH, end stage liver disease, new hepatorenal syndrome, GIB with unstable hematacrit, glowing yellow, etc, etc) to find that the nurse before me had his PRBC's y'd into his maintenance fluid: D5 1/2 NS @ 175cc/h. He got 3 units like that before I picked him up.

I'm curious if that would render the cells useless, with the MIV being a hypertonic solution and all. The day nurse is one of the "older experienced nurses" so I want to make sure this isn't some trick of the trade that I'm not privvy to. I asked my charge nurse, we called blood bank, no one had any specific info for us other than "never mix with anything but NS." The blood was y'd into the port nearest the patient which is about a foot of distance for the two solutions to mix...not sure if crenation would occur under these circumstances or not. ]]> MICU and SICU Nursing Forum jennygo2 http://allnurses.com/micu-sicu-nursing/prbc-transfusion-question-439947.html http://allnurses.com/micu-sicu-nursing/pulse-ox-hematocrit-439933-new.html Thu, 19 Nov 2009 04:20:11 GMT Doing some research on the relationship between pulse ox and crit. Just a couple of random... Doing some research on the relationship between pulse ox and crit. Just a couple of random questions if anyone has any info...

Example: A post-op patient with a crit of 20, they have ruled out that it's dilutional...

1. His pulse ox has been giving me a crappy wave form all day. He appears to be in the 90's when I do get a good read, but most of the time it's crap. Could this be related to the crit? (Also, cold hands, replaced the cord to the monitor, and gave him 2 new finger probes...still no luck.)

2. Asymptomatic most of the day, on room air and doing fine. Got up to walk and gets dizzy, pale, SOB, has to sit down...does giving him additional oxygen help saturate what low levels of hematocrit he DOES have, to help give him a little "boost" while waiting for the transfusion, or is that worthless, or am I confusing it with something else? Feels like the bottom line is, when your crit is that low, you don't have enough "boxcars" to transport the O's no matter how many liters you put him on...

I'm just thinking out loud and have actually managed to confuse myself in the process. Your thoughts are appreciated. ]]> MICU and SICU Nursing Forum Caroline RN http://allnurses.com/micu-sicu-nursing/pulse-ox-hematocrit-439933.html http://allnurses.com/micu-sicu-nursing/repositioning-oscillator-pts-439785-new.html Wed, 18 Nov 2009 16:32:43 GMT Can you all share with me what your current practice is with oscillator patients and repositioning?... Can you all share with me what your current practice is with oscillator patients and repositioning? We are running quite a few of these vents with the "season" in full swing. As long as respiratory has a full "wiggle" if you will, and peak airway pressures recover quickly, why not turn these patients with pillow propping to the left and right?

Simply put, my patient is on 100% fio2 on an oscillator, we're maxed.... yes he does desaturate to 86% with movement, but recovers in 30 minutes... why go through all this and have the pt. die from massive pressure wounds if you can prevent them with turning, even Q4 hrs.

Like prone positioning, the patient desats initially but recovers and benefits from the turning therapy. I believe we cause patients to become intolerant to turning based upon lack of turning.

So if we still have a full "wiggle" and quickly resolving mean airway pressure, why not turn these guys? Our pulmonologist wrote a specific order not to turn my patient, so what gives? If my patient recovers in a safe amount of time, why set him up to die from preventable wounds?

Now I know how complex this is and I am really dumbing it down, but it really IS that simple. Please share your current practice as I'm having a hard time finding evidenced based practice as to what policy or practice is occurring in other facilities. When I polled my peers almost half said they would turn and half not, so we have to resolve this quickly. While each patient situation is at the discretion of the RN (we've all been there), surely, some of you have a policy in place that addresses immobility and skin protection protocols?

Lastly and thank you for your patience, medicaid/medicare does not reimburse therapy from hospital acquired wounds.... I'm hoping to use this as an additional incentive to just simply prop some pillows and tilt a patient which only improves lung recruitment and can benefit my patients overall recovery.

Final words, my pt. is hemodynamically stable, beautiful vs, just desats with the initial turn, we can't do anything else from an RT standpoint, maxed on 100%fio2, I can argue both sides. "don't dare turn, airway and o2 is the priority" but the decompensation is brief. Massive skin ulcers, which can result in a secondary morbidity and lack of compensation in pay is a huge concern as well.

How are you practicing? Lets keep this simple please, we all understand the complexity involved. ]]> MICU and SICU Nursing Forum Zookeeper3 http://allnurses.com/micu-sicu-nursing/repositioning-oscillator-pts-439785.html http://allnurses.com/micu-sicu-nursing/what-like-icu-439751-new.html Wed, 18 Nov 2009 09:58:49 GMT ....Im curious to know what it is like to be an RN in the ICU.....can anyone give me insight into... ....Im curious to know what it is like to be an RN in the ICU.....can anyone give me insight into what they know?
thanks..:specs: ]]> MICU and SICU Nursing Forum Canadian eh? http://allnurses.com/micu-sicu-nursing/what-like-icu-439751.html http://allnurses.com/micu-sicu-nursing/ccrn-exam-changing-439589-new.html Tue, 17 Nov 2009 17:19:26 GMT Be advised that AACN is changing its test plan for the CCRN exams (Adult, Pediatric, and Neonatal)... Be advised that AACN is changing its test plan for the CCRN exams (Adult, Pediatric, and Neonatal) as of January 13, 2010.
Here's the new test plan for the Adult exam:

http://www.aacn.org/WD/Certification...-AdultCCRN.pdf

This should generate lots of new income for AACN as their new study guides come rolling off the presses. All other guides/study aids will be woefully outdated, of course, and the new and improved editions will be highly recommended.

And the beat goes on...:spin: ]]> MICU and SICU Nursing Forum WindwardOahuRN http://allnurses.com/micu-sicu-nursing/ccrn-exam-changing-439589.html http://allnurses.com/micu-sicu-nursing/why-do-nurses-439196-new.html Sun, 15 Nov 2009 12:40:42 GMT I've been off orientation for about 9 months now and it just seems like all that ever gets back to my manager about me is the negative stuff. It's really starting to **** me off because I may not be a great critical care nurse yet, but I've done some good things too!

I have family members and patients tell me how nice it's been to have me as their nurse, I've always been on time, I'm always willing to help someone else out if I'm not doing anything, etc, etc. It's just so frustrating that the couple things I've done that are negative are outweighing the good by so much!

For example, there's this one nurse I was with during orientation and I didn't have the labels with me when I went in to draw a patients' STAT labs, they were right outside the door and after I was done, I got them, checked them with the patient, and I sent them. She was sooooooooo aloof and said that I shouldn't have done that (I know), that I was a critical care nurse now and should start thinking like one. Just the way she said it was so annoying....anyhoo, not a week later, I see her doing the SAME THING with a patient who just had routine labs to be drawn!! I felt like saying something, but I didn't cause I didn't want to give her another reason to not like me.

I just wish that all the criticism was constructive and that it was balanced with some good cause that would really help my morale!

Thanks for letting me vent.

]]> MICU and SICU Nursing Forum GucciRN22 http://allnurses.com/micu-sicu-nursing/why-do-nurses-439196.html http://allnurses.com/micu-sicu-nursing/techs-in-icu-438983-new.html Sat, 14 Nov 2009 03:54:37 GMT Hello,

My manager told us today in the break-room that techs are luxury to "our" ICU. We only have two techs Monday through Friday 7 A to 3 PM with NO weekend or night coverage for 32 beds. We have two Icu's and this is tech coverage for both of them. 90% of our patients are total care. My hospital is a 440 Bed county hospital with two ICU's totaling 32 beds at at 90% occupancy. And if we have no secretary coverage, we loose our tech for the day because they are crossed trained.

I have worked on other floors in my hospital (telemetry) and we always had 2 techs per 20 patients for day, night, and weekend shift.

Do your managers have this same mentality? How do yall manage techs to patient ratios within the icu? ]]> MICU and SICU Nursing Forum bucknangler http://allnurses.com/micu-sicu-nursing/techs-in-icu-438983.html http://allnurses.com/micu-sicu-nursing/working-per-diem-438740-new.html Thu, 12 Nov 2009 22:29:39 GMT I work @a VA hospital in the MICU/SICU. I am thinking about getting a second job because OT is... I work @a VA hospital in the MICU/SICU. I am thinking about getting a second job because OT is never available at my hospital, I need some extra $$, and would like some additional experience with a more varied patient population. What is everyone's experience with working Per Diem vs Agency as ICU nurses. I am guessing they probably won't give me the sickies which might defeat the purpose of my taking an extra job in the first place.

I would also like to mention that I have an interview for per diem ISCU/SICU at a level I trauma center in the metro. As We all know, the VA is not well known for its trauma patients. If anyone thinks I am getting in over my head here some candor would also be greatly appreciated :)

(As an aside)
....Why do I feel like an a**hole for getting a second job when some people can't even find one???? ]]> MICU and SICU Nursing Forum jennygo2 http://allnurses.com/micu-sicu-nursing/working-per-diem-438740.html http://allnurses.com/micu-sicu-nursing/icu-orientation-reading-438719-new.html Thu, 12 Nov 2009 19:56:20 GMT Hello, I am developing a reading list to hand out to new hires and nursing students who are new to... Hello, I am developing a reading list to hand out to new hires and nursing students who are new to critical care to provide a framework/historical background/basis of evidence for many of our common practices. Has anyone else here tried to create something like this? Of course a reading is inherently controversial in terms of inclusions and omissions and this list is not intended to be perfect or comprehensive, but rather to help get someone new to critical care started off in the right direction of having an evidence based nursing practice. Any suggestions for other articles or resources to include in this list would be appreciated. The list (in progress) follows:


Thanks in advance for your comments.

Glucose Control in the ICU
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK,McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ. (2009). Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 26;360(13):1283-97.
Van den Berghe, G, et al. (2001). Intensive insulin therapy in critically ill patients. N. Engl. J. Med. 345:1359-1367.

Therapeutic Hypothermia
Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K. (2002). Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia N Engl J Med 346:557

Hypothermia after Cardiac Arrest Study Group. (2002). Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 21;346(8):549-56. http://content.nejm.org/cgi/content/full/346/8/549

Sepsis (Early Goal Directed Therapy)
Dellinger RP, Levy MM, Carlet JM, et. Al. (2008). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 [published correction appears in Crit Care Med 2008; 36:1394-1396]. Crit Care Med; 36:296-327.
Rivers, E, et al. (2001. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N. Engl. J. Med. 345:1368-1377.

ARDS – Lung Protective Ventilation
The Acute Respiratory Distress Syndrome Network. (2000). Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. N Engl J Med. 342: 1301-1308
Bernard GR, Artigas A, Brigham KL, et al. (1994) The American European consensus conference on ARDS: definitions mechanisms, relevant outcomes and clinical trial coordination, Am J Respir Crit Care Med. 149:818–24.
Eichacker PQ, Gerstenberger EP, Banks SM, et al. (2002). Meta-analysis of ALI and ARDS trials testing low tidal volumes.Am J Respir Crit Care Med; 166:1510-4.
Best Practice Bundles
Girard T, Kress J, Fuchs B, et al. (2008). Efficacy and safety of paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awake and Breathing Controlled trial): a randomized controlled trial. Lancet; 371:126-34.
Tablan, O. C., Anderson, L. J., Besser, R., Bridges, C., & Hajjeh, R. (2004). Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR. Recommendations and Reports: Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control, 53(RR-3), 1-36.
http://www.cdc.gov/ncidod/dhqp/guidelines.html - a collection of guidelines for the prevention of health care associated infections.
Miscellaneous
Connors AF, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996;276:889-897.
Gawande, A. The Checklist: If Something So Simple Can Transform Intensive Care, What Else Can It Do? The New Yorker. December 10, 2007. http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

Useful Websites
www.survivingsepsis.org/Pages/default.aspx
www.learnicu.org
www.pacep.org
www.icudelirium.org
www.ardsnet.org ]]> MICU and SICU Nursing Forum PDX_RN http://allnurses.com/micu-sicu-nursing/icu-orientation-reading-438719.html http://allnurses.com/micu-sicu-nursing/first-night-off-438219-new.html Tue, 10 Nov 2009 17:36:33 GMT Tonight will be my first night off of orientation - whoa! I'm a new grad - had my first 6 weeks on a tele floor, and I'm on my 8th in the ICU. I am feeling a mixture of extreme terror and excitement - ha!

My hospital has been really good to me so far - TONS of experiences, classes and education, wonderful tele & ICU preceptors and CM's and decent colleagues for the most part. Maybe I am in some kind of honeymoon phase, but since I started every single day I think about how much I love being a nurse, and how I feel like I'm doing what I was meant to do.

A few weeks ago my preceptor and I were taking care of someone with severe ARDS & sepsis secondary to H1N1. She was on a rotoprone bed and the 1st night she was doing awful, and the second night she went from really bad to worse - we didn't think there was any way she was going to make it. No lung sounds except in very upper lung fields and barely. She was on drips of Levo, dobutamine, vasopressin, epi. They were all over the max. She was on a gazillion different antibiotics, and was on an insulin drip too. Every half hour we would check her sugar we had to go up on the insulin trip and sometimes bolus her with up to 12 units. She was making NO urine. Massive edema. Toes turned purple. Mottled knees. We started her on Xigris which my preceptor said is totally last ditch. I took her temp and when the thermometer said 105.8, I got weak in my knees and didn't believe what I was seeing. 105.8!!! I put ice packs everywhere and managed to bring her down to a cool 103.5. I prayed for her and her family. We did not expect she would make it through the day.

But she did, and the third night she improved to our astonishment. It was the most amazing feeling in the world. I have chills thinking aobut it. 4 pressors were cut down to 2. She made a little urine. Her skin was pink. Temps weren't so high. And she actually had breath sounds.

Several days later she was off of the vent.

I had the pleasure of taking care of her last week before she got transferred to tele. She was drastically weakened but mentally intact. I stopped by her floor the other night to say hi, but she had left for rehab.

I feel blown away just thinking about the whole thing.

Anyway, just wanted to share. Please keep my patients and I in your prayers tonight - we need them ;) ]]> MICU and SICU Nursing Forum LoveActually http://allnurses.com/micu-sicu-nursing/first-night-off-438219.html http://allnurses.com/micu-sicu-nursing/backpriming-question-student-438205-new.html Tue, 10 Nov 2009 16:08:43 GMT Hello, I am a student currently assigned to ICU. I'm a little confused about how to backprime, I hadn't seen this untill this rotation. I understand you drop the secondary bag down lower than the primary bag so the primary solution flushes the saline or other fluid through the secondary line so that you do not have to change/waste tubing.

Do you hold the old secondary bag down low (both primary/secondary unclamped) till fluid flows into the bag and then clamp the line, raise it back up and spike a new secondary bag, unclamp and you are ready to go?

Thanks in advance for any clarification. ]]> MICU and SICU Nursing Forum RamaMama http://allnurses.com/micu-sicu-nursing/backpriming-question-student-438205.html http://allnurses.com/micu-sicu-nursing/when-nurses-eat-437711-new.html Sun, 08 Nov 2009 17:11:40 GMT Ok, so I'm super excited... I just got my first job at an ICU, a place I LOVE TO BE. There is so much going on, so much to learn, and so many ways in which we can make a difference. I asked some of the seasoned nurses that I work with now (I'm a part time tech in an ICU unit) what I can do to be successfull in my new job. Some of the replies I got were a little.... disturbing. I was told not to voice my opinion (ever) because since I'm a new grad, I haven't earned the right to have one (apparently, you can only voice an opinion if you are an experienced nurse). I'm not supposed to ask certain questions because that is questioning the judgement of the nurse, and not the procedure (no matter how the question is phrased).
I'm at a total loss. I've worked my tail off to get this far, and I found a place where I really want to be, but feel like I'm being chewed up and spit out by the same people that are supposed to teach me so that when they retire or leave the unit, that knowledge won't get lost. I've gotten to a point where I'm questioning myself as to whether or not I even want to be a nurse anymore. I know that I don't have the knowledge or expeirence to walk into an ICU and take care of a critical patient... but I'm willing to learn, and I don't know how I'm supposed to do that if I can't ask questions or have an opinion. I've been told that I'm not a team player, and that people in general do not like me because I'm aggressive and independant, too focused on the details, and have 'an authoratative tone' when discussing concepts. I know that I shouldn't let one instructor review, or even one or two other nurses opinions stop me, but if I'm getting this from multiple places it really makes me wonder if I'm cut out for this... I'm struggling to figure out how to fix this so that it doesn't become a problem in my new job.. I just don't understand. If I'm caught up with my patients, I ask the other nurses if there is anything I can do to help... If the doctor comes in for an update on a patient that I've been with all day, do I let my preceptor answer him, or do I speak up? If another student asks me a question, and I know the answer, I tell them (and if not, we look for it together). If I don't understand why we are doing something, do I question it, or do I accept the judgement of more experienced nurses?
So I guess my question is: How can I be successful in my new job? What can I do to NOT be perceived as a...witch...? Any guidance would be great...:sniff: ]]> MICU and SICU Nursing Forum phoenixfire http://allnurses.com/micu-sicu-nursing/when-nurses-eat-437711.html http://allnurses.com/micu-sicu-nursing/ccrn-question-437452-new.html Sat, 07 Nov 2009 08:05:20 GMT Hi, I'm sure you hear this question a lot but I think the answers very over the years. How far in advance should you start studying for CCRN and what are the best materials out to aid in studying? ]]> MICU and SICU Nursing Forum AnRNIam http://allnurses.com/micu-sicu-nursing/ccrn-question-437452.html http://allnurses.com/micu-sicu-nursing/oscillating-ventilation-437369-new.html Fri, 06 Nov 2009 22:18:30 GMT Can somebody please explain to me what oscillating ventilation is and when it would be indicated?... Can somebody please explain to me what oscillating ventilation is and when it would be indicated? I've never seen it used or used it before. Thanks ]]> MICU and SICU Nursing Forum putmetosleep http://allnurses.com/micu-sicu-nursing/oscillating-ventilation-437369.html