[Cat84]

HI everybody,
I am sorry but I need to vent. Let me start by saying I am a new grad in the ICU who got off orientation at easter time. I work 12 hour midnights with a very "young" staff of RN's who have similar to 1-3 years experience. I came into work the other night to a very difficult situation.

I was assigned the hardest patient on the floor by the charge nurse, which is okay but I quickly felt uncomfortable. My pt was in full blown DIC. She was a HIT pt and had more drips then I have ever seen in my life. She had d5 with 3 amps bicarb, diprivan, vasopressin, levo, ns for piggybacks, morphine drip (but was a full code), and tpn/lipids. All of this was going through a Right IJ triple lumen with cordis, also CVP lumen, R subclavian triple, and she had a right femoral art line. I was struggling to find out what was compatible to run everything. She was oozing from all these. She had blood running down her face from eyes, nose, and mouth. She had no reflexes (blink gag cough), and was incredibly busy with 24 packs of platelets, 4 units of ffp, 2 units blood, and xigris on my 12 hour shift. The patient was on pressure control vent (which I don't think I am totally grasping the concept of), we usually have people on AC. I was drawing ABG's every 30-60 minutes and talked to the intesivist 5 times. I felt so overwhelmed, and I feel like I did nothing for her. Even on 100% PC vent she was sating like 65%. To top it all off our unit has been in contact iso for 2 weeks for acinobactor, so gowning and gloving for everything. I have to work tomarrow, and really do not want to go. I was asking people for help, but was so busy I couldn't really tell them how to help me. I feel like I did nothing for this patient, who seemed close to death when I left.

I feel like the other nurses were mad because I had one pt, while another nurse was tripled, and could barely keep up with that. I felt so out of control my entire shift, that I came home and slept for close to 18 hours! I did not bathe her as, she was not tolerating movement (b/p down even on pressors). The nurse before me was tripled with this pt. Am I that unorganized that I can't keep up? I am feeling disgusted with myself for freaking out a bit, and irritated that I felt like I was drowning. I have been on the unit since January and feel like I am a slow learner. Anyone have any advice about 1)pressure control vent 2)how to be more calm and 3)any advice for a new nurse in ICU

Help is greatly appreciated

Courtney

[dianacs]

Are you saying that the nurse before you had 2 other patients plus this patient? No way is that even possible with all that your patient had going on!

Sounds like you did fine, with a patient like this it's all you can do to keep your head above water. When I've had a patient like this, it seems like all I do is give blood product after blood product and titrate pressors. And talk to our physicians a million times! And draw a bajillion labs so often that by the time you start correcting them, you're due for another set.

I too feel overwhelmed (and definitely stressed) when caring for this type of patient. Most people do! As long as I stay focused on the ABCs, the rest can wait. A bath would be priority #999. But it's frustrating when it seems like everything you're doing just isn't enough--and when someone's as sick as that, it often isn't. We do the best we can and that's all we can do.

I will leave it to someone more eloquent than me to explain pressure control ventilation--we rarely use it either.

It sounds like you did fine and I definitely relate to your feelings about this kind of situation. Once some time has passed, reflect on what you have learned. Then the next time may be slightly less overwhelming. Good luck and hang in there.

[incublissRN]

It sounds like you did all that you could for your patient. Good job! When someone is that sick it's hard to feel like you accomplished something.

To answer your question about pressure control ventilation:

RTs adjust the amount of pressure that supports the breath according to what has been ordered. Lung compliance determines the amount of tidal volume. If they have tighter lungs then they will have a smaller tidal volume and may need paralyzed or sedated.

Check out www.icufaqs.org on vents and ABGs.

[blueinplaid]

courtney,

let me say good going, girl! First off because your pt survived the night, that can be a feat in itself with a DIC pt. With that sort of bleeding it can feel like youre just trying to stay above water- if that! so you did well. i know i look back frequently over my shift and analyze what i could have done better, done faster, seen quicker...whatever....i feel that i am a good nurse for it so i hope you do too!

we used pressure control settings for our little ones frequently for lungs that were noncompliant- had been ventilated before for an extended period of time or whatever. it is a more acute setting than volume control. if the ventilator were to deliver that set amount of volume to a patient with very stiff lungs, it could give them a pneumo or worse. pressure control delivers a certain amount of pressure with each breath- so your tidal volume is what you need to pay close attention to. if it starts to decrease then something is changing with your patient i.e. waking up from sedation/paralytics, or need to be suctioned etc. with volume control, the amount of pressure could change to deliver whatever the volume is set to. we used also prvc which is both pressure and volume regulated again to be aware of the amount of pressure the vent is giving to deliver a set volume.

it has been a long time since i've had to think about this, so i am removing a lot of cob webs! working in my er now doesn't give me the time to think about those things!

hope this helps!

[suanna]

Wow! this sounds like the kind of patient I love to care for. I know it doesn't seem like it now but with a few more mos experience you may go home feeling pumped up about maxing out your skills to meet a difficult patients needs rather that spending your night doing the endless mindnumbing tasks that seem to compose most nights in ICU nursing. Hang in there- if you got through the night and the patient still had a pulse you did your job, and you both came out ahead. The next time you have a patient like this you will bring new insights and skills to the bedside.

[Cat84]

Thanks for all your help guys! I am about to check out the icu link. To answer an earlier question, yes the nurse before me was tripled with this patient! I felt bad for her because she was agency, and not regular staff (well I felt bad for her anyway). I don't know how she kept her head above water. I let the charge nurse know when I left that it was a really inappropriate assignment.
About the bath, I could also care less whether this patient got bathed or not, except day shift harrassed me about it when they came in. Also, I like the patients to look relatively clean (no blood on her face at least) when family comes. One more question though, for pressure control do people always have bipap settings. i.e. she was pc with 30/12 100% rate 24. Sometimes she was pulling her volumes sometimes as little as 150. I ended up switching her to AC 24, 450, 100%, peep 15 before I left based on ABG's.

I thank you all again. It was hard to switch to midnights where I feel I have no resource person to ask these sorts of things. Thanks again Courtney

[GrnHonu99]

Wow...her O2 sats were 65% on 100%??? The intensivist should have been at your bedside!! Does your hosp. use RTs? Our RTs manage our vents not that we dont work with them and understand the vent settings. Our Rts draw ABGs and insert Alines...Where was your charge nurse? I am a new grad in a large neuro icu..but we always know where the really sick pts are and we are always helping our coworkers..espically if we have easier pts..OUr charges always help too...so even if i feel overwhelmed (which i def have before!) im never working alone...On an ave night there are atleast 18 nurses on my floor...there is always someone to help. I hope you had help!

[Cat84]

Yeah, the RT's change the vent settings but we do our own abg's. The intensivist admitted there was nothing else to do. Family could not agree on code status. If lungs are broken and pt is septic you can blow all the o2 you want they aren't going to use them....pt also had dead bowel (already had a new ileostomy that was necrotic) not a surgical cantidate.....

[Cat84]

oops and our charges have their own patients on midnights...makes it tough sometimes. There were five other nurses on my "side" (we have two hallways) there were other patients not doing well. It got better at 0400 when some of the more experienced nurses came in....Thanks CAT

[imagin916]

OMG That is a scary patient to have, but you did great! Patients that sick rarely survive and you are doing a great job trying to keep her alive. Don't feel that its your fault if something happens to her, because there is only so much we can do, but we can't prolong the inevitable forever. That stinks that nobody was there to help you, that patient should have 2 nurses instead of one! I dont know how that one nurse had this patient with 2 others! Hang in there, you are doing a great job!