[goinforit]

Hello all. I just graduated on May 16th and took the NCLEX on the 30th, and drum roll.............. I just found out that I passed!!!
I am so excited, I will begin my career as a nurse on a neuro/surgical/trauma floor at a level one trauma teaching hospital. I really feel like I have gotten the dream job. To be honest, I have been so consumed with school and taking boards, and now that I am done with all that reality is hitting me, I will be taking care of some of the most critically ill patients possible. I would love some advice, really a top 10 list of things that would be good to research prior to starting. I have five weeks before I start so I have some time. I greatly appreciate it!

[goinforit]

Are there many neuro nurses on this board? Hoping to get inspired, and to get lots of ideas here. C'mon fellow nurses!

[nrsang97]

I work a strictly neuro surg icu. We don't get a lot of trauma. These are the thing I see alot.

Crani for tumor.
Subarachonid hemorrhage (read up on triple H therapy, Hypertensive,Hypervolemic,Hemodilution)
Vasospasam
Read about aneurysm clipping and coiling
Intracranial hemorrhage
CVA ischemic and hemorrhagic
seizures
Lumar drains (palced for pt with CSF leaks)

I hope this helps some.

[nrsang97]

Oh also know the meds you are giving.

We give LOTS of

Dilantin,Versed,Fentanyl,Propofol,Neosynepherine,2 % nacl, 0.9ns+20kcl,Nimodipine, Keppra, stool softeners, and I am sure I am forgetting some.

Some pt have orders for fluid boluses for ex, "If intake less than 300cc + (positive) for 4 or 8 hours (depending on order) give 500ml 0.9ns bolus"
If CVP <8 give 500ml 0.9ns bolus. These orders are common for SAH and Vasospasam patients.

You will have frequent labs to draw. Lots of patients are q6h lytes,mag,phos,serum osmo. Some patients will paramaters according to their lab values.

[goinforit]

Thanks for the info nrsang97! You have given me a good list of things to study up on.

[ELKMNin06]

Lets see..just to add...know about

EVD's http://uuhsc.utah.edu/pated/handouts...handout559.pdf
remember they work by gravity so its important that they always be level. So if you move your pt. remember to always close the drain!

Invasive monitoring...we use a lot of Arterial lines for BP, swans when triple H ing...CVP monitoring, etc.

Vasoactive drips...lots of Neo, Cardene, Levophed, dobutamine, dopamine, insulin drips

learn about diabetes insipidus...know the main criteria for calling the doc..250cc out an hour or over...spec grav less than 1.003, sodium high

also know about cerebral salt wasting which is similar but the sodium goes down

know what labs are importatnt and why, Na, K, Mg, serum os

good luck

[Christie RN2006]

Originally Posted by goinforit

Hello all. I just graduated on May 16th and took the NCLEX on the 30th, and drum roll.............. I just found out that I passed!!!
I am so excited, I will begin my career as a nurse on a neuro/surgical/trauma floor at a level one trauma teaching hospital. I really feel like I have gotten the dream job. To be honest, I have been so consumed with school and taking boards, and now that I am done with all that reality is hitting me, I will be taking care of some of the most critically ill patients possible. I would love some advice, really a top 10 list of things that would be good to research prior to starting. I have five weeks before I start so I have some time. I greatly appreciate it!

First of all congrats!! I work in a surgical intensive care unit in a level 2 trauma hospital and I really like it (well, the majority of the time :P) My unit gets all the neuro, surgical, bleed, and trauma patients... as well as the occasional cardiac, post partum (delivery gone bad) and lots of respiratory patients.

What I really recommend is:
1. Brush up on is your assessment skills. Know the normals!
2. Know how to do a neuro assessment!
3. Brush up on your BLS skills.
4. Start studying for ACLS now and get into a class as soon as you can.
5. Make sure you know heart rhythms and how to interpret them.
6. Read about ICP and lycox catheters. We use those a lot with our neuro patients.
7. Make sure you know how to log roll a patient and how to put on/adjust a c-collar correctly.
8. Read about types of sedation... ativan, diprivan, etc. (we use mostly diprivan with our neuro patients)
9. Now your drips and how to titrate them... nitro, cardene, levophed, dopamine etc.
10. Study types of traumas... closed head injuries, blunt force trauma, etc.

Word of advice from a recent grad... Listen to your preceptor and don't be afraid to ask questions! Don't ever do something or give a medication unless you know what it is and what you are doing. Talk to your patients, even when they are in a coma, you never know when they might wake up! (yep, there is a story behind that one)

[istartcpr]

Congrats- The replies are pretty comprehensive, although I have one suggestion... Study up on spinal cord injuries also. When I graduated in 1980
I went into Neuro Icu. Really scary at first but I worked with a group of great nurses that I couldn't have made it without. Good Luck to you

[neurogeek]

Originally Posted by goinforit

Hello all. I just graduated on May 16th and took the NCLEX on the 30th, and drum roll.............. I just found out that I passed!!!
I am so excited, I will begin my career as a nurse on a neuro/surgical/trauma floor at a level one trauma teaching hospital. I really feel like I have gotten the dream job. To be honest, I have been so consumed with school and taking boards, and now that I am done with all that reality is hitting me, I will be taking care of some of the most critically ill patients possible. I would love some advice, really a top 10 list of things that would be good to research prior to starting. I have five weeks before I start so I have some time. I greatly appreciate it!

First of all, welcome to the official neuro site! And congrats on passing boards:hatparty:. Ok, there have been lots of great responses to your post but let me add to them ok?

1. Know your neuro A&P like the back of your hand. You can not in any way understand what is going on till you do.
2. KNow how to perform a thorough neuro assessment that includes the cranial nerves and peripheral nerves (sensory & motor of all). That means testing reflexes, assessing for hot/cold differentiation, vibration, touch (sharp vs dull) etc. It's a must for any good neuro nurse.
3. Know your endocrine disorders that are closely related with neuro patients and WHY: DI (think pituitary tumors or thalamic/hypothalamic lesions or tumors); SIADH (know that it's dilutional hyponatremia & why low Na is so dangerous to the neuro patient as well as the treatment)
4. Know that infusing 3% NaCL is very dangerous and that rapid infusion can cause pontine demyeliantion leaving your patient a quad.
5. Know your surgical procedures and possible adverse affects related to them (such as DI, bleeding, edema, and VERY important pneumocephalus).
6. PEARL of wisdom: easy fix for pneumocephalus is 100% O2 NRB. Most pt's experience relief of their HA within hours. The air in the brain dissipates up to 90% faster with 100% O2 on relieving their s/s faster & often preventing the need to return to the OR>
7. Know that you can NEVER, EVER, NEVER, EVER flush the brain or any tubing going into the brain with saline that is bacteriostatic. It is caustic to the brain & will cause necrosis and seizures.
8. Know that you can NEVER, EVER, NEVER, EVER use alcohol any anything that is entering the brain because it is caustic & will cause necrosis and seizures.
9. Know the proper way to manage your CPP. Often it's a juggling act between raising your MAP and lowering your ICP. If you're on a med-surg unit focus on other ways to lower ICP if your pt's level of consciousness decreases such as keeping the neck & body in alignment (turning of the head occludes the venous drainage of the brain), keeping minimal hip flexion (hip flexion increases intrathoracic pressures leading to decreased venous drainage from the brain), and elevating the HOB (the #1 first priority) to > 45 degrees.
10. Know your medications well and possible side effects (such as missing a dose of steroids on a pt whose been receiving them a while could result in adrenal crisis and kill your patient). Little things like that.

Hope this helps some. Hang in there!
J. Krebs, RN, CNRN

[poppy07]

what efforts do you make to control/reduce ICP, how about turning and repositioning pt?