Crash course in quick responses

Christie RN2006 · Nov 5, 2007

What if pt's HR is 15-30, but you can't feel a pulse...do you grab a doppler?If patient on monitor and pulse is 15-30 you know you have a pulse. Do EKG to see if patient has a heart block. Patient AXOX3 asymptomatic Put patient on pacer pads with pacer at bedside, keep atropine at bedside, get vital signs, call doc. PT symptomatic maybe starting loose conciousness call code becoming disoriented may want to call code.

I do have one comment to make on this... you cannot rely on your monitor at all times! I had a patient that on the monitor looked like they were in NSR, but they were actually in PEA. Like someone else said, the number one rule of nursing is that you always have to assess your patient! Just because the monitor is saying they have a pulse, doesn't mean that they actually do. If their HR is that low and you can't feel a pulse, ACLS says you have to start compressions. Even if they have a pulse you can find with doppler, they will not keep that pulse for long.

poppy07 · Nov 5, 2007

My orientation is OVER! I feel like I should've gotten more out of it, the precise reason I ask these questions... This is the way I think about the pt's I've cared for, anticipating what could happen, understanding why I'm doing what, and how to be prepared for the next time...

angelique777 · Nov 5, 2007

new in ICU... I haven't gotten the EKG basic class yet, let alone ACLS. How would you know about the pacer pads? Is that learned in ACLS? Well if your new to ICU in our hospital they send you to Critical Care Course and in order to work in the ICCU/CCU/MICU/CSI being ACLS certified is required along with basic dsyrhythmia training. Actually even as a nursing student in 2005 I had a great cardiac instructed and we learned this in class. It a NCLEX cardiac question in terms of what to do if patient is Sinus Bradycardia.

But you can review this on your own. The Basic intervention with Sinus Bradycardia. Nursing interventions are Pacer @bedside and pacer pads on top along with atropine in case pt goes into asytole or becomes symptomatic with there bradycardia. If patient stable aysmptomatic patient is just monitor for rate and for any pauses. (This is taught in basic dysrhythmia course) and also a basic NCLEX cardiac question which I got in my review course.

You should be shown where on your unit where is the difibrillator located and how to change for pacing/ how to just monitor a rhythm and how to use to defibrilate. You should be shown how to connect defibrillator pads and how to connect pacer pads. How to test the unit. You should know where the crash cart is.

If your new to the unit they should teach you all the above or how could you know what to do.

Also, what about PEA... good rule of thumb is to just go ahead with compressions if you can't get a pulse immediately?

If you're the only one in your pod in the ICU and you have a bad situation, how do you call for help?

In our hospital there is a code button in each patient room its color blue. It flashs and has a certain sound and we know its a code. The operator receive the signal and pages the code team to the room. I started on my unit just 2years ago and the first time I used that button I was so amazed. I found my patient on the floor. He stood up to go to the bath room and collasped. I pulled the code bottom after I checked he was unresponsive in the time I kneeled down to the patient the code team was in the room doing everything it was that fast.

When mentioning "moving a patient" with a high PEEP--20-25, I'm referring to repositioning, pulling up in bed, turning, etc. How do you handle?

THANKS A LOT!!! : )

Again my unit does not get a lot of vents this will change soon since we will begin to get 1st day post op CABG patients Our protocol is unless its one of our post op CABG patients we do not get the vents they go to CCU. On the time I have had vented patients I always used caution in pulling and moving patients, I never been told they could not be moved b/c of the peep.

I was on a vented unit while in a nursing internship program and also was never given that precaution about moving . Pts need to be repositioned to be cleaned and to prevent bedsores and they where also moved gently. and with assistance.

The only time I told a CNA not to move a vented patient that she wanted to to for general morning care (it the first time a CNA got so upset I did not let her clean the patient. I told its because of her heart rate but the CNA stormed off as if I did a horrible thing.) was when her HR was in RAFIB 170's and patient needed cardizem drip told CNA not to move patient I did not want her heart rate to go any higher. I was a Cardiac Nurse working a med surg floor and they can not hang gtts so the Doctors gave cardizem IV push. and awaited to transfer patient to my unit. Monitor patient closely on EKG machine since no telemonitor available and monitor BP closely. The scary thing with cardizem is that it can suddenly drop the heart rate in some patient I have seen it happen.

If you do not know your ACLS/ your basic dysrhythmias or how to use defibrillator or pacer do not fear your preceptor will have to go over all those things prior to letting you go solo. I hope something I said helped a least lol.

Hope something I wrote helped wish you the best on your unit. Do not worry they will teach you. Ask your nurses they will teach you. I had great preceptors on my unit I still ask lots of questions learning never ends so much more to learn on my unit. May consider transfering to CCU in the next year still debating

CCU still scares me a little but I love the challenge of learning more stuff.

poppy07 · Nov 6, 2007

I haven't been shown the pacer, defribrillator, how to operate, etc. I have been forced out on my own (after requesting to stay on orientation...told I'd have 12---they tried to take me off at 8, I demanded my 12!)

Medic/Nurse, BSN, RN · Nov 6, 2007

new in ICU... I haven't gotten the EKG basic class yet, let alone ACLS. How would you know about the pacer pads? Is that learned in ACLS?
* I am just amazed that you are working in the ICU without a working knowledge of EKG/ACLS. I hope that you are in a clinical internship with class time devoted to essentials of critical care. I would be just terrified of doing your job without a fairly specific body of knowledge (ECCO, ACLS, Hemodynamics) - wow!
Also, what about PEA... good rule of thumb is to just go ahead with compressions if you can't get a pulse immediately?
* Actually, A - B - C. But, assuming that you have good ventilation/oxygenation and PEA - yep, compressions is the next step.
If you're the only one in your pod in the ICU and you have a bad situation, how do you call for help?
* Hit the code button on the wall - should get you some help. I don't leave my patient. Every ICU that I have been in has wall mount oxygen, suction and BVM's at the bedside. First, take care of the patient in distress. Assess patient for need of critical interventions. Open airway. Ensure Ventilation via BVM with 100% oxygen. Check for circulatory compromise. Start compressions if necessary. Also, remember to check all the "drips" that many patients are on - often in a patient that becomes "bad" - it may be necessary to turn some things off.
When mentioning "moving a patient" with a high PEEP--20-25, I'm referring to repositioning, pulling up in bed, turning, etc. How do you handle?
* Just moving a patient in bed, should not be a problem with most patients. I took the earlier mention as a "road trip". Just ensure that the ETT is secure and vent circuits move freely, suction any secretions in the patient that may need it, ensure that the patient is "comfortable". There are a lot of variables with vented patients. 20-25 of PEEP would let me know that this patient is complex - if you are concerned, I think that enlisting a RT to the bedside is essential. Sure, pneumo's happen in vented folks - and yes, that is a bunch of peep. But, that patient is on that much PEEP because they have A: pulmonary compliance problems and/or B: ventilation/perfusion mismatching. Either or both of these means your patient is sick. Asking for assistance shows that you are a great nurse!
THANKS A LOT!!! : ):balloons:

Hey there poppy07 -

Wow! You have some good questions for a new ICU nurse - I hope that you have a good preceptor or clinical educator that can assist you. But, you are asking the questions and that is everything!

Best of Luck with the ICU. You will always learn something. (I still do everyday.)

Join AACN - take advantage of every learning opportunity that comes your way!

Christie RN2006 · Nov 6, 2007

I haven't gotten the EKG basic class yet, let alone ACLS. How would you know about the pacer pads? Is that learned in ACLS?

~Where I work, we are required to become ACLS certified within a year. We are not allowed to take ICU or Tele I patients anywhere until we become ACLS certified. I learned about pacing in both my Critical Care classes and in ACLS. You really need to try to get into an ACLS class ASAP!

Also, what about PEA... good rule of thumb is to just go ahead with compressions if you can't get a pulse immediately?

~ACLS states that if you cannot definitely find a pulse, you need to start compressions.

If you're the only one in your pod in the ICU and you have a bad situation, how do you call for help?

~If it is a code situation we have a button to hit that is blue and it flashes outside the door and there is a system in all the critical care units that has a special alarm system on the ceiling that has all the different critical care units listed and where the code button is hit, that units light starts flashing and it does this really loud/annoying alarm. We also can dial "55" by phone and tell the operator where the code is and they will start paging it even before you hang up the phone.

~If it is not a code you can call your charge nurse for help.

~That is an issue that we will never have where I work because our policy is that you have to have 2 RNs in the ICU at all times.

UM Review RN, ASN, RN · Nov 6, 2007

I haven't been shown the pacer, defribrillator, how to operate, etc. I have been forced out on my own (after requesting to stay on orientation...told I'd have 12---they tried to take me off at 8, I demanded my 12!)

Poppy, I sure don't mean to sound harsh, but if you're off orientation and you're on your own and you don't know the answers to those questions and there is no one to mentor you on your home unit about those things, I would seriously suggest that you have a talk with your manager.

Orientation is supposed to prepare you to the point that you're ready to care for the critically ill patient and from the questions that you're asking, you are not ready. If you can't get more training and adequate preceptorship, I would have to suggest that you move to a different unit or a hospital that has a better orientation/preceptor/mentoring program.

That is not to say that you cannot learn.

(I put it in boldface because this is a situation that is obviously caused by poor orientation and preceptorship, not by your failure to learn.)

I don't think that you have gotten sufficient training nor do you appear to have adequate mentoring with the other nurses that you're working with on your unit.

Please let us know how your situation proceeds. We care and we really want you to succeed.

cardiacRN2006, ADN, RN · Nov 6, 2007

I agree Angie----we aren't supposed to know everything once off orientation, but you really should have been able to answer most of these questions.

I wasn't allowed off orientation until after I was ACLS certified, had passed a critical care course, and hade my competencies done. This included training on the code cart, pacer/defib, etc.

At a minumum, if you don't know what to do when a pt has a HR of 15 with no pulse-then you aren't ready for ICU patients.

poppy07 · Nov 6, 2007

So do you guys have any suggestions since when I talk to the Mgr and Charge RN, both saying "you'll never feel ready"..."what do you need a year of orientation"...etc. and "you're never really on your own"... am I supposed to be just picking up on the rest of these details as I go and experience more? My preceptor seemed to think it was just their job to watch me on my own and act as a resource (while rarely even being available when needed) occasionally reminding me, "don't forget you need to note orders, draw this lab, chart your assessment" etc. rather than trying to teach me new things as have been mentioned earlier. Seems like the unit is desperate for more nurses working on their own and they don't care how thoroughly prepare we are...I'm stuck!

UM Review RN, ASN, RN · Nov 6, 2007

:down:In that case, you go to your Manager with a written two-week notice.

They're trying to blame the failure of their "orientation program" on you.

:nono: Wrong and bad.

But better you leave this place and get the proper orientation than be involved in the accident that's waiting to happen on that unit.

Best wishes, poppy. Keep us updated, ok?

poppy07 · Nov 6, 2007

I cannot quit. I'm a new grad and have a contract.

cardiacRN2006, ADN, RN · Nov 6, 2007

I cannot quit. I'm a new grad and have a contract.

I'm sure somewhere in your contract it states that you will receive an adequate orientation too. I'm sure you can find a way out.

I disagree with what they said about never feeling ready. I pulled myself off orientation one month early because I was ready,

But, I had a six month orientation with critical care classes.

You are getting a raw deal, and no contract is worth that. What did you get in return for the contract? A sign on bonus? Loan repayment?