Latest Likes For Lev <3

Lev <3, BSN, RN 46,326 Views

Joined Jun 3, '11 - from 'Another planet'. Lev <3 is a ED Registered Nurse. She has '4' year(s) of experience and specializes in 'Emergency - CEN, upstairs, troll bashing'. Posts: 2,799 (53% Liked) Likes: 5,203

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  • May 27

    The first treatment for hypotension in septic shock is fluids. (30ml/kg given as a bolus over 0.5-1 hour). The main hemodynamic factor which causes decreased BP is profound arterial vasodilation. Therefore, you must fill the tank and see if the patient is fluid responsive before starting any vasopressors.

    But even though their SVR is increased, they are still hypotensive.
    I think what he means is that although the SVR is increased initially as a compensatory mechanism to bring up the BP, eventually this mechanism fails and you have a shock state.

    Leukotrienes cause the bronchoconstriction. Medscape: Medscape Access

    The alpha effect includes tachycardia, increased strength of contraction, and increased cardiac output and therefore BP. However, the vasodilation in septic shock is so profound that this compensatory mechanism may fail. The vasopressors/constrictors clamp down on the vasculature and create some counterpressure to the bloodflow aka increased SVR and thereby increase BP. This is why volume is so important. You must fill the tank.

  • May 27

    Quote from tara07733
    That's the kind of manager that the thought of her leaving sends chills down your spine. She sounds great; you are lucky.
    You are right. When a good manager leaves, staff often follow if they can or leave themselves. Usually the person who replaced them cannot fill the big shoes left over.

  • May 27

    I once had a young patient in the ER who was triaged as an ESI 3 for abdominal pain. "I think he's a bit drug seeking" I was told in report. The patient had gotten multiple doses of narcotics. I went in to assess the patient. He stated that he was in a lot of pain although he had just gotten a dose of morphine about 20 minutes before. I said I would talk to the PA to see if he could get an additional dose. I came back with more morphine which did not help his pain. The patient started getting agitated and snippy with me, but then he apologized for his behavior. The patient was becoming diaphoretic. He was also still in excruciating pain. Something did not sit right with me. I called the PA "We've given him a lot of pain medicine, but it's not touching him. He doesn't look good. I need you to take a look at him." The patient ended up being emergently rushed to the OR to removed a large thrombus which occluded his left femoral artery. Good thing the first nurse who had the patient had effectively assessed and documented the patient's pedal pulses. So when his foot went pulseless on us, it didn't look like we had missed this problem initially.

  • May 25

    I think "will come in scrubs to help out" is a common denominator. Spend some time away from the desk!

  • May 24

    I had a great manager who was willing to let me grow. When she hired me into the ED, I expressed that I wasn't sure the ED was for me. But she was ok with that and said that I would see many different patient populations in the ED and I could find which one I liked working for. A manager who doesn't feel like she has to hold on to her employees and not let them move on is a great one.

  • May 24

    Quote from Ruby Vee
    I've had good managers and bad ones, too. The good ones will listen to the story, the problem, both sides of the argument before reacting.

    The good managers will support their employees and then, if required, discipline them behind the scenes. I had a colleague make a really dumb mistake, and she made it in the middle of physician rounds. Voices were heard loudly exclaiming about the morons that work in this ICU, and how did someone so stupid make it through nursing school. The manager went in, defused the situation, told the physicians they needed to apologize for their rudeness toward her nurse (and waited until they did) and then whisked the nurse into her office for a little talk. Only after my colleague was done crying over being humiliated so publically did the manager discuss the actual mistake with her. And although not everyone knows it, there was discipline involved as well. The bad ones -- and this was me -- will pile on publically and then never seek out the rest of the story. "Did you, Ruby, tell Dr. Iusedtobeapathologistandamnowtryingoutcardiacsurge ry that he was a moron?" "No, ma'am. I only told him that if he wanted to do a heart transplant on every patient who had a cardiac tamponade, he'd better have a cousin in the enforcer business to go around and line up donors for us. He told me that only an idiot would say that to a man who had just finished telling a patient's wife her husband was going to die without a transplant, so I told him that only a moron would talk to the wife about a heart transplant without at least checking with his Fellow about opening the chest because the experienced ICU told him his patient had a tamponade and he needed to get on it NOW rather than after his pizza break." (OK -- I was somewhat more tactful -- but the manager didn't understand my POINT. The patient had a tamponade -- needed to be fixed now. He didn't need a transplant, although he would have needed a pine box had the charge nurse not dragged the Fellow out of the OR -- the resident was so sure he was right and I was wrong he wouldn't even PAGE him -- and we opened the chest.) She told me I needed to apologize to Iusedtobeapathologistandamnowtryingoutcardiacsurge ry; the Cardiac Surgery Fellow brought HIM to apologize to ME.

    A bad manager tells you that if you need Wednesday off because the biopsy came back positive and the HMO's only oncologist is only available on Wednesday in the clinic three hours away, you'll need to find your own replacement. A good manager asks you how you're doing, and if Wednesday is the absolute soonest you can get an appointment and if she can call her friend who is the oncologist's scheduler's mother to see about getting you in sooner. And by the way, I've taken you off the schedule for Wednesday and if you need any other days off, please let me know.

    A poor manager hears about you being on your cell phone all day while your orientee (who is nearing the end of her orientation) and tells you that you're obviously not fit to precept. A good manager asks you if anything is going on at home, because you're not usually on the phone at work. When you tell her that Mom has Alzheimer's and your sister programmed your cell phone number into Mom's direct dial and Mom has been calling you all day looking for your father, who died two years ago, a good manager takes you off the schedule so that you can fly home and sort out Mom's living situation, faxes the FMLA papers to you in hour home town that is so small there's no cell phone coverage and sends you an Edible Arrangement because that's all you have the time and energy to eat.

    A bad manager accosts you at 7:35, waves your rhythm strip which is already analyzed and signed in your face and says "This is inadequate charting." A good manager wanders by at 7:35, sees that you've already posted your rhythm strip and says "Good -- now we'll have documentation that he actually WAS in atrial fib so that cardiology resident will have to believe that nurses can distinguish A fib from that other rhythm."

    A good manager either knows the job and can do it well, or understands the outlines of the job and trusts her staff to do the job well and believes them when they tell her that they need more X, Y and Z and perhaps someone could talk to Dr. Dick and explain to him that "Yes, nurses can analyze a rhythm and if he ever again refuses to come when called because of a serious dysrhythmia, she'll be having a talk about it with the Highest Head Honcho of Doctoring." A bad manager will talk to her nurses about not pestering Dr. Dick at nigh because he needs his sleep.

    Ruby Vee, I love your stories!

  • May 24

    I had a great manager who was willing to let me grow. When she hired me into the ED, I expressed that I wasn't sure the ED was for me. But she was ok with that and said that I would see many different patient populations in the ED and I could find which one I liked working for. A manager who doesn't feel like she has to hold on to her employees and not let them move on is a great one.

  • May 24

    Quote from brownbook
    Willing to use common sense over policies.
    I think this is an often overlooked quality but in my opinion very important. Policies are good, but there are certain situations where rules can actually make things unsafe.

  • May 24

    Quote from Ruby Vee
    I've had good managers and bad ones, too. The good ones will listen to the story, the problem, both sides of the argument before reacting.

    The good managers will support their employees and then, if required, discipline them behind the scenes. I had a colleague make a really dumb mistake, and she made it in the middle of physician rounds. Voices were heard loudly exclaiming about the morons that work in this ICU, and how did someone so stupid make it through nursing school. The manager went in, defused the situation, told the physicians they needed to apologize for their rudeness toward her nurse (and waited until they did) and then whisked the nurse into her office for a little talk. Only after my colleague was done crying over being humiliated so publically did the manager discuss the actual mistake with her. And although not everyone knows it, there was discipline involved as well. The bad ones -- and this was me -- will pile on publically and then never seek out the rest of the story. "Did you, Ruby, tell Dr. Iusedtobeapathologistandamnowtryingoutcardiacsurge ry that he was a moron?" "No, ma'am. I only told him that if he wanted to do a heart transplant on every patient who had a cardiac tamponade, he'd better have a cousin in the enforcer business to go around and line up donors for us. He told me that only an idiot would say that to a man who had just finished telling a patient's wife her husband was going to die without a transplant, so I told him that only a moron would talk to the wife about a heart transplant without at least checking with his Fellow about opening the chest because the experienced ICU told him his patient had a tamponade and he needed to get on it NOW rather than after his pizza break." (OK -- I was somewhat more tactful -- but the manager didn't understand my POINT. The patient had a tamponade -- needed to be fixed now. He didn't need a transplant, although he would have needed a pine box had the charge nurse not dragged the Fellow out of the OR -- the resident was so sure he was right and I was wrong he wouldn't even PAGE him -- and we opened the chest.) She told me I needed to apologize to Iusedtobeapathologistandamnowtryingoutcardiacsurge ry; the Cardiac Surgery Fellow brought HIM to apologize to ME.

    A bad manager tells you that if you need Wednesday off because the biopsy came back positive and the HMO's only oncologist is only available on Wednesday in the clinic three hours away, you'll need to find your own replacement. A good manager asks you how you're doing, and if Wednesday is the absolute soonest you can get an appointment and if she can call her friend who is the oncologist's scheduler's mother to see about getting you in sooner. And by the way, I've taken you off the schedule for Wednesday and if you need any other days off, please let me know.

    A poor manager hears about you being on your cell phone all day while your orientee (who is nearing the end of her orientation) and tells you that you're obviously not fit to precept. A good manager asks you if anything is going on at home, because you're not usually on the phone at work. When you tell her that Mom has Alzheimer's and your sister programmed your cell phone number into Mom's direct dial and Mom has been calling you all day looking for your father, who died two years ago, a good manager takes you off the schedule so that you can fly home and sort out Mom's living situation, faxes the FMLA papers to you in hour home town that is so small there's no cell phone coverage and sends you an Edible Arrangement because that's all you have the time and energy to eat.

    A bad manager accosts you at 7:35, waves your rhythm strip which is already analyzed and signed in your face and says "This is inadequate charting." A good manager wanders by at 7:35, sees that you've already posted your rhythm strip and says "Good -- now we'll have documentation that he actually WAS in atrial fib so that cardiology resident will have to believe that nurses can distinguish A fib from that other rhythm."

    A good manager either knows the job and can do it well, or understands the outlines of the job and trusts her staff to do the job well and believes them when they tell her that they need more X, Y and Z and perhaps someone could talk to Dr. Dick and explain to him that "Yes, nurses can analyze a rhythm and if he ever again refuses to come when called because of a serious dysrhythmia, she'll be having a talk about it with the Highest Head Honcho of Doctoring." A bad manager will talk to her nurses about not pestering Dr. Dick at nigh because he needs his sleep.

    Ruby Vee, I love your stories!

  • May 24

    Quote from Ruby Vee
    I've had good managers and bad ones, too. The good ones will listen to the story, the problem, both sides of the argument before reacting.

    The good managers will support their employees and then, if required, discipline them behind the scenes. I had a colleague make a really dumb mistake, and she made it in the middle of physician rounds. Voices were heard loudly exclaiming about the morons that work in this ICU, and how did someone so stupid make it through nursing school. The manager went in, defused the situation, told the physicians they needed to apologize for their rudeness toward her nurse (and waited until they did) and then whisked the nurse into her office for a little talk. Only after my colleague was done crying over being humiliated so publically did the manager discuss the actual mistake with her. And although not everyone knows it, there was discipline involved as well. The bad ones -- and this was me -- will pile on publically and then never seek out the rest of the story. "Did you, Ruby, tell Dr. Iusedtobeapathologistandamnowtryingoutcardiacsurge ry that he was a moron?" "No, ma'am. I only told him that if he wanted to do a heart transplant on every patient who had a cardiac tamponade, he'd better have a cousin in the enforcer business to go around and line up donors for us. He told me that only an idiot would say that to a man who had just finished telling a patient's wife her husband was going to die without a transplant, so I told him that only a moron would talk to the wife about a heart transplant without at least checking with his Fellow about opening the chest because the experienced ICU told him his patient had a tamponade and he needed to get on it NOW rather than after his pizza break." (OK -- I was somewhat more tactful -- but the manager didn't understand my POINT. The patient had a tamponade -- needed to be fixed now. He didn't need a transplant, although he would have needed a pine box had the charge nurse not dragged the Fellow out of the OR -- the resident was so sure he was right and I was wrong he wouldn't even PAGE him -- and we opened the chest.) She told me I needed to apologize to Iusedtobeapathologistandamnowtryingoutcardiacsurge ry; the Cardiac Surgery Fellow brought HIM to apologize to ME.

    A bad manager tells you that if you need Wednesday off because the biopsy came back positive and the HMO's only oncologist is only available on Wednesday in the clinic three hours away, you'll need to find your own replacement. A good manager asks you how you're doing, and if Wednesday is the absolute soonest you can get an appointment and if she can call her friend who is the oncologist's scheduler's mother to see about getting you in sooner. And by the way, I've taken you off the schedule for Wednesday and if you need any other days off, please let me know.

    A poor manager hears about you being on your cell phone all day while your orientee (who is nearing the end of her orientation) and tells you that you're obviously not fit to precept. A good manager asks you if anything is going on at home, because you're not usually on the phone at work. When you tell her that Mom has Alzheimer's and your sister programmed your cell phone number into Mom's direct dial and Mom has been calling you all day looking for your father, who died two years ago, a good manager takes you off the schedule so that you can fly home and sort out Mom's living situation, faxes the FMLA papers to you in hour home town that is so small there's no cell phone coverage and sends you an Edible Arrangement because that's all you have the time and energy to eat.

    A bad manager accosts you at 7:35, waves your rhythm strip which is already analyzed and signed in your face and says "This is inadequate charting." A good manager wanders by at 7:35, sees that you've already posted your rhythm strip and says "Good -- now we'll have documentation that he actually WAS in atrial fib so that cardiology resident will have to believe that nurses can distinguish A fib from that other rhythm."

    A good manager either knows the job and can do it well, or understands the outlines of the job and trusts her staff to do the job well and believes them when they tell her that they need more X, Y and Z and perhaps someone could talk to Dr. Dick and explain to him that "Yes, nurses can analyze a rhythm and if he ever again refuses to come when called because of a serious dysrhythmia, she'll be having a talk about it with the Highest Head Honcho of Doctoring." A bad manager will talk to her nurses about not pestering Dr. Dick at nigh because he needs his sleep.

    Ruby Vee, I love your stories!

  • May 24

    I think "will come in scrubs to help out" is a common denominator. Spend some time away from the desk!

  • May 24

    Quote from Ruby Vee
    I've had good managers and bad ones, too. The good ones will listen to the story, the problem, both sides of the argument before reacting.

    The good managers will support their employees and then, if required, discipline them behind the scenes. I had a colleague make a really dumb mistake, and she made it in the middle of physician rounds. Voices were heard loudly exclaiming about the morons that work in this ICU, and how did someone so stupid make it through nursing school. The manager went in, defused the situation, told the physicians they needed to apologize for their rudeness toward her nurse (and waited until they did) and then whisked the nurse into her office for a little talk. Only after my colleague was done crying over being humiliated so publically did the manager discuss the actual mistake with her. And although not everyone knows it, there was discipline involved as well. The bad ones -- and this was me -- will pile on publically and then never seek out the rest of the story. "Did you, Ruby, tell Dr. Iusedtobeapathologistandamnowtryingoutcardiacsurge ry that he was a moron?" "No, ma'am. I only told him that if he wanted to do a heart transplant on every patient who had a cardiac tamponade, he'd better have a cousin in the enforcer business to go around and line up donors for us. He told me that only an idiot would say that to a man who had just finished telling a patient's wife her husband was going to die without a transplant, so I told him that only a moron would talk to the wife about a heart transplant without at least checking with his Fellow about opening the chest because the experienced ICU told him his patient had a tamponade and he needed to get on it NOW rather than after his pizza break." (OK -- I was somewhat more tactful -- but the manager didn't understand my POINT. The patient had a tamponade -- needed to be fixed now. He didn't need a transplant, although he would have needed a pine box had the charge nurse not dragged the Fellow out of the OR -- the resident was so sure he was right and I was wrong he wouldn't even PAGE him -- and we opened the chest.) She told me I needed to apologize to Iusedtobeapathologistandamnowtryingoutcardiacsurge ry; the Cardiac Surgery Fellow brought HIM to apologize to ME.

    A bad manager tells you that if you need Wednesday off because the biopsy came back positive and the HMO's only oncologist is only available on Wednesday in the clinic three hours away, you'll need to find your own replacement. A good manager asks you how you're doing, and if Wednesday is the absolute soonest you can get an appointment and if she can call her friend who is the oncologist's scheduler's mother to see about getting you in sooner. And by the way, I've taken you off the schedule for Wednesday and if you need any other days off, please let me know.

    A poor manager hears about you being on your cell phone all day while your orientee (who is nearing the end of her orientation) and tells you that you're obviously not fit to precept. A good manager asks you if anything is going on at home, because you're not usually on the phone at work. When you tell her that Mom has Alzheimer's and your sister programmed your cell phone number into Mom's direct dial and Mom has been calling you all day looking for your father, who died two years ago, a good manager takes you off the schedule so that you can fly home and sort out Mom's living situation, faxes the FMLA papers to you in hour home town that is so small there's no cell phone coverage and sends you an Edible Arrangement because that's all you have the time and energy to eat.

    A bad manager accosts you at 7:35, waves your rhythm strip which is already analyzed and signed in your face and says "This is inadequate charting." A good manager wanders by at 7:35, sees that you've already posted your rhythm strip and says "Good -- now we'll have documentation that he actually WAS in atrial fib so that cardiology resident will have to believe that nurses can distinguish A fib from that other rhythm."

    A good manager either knows the job and can do it well, or understands the outlines of the job and trusts her staff to do the job well and believes them when they tell her that they need more X, Y and Z and perhaps someone could talk to Dr. Dick and explain to him that "Yes, nurses can analyze a rhythm and if he ever again refuses to come when called because of a serious dysrhythmia, she'll be having a talk about it with the Highest Head Honcho of Doctoring." A bad manager will talk to her nurses about not pestering Dr. Dick at nigh because he needs his sleep.

    Ruby Vee, I love your stories!

  • May 24

    Saying "she's here all the time" is the type of triage language/tunnel vision that gets people killed.

    I agree with your ESI 1 designation. If she wasnt symptomatic (diaphoretic and tachypnic) then she would be an ESI 2. HR alone with a borderline BP and symptoms can put her in ESI 1 territory because either a) she will need fluid rescusitation and/or b) chemical/ electrical cardioversion (if afib rvr lets say)

  • May 24

    Quote from Ruby Vee
    I've had good managers and bad ones, too. The good ones will listen to the story, the problem, both sides of the argument before reacting.

    The good managers will support their employees and then, if required, discipline them behind the scenes. I had a colleague make a really dumb mistake, and she made it in the middle of physician rounds. Voices were heard loudly exclaiming about the morons that work in this ICU, and how did someone so stupid make it through nursing school. The manager went in, defused the situation, told the physicians they needed to apologize for their rudeness toward her nurse (and waited until they did) and then whisked the nurse into her office for a little talk. Only after my colleague was done crying over being humiliated so publically did the manager discuss the actual mistake with her. And although not everyone knows it, there was discipline involved as well. The bad ones -- and this was me -- will pile on publically and then never seek out the rest of the story. "Did you, Ruby, tell Dr. Iusedtobeapathologistandamnowtryingoutcardiacsurge ry that he was a moron?" "No, ma'am. I only told him that if he wanted to do a heart transplant on every patient who had a cardiac tamponade, he'd better have a cousin in the enforcer business to go around and line up donors for us. He told me that only an idiot would say that to a man who had just finished telling a patient's wife her husband was going to die without a transplant, so I told him that only a moron would talk to the wife about a heart transplant without at least checking with his Fellow about opening the chest because the experienced ICU told him his patient had a tamponade and he needed to get on it NOW rather than after his pizza break." (OK -- I was somewhat more tactful -- but the manager didn't understand my POINT. The patient had a tamponade -- needed to be fixed now. He didn't need a transplant, although he would have needed a pine box had the charge nurse not dragged the Fellow out of the OR -- the resident was so sure he was right and I was wrong he wouldn't even PAGE him -- and we opened the chest.) She told me I needed to apologize to Iusedtobeapathologistandamnowtryingoutcardiacsurge ry; the Cardiac Surgery Fellow brought HIM to apologize to ME.

    A bad manager tells you that if you need Wednesday off because the biopsy came back positive and the HMO's only oncologist is only available on Wednesday in the clinic three hours away, you'll need to find your own replacement. A good manager asks you how you're doing, and if Wednesday is the absolute soonest you can get an appointment and if she can call her friend who is the oncologist's scheduler's mother to see about getting you in sooner. And by the way, I've taken you off the schedule for Wednesday and if you need any other days off, please let me know.

    A poor manager hears about you being on your cell phone all day while your orientee (who is nearing the end of her orientation) and tells you that you're obviously not fit to precept. A good manager asks you if anything is going on at home, because you're not usually on the phone at work. When you tell her that Mom has Alzheimer's and your sister programmed your cell phone number into Mom's direct dial and Mom has been calling you all day looking for your father, who died two years ago, a good manager takes you off the schedule so that you can fly home and sort out Mom's living situation, faxes the FMLA papers to you in hour home town that is so small there's no cell phone coverage and sends you an Edible Arrangement because that's all you have the time and energy to eat.

    A bad manager accosts you at 7:35, waves your rhythm strip which is already analyzed and signed in your face and says "This is inadequate charting." A good manager wanders by at 7:35, sees that you've already posted your rhythm strip and says "Good -- now we'll have documentation that he actually WAS in atrial fib so that cardiology resident will have to believe that nurses can distinguish A fib from that other rhythm."

    A good manager either knows the job and can do it well, or understands the outlines of the job and trusts her staff to do the job well and believes them when they tell her that they need more X, Y and Z and perhaps someone could talk to Dr. Dick and explain to him that "Yes, nurses can analyze a rhythm and if he ever again refuses to come when called because of a serious dysrhythmia, she'll be having a talk about it with the Highest Head Honcho of Doctoring." A bad manager will talk to her nurses about not pestering Dr. Dick at nigh because he needs his sleep.

    Ruby Vee, I love your stories!

  • May 23

    Quote from brownbook
    Willing to use common sense over policies.
    I think this is an often overlooked quality but in my opinion very important. Policies are good, but there are certain situations where rules can actually make things unsafe.


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