EyeSeeYuRN 1,204 Views
Joined Jul 18, '11.
Posts: 20 (10% Liked)
Deep breath, relax. The worst that can happen is you'll have to take it again. More knowledge gained.
Expat, that's very interesting that you don't use restraints. I can see how that could be employed in our unit for our standard resp failure patients, but that's not all we have. How do you control organically agitated patients, eg ETOH or hepatic encephalopathy without restraint use? I can't see how any amount of talking down and deescalating would keep these types of patients from yanking their tubes out..... I'm curious to hear your experiences.
Yup, the lack of a locked unit is a problem. What usually happens with these patients is that they first end up in ICU because they are not medically stable (receiving dialysis, vented, etc) after being admitted, usually, with a dx of OD. So we treat them, then when they wake up/start feeling better, they stay with us until they are cleared to be medically stable in order to be transferred to an inpatient psych unit. When these patients do get out of hand, we have security at our disposal (which we employ). Unfortunately, they tend to wait til they know that no ones watching to run. Windows do not open from the inside. I'm looking specifically for a set of guidelines that can be put into place when we get these types of patients. Like I said, there are things that many of us employ because we've had something go wrong, then put into practice the interventions because we've had experience with them. Such as taking down the curtains, removing all clothing (to deter running), etc.
I work in a 16 bed ICU in a rather rural community, and because of budget restraints, the BHU upstairs was closed down quite a few years ago. So, we in ICU get the behavioral health patients... We have the standard 2 MD hold paperwork where the patient loses their rights, yada yada, and some of us have our own ideas on the special considerations for these patients (no clothes/belongings in room, visitors leave bags outside, etc) but we don't have any set policies for handing these patients. I'm on UBC and am beginning to draft such a policy. Anybody have any suggestions? Run into the same problem at your work? Here any tips that would be especially helpful on such a policy? I never knew I'd end up being such a psych nurse! Appreciate any thoughts/feedback!
Don't give up on LPN route. Even if you don't land in your desired unit as an LPN, if you maintain your position though til your licensed as RN, you might find it easier to get in to the same hospital (perhaps a different unit) than your colleagues because many places post positions in house first, then open them to external candidates. This could definitely give you a leg up on the 'competition'. Always good to get a foot in the door, no matter what your job details or where it is.
I did full time program (3 terms) plus worked full time (nights). It was grueling...not difficult material but time consuming work... But now I'm done. Worth it in every regard for me.
Last ditch efforts were definitely in play here!
Working night shift adds another whole level of needed creativity, especially if your patients is a walker/talker. See lab duck in the room at 0315? You betcha I'm grabbing any necessary equipment and getting some assessments/checks done. X-ray sits the patient up? Great time to get a good listen to those lung sounds from the back. We don't have any official parameters for when we have to do our assessments (yes, we do 2000, 0000, and 0400) but as far as time frames to do them in, we use our best judgement. Which, all of you have so accurately delineated above.
Anybody using ABCDE bundle? Outcomes for well sedated patients are pretty poor. We're trying to adopt some of these aspects in our unit, but having more awake patients is definitely a lot more work...and more traumatic for the patients (we all argue). We're using Precedex in indicated cases, but have yet to have a patient where we say, "wow, ya that really worked for him". We generally go back to propofol, fentanyl gtt, or versed gtt.
Focker, great ideas. If this guy would have had pre existing pulm issues, could the presence of collateral circulation be a culprit? Does that happen in the lungs like it does in a long hx CAD? Colorado, yes we got a fem CL shortly after echo, so we already knew results....hence not using cvp as a diagnostic.
I appreciate the feedback... That makes sense.... My only thoughts were that it might have been used anyway as a last ditch effort. The other interesting thing about this case was that it presented as classic MI.. With a bit of cardio shock mixed in. We all couldn't believe that it was a PE because his resp distress wasn't too bad, considering what was actually going on.... Any thoughts on this?
Hi, wanted to get some opinions on a recent very interesting patient that I had:Pt. was originally admitted to the floor with chest pain and RVR (both of which resolved in ER once nitro gtt was started). Apparently when he arrived on the floor, the charge there took one look at him and decided he didn't belong there, so I get him in ICU. When he arrives on our unit, he's looks to be about 15 mins from the wrong exit out of ICU (grey, sweatier than I've ever seen anybody, totally clamped down). SBP in the 70s, and of course, no IV access (the field start was infiltrated upon arrival). We quickly get a line in, start 3L NS boluses, and get a stat echo ordered. Echo shows sig right ventricular dilation and nearly no blood movement (which was new since the guys last echo, about 1mo ago). I start Neo which quickly gets up to 300mcg and vasopressin 0.04u/min per the intensivist who's hanging out in the room. We head for the newly ordered CT c contrast: guy has a massive PE. I'll mention here that this entire time, the guy is on 2L, sats 98ish, rate in the low 20s. So, we TPA him, and by 3am he's much improved. I didn't get a chance to ask the intensivist, or the cardiologist who was his first consult, why we didn't head for Levo. We use it all the time and it's usually our firstline pressor. Even when I was maxed out on Neo and vasopressin with MAPs in the 50s, it wasn't even brought up. I've done some research trying to look the reasoning up, but haven't been able to find anything. Any ideas? Pt has history of CAD, stent x2 in circ, HTN, no pulmonary disease to speak of, and chronic a-fib.
On the same note, what do you do for these patients? I've seen Osler's nodes on extremities before, but what about pulmonary/brain emboli risk? Is there any way to break these up to keep them from creating big resp/neuro issues?
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