gigglestarsRN 3,390 Views
Joined: Oct 29, '12;
Posts: 63 (35% Liked)
; Likes: 41
Cardiac stepdown unit; from
1 year(s) of experience
Hi all, I am new to this thread and read the most recent 10 pages to get a feel for things. I'm guessing clc's are group projects? I'm starting the program in September and trying to get a feel on feedback if what to expect and so far it's been very informative.
We take these patients frequently on my floor and are a cardio thoracic step down unit. We keep them on bed rest post hemostasis for 4-6 hrs depending on drs orders then begun to come off bed rest and ambulated. If no bleeding or hematoma, they go home next morning, perclose or other closure. Pretty straightforward as long as no bleeding, and yes to tegaderm, often over a thrombix pad on our unit.
Regarding case studies. I always worry about submitting any detailed case study type scenario. What if a co-worker recognized me here, or someone put two and two together and figured out the hospital where I work. There are always a few super vigilant protectors of privacy that would only be too happy to nail a coworker to the wall for a very remotely possible violation of HIPAA.
It would be nice if we could submit case studies anonymously to you guys, then have the case submitted by a staff member here. That would insure total anonymity.
HeartRN13, now that you mention it, I've had that happen too and the pt had had a massive stroke. I forgot about it because by the time it was discovered, another nurse had the pt so I found out about it some time after...
This is intriguing- please keep us posted! Sorry I don't have many ideas, especially since the CT was negative for stroke. Sounds like a herniating brainstem due to increased icp or something...?
First of all, congrats on two great offers! My initial reaction is that the ED will give you a broad range of experiences. Unless you want to specialize in cardiac, I think that's a better place to start and acquire many skills. Good luck with whatever you decide!
I have learned the wonders of peppermint oil. We can call our pharmacy and they will tube it up. I pour small amounts into medicine cups and place in room, outside door, in hallway- as out of sight as possible. It smells fresh and works especially well with c diff and high output ostomies bring emptied frequently.
That is awesome!!!!
Just tell me vitals stable. I don't want to know every dose of insulin in the las 24 hors and what they had for snacks, especially if they are going home this morning.
I do want to know who has crazy spouses.
All I know is my last few shifts I have had some VERY pertinent information left out of report and thus leaving me swinging in the wind looking like an idiot when asked by patient, family or docs/therapists/social worker about it. Things like......a second planned surgery. A DVT in the left arm. Having been admitted with chest pain the week before and had stents placed at that time. A stage II decubitus. Things that sure, I would find out once I had the chance to review the chart (which, face it....often doesn't happen as soon as we would like). All I ask is report be thorough and accurate.
Chest tubes, pneumothorax, and tension pneumos made clear: Everything you wanted to know about chest tubes and a little bit more. I promise this will answer your question.
This little tutorial started out with a few sample NCLEX questions someone posted. I answered this one....
<< On the way to an x-ray examination a client with a chest tube becomes confused and pulls the chest tube out. The nurse's immediate action should be to:
1. Place the client in Trendelenburg position
2. Hold the insertion site open with a Kelly clamp.
3. Obtain sterile Vaseline gauze to cover the opening.
4. Cover the opening with the cleanest material available.>>
As always in NCLEX-land (and in real life), you're looking for the answer that keeps the patient safest. I know you'd rather cover that hole with something sterile, but what is a greater immediate danger to this unfortunate fellow, an infection (which may not even develop) or a great honking pneumothorax (which certainly will)?
And while we're at it, let's talk about how you know whether to clamp or not to clamp a chest tube that has been disconnected from its drainage device (but is still in the pleural space). To understand this, let's look at the differences between a tension pneumo and a pneumo that isn't a tension pneumo.
Respiratory mechanics first ! When you breathe in, you're not actually pulling air into your lungs with your muscles. You're actually making a suction inside your chest with them (I know this may seem like a distinction without a difference, but stay with me), and the air enters the lungs thru the route provided for it to do so-- your trachea, via your nose or mouth (or trach tube, if you arent so lucky).
Your lungs are covered with a slippery membrane called the visceral pleura. The inside of your chest wall has one too, the parietal pleura. They allow the lungs to slip around with chest wall motion, like you can slip two wet glass plates around that are stuck together. Like the two glass plates, they're hard to pry apart due to the surface tension of the wet between them, and that's why the lungs fill the chest cavity and stay there. But just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.
How does the air get in the pleural space where it doesnt belong? Well, you can do it two ways. One is to play rough with the bad boys (or have surgery, which is, after all, only expensive trauma) and have a sharp object puncture your chest wall and admit air into the pleural space. How does it get in there? Well, you make suction in your chest when you breathe in, and now air has TWO routes to get inside your chest-- down the trachea into the lungs, and thru the hole in the chest wall into the pleural space. This is called a pneumothorax, air in the chest that is outside of the lung. The lung will tend to collapse because the surface tension between the wet layers is now interrupted (remember how the pieces of wet glass can be separated by introducing air between them?) and the lungs are naturally elastic.
The other way to get air into your pleural space is from having blebs/bullae on your lung surfaces, and pop one (or more), or have some other hole in your lung (sharp things again, including a WEDGE RESECTION, which leaves holes that can't be sealed until they heal by themselves). Then air gets out of your lungs thru the hole(s) and disrupts that pleural side-to-side thing, and there you go again, a pneumothorax. This, however, is called a TENSION pneumothorax, because that air increases with every exhalation (the lung now having two routes to exhale air out of, the trachea and the hole in the lung itself). This allows the lung to collapse on that side, and soon enough pressure (tension) will develop in that half of the chest to push the chest contents over to the other side, compromising blood flow and air exchange in the other lung & heart when it does so. (This is when you see the "tracheal shift.") This is also a bad thing.
So: now both of these fine folks have bought themselves chest tubes. The guy with the chest wall trauma has had his trauma hole sewed up, so when he takes a deep breath air enters his trachea only. He has a water seal on his chest tube so he can't pull air into his chest thru the tube-- the water seal acts like the bend in your sink drain and prevents continuity of the inside and outside places. The suction on the chest tube setup has done its job of removing the air from the pleural space where it didn't belong--it was seen bubbling out thru the water seal and then couldn't get back in. (When all the air is gone from his pleural space, there will be no more airleak in the water seal compartment.) Now, if he disconnects his Pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. THEREFORE, when this guy disconnects his tube, you clamp it IMMEDIATELY, to prevent air from entering the pleural space. He should ALWAYS have those two big old chest tube clamps taped to his Pleurevac (so they go with him to xray and all), just in case he does this.
However, the other guy, with the ruptured blebs or wedge resection and the intact chest wall? Well, his chest tube is pulling air out of the pleural space, but more is still getting in there since he still has a hole(s) in his lung. The idea of the CT is to pull it out faster than he can put it in, and allow the hole to heal up, at which point he will no longer collect air in his pleural space and be all better. Meanwhile, though, you see air bubbling in the waterseal chamber, showing you that there is still air being pulled out of his pleural space. He has an air leak. What happens to him if his chest tube gets disconnected?
Well, remember, he still puts air into his pleural space, because there's still a hole in his lung. You put a tube in there to take it out, remember? OK, so what happens if you clamp his tube? Bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket. This guy should NEVER have clamps at his bedside, because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in trouble all over again. If he pulls his tubing setup apart, have him breathe slowly and shallowly (to minimize the air leaving the hole in his lung and getting trapped in his pleural space) while you quick-like-a-bunny hook him up again to a shiny new sterile setup. But do NOT clamp his tube while your assistant gets it set up for you.
Okay, so when I'm in charge I know that I am supposed to take admissions. That does not mean EVERY SINGLE admission. That also means that yes, I deserve a lunch break too! It also means, if we get two admissions at once, guess what, you just might have to do your own admission!
Can we please break away from this idea that having a charge nurse means staff RNs are off the hook for admissions?? I work really hard to make everyone's day a little easier but I can't do back-to-back-to-back admissions all day! And especially not two or three admissions at the same time!
How many pairs of scrubs do you own? dde1c
I am a freshman at a college in virginia. I am interesting in nursing and I am going to apply to the BSN program. If I don't get in I probably will drop out and take my pre-reqs at a community college and apply to ASN programs.
I am sort of learning towards the ASN direction anyways because I want to go back home. I hate the university I am at and I feel I won't be able to concentrate if I enroll in the BSN program. I feel like my time management and grasp on material will come easier if I am back home. Also, if I dont get into the BSN program this year I will have to wait another year and financially does not make sense.
My plan is to get a BSN! If I were to get my ASN I would directly enroll in a bridge program, no doubt.. However, I am just wondering if this will hurt my chances of getting a job. As long as you have a BSN does it matter? or when companies say they are looking for BSNs does it mean that won't hire someone who went through a bridge program to get their BSN?
any advice pleaseeeee! esp anyone from the virginia area!
Something is just brewing inside of me that needs to come out...
This primarily an emotional response but there's some logic and reason that gird it...
Try as I might, I just can't help myself...
Flat out, I...
OK, here it is... I...
and I almost consider it a privilege to work there (though I'm an unabashed capitalist and unionist).
Some of my patients truly touch me... and I feel tinges of what the "it's a calling" crowd must be referring.
Some of the patients are trying... but even many of them are an adventure...
And some of the patients are complete jerks... and mostly I just blow them off and pat myself on the back for not letting them win the emotional tug-of-war in which they insist on engaging.
I had a patient on whom a colleague asked me to start an IV... she was being confrontational. I'm always up for a good confrontation so I took the bait. At one point she said, "Your bedside manner sucks." I replied, "Yep, it does... but I'm really, really good at this so you need to decide if you want a 'one-and-done' IV stick by me or repeated pokes by Nancy-NiceNurse." She picked me and we ultimately found a functional way to interact.
Most of them are kind and decent people who've got my back. It's almost like being in the military again.
A (minute) few of them are catty and, um, doggie, but I actually enjoy engaging them and trying to win them over. Since I refuse to be respect someone's attempt to block me out and push me away... and because I continue to go out of my way to be helpful, we generally end up in pretty decent working relationship.
Oh yes, the physicians... they can be a pretty pushy, demanding, demeaning group of people..... whom I refuse to treat, or address, any differently than I do anybody else.
However, nearly all of the ED docs, are really great to work with... love to teach... will happily engage if engaged... and recognize how much the patients need the nurses in order for anything to get done.
Medical residents? I find them to be some of the most interesting people I've ever been around and I would hate to work someplace without them. (They also don't get ***** when I call them... and if they do, they're ~just~ residents :-)
Even some of the attending MDs with ferocious reputations among the staff, have their way about them, and I enjoy figuring out how to connect. Sometimes it's by learning a lesson from doggie dominance... wherein I basically expose my throat and give them the option to rip it out... from then on, we usually get on fine... and I take barbs really well and can turn almost everything into a joke.
Well, I've got my gripes, to be sure... but having been a senior manager with direct reports and budgetary authority... I also recognize that (a) I probably *couldn't* do it any better and (b) that I wouldn't want to even if I could.
I've had a lot of bosses in my life and I can easily say that the food chain where I currently work is populated by a pretty good group of folks, especially by comparison to some that I've work for.
Could I earn more? Sure. Have I earned more? Well, actually not... though I work an insane amount of OT to get it.
Being an hourly, non-exempt employee under a codified contract (I'm a fan of the California Nurses Association) is a great way to work. I've been salaried/exempt... I've been at-will... I've worked as much as I do now but not been paid for it... and I've recently worked in nursing for $25/hr less than I presently earn with scant benefits... Yes, I earn twice what I earn at my last FT nursing job.
I've got a good thing going... and we're not the highest paid nurses in the region... by any means... but we've got very good bennies and a good work environment.
So, for anybody who's looking for a reason to go into nursing, I can say that, if I could magically change and be a doc or a pilot, I would, but nursing can lead to a very good thing... though it's not a given by any means.
To summarize: I am a nurse, I am happy to be a nurse, and... while it's not cool to admit, I hereby confess that I *like* my job.
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