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  • Jul 22 '13

    Quote from DeLanaHarvickWannabe
    Hey everyone!

    I just need someone to explain to me, in layman's terms even, what the heck the different vent settings mean. (AC? PSV? PEEP? PIP? IDK my BFF Jill?)

    Thanks!
    One of the settings on a vent determines the size of breaths that will be delivered (tidal volume aka Vt). Tidal volumes can be achieved by telling the vent to deliver either a set volume (volume control aka VC) or a set pressure (pressure control aka PC).

    When the vent delivers a breath to achieve a set volume, the pressure required to deliver the breath can vary from breath to breath. This is the PIP (aka peak inspiratory pressure) - the vent's measurement of the pressure required to deliver the breath. Conditions that effect lung compliance, like need for suctioning, atelectasis, or pleural effusions (to name a few) influence how much pressure is required to deliver a set tidal volume.

    When the vent delivers a breath to achieve a set pressure, the PIP will be consistent from breath to breath, but the size of the breath (the tidal volume) will vary from breath to breath. This variation is also due to lung compliance. For example, conditions that decrease lung compliance will decrease the volume of the breath because the vent is set to stop delivering the breath once the set pressure has been achieved (regardless of how big or small the breath is).

    AC - "Assist Control" mode. When AC mode is being used, the ventilator is set to deliver breaths (whether the set rate on the vent or a patient initiated breath above the set rate) to achieve either a set tidal volume (volume control aka VC) or a set pressure (pressure control aka PC). Breaths are relatively consistent from one to the next because even when the patient initiates a breath above the set vent rate, the vent will "take over" once the breath is initiated and deliver a breath that achieves either the set tidal volume or the set pressure.

    SIMV - "Synchronized Intermittent Mandatory Ventilation" mode. In SIMV mode, like AC mode, the vent will deliver tidal volumes at either the set volume or the set pressure for the number of breaths that are SET on the vent. Any patient initiated breaths can be of whatever size the patient wishes - they can take little breaths, they can take large "sigh" breaths - whatever they want.

    PSV - "Pressure Support". Pressure support is used when the vent is in a mode that allows the patient to take variable sized spontaneous breaths, like in SIMV mode. Pressure support is used like the name implies, to help 'support the pressure' required to take a breath. It is normally used to assist the patient to overcome all the extra work of breathing through all of the external apparatus required to use a ventilator - ETT, filters, and the like.

    PEEP - "Positive End Expiratory Pressure" (you may hear this term used interchangeably with CPAP or "Continuous Positive Airway Pressure" - lets ignore the differences for now). This is the set pressure that the ventilator keeps in the lungs at the end of an exhaled breath. It is used at different amounts of pressure for a variety of reasons, but the goal is always to create a little "back pressure" in the lungs. You can easily experiment with this idea - make a loose fist with one of your hands, press your lips against the round end of your fist at your pointer finger and thumb and exhale through it. Now tighten your fist a bit and do the same. Feel the difference? This is creating different levels of back pressure in your lungs. This is the very reason that we teach patients with COPD (for example) to practice "pursed lip breathing" - to create a little back pressure in their own lungs.
    A couple of the common goals of using PEEP on a ventilator are to prevent atelectasis (a little bit of back pressure can prevent floppy, fragile little alveolar air sacs from collapsing at the end of an exhalation), or to force pulmonary edema out of the airways and alveoli back into the capillaries. PEEP is also commonly used to improve oxygenation. Let me use an example of how that works - atmospheric oxygen pressures are different at different elevations because it is under more or less pressure in the environment - think of oxygen at the summit of Mt Everest vs Sea Level - the more atmospheric pressure oxygen is under, the more help it receives in diffusing into the capillaries. Using a vent and PEEP allows you to artificially change the "atmospheric pressure" inside the lungs - increasing the pressure helping oxygen to diffuse into the capillaries.

    Just a little Vent 101 from your friendly neighborhood RT (who is transitioning to nursing). I benefit on a daily basis from trolling the boards and gleaning valuable insight and information from the contributors here. Hope I have finally been able to give something back, lol.

  • Jun 15 '13

    He's compensating for something. Must be a male nurse thing.

  • Jun 15 '13

    Man....I gotta tell you by the end of a 12 hour shift this thing weighs a TON!!!!!!!!!!!!!!

  • May 15 '13

    Nursing is a daunting task for many of us, even when we have time under our belt. Call bells, charting, phones ringing, family members needing time and reassurance, doctors returning calls; and then there is the patient, if you have time.

    At least, that's how it seems.

    Multiply that by 8, 10, sometimes 12 patients, and it is unbelievable that we have decided to carry the responsibility for so many lives. What if we miss something? What if we give the wrong med, or fail to get scheduled treatments done? What if there is some critical lab value, or some assessment detail, that we overlooked?

    Enter critical care.

    As a fairly new nurse, I worked in about a 150 bed mid-level hospital. Oh, we did surgeries, had a nursery, and a good emergency room. We had medical residents available to us 24/7 (some of whom we were able to train pretty well). But I was always overwhelmed. I think the turning point was when the LPN on my team came to tell me my patient's IV had infiltrated. What he didn't say was that the patient's arm was now as big as his thigh. And the man's thigh could have easily fed a family of ten.

    You get the idea.

    It was then that I realized that for me medical surgical nursing was not all it was cracked up to be, primarily because I could not be everywhere. The old adage, "if you want something done right, do it yourself," became my motto, but where to go with it?

    In comes the intensive care unit. I was "accidentally" floated to our 9 bed ICU one night, and it was a dream come true. Labs? Not just under a stack of papers but on the tip of my tongue. Assessments? Done just five minutes ago, and ongoing. Patient allergies? I didn't have to look them up. I was as intimately familiar with each patient as I was with my mother. Ok, much more familiar. And it was heaven.

    Not only did I have a chance to really know my patient - or, at most, two - but I also got to know new details about them. Internal pressures and outputs, in the heart! In the artery! I could see the numbers and the visual. These patients' lives were more fragile than those of the ones on the general medical and surgical floors, but at least I felt like I was the one responsible for them. I reported to me. How wonderful.

    Then there were the medications. IV versions of medications we gave orally on the regular floors. Immediate responses that were immediately measured.

    Speaking of responsive - the doctors were much more responsive as well - they took these patients' problems much more seriously.

    Then there were the relationships I had with these patients. Most were terrified simply by virtue of being in an intensive care unit. It meant that their lives were precarious, at best. And to have at their disposal a nurse essentially at bedside 24/7 - now that is a relationship. You get to know their concerns, from what they should have changed in their will, to what they miss having on their plate. I was hooked, and I transferred to the unit as soon as I was able.

    I remember one lady, Alice, who was about the same size as my mother - 5 feet tall, six inches around, ok I am exaggerating but you know what I mean - she was TINY! She had end stage COPD, and she kept having to go on the ventilator. She was terrified of it. Every time her numbers showed that she could not continue to breathe for herself, she would have the debate: should I go back on the vent, or should I just let nature take its course? It was agonizing to go along with her on this journey of decision, over and over and over again. Obviously this was not a realm in which a nurse could venture an opinion - but that was what she wanted: someone to make the decision for her.

    Then there was Ralph. Ralph was a chronic alcoholic with the tell-tale bulge where his liver was supposed to be. I'm not sure what had taken its place - I think some kind of alien. His coloring was not too bad, he was more florid than cirrhotic. His EKG showed a massive myocardial infarction. His hands showed major delirium tremens. He was jonesing in a bad way, and ugly about it. My challenge was to try to make him laugh a little, and try to help him forget that drink that he needed so badly. And also, to provide that delicate nursing care that would keep his heart going and his temper even.

    There was another woman, Dorothy, who was my first ever code. I was able to see her cardiac rhythm gradually deteriorate, bring the code cart near, warn the doctor, and essentially wait to be able to intervene. Her rhythm grew progressively worse. The code team drew near.

    Once CPR was initiated and the back board placed under her, I was the one to jump on the bed and start compressions. I had a wad of gum in my mouth and spit it out towards the left hand corner of the room. I began to emit a series of unintelligible sounds. The doctor placed his hand on my arm. "Are you oKAY?"

    "Yeah," I said, confidently, as I continued compressions. "I'm just trying to remember her name so I can tell her to come back!"

    By some miracle, Dorothy (as I later remembered her name to be) survived. So too did I.

    There were of course those we couldn't save. I remember a youngish guy (he was then the age I am now) who went from casually conversing with me, to turning purple. He died almost instantly and there was nothing that anyone could do. I was so upset that I attended his autopsy, just to find out what had happened to him, just to see if I could have kept it from happening. I cried as I watched the medical examiner pry out the immense blood clot from his lung. "There was nothing you could have done," the doctor said, trying to reassure me.

    But there was nothing the doctor could have done to change how I felt - that death will always stay with me. But so will Dorothy, Alice, and Ralph. I will treasure them always.

    I'm not saying ICU was easy, or free from stress, not at all. You still have call bells, charting, phones ringing, family members needing time and reassurance, doctors returning calls; and then there is the patient. But in ICU, you have time. For me, it gave me the opportunity to give good, quality, individualized care. And I never stopped learning. There are others who find medical-surgical nursing to be more manageable. Not me! I'd take ICU any day.

  • Feb 5 '13

    to rdnkmom: Sure, there are people who have no interest in recovering. Some come in because they have no food or shelter too and a treatment center provides that. However, not many would choose to be hospitalized rather than to be free to do what they want, unless there's a bigger driving reason than coming in to manipulate the system. Treatment is sooo expensive usually. Drugs are on the streets and easy to get. Coming to a treatment center, well, here's what I think....

    I think many, even most, even the frequent flyers, want to kick their habits when they come in voluntarily for treatment, but it's tremendously difficult even with motivation and super treatment available. The addiction is just that--an addiction! It's a coping "skill" gone bad, tremendously bad. Their bodies are revolting against not having what they're used to being in them. They're physically and mentally miserable. Many often have no money to survive in a healthy way, no family or healthy friends, no other coping skills, and all sorts of other barriers that prevent them from choosing a more healthy lifestyle. They want their "stuff" because that's all they know--it takes loads of time and huge mind-over-matter strength to be able to get past that.

    It saddens me that you sometimes think they need to go through detox naturally. People die when they do that. They often suffer tremendously when they do that. They're already suffering or they wouldn't be addicts--addiction is often a symptom of underlying depression or other life-chaos. Cold-turkey-ing wouldn't give them skills to remain clean and sober. Punishment seldom works to change behavior. Helping a person find alternatives that work for him is so much better. That takes a long time, however.

    There are no clear answers for this. I'm glad you give alternatives. Again, though, remember they're used to something and alternatives aren't always a clearly helpful thing to someone who is used to what he's used to doing.

    New programs need to be developed. 28 day programs are few and far between!

    I'm glad you're liking your new job. Maybe you can be a person who makes some ripples of change to help people get well more than they are now...

  • Feb 5 '13

    yay for you!!!!

  • Feb 5 '13

    Thanks, meriwhen. I'll look for that.

    I found out today that I'm hired!!! She didn't even bring me in to interview with the NP like she originally said. Orientation is the 26th! I'm so excited!! And scared!!!

  • Feb 5 '13

    I agree, there is enough grief and pain in one lifetime to prevent the invitation of anymore- if you've been sober without any relapse issues for greater than 5 years and they don't know it, that's a blessing! Count it as one- and lay low

    You see, time passed means nothing really from their perspective. To them, an addict is a pickle. A pickle once was a cucumber- but no matter what you do, it's never going back to being a cucumber again. You and me are "pickles." We are just clean pickles that can be pickled again anytime. You are ahead of the game if they see you as a "cucumber" still- I wouldn't go looking for dill, vinegar, and a mason jar(sorry, terrible analogy).

    That is a ghost that can haunt your career and lifestyle more than you ever imagined if the BON does not already know your past. I live in that very real haunted present- even with near 5 years clean, and no diversion history or occupational related incidences.

  • Feb 5 '13

    Honestly, unless I was required to (e.g., if they specifically asked about substance abuse issues, if I had disciplinary actions/restrictions on my license, or if I was in a diversion program), I would err on the side of NOT disclosing it for three reasons:

    1. It may make the employer wary of taking a chance on you, especially if they've had bad experiences with staff CD issues. Fair? Not really. But they will be scrutinizing you and weighing the benefits versus risks.

    2. It will not guarantee you the job, no more than my having given birth would guarantee me a job as a L&D nurse.

    3. It could be used as a weapon against you. Could that happen? Yes. How likely is that to happen? Don't know. Some places are very welcoming of nurses in recovery. Others are not...and yes, this also includes some addiction/psych facilities. You may find that whenever you have a bad day, people will wonder if it's related to your addiction. Should narcs or meds go missing, you may always find yourself one of the initial persons of interest even if you were nowhere near the hospital that day. In addition, your coworkers may hold their own beliefs regarding CD and may judge you unfairly.

    However, it is your recovery and your decision, and you need to do what is best for you. If you do feel the need--or are required---to disclose your own recovery, be sure to stress your sober time, how/what you do to help maintain that, and if you have completed any BRN/diversion program requirements. A character reference or two couldn't hurt either.

    Best of luck whatever you decide!

  • Jan 24 '13

    Don't forget Narcan it reverses respiratory depression.
    And Romazicon it reverses the effects benzodiazapines (drugs that have hypnotic-sedative effects).

    I've used these a time or two and they have been lifesavers (literally).


    *Well, after I posted I now see that the last poster included these. Eh, well. They are important anyway.

  • Jan 24 '13
  • Jan 24 '13

    To blondy's excellent list I'll add a few that I give pretty regularly:

    nifedipine
    spironolactone
    diltiazem
    phenytoin
    memantine
    donepezil

  • Jan 24 '13

    This is going to vary hugely by specialty. I could list the meds I give day-to-day and non-BMT nurses will have probably never given any of them. I'll list a few here that seem to be common across the board, though.

    Metoprolol, many beta blockers
    Furosemide
    Coreg
    Bumetidine
    Nitroglycerin
    Lisinopril, many ACEi
    Hydralazine


    Metformin
    Insulin- R, N, Humalog, Novolog, Apidra, Lantus

    Percocet
    Vicodin/Lortab
    Hydromorphone
    Oxycodone
    Methadone
    Morphine
    Fentanyl

    Ondansetron
    Prochlorperazine
    Metoclopramide
    Prevacid/Protonix/Nexium/Prilosec/Acidphex/whatever your formulary PPI is

    Zosyn
    Vancomycin
    Levaquin
    Augmentin
    Meropenem
    Zithromax
    Avelox

    Benadryl
    Ambien

    Klonopin
    Haldol
    Alprazalam
    Lorazepam

    Albuterol/Xopenex
    Advair
    Duonebs

    Prednisone (for EVERYTHING)
    Methylprednisolone

    Heparin
    Lovenox/any Low molecular weight heparin
    Aspirin
    Plavix
    Warfarin

    Hmmmm...all I can think of right now. I'm sure others will add.

  • Jan 24 '13

    "The cure for my depression and anxiety was quitting my job "

    I had a job like that too.

    As for the rest of it, I have lots and lots to say on the subject but I keep writing and erasing.... it is probably better not to say much here. I am looking forward to what the prof has to say about exercising, though. He is going to cover that in a later section, so far he's just said if there was a pill that could make the neurological/psychological changes that exercise does (with the same lack of paradoxical reactions and/or adverse side effects) it would put much of the psychology world out of business (or something similarily broad and sweeping). Even without all the beneficial side effects it has.

  • Jan 24 '13

    Early this year I was quite anxious and depressed, my doctor decided to try me on Celexa. Within 5 days I was feeling suicidal...I'm not a kid, I'm 50. I had to seek emergency help. Then I was put on Effexor XR and wound up in the ER. Those 2 drugs made me feel way worse than what I was dealing with my anxiety and depression.

    The cure for my depression and anxiety was quitting my job


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