GoldenFire5 5,571 Views
Joined: Sep 22, '05;
Posts: 249 (16% Liked)
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5 year(s) of experience
Collapsed as in pneumothorax, or collapsed as in severe atelectasis?
Pneumothorax in this type of patient could be related to high pressure ventilation (barotrauma) or over-inflation (volutrauma) of the lungs in the OR during the surgery. Lungs of premature infants are often not quite normal even once they reach 'term' and are easily injured. High pressure or large volumes can cause a leak in one or more alveoli which allows air to accumulate in the pleural space, which then displaces lung tissue preventing the alveoli in that part of the lung from inflating. Small pneumos will reabsorb as long as the air leak doesn't persist. Larger ones will need needle decompression or a chest tube.
Atelectasis on the other hand can be caused by under-inflation of the lungs in the OR, which is more typical. This is the collapse of the alveoli due to inadequate pressure, volume or both. In the OR the tendency is to under-ventilate; the anaesthetist cannot see the patient's chest wall movement and goes by the oximeter on the console. If the sats are good, all is well, right? And the baby is 'asleep' so s/he can't adjust work of breathing to compensate.
CPAP would be a reasonable treatment in both cases. Your description of the child's desats with feeds suggest that his lungs are still not quite mature. Most children's hospitals insist that infants who were born prematurely who undergo general anaesthetic for any reason in the first year be admitted to ICU or a monitored bed for 24 hours post-op for just this reason.
Peak Respiratory Pressure: Pressure (resistance) at the end of expiration. Just when initiating the inspiration. Normal (20 cm H2O)= 14.71 mmHg.
Thank you, Dinith. I like the milkshake analogy. I guess I should have asked where the most likely place for an air leak would be. The cases I remember where docs were really upset about leaks were thoracotomies. In this case, the pleurevac would be draining blood from the pleural space, right? And a leak would probably be due to the "straw" not being dipped deep enough into the "milkshake," right? I guess what throws me is that I don't picture "free air" in the body. I was wondering where the pleurevace was drawing the air from.
Am I still way off base?
I think it's annoying. I'm a female nurse, and yeah, I get the whole, "We prefer females/males because of modesty/sorry-i-feel-weird-you-touching-my-junk," but the latter? I'd be happy I don't have to take care of them, but it would still rub me the wrong way. Females are more caring that males? What is that suppose to mean? I know some terrible female ICU nurses who say they're busy taking care of their pt who requires total care, but who sit at the computer planning their next trip.
Diurectics aren't necessarily contraindicated. Kidney disease has many different levels of failure. Some pt's still have the ability to produce urine even if it's very little. Think of it like this...Kidneys mainly act as a filter for proteins, electrolytes, wastes, urea, and reabsorbing water. Some pt still can pass water but lack the capabilities of filtering out larger molecules or lack both filtering and excreting water. Different areas of the nephron each have it's own capabilities (proximal tubule, the distal convoluted tubule, and the collecting tubule). The kidney's ability to reabsorb water may still work despite everything else failing. Like a leaf being unable to pass through a pool filter while water passes through.
The GFR measures the kidney's ability to filter, not necessarily it's ability to excrete water. Proteins, creatinine, myoglobin, etc, can't pass through and that is what the GFR is measuring....it's filtering properties. That is why her BUN/ creatinine is high....the kidney can't filter them out. (fyi...did you know that troponin levels are elevated in pt's with kidney failure? Cardiac enzymes levels will produce false positives b/c the kidney are actually responsible for excreting troponin, which are proteins related to heart muscle)
It sounds like your pt still has some capabilities to produce urine (water and urea). The bumex enhanced it by exaggerating water excretion. So the GFR isn't wrong b/c her BUN/ creatinine levels are high, suggesting a failure in filtering. The bumex also allowed the kidney to excrete little more electrolytes than normal. (fyi... An even better measurement of filtering is using the creatinine clearance vs the GFR.)
Another fyi... Your pt's hemoglobin 9.1, meaning she's anemic. Do you know why renal failure pt's are anemic? Your kidneys make something called erythropoietin. When erythropoietin is released, it signals your bone marrow to produce red blood cells. If you have kidney failure, then there no production. So, doctors prescribe Epogen to make up for it. Epogen is what cyclists use during tournaments to increase their hemoglobin production so they can have better levels of oxygenation. This is where is term "blood doping" come from. Most dialysis pt receive Epo after dialysis.
First make sure the PH is in normal range. If the Ph is normal, then there's nothing major to really do (except some fine tuning). It's compensated. When starting out, nurses have an obsession with oxygen levels. As time goes on, you will see that the CO2 is more important. If a pt has a normal co2 level, but a reduced O2 level, they get a nasal cannula. If the o2 is normal to low, but the co2 is high, the pt just bought a Bipap or vent. The body is much more sensitive to co2 as a driving force to breath. When you hold your breath, the crave to breath is from your CO2 level rising, not the O2 dropping. If you hyperventilate, you will get dizzy...not because anything is happening to the O2, but because your Co2 significantly drops. So, make sure the co2 is properly corrected. Kind in mind that not everyone needs a CO2 of 34-45. COPDers can live with a CO2 above 60 and be fully compensated.
Look at the bicarb to see if they are respiratory or metabolic. Chronic CO2 retainers should have higher bicarb levels to buffer the acidic CO2. That's why they are compensated. fyi...If a COPDer goes into renal failure, their ph will bottom out. That's b/c your kidneys produce bicarbonate. Without that, that's not much else to help buffer....except tachypnea or a bicarb gtt.
So, to answer your question on O2. The oxygen saturation is actually pretty accurate. There are times when the O2 sat can be false, but that is from other things going on, like carbon monoxide poisoning (house fire inhalations or car emissions) and other conditions. The O2 sat won't really be saturated with different stuff unless you already know about it (usually). You can go by the O2 sat most of the time. If a pt has a 100% sat, but their PO2 is very low...something else is going on...and it's an emergency. When you are titrating Fi02 on a vent, first note the PO2 level on the blood gas. Many resources say 75-100 for the PO2, but you can be above 60 or 70 and be ok. If the PO2 level is like 150 and you are on 100% Fio2, you can knock it down to 60% (maybe 70% if you want to be cautious). Let them ride for a little bit (1-3 hrs). Then, go by increment of 10-15 %. Watch their o2. Go with each change for a couple hrs. You don't have to have the o2 sat be 100%. 94% is fine. For bad COPDers, you can keep them above 90% (make sure you have a doc's order for the O2 sat range). And, it's ok to even titrate over a couple of days if the lungs are bad. As you start titrating below 45%, go by increments of 5-10%. 40 to 35 to 30. A titration from 90% to 80% isn't a big deal b/c they are already in the plus, but a titration of 40 to 30 can be a big deal b/c you are fine tuning on the lower end of the spectrum. Make sure their o2 sat is staying within range. Some pt's just can't tolerate being below 40%. That's ok. Maybe they just need some time.
Don't feel bad if you need to go back up on the FiO2. It's not a race. Many times, you have to go up and down, up and down. It's not your fault if you can't get them to the good 'ol 30% by the end of your shift.
The other thing is to look at the pt. If their resp rate goes from 16 to 31, then they are not getting what they need. See if they are air hungry. If you see forced inhalation, nasal flaring, and the head bobbing back with each breath (along with the mouth opening wide with each breath) then the pt is air hungry. If all is quiet, then you have a good idea of their respiratory status. I have seen pts with 93% O2 sat, and relatively normal blood gas, but they look like a fish out of water. The vent needs to be adjusted.
Remember your side of the clinical aspect. Is the pt anemic? Do they need blood? Does the PEEP need to be increased b/c of atelectasis? Do they have pneumonia or pulmonary edema? Do they need lasix? Are you mobilizing the pt as much as possible. Could they have a mucus plug or do they need not a bronchoscopy? Is the albuterol treatment cutting it or do they need atrovent and mucomyst added? Are they just way to snowed with sedatives? Maybe they need extensive pulmonary toileting. Is there a lung injury or do you suspect ARDS? Hope this helps
First off, here are a couple decent webpages you might want to review:
Multi-Center Study of Central Venous Oxygen Saturation (ScvO2) as a Predictor of Mortality in Patients with Sepsis
Surviving Sepsis Campaign
In early sepsis, you'll frequently see a hyperdynamic phase. During this phase, heart rate & cardiac output are increased, in an attempt to maintain adequate perfusion/oxygen supply to tissues.
ScVO2 normally runs ~71-89% (first webpage listed above). If your pt's ScVO2 is low, there are several possible approaches to increasing oxygen delivered to the tissues:
- Ensure that your pt has an adequate circulating volume (as directed by CVP or a FloTrac SVV number) - give crystalloids or
colloids if needed
- Increase FiO2 (increase oxygen percentage inspired by the pt)
- Increase Hematocrit (transfuse more oxygen carrying red blood cells)
- If circulating volume, FiO2, and HCT are decent, then consider adding an inotrope such as dobutamine to increase cardiac output
In later sepsis, things are shutting down. Tissue & organs are dying, thus not using available oxygen circulated to them. This is a "bad thing", and may be more lethal than a low ScVO2 (again, see NIH paper).
Goes into some interesting theories as to WHY hyperoxia occurs in sepsis (impairment in microcirculatory blood flow vs mitochondrial dysfunction), the theory that excessive oxygen may be harmful in sepsis pts, and one approach to try and "kick start" dysfunctional mitochondria.
Recently I was traveling in Florida with my family to Disney World and a cement truck traveling in the opposite direction, on I 10, had a catastrophic blow out of a front steer tire. He started flipping and went through the median and hit us head on. The impact threw our car 88ft and we landed in a drainage ditch pointing the opposite direction we were traveling.
To make a long story shorter, I had to be extricated with jaws of life, I went in to shock and while paramedics were medicating me for pain. I had an anaphylactic reaction to Fentanyl and lost my airway.I was airlifted to a trauma center and my kids were taken to ALABAMA to another trauma center because we overloaded the Panama City hospital with our wreck. I didn't know how my kids were doing for over 8 hours.
The worst part was hearing the screams from my kids asking them not to let their mommy die. I am an RN in the MICU and I it was so hard knowing everything going on and having absolutely no control. I was the one that gave paramedics report when they arrived on scene and I told them when I was loosing my airway.
Once I lost consciousness and they cut my clothes off and stuck things in every orifice I had, I became scared and realized I was no longer a nurse, I was a patient. I am used to doing this to my patients and I have never stopped to think how I make them feel. I rarely ever was told what was going on or that they were getting ready to do a procedure to me. I just wonder if any of you have experienced being a trauma patient and how did it make you feel.
This experience has taught me to ALWAYS, whether they are conscious or not, tell my patient what I'm doing. They may not understand but when you are having a rectal probe used on you and they just flop you over and use it..WARN ME that its coming! I never knew how much Lovenox burns when going in, I never realized how hard it is to "cough and deep breathe" with broken ribs, or how it feels to ambulate with a broken foot and busted knees. Also, DVT's HURT like heck! Yeah, I got one.
Needless to say I have learned so much from being a patient and if I can help one nurse realize that patients are scared and just to have a friendly voice or a hand to hold, MAKES a HUGE difference. Once I have recovered and get back on the unit my patient care will be quite different and I think my patients will be better for it.
any patient, and i mean any patient who has even the slightest chance of being a surgical patient, be it an AP or abd pain or trauma, should have a large bore iv 18g or less. the anesthesiologist will put a second larger line in if you dont.
anyone receiving anticoagulant clot busting therapy like TPA or equivalent should have three lines, one 18 or 16 gauge for blood draws before the med is given. pop away.
even if you dont know what you are doing, try and make it seem like you do. be professional, dont let your hands shake, and read your patient. their eyes can tell you alot.
TIE THE TOURNIQUETTE TIGHT. DONT FORGET TO TAKE IT OFF!
good luck if i think of more, ill post it later.
When I've got a person with +4 edema, I get a manual BP cuff, put it midforearm, and pump it up, then let it sit there for about a minute while I get cannula and J loop ready. The BP cuff is pushing all of the fluid out of the area. The second you deflate the cuff, swoop in and feel for the vein -- they'll plump back up first.
The only bad thing about whatever trick you use with the fluffy ones is that it's very easy for the IV to infiltrate -- There are folks where there's just so much swelling I know I've probably only got the tip of the cannula in the vein. If they're getting anything serious, like levophed or IV pushes of anything that can cause necrosis if it infiltrates, try to get a doc to write for a central line. If not, watch that site like a hawk.
I was also saved once because of my charting. I am an ER nurse and a terminally ill patient came in our department requesting to be admitted. We catered to her immediate needs. the Resident on Duty finished managing the said patient and needed to contact her attending physician to give an update regarding her status. Unfortunately, the attending physician's mobile, landline and clinic phone were all not responding. We even tried calling her mobile for 8x but were being cut off. the ROD assumed that maybe the AP was busy or were driving. Feeling the urge to document these, i wrote down on my notes all our efforts of informing her (AP). When I endorsed the patient to the nurse on duty incharge for the patient, I informed him of our efforts of informing the attending physician. Fast forward, the patient went into cardiac arrest and died after all efforts were made. while the code blue team, including me, were doing post mortem care, the resident on duty updated the attending physician regarding the management of the patient and what were done. The attending physician went furious over the phone because she WAS NOT informed that she had an admission that day. She denied receiving calls and SMS. She immediately went to our Nursing Supervisors and Medical Director insisting that this was our laps and that the patient could've been alive if she knew of the admission.
I presented my notes and the exact time where we made the calls, including the records in the operator of our calls made. Even the sent items of the SMS were saved. The management sided with my evidence and the attending physician was given a reprimand by the hospital for denying facts and not attending to newly admitted patients.
A quick and easy way to tell if your heart rhythm has perfusion (if you don't have an arterial line as someone else suggested) is to look at the heart rate on the pulse ox. If they don't correlate, you have a problem.
I had an intubated pt on dialysis a while back. The dialysis nurse came out of the room all frantic saying that she couldn't get a blood pressure reading. Then I noticed that the pulse ox heart rate was not correlating with the rhythm rate. Yup... you bet... CODE!!!
More recently, I went into a room to help another nurse with her pt. She was upset because her pt was tachy according to the rhythm rate, but had a cruddy blood pressure all night. Of course the resident was trying to sleep, and was only ordering fluid boluses. The heart rhythm was kinda funky with very frequent PVC's and PAC's, and I noticed that the pulse ox rate was not correlating-- it was infact much slower-- like in the 30's. I felt for a radial pulse, and yes, the perfusing heart rate was in the 30's. We then paged the resident as the pt's problem was not dehydration, it was rate related.
The most scary thing I have ever seen in my career was the alien creature eat through a man's abdominal cavity in the ER. The man entered the ER with the complaint of cramping, and general malaise, and exhibited a low grade fever. The man was triage, and had been in the ER for about 2 hours, when the he began to scream like a woman. Two nurses, and four paramedics found the man violently arching his back, and his abdomen looked as though it was being poked from something within. The man fell flat on his back and the green alien creature with dinosaur teeth, let out a hiss and growl, and scurried on its was out the hospital ER and never to be found. That was the scariest thing I ever seen in my life.
You will find these type of people all over nursing in every unit, every shift, every department, every facility etc. I came across a few people who just do nothing but kiss butt to the Unit Manager. You skip one initial and they will photo copy the MAR and will turn you in. We all make mistakes and forget an initial here and there. After I heard of these few select people I always make sure that I double check my initials, I dot all my i's and cross all of my t's because I really don't want to get into anything with these select perfect nurses who never make mistakes.
One of the perfect nurses actually made a HUGE mistake when taking a T.O. and instead of photo copying it, I decided to write her a little note alerting her of her mistake and to fix it before the Unit Manager gets a hold of it. There was no thank you, nor did I expect one, but it was fixed the very next day.
I actually needed a clarification of a MD order and he was mad at me because I couldn't read his chicken scratch. I immediately told him that I was new, and that if there's a question on any order I will phone the MD. Do you know what he told me? Learn to read, it broadens the mind. I immediately thanked him for the suggestion and told him that I do read on a daily basis because it broadens the mind. I also told him that good penminship is very important in the medical field because if you can't read a MD order, you can potentially kill a patient. As a patient advocate it's my job to clarify something I don't understand. Then I hung up. I finally saw the MD face to face, he apologized for his behavior and immediately thanked me for being a good patient advocate. The unit was surprised because they say he's always like that.
I was working telephone triage for a children's hospital and took a call from some worried parents one night. The baby was 3 weeks old and "just not acting right." It was taking the bottle *okay* but not as well as before. It was sleeping more than before and crying differently than before. No coughing or congestion, no vomiting or fever. Nothing that just jumped out at me. The parents were totally focused on the feedings. Then the baby started crying and the mom picked the baby up while we were talking. I heard a barely perceptible wheeze. One wheeze. I couldn't really tell what was going on, but the parents were panicking and I had that weird feeling--you know, a 6th sense that something is VERY wrong. So I told them to take the baby to the ER for evaluation.
Two hours later I got a call from an outlying ER...
As they drove up to the ER door, the baby ARRESTED. The parents were screaming, the dad as frantically doing CPR, the nurses grabbed the baby and whisked it to trauma. Turns out that baby had a major, undetected heart defect! Within minutes they life-flighted the baby to the children's hospital and had it on the operating table 10 minutes later. Saved that baby's life.
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