Clinical tidbits I wish someone would've told me.

Specialties MICU

Published

Hey everyone,

I'm a new graduate nearing the end of my orientation at my first job on a busy Stepdown unit at my local hospital. Although we don't deal with vents, we do most every common gtt (cardizem, dopamine, insulin, nitro etc...) and I'd say we have a pretty high acuity. It's not uncommon to have a code or near code situation on our unit during the night, and often times they don't even get called because we have the resources to manage them.

I know my topic of "things I wish someone would've told me when I was a new-grad" is a common question on allnurses, but my goal is to narrow this strictly to clinical facts that you have learned over the years.

For example, "Don't give dopamine to someone who is dehydrated. First replace volume, then the drug will help B/P otherwise you'll make them tachy and worse."

I posted this in Critical care because I think I will get the best and most relevant responses from you all. So finally I ask, what do you wish you would've known when you were a new-grad?... strictly clinical.

Thanks everyone!

Why won't Atropine work on a Transplant patient? I had never heard that before, very interesting!

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Why won't Atropine work on a Transplant patient? I had never heard that before, very interesting!

Understand that the vagus nerve is not retransplanted (the chest/heart is denervated) after transplant and so Atropine would be useless in symptomatic bradycardia. It has also been shown that after transplant a significant proportion of patients respond paradoxically to atropine, leading to asystole as the result of sinus arrest or AV block. Although a plausible explanation for this effect remains speculative, there is data to indicate that the use of atropine or other anticholinergic drugs in patients after transplant is contraindicated.

Atropine Often Results in Complete Atrioventricular Block or... : Transplantation

1 Votes
Specializes in ER, progressive care.
Atropine will not work on heart transplant patients......

...because atropine works on the vagus nerve and heart transplant patients do not have a vagus nerve ;)

Edit: looks like Esme beat me to it!

And while on the subject of atropine, it works on the AV node and higher...so think about your heart blocks. A 1st degree is at the SA node. A Wenckebach (2nd degree type I/Mobitz I) is at the AV node. A Mobitz II (2nd degree type 2) is at the Bundle of His and a 3rd degree block is at the purkinje fibers. Atropine will only work on blocks at the AV node or higher. It wouldn't really hurt to administer in a patient with a Mobitz II or 3rd degree but it probably won't help because those blocks are below the AV node. These patients need to be paced.

If a patient is admitted with bradycardia, keep atropine and some pacer pads at the bedside should they become symptomatic.

3 Votes
Specializes in Care Coordination, MDS, med-surg, Peds.

Levaquin can make the elderly loopy as well. Also, if an elderly male becomes suddenly confused, agitated, combative, check for a UTI. These elderly males don't tolerate UTIs very well.

Atropine will not work on heart transplant patients......

That's interesting--why is that?

I see this has already been answered. :)

Specializes in ICU.

Always listen to your patient when they say that something "just isn't right." try checking a blood sugar- then if WNL and sense of impending doom persists, grab an ABG.

Get ready to clamp the NG/OGT ASAP (or hook to sxn) after placement, those things can become a pressurized fountain of stomach contents!

A normal HR can mean disaster if the pt had previously been very tachy- have had 2 pts recently with HR in the 70s who were minutes away from asystole- luckily both were DNRs (but still being treated).

1 Votes
Specializes in Med/Surg,Cardiac.

Press Ganey is the devil.

Always make sure the patient doesnt have a test that requires NPO before giving a snack.

Dont draw labs from a hep line without flushing really well first.

Explain what you are doing to everyone, even if they are confused or are not conscious.

Label every line. Check every line at shift change.

If you run a drip as a secondary, make sure the clamp is open. I have come into work to find drips programmed but not infusing. Eek incident

If you make a mistake, own up and learn from it. Seek advice and let the md know so it can be treated.

Get vitals every time you call the doc.

Make sure all patients with any heart problems or potassium issues are monitored.

Pharmacy is awesome as a resource. Ask them to help manage drips and such. Any med questions they can usually advise you some.

Make sure SCDs are plugged in and running correctly. I hate seeing SCDs charted as on when they are not plugged in.

1 Votes
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Press Ganey is the devil........rotflmaoke0.gifNow that is funny.....true, but really funny!!!!

Specializes in CTICU.

Airway

Breathing

Circulation

Step #1 with someone who's falling in a hole.. add or increase O2.

Specializes in Med-Surg Nursing.

Yes, we must be better based on Press Ganey surveys. I

I recently filled one out myself for my 8yr old son's ER visit at the beginning of the month where the Dr misdiagnosed him and never even LOOKED at my son's lip during the visit. When we called the ER the next day he never said bring him back in, just put him on prednisone. Turns out my son developed a lip abscess that was MRSA positive and not surprising given his history of it. Had that first ER dr properly diagnosed my son, we might have avoided a trip to Rainbow Babies Hospital in Cleveland where my poor son had to undergo a painful I&D of the abscess under local anesthesia, ended up missing a week of school and a week of football practice and game. The ER director called my husband last week...never really apologized for his colleagues screw up but only said that he was glad our son was better!!:no: So I will NEVER EVER take anyone to that ER when this certain DR is working!! I'll call first and if he's on...I'll drive farther where I know I'll get better care!

Anyway....tidbits. You can use a 60cc syringe to empty contents from a JP drain! the luer lock end of the syringe screws on the opening of the JP and VOILA! Remove the contents without making a mess!

3 Votes
Specializes in ICU.

Also protects your eyes from splash back of blood when some is Hep C or HIV pos.

Specializes in Public Health Nurse.
Atropine is NOT for bradycardia. It is for SYMPTOMATIC bradycardia.

That is ACLS and PALS 101.

Also, I learned during my rotation at ICU, always double check the dose that the MD gives to a patient for pain...sometimes they do not consider how frail or little a patient weighs and it is up to the nurse, who works closely to the patient, to ask the MD to modify the order.

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