Clinical tidbits I wish someone would've told me. - page 3
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... Read More
0Sep 28, '12 by GM2RNQuote from ChiscaVery cool. I didn't know these existed.If your cardiac monitors have ST segment alarms use them. Get into the habit at the beginning of your shift of checking for correct lead placement and setting ST alarms. It may be your first indication somethings wrong with your patient.
3Sep 30, '12 by turnforthenurseRNIf your patient suddenly has no urine output, you better jump on the docs and start to intervene. I know that seems like common sense, but it's true. I've seen this with three patient so far, and unfortunately they all died. Patient A came in from a nursing home at like 0400, and at the end of my shift had 250cc urine. I wasn't back the next day, but apparently no one on dayshift was paying attention to the patient's urine output...patient didn't put out any! Patient also wasn't putting out any on that night shift, either. Needless to say, the patient went downhill, nurse got a DNR signed and the patient passed.
Patient B had a sudden decrease in urine output to basically nothing on dayshift. Patient was in ICU, nurse started a 500cc NaCl bolus and was transferred to my unit. Docs were aware the patient wasn't putting out any urine. After the bolus, patient still had no UO in their foley bag. I already had a bad feeling about this patient and they weren't looking good to begin with, so I paged the doc...but of course, they code on me. Within an hour of being on my unit from ICU. They went back up to ICU and coded again later in the night but didn't make it.
Patient C had a sudden decrease in urine output. Patient only had about 50cc on dayshift. Creatinine was rising. I kept calling the on-call about this and also collaborated with the nephrologist because the patient's BP dropped to 70-80 systolic. Got an order to give a 1,000cc bolus, after I told the on-call the patient's BNP was >35,000 and they said they didn't care, just give it. No order to put in a foley at that time. Patient STILL had no UO after the bolus and the patient didn't have the urge to go...their bladder wasn't distended. Finally got an order for a foley cath and to start the patient on dopamine. I only got 250cc of urine. Patient's BP was improving but despite dopamine, nothing! I notified the on-call but no new orders were received. Finally, dayshift comes on and lab calls with an increase in the already critically-elevated creatinine, which went from 5.3 to 6.4. The patient ended up being transferred to ICU and died a week later.
I remember viewing a video about the best way to tell if a patient is very sick on you...and it's about urine output! If their UO just keeps dropping, they might die. I believe it.
0Sep 30, '12 by turnforthenurseRNQuote from RNCCRN9706I'm sorry that happened to you and your son! How frustrating.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!! 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!
As for that tidbit...thanks! I never knew that. I just always squeeze the contents of the JP into a cup and hope I don't make a mess....
1Oct 4, '12 by armyicurnIf you are running pressor gtts or propofol/versed/fentanyl, always make sure you have plenty left in the bag. I had a couple of times where a colleague gave report and stated that there was plenty of juice in the bag. From now on, when I take pt's from that "colleague," we do a full 200% hands on and visual inspection during hand off. If I find a bag running low, I make them order a new one before they go home.
0Oct 5, '12 by turnforthenurseRNQuote from armyicurnAnd if you work in a place that doesn't have a 24hour pharmacy and you do not carry the drip in your Pyxis/Omnicell or whatever, make sure you check first and tell pharmacy or your supervisor ahead of time...don't wait until the bag is nearly empty!If you are running pressor gtts or propofol/versed/fentanyl, always make sure you have plenty left in the bag. I had a couple of times where a colleague gave report and stated that there was plenty of juice in the bag. From now on, when I take pt's from that "colleague," we do a full 200% hands on and visual inspection during hand off. If I find a bag running low, I make them order a new one before they go home.
1Oct 7, '12 by MullyQuote from armyicurnI'm with you there. Except for insulin, since 45mls of it might look like it's about empty but that could easily last the whole shift depending on the rate.If you are running pressor gtts or propofol/versed/fentanyl, always make sure you have plenty left in the bag. I had a couple of times where a colleague gave report and stated that there was plenty of juice in the bag. From now on, when I take pt's from that "colleague," we do a full 200% hands on and visual inspection during hand off. If I find a bag running low, I make them order a new one before they go home.
0Oct 10, '12 by SaylindGood tidbits. Like someone stated earlier urine output is very important. Huge indicator in cardiac output and fluid status for open heart patients.
Another piece I've learned that when you program your IV pumps double check your rate and volume to infuse. Also know your doses of IV meds before you talk to the doc, not just the cc's. My docs hate when some nurses tell them cc's and not dose.