Clinical tidbits I wish someone would've told me. Clinical tidbits I wish someone would've told me. - pg.4 | allnurses

Clinical tidbits I wish someone would've told me. - page 4

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

  1. Visit  JustKeepSmiling profile page
    2
    Not necessarily a "hack" but something I thought to do.. Put a stopcock on the IV to draw blood so not to have to undo the leur lock and reconnect.
    For example if you're getting continuous CVP through distal, put the stopcock on the port so you can get Scvo2 and blood draws without having to disconnect.
    I've transduced CVPs through the stopcock without change in waveform and the CVP value was consistent with and without the stopcock, haven't found EBP on this so please let me know if you do.

    I also prefer using bi/trifuses instead of y-siting if compatible gtts. Those can be really handy if you have limited access.
    calivianya and icuRNmaggie like this.
  2. Visit  icuRNmaggie profile page
    5
    If you have an arterial line but no arterially based cardiac output technology to check SVV,
    do the passing leg lift maneuver.
    Raise the legs 45 degrees and if the art line waveform increases and the ABP increases, the person is volume responsive.

    There are nurses who do this with a cvp by watching the monitor for an increase at end expiration using the resp waveform and the cvp.
    I would ask a helper to lift the legs while I watched the monitor.

    This is EBP and just a simple non invasive assessment to determine if the person needs volume or pressors.
    Last edit by icuRNmaggie on Sep 14, '15
  3. Visit  arnwest profile page
    3
    Before traveling to MRI, make sure your patient is small enough to fit in the machine. (If they're on the heavy side, I always call the tech up to measure them beforehand. It's saved us both a lot of trouble). For that matter, before traveling anywhere, always make sure you have enough drugs to get your through the trip. Always expect the unexpected!
    Double check your drips. I always follow tubing from the bag all the way to the patient. I've caught high alert drugs erroneously running in fast as secondaries, and frequently find fentanyl drips y-sited in with Versed drips that have been turned off, which, at 2cc/hr through a central line, means the patient isn't getting any fentanyl at all.
    Do bedside report. Or at least have a face-to-face with the previous/next nurse and the patient. Quickly review drips, vent settings, bedside safety equipment, etc., with the other nurse. This holds them accountable, and shows that you're accountable as well.
    If your monitor alarms, don't get excited before first looking at the patient. Always assess the situation before calling the doc.
    Always check for consent - blood, bedside procedure, etc. And don't witness a consent without physically hearing it.
    That's my two and half cents.
    vegasmomma, calivianya, and icuRNmaggie like this.
  4. Visit  kalycat profile page
    0
    Phenomenal information in this thread. Glad I found it.
  5. Visit  calivianya profile page
    4
    Quote from icuRNmaggie
    If you have an arterial line but no arterially based cardiac output technology to check SVV,
    do the passing leg lift maneuver.
    Raise the legs 45 degrees and if the art line waveform increases and the ABP increases, the person is volume responsive.

    There are nurses who do this with a cvp by watching the monitor for an increase at end expiration using the resp waveform and the cvp.
    I would ask a helper to lift the legs while I watched the monitor.

    This is EBP and just a simple non invasive assessment to determine if the person needs volume or pressors.
    Your advice is starting to sound way too similar to NICOM monitoring and I hate that machine with the passion of a thousand fiery suns. Stop!

    Totally kidding, of course. I love your advice - you are just phenomenal and I love reading your posts.


    Seriously, though - just because a patient is fluid responsive, don't assume fluid is going to do them good. I had a patient a couple weeks back on NICOM who continually read as fluid responsive all night long. I was giving bolus after bolus after bolus per NICOM protocol - if delta SVI is greater than 20% with a leg raise, we give 500ml, and if it's greater than 10%, we give 250ml.

    I finally thought we were giving way, way, way too much fluid (patient was something nuts like 15L positive in less than 18 hours of being admitted) and I hooked up a CVP - patient CVP after being zeroed was 33. I had just run a leg raise and I got >20% - the machine wanted me to give the patient another bolus, and the patient's lungs were already wet. I called the physician and got the NICOM monitoring d/ced.

    Fluid responsiveness needs to be treated with a degree of caution and critical thinking. Patients can still be fluid responsive right up to the point of going into pulmonary edema from overload. Yep, fill the tank before starting pressors - but if you have already done a decent job of filling the tank, just start/titrate up a pressor.
    canoehead, idodialysis, ICUman, and 1 other like this.
  6. Visit  icuRNmaggie profile page
    4
    I have never worked with the nicom or a nicom protocol but thanks for the heads up.

    I totally agree that if the patient is not responding to boluses we shouldn't drown them in fluid which used to be exactly what we did until the patient looked like the Michelin man. A low diastolic in spite of adequate fluid resuscitation means no vascular tone and the patient needs pressors to restore organ perfusion.
    Julius Seizure, canoehead, ICUman, and 1 other like this.
  7. Visit  calivianya profile page
    2
    Quote from icuRNmaggie
    I have never worked with the nicom or a nicom protocol but thanks for the heads up.

    I totally agree that if the patient is not responding to boluses we shouldn't drown them in fluid which used to be exactly what we did until the patient looked like the Michelin man. A low diastolic in spite of adequate fluid resuscitation means no vascular tone and the patient needs pressors to restore organ perfusion.
    You are lucky that you've never had to deal with that machine... I am not at all convinced that it works. It is a super cool concept but I always feel like I get funny numbers and nearly drown my patient every time.

    Cheetah NICOM
    ICUman and icuRNmaggie like this.
  8. Visit  nursefor profile page
    0
    Love this thread very informative
  9. Visit  Greenclip profile page
    0
    I love NICOM but we never do the leg raise protocol, only the standard one. One of our very experienced RNs told me that she has done a leg raise with NICOM only once since we've had it on the unit. But we don't run the protocol over and over. I might run it twice or three times over a couple of days. I would give the 250 mL bolus that's required to run the test and then they would probably order 500 or 1000 if the delta SVI showed that the patient was fluid responsive. Then they would leave it for a while and see how the patient responded.
    I actually have more of a beef with the CVP. I feel like the docs order it, ask what the initial CVP is, and then don't use it for making decisions.
  10. Visit  Traveler2 profile page
    12
    ICU RN here. some things I have learned through my experience ( and floating a ton!)

    ALWAYS give report by system. If you jump around, you are more likely to forget something than if you focus on one system at a time. You will also take longer to give report if you jump around since the other nurse will have no context for what you're talking about. Jumping around is disorganized and more likely to lead to error. Period.

    Clinical tibdits by system:

    neuro:

    BP management is a priority for most neuro patients. Know your BP parameters. high/low BP, BP out of prescribed parameter can lead to DEVASTATING consequences for many stroke patients. Do you have anti-htn PRNs? enough drip volume? is their BP unstable? Does their exam change with their BP? (neuro icu hack here)

    always do a full neuro assessment at the beginning of your shift. even if their chief complaint isn't neuro-related. Your vented, sedated, 89 y/o pneumonia, Afib patient s/p fem-pop is still at risk for stroke. pause the sedation (if stable), check pupils. do they follow commands? are all their extremities anti-gravity? You don't want to miss s/sx of a stroke because then they may never, ever get better. and remember, you are responsible for caring for the pt as a whole--don't become lax and miss something!

    always check that your ventric is level, and check the order! I've seen nurses have a ventric open @ the wrong level, but it turns out that neurosurg changed the drain without telling the nurse and then never placed the order. this affects your ability to appropriately monitor your patient's tolerance of the drain change. make sure the MD always, always places an order and explain to them the importance of the aforementioned. Docs need a succinct indication for why they should make something like that a priority. (They have to prioritize too, of course)
    "You need to place an order, and notify me, because if I don't know you did that, then nursing will unclamp the drain thinking it was a mistake/ not assess q15min for increased/decreased drainage since it's only written q1h/ this affects our monitoring of their tolerance b/c...."

    check the ICP waveform, and document it's characteristics. changes to this waveform, especially in a heavily sedated, paralyzed, or comatose pt w/ “no exam”, is paramount.

    Respiratory arrest? Not waking up? think anoxia. ask for MRI when stable. check ABG.

    DO NOT GIVE HYPOTONIC MIVF TO NEURO PATIENT!!!! in a nutshell, can cause brain swelling!! increased ICPs! worse outcomes! even herniation and death! noooooooo bueno, ya’ll.

    ALWAYS check your drips to make sure they are mixed in NSS, if possible. (some necessary meds are only stable in certain ivf mixtures, so check compatibility and suggest mixture in nss if possible--but pharmacy should be on top of this, anyway.) If the patient has neuroendocrine issues following tbi, there may be exceptions to this as well. but as a general rule, think twice before hanging 125c/hr of 1/2 nss.





    CV:

    use the calipers function on the central monitor to measure your tele strip. if you prefer to do it manually, as many nurses do, go for it. It just saves me time to use the computer.

    set your alarms. check your facility protocol on this ( because every hospital is different**), but if a stable patient’s baseline HR is 50-75. I’ll set my low limit to 45, and my high to 95. alarm fatigue is dangerous. use judgment as allowed by facility.

    always sets bp alarms. check your a-line waveform. always level and zero. make sure pressure bag is inflated properly--deflation can lead to a loss of the line.

    make sure your CVP is on distal port of CVC.

    keep an eye on your swan ganz, and the balloon port. I’m paranoid about that. (I also don’t work with swans very often not only because I primarily have a background in neuro icu, but because swans are so invasive, and there is a trend towards less invasive monitoring especially outside of cardiac, so this leads me to another point…)

    if you’re floating and haven’t worked with a certain device or new/ old model of said device in a while (again, every hospital is different and has different models and manufacturers of equipment that have the same principle) ask another STAFF nurse for a quick refresher. “Hi there, I haven’t worked with this 2015 model of “X device” by “Y manufacturer”--I’ve seen the 2014, 2013 and 2004 version and the model made by “Z manufacturer” --could you watch me zero/calibrate, collect FLOD, etc? or could you show me how to do XYZ with this specific model?”. You will be surprised how different monitors/devices can be between manufacturers, and you are responsible for knowing how to use them and troubleshoot them.

    And hey, don’t feel bad. You’re not dumb for asking for an inservice on a Zoll defibrillator when you’ve only seen a Phillips defibrillator. Same concept of course, just different button and dial locations. Remember, you are pro-active, smart and versatile. You can manage this patient…...and if after some “teach one, show one, do one” w/ a device, and you still feel uncomfortable, notify your charge nurse, and switch assignments because patient safety is #1!

    optimize e-lytes in a timely fashion. lots of PVCs? hx of torsades? pt may need patient-specific e-lyte goals to keep them stable. a mag of 2 may be normal, but maybe your pt needs mag of 2.5 because he runs into trouble every time his serum mag falls below 2.5...this decision is the MD’s of course. but it is a trend you can point out to potentially help guide treatment choices.

    Check pt’s pulses frequently after angio/heart cath. assess, assess, and re-assess! especially after sheath and fem line removal. (One time, a co-worker’s patient had a fem line removed by NP--I think it was just a fem art line? Can’t remember. NP held manual pressure, per facility guidelines. A-line starts alarming….pt hypotensive. Co-worker surprised. Assesses pt. Removes sheet to look @ groin and finds huuuuuuuuuuge puddle of blood at fem line site. pt needs be transfused, started on pressors, etc.)

    Y-site cautiously. label everything.

    check the hospital protocol for infusing drugs, certain drug concentrations AAANNDD certain drugs at certain rates via certain lines (what a mouthful, huh!)…….They’re different at every hospital and you are liable for knowing! (I.e. can’t run 3% hypertonic via piv @ hospital “A”, cannot run Vanc through Midline PICC at hospital “B”, can run Levo peripherally for up to 2 hrs @ hospital “C”, it goes on and on.)



    FILTERSSSSSSSSSSS FOR DRIPS! amio, dilantin, mannitol. can’t think of the others. be careful.( while floating one time, floor nurse told me, “on our unit, we don’t require filters on peripheral amio drips”. That’s fine, but I’m going to put one on anyway. Can’t hurt. It’s in the drug guides, and the pharmd confirmed my concern sooooo…..just put one on. )

    Low-sorbing tubing and nitroglycerin!….ummmm...not sure what other drugs require this, but apparently, nitro has been studied in low-sorbing tubing, not reg pvc tubing. so if given via pvc tubing, the dose delivered may not be accurate.

    Unexpected increase in pressor requirements, fluid, and changes in vital signs? OMG are they bleeding? about to code? NOPE. YOUR MANIFOLD IS LEAKING, AND YOUR DRIPS ARE ALL OVER THE PILLOWCASE. This happened to me once and I will NEVER forget it. Equipment malfunctions, and luer locks become loose sometimes w/ movement.Check your manifold, stopcocks (make sure they’re open, you guys!), and check your luer locks! I once got bedside report, and the pt was flipping out. The night nurse was concerned and we look @ the prop line and see the propofol had disconnected from the piv.

    Resp:

    ALWAYS have an ambu bag, 2 suction canisters and yankauer, o2, peep valve, etc in your room. PERIOD. Even if it’s not protocol on the unit you are floating to. If you feel uncomfortable, and think the pt looks Rapid Response-y, then put it in the room, and call the doctor !

    check w/ MD and/or hospital protocol for guidelines about when to get ABG after vent change. make sure you know who is responsible for collecting ABG. RN, RT, ABG team?

    have clamps at your bedside w/ a pt who has chest tubes. PERIOD.

    pt w/ afib, no anticoagulation, bedrest, has cancer and/or post-op? new onset of agitation, confusion, impending doom, tachypnea, tachycardia, hypoxia? decreased breath sounds and increasing o2 requirements? think PE.

    Vented pt w/ fever, increased, irreg quality sputum? inc 02 requirements and coarse breath sounds? collect sample and have it ready when you notify md so you can get an order to send it and move on.

    Be careful NT suctioning patients. only do if well tolerated. laryngospasm, bronchospasm is no fun for pt. triggering excessive gagging and vomiting, also no fun. and aspiration risk.

    NT, and tracheal suctioning should be conducted w/ sterile gloves. would you want a non sterile cath passed into your trachea? Didn’t think so.

    very poor mental status w/ very sonorous breathing? lots of secretions? but abg stable and md doesn’t think intubation is indicated? ask md to seriously consider intubating for airway protection. pt may not last very long like that and there’s no harm in asking for the MD to give this a second thought………


    check your vent settings q4h. every now and again, someone may change fi02 or rate or mode and forget to switch it back. sometimes, the MD, such as intensivists or pulmonologists will change vent settings to see what happens on CPAP, for example. and then forget to turn it back. you walk into the patient’s room and they’re clearly not tolerating this, and desatting….”OMG what's happening?!?!”, you think to yourself. You look @ the vent and realize that pulm tried cpap on the pt and walked away w/o telling anyone. call RT to notify, make sure pt is stable, and ask RT to change settings as tolerated. Ask MD not to do that again without notifying. Explain rationale.


    Don’t understand vent modes b/c you’re used to working w/ puritan bennett and this vent is a different manufacturer and completely different? run through it w/ RT and have them tell you what modes are what in the terminology you’re used to. (i.e. assist control is called blah blah w/ this kind of vent…)

    Assess lung sounds after lasix, blood products, and after fluid boluses IN ADDITION TO your routine assessments. Gotta know which way your pt is headed, even if you have a CVP, vigileo, swan, etc. You still have to look at the ACTUAL PATIENT not just numbers on a screen.



    GI:

    Don’t feed a patient w/ a facial droop, slurred speech, or wet voice. Just don’t. Even if they don’t cough, they can still be aspirating. Nursing SHOULD NOT be doing bedside swallows on cases such as these, and you should talk to your manager about setting a protocol in place for nursing to defer bedside swallow to SLP. Don’t put the patient or your license at risk. Express your concerns to the doctors in a succinct manner. ask for an NGT for meds to help keep the pt safe. It’s better for the pt have an NGT for a day, than to aspirate on their meal tray due to being inadequately screened.

    Give meds, flushes, bolus feeds via gravity when possible. If given via push quickly, pt more likely to complain of fullness, nausea.

    GU:

    Place fecal incontinence device for diarrhea, especially with fem lines! Ask for fem lines to be removed, and placed somewhere clean, like subclavian or PICC. Advocate!

    Monitor UOP and calculate based on the pt’s weight. Monitor BUN/Cr and e-lytes.

    Pt barely eating and drinking? Notify md and express concern that they may not been meeting their needs for adequate hydration and nutrition...the MD may say “just encourage her”, but encouragement is often not enough when the the pt has a poor appetite, mental status, pain, nausea, vomiting. Explain this to MD and ask if they will consider IVF, or tube feeds until pt starts meeting their hydration and caloric needs PO. Advocate!


    Skin:

    Use sterile gloves when changing dressings. Even if it’s a bum wound, your sterile gloves carry no risk to the pt’s wound.
    Band Geek, acerbia, kalycat, and 9 others like this.
  11. Visit  Brittms4life profile page
    0
    Nice, never thought of this. 5 years ICU nurse.
  12. Visit  hotcoffee profile page
    3
    Use a jaw thrust when bagging a patient, or on someone who is obstructing. most RTs and RNs I have seen bagging don't do it.
    Emergency Ventilation in 11 Minutes on Vimeo
    puppyrunner, acerbia, and kalycat like this.
  13. Visit  kalycat profile page
    0
    Quote from hotcoffee
    Use a jaw thrust when bagging a patient, or on someone who is obstructing. most RTs and RNs I have seen bagging don't do it.
    Emergency Ventilation in 11 Minutes on Vimeo
    This and cricoid pressure are the two things I've seen overlooked or forgotten (frequently) during an emergency or RSI.

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