Advice regarding student in Neuro ICU - page 2
I wanted to ask a question to all the ICU nurses out there. If you could teach the preceptor students 1 or 2 things before they arrived to start their preceptorship what would it be and why? ... Read More
Apr 23, '04Quote from gwenithI have started a sticky thread in this forum for people to add books and articles that they find useful - if you can add to that please go ahead!!!
Thanks for the websites gwenith! I copied and pasted some of the charts on them to print onto my 3 by 5 index cards.
3rdshiftguy, I'll make it a priority to look up those meds that you noted earlier.
I'll let you guys/gals know how it went after I get off on Saturday.
Apr 24, '04Today wasn't that bad. We had one pt with a subdural hematoma (resolved) going through DT's from alcohol withdrawal. He was a combative little thing. The other guy being on "floor status." We had a new admit that was hit in the head with a 25lb anchor. He was a site for sore eyes :chuckle (pun intended) Periorbital hematoma like crazy. Nice 3 inch laceration across his brow too. Oh man I have so much to share and so little time to do it in. This was my first time eve working a 12hr shift and it was tiresome. There is one thing I know for sure and that is I'll be buying new shoes before I start work after graduation. My legs are killing me!! Anyways, I had a great day and learned a ton. I can't wait to go back tomorrow. I will share more in the next day or too as soon as I catch up on some sleep. Going in again at 7am Sunday, so I'm hitting the sack. I've got to learn how to be a pro at this 12hr shift thing. I'm just fixing to pass out now as it is typing while lying in my bed. I'm really loving the unit so far...........zzzzzzzzzzzzzzzzzz
Apr 24, '04Glad to hear that you had such a good day, and rewarding at that..............
Keep up the good work.................
and please keep us posted.
Apr 24, '04Peri-orbital haematoma eh??? Look up the term "racoon eyes" it has special significance and a whole slew of special "Do not's"
Racoon eyes (Bilateral periorbital haematoma) and Battle's sign ( Bruising over the mastoid) may be signs of base of skull fracture. If you notice either sign you should look for CSF leaks from nose or ears. Especially be on the look out for halo's sign.
NEURO DO NOT's for base of skull fracture
Do not ever put anything up the patients nose or in thier ears
Monitor for infection
Do NOT put anything up the patients nose or in their ears
Do not allow them to blow thier nose - especially if there is evidence of a leak
Put NOTHING in the patients nose or ears
Monitor pupils and vision very carefully as the fracture may impact on the optic nerve
When I say don't put anything up the nose or ears that includes suction catheters ear wicks and nasogastric tubes
Monitor functioning of the 3,4 and 6th nerve
Did I mention about not putting anything up the patient's nose or in thier ears??
I was going to post a picture of a CT which shows the brain intubated by a nasogastric tube but I can't find the picture - which is probably just as well as it is rather shocking.
Apr 25, '04this is really interesting to me to hear all these tips! I am a third year out of four years nursing student, and just recently found out I will be working on a neuro unit this summer (an externship) and am eager to learn as much about neuro nursing as I can! It is not an area of nursing I really have any experience with at all, except for a little with family members. I am not sure at all what to expect! It is not an ICU, but a general neurology unit with a focus on epilepsy. Thanks for all the tips and keep them coming!! I will have to keep you all posted on how my externship goes (it starts June 7). Thanks again!!
Apr 25, '04I'm just a student as well but I just precepted in two of the ICU's at the largest hospital in the state three days ago. My preceptors were excellent!! They wanted me to remember: Make sure the MAP (mean arterial pressure) stays above 60, DOCUMENT DOCUMENT DOCUMENT, and stay organized. Good luck!
Apr 26, '04Keeping the MAP above 60 is good advice for a general ICU but in Neuro we usually like it a bit higher than that.
Trauma to the brain disrupts the normal autoregulation of blood so perfustion becomes "passive" relying on absolute values. This is why we like to keep the Cerebral Perfusion Pressure >60.
Cerebral Perfusion Pressure is MAP - ICP or Mean Arterial Pressure minus the Intercranial pressure.
In the case of the patient with subarachnoid haemorrhage (SAH) it is well documented that these patients develop severe vasospasm and although we do administer nifedipine to prevent or reverse the vasospasm many units still run SAH patients with very high MAPs i.e. MAP 100 - 110.
Entertainment is watching a neurosurgeon and a cardiologist discuss blood pressure:chuckle
Apr 26, '04Gwenith, you're just one big ball of knowledge. Ever thought about teaching?
Speaking of MAP and BP in general. I have a question. We received two pt's, husband and wife, from a motorcycle accident. Don't really know much about the wife (she wasn't our patient). The husband on the other hand was found to have a intracranial clot. The neurosurgeon removed the clot and placed a JP drain inside the scalp. Pt had Art line. Pt would open eyes to sound. He was trached. Pt localized pain. He was vomiting (aspirated). RT was suctioning and she aspirated some nice chunky stuff. Supposedly his family said they were eating at the Waffle House before the accident. He had a OG tube in place to decompress the stomach, but he was still coughing up chunks of this food. Just wanted to give you a picture of the patient.
My question is this. His BP cuff stated pressures in the 125-135/75-85 mmHg range. His art line pressures were 190-205/95-105 mmHg range. Which one do you use to guide your decision on BP medication? The nurse I was with wasn't too worried about the Art line pressures because the patient was fussy whenever we did 1hr neuro checks. The transducer was level with the patient's atrium. I just want to know what you would have done in this situation.
This board is a wonderful thing!!!
PS---The MAP was around 130 on the Art line.
Apr 27, '04Hey Dustin,
Sounds like you have gotten some very good advice from some seasoned neuro nurses. I love your enthusiasm and it's great to see someone who really enjoys learning about neuro patients.
To answer your question about your trauma patient, as long as your transducer is level and zeroed, I would go by the art line pressure. Occassionally, the position of the tip of the catheter in the artery will result in a falsely elevated pressure and this can be determined by a very sharp upsweep in your waveform. However, if your waveform is nice and peaked and you get a good square wave when you flush the line, I would go with the art line pressure.
What were your parameters for SBP? Ours are usually something like 100-180 and I'll usually call for prn hydralizine or labetolol if they're sustained over 190. However, you did mention that your patient would become agitated with the frequent neuro checks and I'm wondering if you had any prn sedation ordered? If you think about it, his head probably hurts like crazy and here we are talking to him loudly and shining a bright light in his eyes every hour or so. If you have prn morphine or ativan, I would try giving those first and seeing if calming him down helps his BP. You might be amazed how well 2mg MSO4 will chill some patients out.
On another note, I learned a great analogy to how it must feel to be a neuro patient:
Imagine yourself just underneath the surface of the water. You can hear people talking all around you and trying to pull you out, but you can't make out what they're saying. It's mostly dark, but every so often the sun is so bright you can't stand it. You keep trying to break through the surface, but for some reason, you just can't quite make it.
Of course this doesn't apply to all neuro patients, but I'm sure you'll see ones that fit this description, if you haven't already. Keep up the good work!
Apr 27, '04Elenaster, the parameters for his SBP were anything higher than 160 needs to be reported. I read this in the chart and that is when I questioned about which BP reading do we use. That's when she told me we'll go with the cuff pressure because it was a more normotensive reading. She was convinced the Art line pressure was probably elevated due to his fighting us when we did neuro checks. But, it wasn't like his art line pressure would go down after neuro checks they would stay the same throughout the hour. We did have Ativan and MS4 ordered. We gave both. That didn't bring his BP down much at all. I have attached a drawing of what the Art line reading looked liked when she flushed it. You can tell me if that is what it's supposed to look like. The art line readings were peaking nice and high and she said they had a safe-set device on their because if it wasn't on there the peaks of the art line pressures would go sky high on the monitor. I guess because his readings were so high. I'm not sure. I need more teaching about art lines. They say you get that during your critical care training class.
Let me know what you think.
PS--I also printed out the little neuro saying that you had and posted it on my notebook. I thought it was pretty good.
Apr 27, '04Dustin,
By the look of that waveform, I can see why your supervising RN wanted to go with the cuff. I'm really impressed that you attached a drawing for me. I'm not that talented, but I did find a link that may help. The key to a good square wave test is the way the waveform oscillates (moves up and down vertically) at the end of the square wave.
I actually have this little brochure myself, but take a look at it and see what you think:
Also, what was the size of your BP cuff in relation to the patient?
Gotta go now, but I'll check back later...
Apr 27, '04Like Elanaster - that waveform does NOT look like a good waveform to me. When I have had discrepencies in BP the docs usually tell us to go with the one THEY like best i.e. if the BP is too high they will go with the lower reading - AAARRRRGGG!!!
Usually though it so depends on the patient. Sometimes if they suspect that there is a lot of cerebral vascular spasm they will opt for the higher readings and be happy with MAPS of 110-120.