Case Study #3

StudentOfHealing · Jul 20, 2014

so we are here....what is next?

-Sterile Gloves (obvious reason)

-Make sure airway is aligned for visualizing. So we will place a pillow behind their neck to move their head up just a tad as if making a "snotty look".

-Suction catheter/Yaunker tip (Yaunker tip allows more secretions to be suctioned)

-NGT for gastric decompression and feeding. Although if pt ends up intubated longer than expected, I'd expect an order for a central line.

-BVM

-Normal Saline (I would get some NS because intubation and propofol sedation can cause a further drop in BP and further rise in HR)

-Some type of lubricant for when the physician intubates

-Laryngoscope and blade

The doctor will order propofol and succinylcholine. FIRST you administer propofol and THEN succinylcholine. Never the other way around.

Immediately after intubation we check for bilateral breath sounds because sometimes it'll go into the LEFT main bronchus.

Hopefully someone called for a portable Xray before this so by the time we're done they're here to snap some xrays and confirm placement.

This is what I found from my research through my nursing books and a little knowledge recall from clinical experience.

Edit: I came across cricoid pressure but a CRNA told me it's controversial because you can just occlude the airway if you're not careful.

Esme12, ASN, BSN, RN · Jul 21, 2014

Technically you do not need sterile gloves to intubate.

Remember to pre-oxygenate with 100% O2 Have you equipment set up. BMV. Ensure the blade is functional (hint the light bulb at the end needs to light up) have 3 tubes ready one above the one you will use and one below just in case. Check the balloon. Prepare rapid sequence drugs as per orders...know patients weight if you are estimating get a second person to guess with you. Have suction open and ready. Prepare tape a head of time ( if your institution still uses tape).

Some MD's do not like the roll behind the neck they feel it might affect the vertebral arteries in the elderly and can cause a small CVA (I have seen it happen), Cricoid pressure...gently!

The doctor will order propofol and succinylcholine. FIRST you administer propofol and THEN succinylcholine. Never the other way around.

Why not? why don't you want to give succinycholine first?

Immediately after intubation we check for bilateral breath sounds because sometimes it'll go into the LEFT main bronchus.
Hopefully someone called for a portable Xray before this so by the time we're done they're here to snap some xrays and confirm placement.

Don't forget to check with your CO2 detector.

Then yes foley and NGT...very good! Consider a second IV

OP what happened next?

emtb2rn, BSN, RN, EMT-B · Jul 21, 2014

So, ct negative, csf clear, tox screen + opiates (suboxone remember), repeat rectal 99.2, hr 80s, bp 120s/60s, peacefully milk of amnesiad, my shift is done.

Conclusion: extubated 2 days later, discharged 2 days after that with dx of, wait for it........ Fever. Yep, neuro, id, pulm & psych consults were unanimous in their verdict of "I dunno what happened".

I'll post another case study but in deference to grn teas request to work these as nursing not medical, it will not be an er story. Thanks for playing.

nurseprnRN, BSN, RN · Jul 28, 2014

Since I mentioned it what is the drug used for NMS with hyperthermia?

Dantrolene (dantrium sodium)

nurseprnRN, BSN, RN · Jul 28, 2014

See, I came late because from the beginning I saw this was all pretty much going in the "medical diagnosis" and "medical plan of care" mode. New grads, don't think you're gonna be giving that banana bag and propofol and dantrium and sending the guy to CT and all because you think they're good ideas.

Precious little nursing in here. Fun, and sure, I like that stuff too, and sure, we have to know a lot of medicine (truth to tell, probably a lot more than medicine knows about nursing) and of course someone with experience will be reaching for the O2 and banana bag as the stretcher rolls across the threshold but... can we at least address some nursing plans of care in addition to "implement (items in medical plan of care) per Dr. Smith" ? (note, I abhor saying, "Doctor's orders" and "As ordered," because we are not in the military.)

NURSING!!!!

Esme12, ASN, BSN, RN · Jul 29, 2014

While I comple5tey get what you are saying I still believe it is helpful for the students to "think like a nurse" Which first starts out with...what is important? what should I be looking for? what should I do first? what should I be looking for? what should I ask the MD for? what are the complications? what is important? Should I be worried? These are ALL nursing tasks that those of us who are older do without thinking or blinking an eye. Critical thinking and prioritization the two very basic things we do everyday without thought. These are not about care plans per se....this is like active sim lab on a screen.

This is something a new nurse doesn't know because he/she hasn't experienced it before. I have seen it a hundred thousand times...experienced nurses will stand back, roll their eyes, cluck their tongues about the "unsafe practice" of a new grad...they gossip (not so discretely I might add) about the poor quality of new grads these days yet never once offer a suggestion or lift a finger in guidance to these new nurses leaving them feeling berated, abandoned, overwhelmed, and unsupported.

I had wonderful mentors that would guide me through the process when I was new. They would gently stand to my side and whisper suggestions about what to think of next. I found it to be comforting and safe to learn my new craft. They didn't stand back silent and chastise me about being incompetent and when I stumbled they caught me before I fell.

It made me a better nurse.