General Questions From a New Grad plus some venting

Pediatric Critical Care Columnist · Nov 27, 2010

Some days, I am confindent and feel accomplished about the care I have provided. But, as soon as something semi-emergent happens, I feel like a complete idiot and have no clue what I would do without the nurses around me helping out. I know I am 10x better then when I first started, but does it get easier? I know I will never know it all, but I just want to feel more confident in certain situtations.

Welcome to the club! Do you know why those nurses who are helping you make it all look so controlled? They've done it all a lot of times before. It takes 1000 repetitions of a new skill for it to become automatic. Think about the first time in your life you made a peanut butter sandwich. Bet it took 10 minutes and there was peanut butter on more than just the bread. It's a simplistic analogy but it works. Until you've been involved in a number of hairy situations, you're going to be breaking it all down into steps. It's how we learn.

Sometimes I feel totally hopeless. There are days I just get into my car and cry even though I didnt do anything wrong. Whats the worst is my fear of what will happen when I am off orientation, which is not long at all. I love my job with all my heart but I am scared of missing something when I am without a preceptor.[\quote]
Not unusual either! When you come off orientation, you're not completely cut adrift because there will ALWAYS be other people around to bounce your thoughts off, to ask those questions you think are stupid but aren't, to validate your assessments and so on. It gets better.
Also, some days I rock at report and other days I am so scatterbrained and just wonder why I cant seem to put it together. My preceptors have both told me I am where I should be...but sometimes I just wonder. Please share and stories, thoughts, or advice about being a new nurse. I could use some encouragement and just wonder if this happens to everyone.
I've worked in PICU for a long time and can rattle off a report that sounds like a foreign language, but you know what? The last two times I reported in rounds I completely left out the kid's BP. Never even thought about it. I'd wager that those days that you rock report are the days when you're organized early and have time to put it all together in your head before it has to come out of your mouth. And the days that aren't so stellar are the ones that start out busy and you've been zipping from task to task to task. That happens to us all. As time passes and the report format has been repeated 1000 times, you'll find that it will roll along without much of a push.
1) Even though its been explained to me a million times, I don't understand what kinds ventilation/pressure supports you do and do not want to use in patient's with HLHS after Norwood, Glenn, and Fontan?[\quote]
Your preceptor should answer these for you, but since you asked... Think about how the blood circulates in the heart of a post-op Norwood. In order to optimise their cardiac output, they're ventilated with a pressure control mode and low FiO2. The challenge is balancing the systemic and pulmonary circulations so that cardiac output is maintained. With the Glenn, venous return from the head is passive, so it's best if positive pressure ventilation is avoided if possible. High peak pressures are never a good thing in these kids. High pressures of any sort in kids with open sternums is not recommended either because there's limited extrinsic intrathoracic pressure so the lungs may become hyperinflated.
2) If I have a ventilated patient that codes, do I start chest compressions or bag them first? I know its airway, breathing, circulation. So does the fact that they are already intubated count as airway? Once help arrives, is the pt bagged while chest compressions are going on? Or is it seperate?
In this situation you start compressions and call for help. They have an airway and are being ventilated already, but once compreesions have started, a respiratory therapist will take over hand-ventilation; the rate for handventilation in a code is much lower than the usual. And with an artificial airway and hand-ventilation there's no need to pause for ventilations, compressions continue uninterrupted.
3) A post op heart transplant pt that was next to my pt was intubated and only 1day post op. He has periodic runs of v-tach. Everyone just sits there and watches the monitor. Why would we not perform CPR in this situation?
The patient would have an art line, correct? So the monitor would indicate whether there was a pulse with the runs of V-tach and how the patient's blood pressure was being affected. I would guess that the patient's cardiac output was being maintained and that had that changed or the runs lasted longer and longer that they would have intervened.
4) I know Milrinone helps the heart pump...but the exact action of it has never been explained to me. What is the difference between that and epi drips?
Milrinone improves myocardial contractility, or squeeze, so it has that in common with epi, but it works without increasing heart rate. At the same time it helps the left ventricle relax more in diastole so that it fills more completely, which epi does not. And it has vasodilatory effects that reduce the workload on the heart, which epi does not.
5) Is there a general rule about how long you should give a fluid bolus over? Keep in mind that I work with heart kids, many of them are single ventricles.
There's no hard and fast rule. The goal of a fluid bolus in these kids is to improve cardiac output. So you watch their filling pressures (CVP and LAP) while you're giving the fluid and adjust to maintain the LAP less than 12mmHg. (At least that's my threshold.) You also want to watch the HR so that if it starts falling you can slow down your bolus. But you want to get the arterial BP up so there's end-organ perfusion. Ask your preceptor(s) how fast they give them and how they monitor what they're doing.
6) What is 'overdrive pacing' (setting the rate high) and what is it suposed to help?
When your patient is in JET and they're symptomatic, something has to be done quickly to slow the heart down so that it can fill. In this instance, the native pacemaker is firing like it's supposed to but there's a competing little bundle of cells at the AV junction that are also firing, and the ventricles contract with both. The atria don't have time to repolarize and so the P waves are not visible. Overdrive pacing basically resets the SA node so that it asserts itself. The external pacemaker is set to about 120% of the endogenous rate in either AAI or DDD mode (we use DDD); once 1:1 capture is achieved the rate is then slowly dialed back down until the pacemaker is just a backup and the endogenous rate should have a sinus rhythm.
7) Any advice for pedal pulses? I can feel the normal ones, but cardiac kids still take me forever...some of them anyways.
Sometimes you have to resort to Doppler. Between edema, vasoconstriction, cooling and the rest, it can be very difficult. I've found that if I can't feel a pulse in the "usual" spot, I can often find one in the notch between the tendons over the ankle joint. Try it on yourself. Then I put a finger over where I feel the pulse and line my other fingers up next to it over the child's instep. Sometimes I can find a pusle further down and sometimes not. But if I can feel one in the notch, then I'm not worried.
8) What does Mg, Ca, and Potassium do on a cellular level that make them so important for us to monitor?/quote]
All of those electrolytes are important in action potentials, which are the signals to muscles that they have to contract as well as how strongly they do it. Normal levels of Ca2+ and K+ are usually adequate to maintain normal rhythm, but typically in cardiac patients the Mg2+ is kept on the high side. Ca2+ and Mg2+ affect vascular tone and therefore systemic blood pressure. So they're important.
9) How much chest tube output is too much for a fresh post-op?
That's a unit- and/or surgeon-specific issue. We consider > 3 mL/kg/hr for 2 consecutive hours to be the tipping point.
Does that help?

chickidee717 · Nov 27, 2010

Yes! Thank you so much:o

WoosahRN, MSN, RN · Dec 14, 2010

Good grief Jan! You are a genius! I am always very humbled when I read your posts. Is this all experience talking or do you actively participate in reading, studying, continued education?

Pediatric Critical Care Columnist · Dec 14, 2010

Woosah, thanks so much for your kind words! For me it's six of one and half a dozen of the other. A lot of what I post here is from experience but some of it comes from looking it up. I do a lot of reading and subscribe to several nursing journals, attend conferences and workshops all the time and am avidly curious. Working in a teaching hospital is great for ongoing education. I make a point of paying attention when the attending is teaching during rounds because I like to know what's going on. The other thing is that I'm cursed with an eidetic memory so I'm a repository of useless information.

bella14k · Nov 8, 2014

1) Even though its been explained to me a million times, I don't understand what kinds ventilation/pressure supports you do and do not want to use in patient's with HLHS after Norwood, Glenn, and Fontan?
2) If I have a ventilated patient that codes, do I start chest compressions or bag them first? I know its airway, breathing, circulation. So does the fact that they are already intubated count as airway? Once help arrives, is the pt bagged while chest compressions are going on? Or is it seperate?
3) A post op heart transplant pt that was next to my pt was intubated and only 1day post op. He has periodic runs of v-tach. Everyone just sits there and watches the monitor. Why would we not perform CPR in this situation?
4) I know Milrinone helps the heart pump...but the exact action of it has never been explained to me. What is the difference between that and epi drips?
5) Is there a general rule about how long you should give a fluid bolus over? Keep in mind that I work with heart kids, many of them are single ventricles.
6) What is 'overdrive pacing' (setting the rate high) and what is it suposed to help?
7) Any advice for pedal pulses? I can feel the normal ones, but cardiac kids still take me forever...some of them anyways
8) What does Mg, Ca, and Potassium do on a cellular level that make them so important for us to monitor?
9) How much chest tube output is too much for a fresh post-op?
Im sure theres tons more...but this is what I can think of for now. Thanks everyone.

First of all, i'm in an adult MICU...I have the theory, but i'm not assertive enough, i seem to be unable to multitask, and i'm on day 11 (or 3 weeks in--i work 3 days/week so far). I'm incredibly worried that i haven't progressed.

However, the questions you have asked, although good ones, should be the ones you ask your preceptor, or you should already know the answer.

1. idk

2. I have seen some codes so far, usually the RN will run out the room call for help, get the crash cart, put the board under the patient first, so that when help does come, it'll be ready. This takes a while (well, a few seconds but every sec counts) so it should be done first. OR someone else brings in the cart, and the RN (after pressing the code blue button and yelling for help) will bag the patient. Yes, vented patients are bagged.

3. Depends on the patient's baseline...more importantly, V-FIB is what you would be doing compressions for...

4. not sure

5. check with RN..this is where RN judgement comes in but i'm not 100% sure either. obvisouly you don't want to put them in CHF...what kind of bolus, what drug, and what's the MD order? Bolus doesn't always mean a large volume at once, but it can also mean a one time administration of something, ex: magnesium sulfate.

6. Not sure, but i'd like to know

7. Use a doppler to get pulses instead of spending hours looking

8. MG, CA, and K is important for cardiac functioning and neuro functioning , this was learned in school

9. Too much chest output in..an hour? there's no such thing as too much, but it depends in how much output in a certain period of time...but i knew what you meant. I think if i's over 400cc/hr, you should call the dr..i'm not 100% sure on that, i need to look back at my notes as well!

These are great questions to ask your preceptor...if you still don't understand it, you should do some studying during your own time..and if all else fails I suppose come to AN!!

That's awesome that your preceptor says you are where you should be!

Pediatric Critical Care Columnist · Nov 8, 2014

Just a comment, bella14k... this thread is 4 years old. chickidee717 hasn't even posted here since July 2011.