Advice regarding student in Neuro ICU

suzanne4, RN · Apr 20, 2004

1. Never reposition the patient who has a ventriculostomy open to drain, without having your preceptor close the drain first.

That is the most important thing that I can think of right now, that would be different from most of the other ICUs.

Good luck................. :balloons:

DustinRN · Apr 20, 2004

1. Never reposition the patient who has a ventriculostomy open to drain, without having your preceptor close the drain first.
That is the most important thing that I can think of right now, that would be different from most of the other ICUs.
Good luck................. :balloons:

Thanks for the advice Suzanne! I just want to seem half-way competent when I go there.

Can anyone else think of anything that would be helpful to know before I start?

gwenith, BSN, RN · Apr 21, 2004

Learn how your colleagues use and assess with the GCS - there is huge variance in how people assess using this tool - learn how THEY use it so that you are all on the same playing field.

Pupils are not neccessarily the first things to change with rising ICP

When thinking of those things that increase ICP think of the worst hangover/headache you have ever had - now think of those things that you did not do

i.e. cough/sneeze

strain at stool

twist your neck around

listen to loud music/noises

now still thinking of that headache/hangover imagine if someone dropped some money on the ground in front of you and told you that if you bent over so you were head down you could pick up a keep the money - how much money would we have to drop on the floor before you picked it up????

Get the picture - you never ever place a patient with increased ICP in the head-down position usually 30 degrees head up.

Keep us posted on your progress - if we can't answer your questions there should be someone who can.

Tweety, BSN, RN · Apr 21, 2004

Good advice Gwen. When I worked neuro the nurses seemed to be obessed with the pupils. LOL

I would definately bone up on the signs of increased ICP. Just be a sponge, open minded and ask a lot of questions.

Also try not to judge the nurses. Students have a way of being very judgemental, that's not a slam to students, because I was probably the same way. Just realize there are all kinds of nurses out there from different backgrounds with different ways of doing things. Become the nurse you want to become without worrying about what others are doing, and don't compromise.

I love having students around, because they have such fresh knowledge that I can learn from, I may have the skills, so we can equally benefit.

Good luck!

Again, ask lots of questions.

DustinRN · Apr 21, 2004

Good advice Gwen. When I worked neuro the nurses seemed to be obessed with the pupils. LOL
I would definately bone up on the signs of increased ICP. Just be a sponge, open minded and ask a lot of questions.
Also try not to judge the nurses. Students have a way of being very judgemental, that's not a slam to students, because I was probably the same way. Just realize there are all kinds of nurses out there from different backgrounds with different ways of doing things. Become the nurse you want to become without worrying about what others are doing, and don't compromise.
I love having students around, because they have such fresh knowledge that I can learn from, I may have the skills, so we can equally benefit.
Good luck!
Again, ask lots of questions.

Gwenn and 3rdshiftguy, those are very helpful tips. I've never thought of all things I try to avoid when I have a migraine. When you spell them out like that it really makes since as to what I should try to avoid so they don't increase their ICP.

3rdshiftguy, I have definitely noticed that all nurses have their particular ways of getting tasks done. At first It would frustrate me, because I was like, "Wait! That's not how the nurse yesterday did it!" Now I realize that everyone has their own specific way of doing things and as long as it doesn't compromise patient safety it's fine. I've actually learned a lot of different techniques for a lot of different procedures.

Thank all of you for the help. Trust me, I'm soaking this stuff up. You can be assured that I will ask numerous questions when my preceptorship starts on Saturday. :chuckle

Kudra · Apr 22, 2004

here's from 1 student to another: mouth care, mouth care, mouth care...

i found neuro patients almost always had a distinctive smell about them, usually stemming from their oral cavity... mouth care at least ever 2 hours is a must... it sounds really simple and inconsequential considering all the other things going on with the patient, but seriously, it helps... the family appreciates it...

i second the open drain comment...

and remember, this is an excellent time to perfect your assessment skills... everything i ever learned in my Physical Assessment course, i put into use my first day caring for a neuro patient in the ICU... it was awesome!

beth

gwenith, BSN, RN · Apr 23, 2004

I absolutely totally agree about the mouth care - there is an old nursing saying that the worse the smell from the mouth the worse the head injury.

Hmmmm perhaps we should research that..........

NeuroICURN · Apr 23, 2004

I HEAR YA ABOUT THEIR BREATH....WE CALL IT "HEAD BREATH"!!! YUK!!

Dustin, what area are you in?

Anyway, as a neuro ICU nurse, there's soooooo much I could tell you, but it would take up the entire page! LOL :chuckle Most importantly, don't be afraid to ask a question! Neuro is a REALLY intense and specialized place...you can't always tell what's going on just by looking at a monitor, so your assessment skills have to be right on.

First of all...thank you to the person that said not to move the HOB for a patient with an EVD (a venticulostomy). I don't know how many times I've had to run, yelling toward my patient's bed as a supplemental staff member (i.e. speech therapy, OT/PT) started to move it! Most know better, but sometimes you get a new one who doesn't!

Also, yes, pupils are important, but also remember that assymetry of pupils CAN also be normal!!! Go with things like their level of consciousness...are they more lethargic now? are they not as strong on one side as they were before??

Now, write this down...The TRUE test of upper body strength is to test for pronator drift! Have the patient hold their arms up in the air, palms to the sky (as if they're holding a big pizza box), tell them to close their eyes and hold the arms still and not let them move for approximately 5 seconds. Especially in patient's who've had an aneurysm that bled and had one clipped or coiled, that is often one of the FIRST signs you'll see if they're going into vasospasm!!!

Finally, don't be afraid to trust your instincts!!! Some of neuro nursing is listening to your instinct.....there are times when just the slightest little thing may be different from your previous assessment, but if it JUST DOESN'T FEEL RIGHT, sometimes, it's not!

Feel free to personal message me with any further questions you may have! Hope I gave ya a few helpful tips to get ya started.

Take care!

PS...I'd love to hear from all my fellow neuro ICU nurses out there!

gwenith, BSN, RN · Apr 23, 2004

Absolutely agree with Neuroicurn - The pupil thing - I was being nice - so many many people focus on just the pupils - focus on level of consciousness and rousability. One of my "gripes" with the standard glasgow coma scale is that it does not accurately assess rousability beyond the eye opening. One very good article I read when I was researching the GCS recommended "timing" the noxious stimuli you were performing both to get a more accurate assessment of rousability and to prevent people from "overdoing" it.

I hear you too NeuroICURN about hearing from more Neuro nurses in general. I would love this forum to become more active and have tossed around the idea of making it a more general neuro forum.

DustinRN · Apr 23, 2004

First of all thank you for the tips. Keep them coming! :chuckle I will make sure to implement all of these tips that I received from everyone.

NeuroICURN, the unit I'll be going to is Neuro/Trauma ICU. This is possibly the unit I will work on when I graduate on May 11th. The nurse manager has two positions open and I believe she is holding them for a classmate and me. I just want to make a good impression during my preceptor experience.

These are just a few things I plan on reviewing before I start on Saturday.

1. I'm going to read the whole neuro chapter in my med-surg book.

2. Make a couple of 3 by 5 index cards regarding ICP and GCS

3. Record all the normal values for ICP, CPP, MAP, PAWP, and PAP. I can't really thing of any other values off the top of my head right now.

4. I'm going to try and review ventilators in my textbook

Those are just a few things that I'm going to look before I go in on Saturday. If there is anything that you think I should focus more on I'm all ears! :chuckle

Do you think this is enough to review, or do you think I need to review different material?

Again, I have recorded all of the tips that everyone has provided and I thank you.

Tweety, BSN, RN · Apr 23, 2004

Dustin, you'll do great, don't feel you have to know it all. Perhaps you might want to bone up on the common neuro meds like pentobarb, dilantin, decadron and sedatives like fetanyl, norcuron (sp?), etc. The other guys can tell you what they've used, as when I floated to neuro ICU from the intermediate unit (my home for three years) I took more stable patients.

Good luck. Let us know what you think after Saturday. :)