Clinical tidbits I wish someone would've told me.

Specialties MICU

Published

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 (cardizem, dopamine, insulin, nitro etc...) and I'd say we have a pretty high acuity. It's not uncommon to have a code or near code situation on our unit during the night, and often times they don't even get called because we have the resources to manage them.

I know my topic of "things I wish someone would've told me when I was a new-grad" is a common question on allnurses, but my goal is to narrow this strictly to clinical facts that you have learned over the years.

For example, "Don't give dopamine to someone who is dehydrated. First replace volume, then the drug will help B/P otherwise you'll make them tachy and worse."

I posted this in Critical care because I think I will get the best and most relevant responses from you all. So finally I ask, what do you wish you would've known when you were a new-grad?... strictly clinical.

Thanks everyone!

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 :D!

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 coorifice 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.

Nice, never thought of this. 5 years ICU nurse.

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

Specializes in CVICU CCRN.
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.

Specializes in ED, ICU, PSYCH, PP, CEN.

OMG, what a treasure trove of great things to do. Thanks

Always make sure your suction is set up and ready to go and your ambu bag is close by. 

Always scan your meds before giving them. Cared for a patient for several days, gave a med before scanning, only to realize they decreased the dosage and I gave too much. No patient harm, but scan first! 

 

Specializes in ICU, CCU, COVID ICU.
On 9/15/2012 at 11:47 AM, Esme12 said:

Like anything else in medicine...things come in threes....and if you are working a trauma unit you will see more declaration of brain death utilized.

clinicla tidbits......that is tough. First to remember is that the first year is the hardest. If there is no pulse start CPR and think epi. You can give dopamine for low B/P but you must also correct volume issues for it all to be effective. Always check you patient LISTEN to what they are saying. ANY patient on a monitor must have at least a heploc/saline lock/IPID and when you have drips always start that heploc for your open line.

Organization is key.....you need a good brain sheet.......here are a few.

doc.gif mtpmedsurg.doc doc.gif 1 patient float.doc‎

doc.gif 5 pt. shift.doc‎

doc.gif finalgraduateshiftreport.doc‎

doc.gif horshiftsheet.doc‎

doc.gif report sheet.doc‎

doc.gif day sheet 2 doc.doc

critical thinking flow sheet for nursing students

 

student clinical report sheet for one patient

 

I made some for nursing students and some other an members have made these for others(daytonite).....adapt them way you want. I hope they help

 

 

I know this is a long shot, but is there any chance I could get you to send me your links? I'm not able to open them here. 

I just started in our MICU/CCU/COVIDICU as a new grad and greatly appreciate all the information 

 

Specializes in CTICU.

Read the patient, not the chart. 

Sooooo many times someone tells me something based on what is documented but they didn't check it themselves. Don't go by someone else's assessment - do your own, as soon as you can get in the room. 

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