Hardest Equipment to work with in Nursing

Hey Again

Promise, it's a COINCIDENCE.

The absolute WORST piece of equipt was the old old 'Big Boy Bed' that would not raise the Pt to working height. I'm a long drink of water (about 6'3") and remember a 400lb patient, completely flaccid, tube feeding diarrhea running off the bed, and the whole scene was about the level of my knee caps.

What a back ache!!!

The new ones are fabulous, raise the pt, assist to turn, t-berg and reverse t-berg at the push of a button.

Papaw John

is that the sand bed that looks like a tub where u can't turn ur patient properly no matter what u do

That's another candidate isn't it? They're 'Clinitron' bed and they're filled with tiny tiny little ceramic beads which are warmed and 'blown' by air pressure so that the surface the Pt lays on is 'fluidized'--like a water-bed.

Best story re Clinitrons. Long time ago ICU stretchers were simple thickly stuffed, rubberized mats. When the surgical resident put in a central line in your pt he would (with great flourish) plunge the stylus of the central line kit right into the mattress. (I know--covered with blood, stuck into a place that'll never be disinfected--what can I say.)

The first time I saw a Clinitron was in an open-ward type ICU--stretchers around the walls, nurses station in the middle, patients seperated by curtains. Surgical resident is putting in a SubClav; he gets the vein, pulls the stylus out and with the ususal proud wave sticks the stupid thing right into the Clinitron mattress!

A geyser of tiny tiny ceramic bead erupted out of the mattress into the air about 3ft high. Of course all over the SubClav site, into his intent, proud face, all over the floor.

And being little round beads, they're slippery as snot!! All of us were slidding and skating and hanging onto the furniture just trying to keep on our feet! Had to turn off the Clinitron, transfer the Pt to regular bed still slipping and sliding. Housekeeping was called and mopped the floor. Wouldn't ya know, those ceramic beads FLOAT? We ended up 'carpeting' the ICU with bath blankets that night.

PJ

That's another candidate isn't it? They're 'Clinitron' bed and they're filled with tiny tiny little ceramic beads which are warmed and 'blown' by air pressure so that the surface the Pt lays on is 'fluidized'--like a water-bed.

Best story re Clinitrons. Long time ago ICU stretchers were simple thickly stuffed, rubberized mats. When the surgical resident put in a central line in your pt he would (with great flourish) plunge the stylus of the central line kit right into the mattress. (I know--covered with blood, stuck into a place that'll never be disinfected--what can I say.)

The first time I saw a Clinitron was in an open-ward type ICU--stretchers around the walls, nurses station in the middle, patients seperated by curtains. Surgical resident is putting in a SubClav; he gets the vein, pulls the stylus out and with the ususal proud wave sticks the stupid thing right into the Clinitron mattress!

A geyser of tiny tiny ceramic bead erupted out of the mattress into the air about 3ft high. Of course all over the SubClav site, into his intent, proud face, all over the floor.

And being little round beads, they're slippery as snot!! All of us were slidding and skating and hanging onto the furniture just trying to keep on our feet! Had to turn off the Clinitron, transfer the Pt to regular bed still slipping and sliding. Housekeeping was called and mopped the floor. Wouldn't ya know, those ceramic beads FLOAT? We ended up 'carpeting' the ICU with bath blankets that night.

PJ

I love stories like that, thanks for the laugh. The clinitron beds are terrible for patient care, I also have difficulty using the hoyer weight lifts (our ICU doesn't have weight beds for all the patients?). What a pain to move all the lines and lift the patient without extubating them.

how do you put together, insert, and use a swan-ganz in cases of heart failure?

are u asking for a swan set up? it comes prepackaged with caps, u just need an introducer sheath which is in a different package...then set up a pressure bag with 300mmhg pressure with heparinized saline or reg saline. zero just like an alin then thread, taking the baseline hemo numbers as u go along, i'm not really sure what ur asking though...is that what it was?

i guess what I am asking is how do you determine heart failure with this type of catheter?

are u asking for a swan set up? it comes prepackaged with caps, u just need an introducer sheath which is in a different package...then set up a pressure bag with 300mmhg pressure with heparinized saline or reg saline. zero just like an alin then thread, taking the baseline hemo numbers as u go along, i'm not really sure what ur asking though...is that what it was?

Hi...So basically I guess ur still in school correct? There are alot of resources for Hemodynamic monitoring around in any critical care book and even on the internet. But just to answer your question simplistically, well the catheter is threaded thru the heart chamber and ending in the pulmonary artery. By passing each portion of the heart, u r able to gauge the amount of pressure generated at that part. Pressures in the right atrium, right ventricle, the pulmonary artery and the left side of the heart, including the resistance of the arterial walls outside the heart where it would have to work thru to pump the blood into the organs....by analyzing datas and incorporating it with patient's symptoms, one can deduce wether a patient is in heart failure as evidenced by a low cardiac output and high svr...there are other variables the swan can give you and will let you know if your patient is hemodynamically unstable, hypovolemic, in a sever shock state, or other disease states. It can also guide your treatment by optimizing your patient's cardiac output by performing starling 's curve with the aid of a swan by using multiple agents maybe it be volume or inotrope to guide ur treatment....there are entire books written just for this sole subject and it would be a disservice to anyone especially a student just to give a paragraph summary. I would advise taking out a critical care book.

No, i am not in school. However, I am always learning. I was hoping that you could be explicit or give an example of actual pressure readings. I understand the concept behind the technology. I have read on my own concerning the subject, however I figured a nurse would be better explaining it to another RN than trying to read through some cardiologists rambelings. I am seeking some insight.

Ok I guess a basic scenario, I assume you're familiar with the basic concepts including the normal values for each. Focusing on cardiogenic shock, basically it's increased preload with concomittant decrease in cardiac output and increase in afterload which leads to decreased tissue perfusion. Basic definition. Preload is adequate or high in cardiogenic shock though the problem is the heart's contractility forces is suboptimal may it be due to MI or other eitologies leading to a decrease in cardiac output or index. In turn, your body is trying to compensate in the decrease cardiac output by increasing the arterial tone to provide perfusion to the vital organs...Though it becomes a cycle, a bad cycle. Because when your SVR increases the heart is working harder to pump the preload out of your heart to your organs, in turn precipitating a cycle that would just not get better if you do not treat it. Taking into account the pt's symptoms, swan numbers can help you guide the treatment and wether it's working properly or not. To decrease preload and alleviate some symptoms of chf such as pulmonary edema, lasix or diuretics are given to decrease the pawp, which is the pressure generated by the preload in the left ventricle. In turn, starting ntg can vasodilate a patient which would lead to a decrease in svr making the heart pump blood out more with less resistance. Ntg you know also helps the heart become more efficient by increasing the blood flow to the myocardium thereby making the heart work a little less and more efficient. Now to maximize the potential of your tank, i.e. the heart, certain medications can be given such as inotropes like dobutamine to increase the cardiac output/index. With all of the pharmacological agents, you can combine these to optimize your patient's status. Doing hemodynamic numbers before starting to have a baseline and half hour later after starting the medications will help you gauge wether or not your interventions are helping as evidenced by an increased in the cardiac output and a decreased in the svr, leading to hopefully and increase in the blood pressure, a decrease in the heart rate, and increased urinary output. There are alot of before and after numbers on the internet that compares pt's hemodynamic values after institution of various medication and you'll be able to see side by side how it is able to help your patient, in turn you will see your patient hopefully get better clinically. If pharmacological means are not enough, there are certain avenues you can pursue, including the use of IABP. But that's another post. I think Swan has been one of the most important innovations in the modern medicine after the ventilator and mastering the values and how different medications affect makes you much equipped to take care of critically ill patients...now i know this is very simplistic and i have omitted many many many details in managing of heart failure with a swan, but i do hope it gives you a little bit of an idea.

Hey Erik

The ol' SwanGanz throws lots of people off because of all the numbers, waves and calculations. The trees get in the way so it's hard to see the forest.

The concept of heart failure is actually pretty simple: the heart fails to be an adequate pump. So stop imagining an ICU Pt with wires everywhere and lines and waves all up and down the monitor and a vent alarm likely going off and etc. Simplify!!! Make a cartoon in your head--imagine two little cartoon guys inside your Pts chest working away at two bicycle pumps, OK? Got that picture? One is a BIG guy working away at a BIG bicycle pump; the other is a little skinny guy with a little pump. They are working in tandem (we hope--lets assume NormalSinusRhythm) rising and falling in unison as they work.

You see where I'm going, right? This heavy oily fluid comes into their workshop in a pipe and gets to the little guy's little pump. He sends it out to a system that fills it with Oxygen and sucks out the CO2. It's a really really low pressure system--which is why we gave the little guy that part of the job.

From the little guy and the Oxygen tank, this heavy thick fluid cycles around to the big guy and his big pump. This guy pumps it around the rest of our factory where lots of work is done with the fluid.

We all watched these "scientific cartoons" in 3rd or 4th grade, yeah? Not a hard picture to get.

Now your the plant engineer, ok? And you get the report that there's trouble in the bicycle pump room. So you start looking at the pressure in the various parts of the system. But you don't have any guages along the pipeline or in the pumps!!! OhMyGod!!! You can't shut the factory down. Whatcha gonna do.

You take a LOOOOONG thin flexible tube and insert it into this system at some point before the fluid gets to the little guy's pump--and you put a pressure guage on the end of the LOOOOONG tube that you've got in your hand and IT TELLS YOU THE PRESSURE AT THE OTHER END. You can follow that, right? As you thread this tube along the system, you can see the pressure at each segment. OK?

That's really all there is to a Swan. Promise!! Now you know pretty much all you need to--everything else is details.

If the problem that the pumpers have is with the BIG GUY, the pressure will be WAY too high in the Oxygen tank. (This will result in PulmEdema.)

Let's say that's what you find--the big guy is sick and pressures are high in the O2 tank and our fluid is oozing out of the pipes and making a hell of mess all over the place. What you gonna do about that? Everybody is counting on you, OK?

First of all--you could give the big guy a burst of energy--make him pump harder. (You hang Dobutamine.)

Or you could vent off some of the pressure that he's working against--that would make his effort of pumping easier for him. (You hang NitroGlycerin.)

Or you could just take some of the fluid out of the system--which would reduce his work, too. (You give Lasix.)

You could turn the Oxygen tank up to higher levels so that even though LESS fluid in getting to the factory--it has higher O2 level and the factory goes on working. (You put a 50% VMask on your Pt.)

Eric--you're taking care of a Pt in CHF using your Swan!! Good work, my man.

Thinking Simply....

Papaw John

hey erik

the ol' swanganz throws lots of people off because of all the numbers, waves and calculations. the trees get in the way so it's hard to see the forest.

the concept of heart failure is actually pretty simple: the heart fails to be an adequate pump. so stop imagining an icu pt with wires everywhere and lines and waves all up and down the monitor and a vent alarm likely going off and etc. simplify!!! make a cartoon in your head--imagine two little cartoon guys inside your pts chest working away at two bicycle pumps, ok? got that picture? one is a big guy working away at a big bicycle pump; the other is a little skinny guy with a little pump. they are working in tandem (we hope--lets assume normalsinusrhythm) rising and falling in unison as they work.

you see where i'm going, right? this heavy oily fluid comes into their workshop in a pipe and gets to the little guy's little pump. he sends it out to a system that fills it with oxygen and sucks out the co2. it's a really really low pressure system--which is why we gave the little guy that part of the job.

from the little guy and the oxygen tank, this heavy thick fluid cycles around to the big guy and his big pump. this guy pumps it around the rest of our factory where lots of work is done with the fluid.

we all watched these "scientific cartoons" in 3rd or 4th grade, yeah? not a hard picture to get.

now your the plant engineer, ok? and you get the report that there's trouble in the bicycle pump room. so you start looking at the pressure in the various parts of the system. but you don't have any guages along the pipeline or in the pumps!!! ohmygod!!! you can't shut the factory down. whatcha gonna do.

you take a looooong thin flexible tube and insert it into this system at some point before the fluid gets to the little guy's pump--and you put a pressure guage on the end of the looooong tube that you've got in your hand and it tells you the pressure at the other end. you can follow that, right? as you thread this tube along the system, you can see the pressure at each segment. ok?

that's really all there is to a swan. promise!! now you know pretty much all you need to--everything else is details.

if the problem that the pumpers have is with the big guy, the pressure will be way too high in the oxygen tank. (this will result in pulmedema.)

let's say that's what you find--the big guy is sick and pressures are high in the o2 tank and our fluid is oozing out of the pipes and making a hell of mess all over the place. what you gonna do about that? everybody is counting on you, ok?

first of all--you could give the big guy a burst of energy--make him pump harder. (you hang dobutamine.)

or you could vent off some of the pressure that he's working against--that would make his effort of pumping easier for him. (you hang nitroglycerin.)

or you could just take some of the fluid out of the system--which would reduce his work, too. (you give lasix.)

you could turn the oxygen tank up to higher levels so that even though less fluid in getting to the factory--it has higher o2 level and the factory goes on working. (you put a 50% vmask on your pt.)

eric--you're taking care of a pt in chf using your swan!! good work, my man.

thinking simply....

papaw john

papaw,

i sure hope that you are a preceptor! i love your analogy! as a preceptor myself, i am always thinking up "scenarios" to explain things to my patients and orientees! this one is great, nice job! i am sure you are an excellent teacher!