ICU acuity

arkgolfer · Jan 2, 2003

Absatively posolutely! I first wanted to become a CRNA in 1988, during paramedic school. I graduated with an ADN in 1994, and will graduate in May with my BSN, all along with the intention of becoming a CRNA. Between '94 and present, kids, demotions into mgmt, etc... has come between, but the goal is getting clearly in focus now.

smiling_ru · Jan 2, 2003

Thought this one was appropriate

And, here's the real way we do things:

RULES FOR MANAGING PATIENTS IN THE I.C.U.

Immediately intubate the patient and attach to the new General Motors Super Servo 300 ZX Ventilator. Powered by a Pratt & Whitney Turbo-jet Engine. This ventilator forgoes the usual IMV and A/C modes and uses the new BGDI mode (Breathe, God Darn It). The ventilator has been known to ventilate concrete. Adjust the ventilator so that the pH = 7.40, PaCO2 = 40, and PaO2 = 100. Any deviation from these numbers is not permitted. An oximeter may be used to monitor the patient, but we found that hooking the arterial line directly to the blood gas machine is more accurate and convenient.

Insert arterial lines (see above). If MAP is less than 60 mm Hg, infuse Dopamine, Levophed, Phenylephrine, FFP, Hetastarch, Dextran, and Lactated Ringers. There is no need to waste time thinking about what form shock is present, this solution will cure all of them. They have been conveniently pre-mixed in a gallon jug for ready infusion.

Insert rectal tube. This keeps the sheets clean, the room smelling fresh, the laundry happy, and makes rectal exam possible. If foul odors continue to abound, pour Peppermint Oil on every wound and orifice.

Insert NG tube. Infuse continuous Maalox through this tube. The resultant diarrhea maintains good flow through the rectal tube and prevents clogging.

Insert Dobhoff tube through other nostril. Infuse Supercal, a new feeding solution containing ground tree bark and walnut shells (look how long Ewell Gibbins lived) and creamed spinach (the Popeye effect).

Insert CVP and Oximetric Swan-Ganz Catheters. Keep CVP at 10 and PCWP at 20 with appropriate solutions. Fresh bottles of "CVP Raising Solution" and "Wedge Raising Solution" USP are now available so that it is no longer necessary to wrack one's brains figuring out, e.g., if the patient has heart failure and whether to give salt. If these pressures rise above the stated levels, fluid is sucked out of the stated line with a 50 cc syringe until the

pressure normalizes. Although keeping the CVP at 10 and the Wedge at 20 simultaneously is difficult, remember, that this is your most important job in the ICU. All else pales in comparison.

Insert transverse pacemaker. Set pacer at 70. If heart rate exceeds this, administer 2 mg Digoxin, 5 mg Inderal, and 20 mg Verapamil (now in a pre-mixed form called Lowerate® - MSD).

Insert Foley Catheter. Keep urine output at 40 2cc/hr. If less than 40 cc, use a pre-mixed solution of Mannitol 25 gm, Lasix 120 mg, Edecrine 100mg, Bumex 20 mg, and Zaroxolyn 10 mg as a bolus (a hearing aid is provided by the manufacturer for use with this solution). Remember that patients may get slightly hypokalemic with this solution and its use should be followed by hourly infusions of KCl. If this fails, hook the Foley up to wall suction. In

the unlikely event that none of this works, CAVH, PD, and hemodialysis are only a phone call away. For urine output greater than 40 cc/hr., tighten the adjustable clamp on the Foley to reduce the flow rate.

Administer Gentamicin, Solu-Medrol, INH, Heparin, Maalox, and several 3rd generation Cephalasporins to everyone whether they need it or not. Cultures are not needed. These drugs kill all organisms. If white stuff forms in the mouth, add Amphoteracin B.

Place the patient on the new Cliniscus bed. This bed is a totally automatic, motorized bed that prevents bed sores by blowing steel pellets around the patient. It also changes its own linens, weighs the patient, deodorizes itself, and transports the patient to X-Ray on its own.

Consult Renal, Cardiology, ID, Pulmonary, and Hematology the moment the patient arrives in ICU. Let them consider differential diagnosis. This gives you extra time to monitor the CVP and Swan-Ganz lines. There is no need for them or you to consider treatment, since this protocol will cover the patient for all possible diseases.

KEEP AWAY FROM THE PATIENT!!!! Do not perform a physical examination. You will only get tangled up in the lines and tubes or trip on a wire. Also, the nurses will be busy putting on eye patches, TED hose, and "bunny" boots. They will be putting on mittens on the hands and tying them down. They will have the patient on his side with an ottoman stuffed between him and side rail to hold him up. You will only be in the way.

Always keep in mind that your patient may be dead. This is easily overlooked. The ventilator makes it look like he is breathing, the pacemaker keeps his heart beating, and an arterial pressure reading of zero may merely be a clogged line. Peripheral pulses are inaccessible due to bandages, lines and hematomas.

loisane · Jan 3, 2003

smiling_ru,

As soon as I can quit laughing long enough to get the slightest bit of breath back in my body, I am going to print and distribute this (with your OK, of course).

This has got to be THE most hysterical thing I have ever read. It has been many years since I was in the ICU, but this most definitely brought it all back in vivid detail.

Thanks so much for sharing

loisane crna

smiling_ru · Jan 3, 2003

Go right ahead, it was sent to me today, have no idea where it originated, but it's a good one.

g8rlimey · Jan 3, 2003

That ICU excerpt is hilarious!!! It will be a source of smiles for along time to come in my circle of nurse-friends....thx for sharing

CoreyB · Jan 3, 2003

Another thing to consider, is that unlike your peers in other majors, you will have no trouble finding a job even with the economy in the shape it is. Most BA/BS grads can't say that.

Also if your main goal is to avoid wiping ass, you may want to consider the OR. I have a friend in my class (sr yr BSN) who did the summer III program at the mayo clinic and now has a preceptorship in the OR. He rarely is confronted by code browns, but he won't have the kind of autonomy you'd find in the ICU.

I can't say I'm thrilled with the amount of wiping I'm doing in the ICU, but I figure it's just part of paying dues. Being a CRNA seems like an incredible opportunity, and in the end I think it will be worth it.

megmermaid · Jan 3, 2003

smiling_ru, that was GREAT! I can't wait to print a copy to hang at work- I love it!

To the original thread, I truly feel I make a positive difference in the world with what I do- even if just for a short while. I comfort people when they are (probably) in the biggest crisis of their lives. That statement applies to patients and their families. Yes, I have techs in my unit but usually want to be in there inspecting skin, watching lines, and monitoring patients (I've had more than one almost code during turning). It can defenitely get exhausting though...

Yesterday I had three patients to start with (which sucks anyway), transferred one, gave one away, then had to admit a fresh kidney transplant. Our KT's are usually 1 on 1 for at least 6 hours or longer, and mine wasn't peeing yet. Sometimes I almost wish my charge nurses didn't have so much faith in me.

Goofball · Feb 10, 2005

Not to be gross or anything, but for all you who have worked in ICU, do you see as much poop as you do when doing med/surg?
God, I hope not. I will start an ICU clinical this March and I really would like to think it will make me exercise my mind and allow me to learn techniques which require some skill. I am a bit worried that I have just earned a bachelors in order to scoop poop.
zzzzgirl

I think you will see more poop, because ICU pts are usually too sick and out of it to ask for a bedpan.They just let loose. And if they don't let loose for a few days, you have to induce a code brown with bowel care. Sometimes you will think that a whole team of Clydesdale horses was up on the bed letting loose. But who cares? It is such a trivial thing in the larger scheme. You just learn to breathe through your mouth, eyes, ears, etc. and think more about all the lives you help save, and fabulous, fascinating learning opportunities and experience you will gain in the ICU. It's all good, even when it's bad, and if you hate it, you don't have to stay forever. But if you don't try it, you will always wonder what you missed.

convuluterrn · Feb 11, 2005

Can you say......................fecal pouch. :rotfl:

PJMommy · Feb 11, 2005

Love the rules of the ICU thread. Thanks!

Here's another thought...how about PACU. Couple of friends of mine went there as their stepping stone to CRNA school. They tell me that they don't deal with the code browns, the family drama, etc. etc. Lots of autonomy and only the occasional temper tantrum by the surgical-resident-on-his-high-horse. They also have fairly decent hours...not a lot of the overnight stuff unless ICU is overflowing and they have to keep a couple in Recovery overnight.

sway · Feb 11, 2005

I'd have to say that I see WAY less poop in the icu, than I did in the step down unit I started on after graduation. The surgical patients we get usually don't start poopin' for a day or two, since they were NPO before the surgery...so they're usually outta here by the time they start to go. It seems to come in spurts (he he), with no poop for a couple weeks, then you get a GI bleed. Usually if people are eating (and pooping), they move 'em out to our PCU. In my old job I cleaned orifice probably 1-2 times per shift average, and here I average probably once every 3 shifts. I go whole weeks without touching poop, and no, we don't have anyone who will clean it up for us.

*PICURN* · Feb 11, 2005

hmmmm.....you know PICU there is at least SMALLER poop (most of the time)

...and I don't think cleaning up baby/kid poop is as gross as some 200 lb adult!