Since choosing Pre-Nursing as my major I knew I wanted to be a critical care nurse. When I landed a position in the cardiac ICU I was ecstatic - this was my dream job. Still, the thought of handling emergencies was terrifying. One thing that helped me prepare was reading stories of how other nurses did it. Here's one of mine.
78year old M patient with a hx of COPD CAD CHF DM HTN HLD Afib admitted for shortness of breath and chest pain. Found to have 100% occlusion in a carotid artery. Complications arose during treatment and he ended up intubated & on a balloon pump. For my shift the patient is 2 days off balloon pump and 1 day extubated starting dialysis d/t fluid overload, non-responsive to diuretics, high BUN & creatinine. Lethargic but A&O, afebrile, V-paced, BP 130/78, pulses palpable, on room air, lungs diminished in bases, very low urine output, heparin gtt infusing.
All through my shift this patient slept or watched tv, c/o mild generalized pain but no chest pain or shortness of breath. Sleepy, but that is expected d/t dialysis and it being night time and all. Lack of urine production I also attributed to dialysis that evening, and that was his trend for the last several days.
I was helping another nurse bath a patient around 5AM. When I left to grab a gown I peaked into my two patients' rooms: one was sound asleep, all vitals WDL, but the 78yr old was desatting to 88%...87...86.
I woke him up. His eyes shot open in surprise. I asked how he was doing and he said he was just fine. He was still A&O, but pursed lip breathing and his belly was moving with every inhale. I placed a nasal cannula and cranked it to 6L. "Are you having any trouble breathing?"
He took a few more breaths before responding. "I think... I don't know. Maybe a little."
I raised the HOB to 90 degrees and called Respiratory and the on-call Resident. LS and were the same but I still suspected fluid overload since dialysis hadn't remove much. Respiratory and Resident agreed. Bipap was placed. Bumex was ordered. I pointed out the crappy renal function. The resident still wanted to try it. I suggested labs. ABGs and a lactate was ordered. The tech and I stuck the poor guy 8 times before I decided to go for a subclavian vein with success. His hands were growing cooler. A short while after sending labs I received a call for critical values: PH 7.1 & Lactate 17.
I told the Resident and then pinned down the patients arms as he was trying to rip off the bipap. I asked for the charge RN's help but she on the opposite side of the unit with another decompensating patient. Great.
The Resident called the attending. Before I knew it, the patient's BP was 68/30, and I was slamming in a liter of fluid, pushing 6amps of bicarb, starting a norepi & vasopressin gtt, infusion Zosyn, and preparing the patient for re-intubation and A-line placement. Cardiogenic shock vs mesenteric ischemia was in question.
It amazed me how quickly this guy turned. He is still sick but vitals are under control. I left that day feeling okay and thinking, "For a new grad nurse 9 months in, I didn't do too bad there."
The tech and I stuck the poor guy 8 times before I decided to go for a subclavian vein with success.
You went for subclavian vein for a central cath placement? I mean this is a blind approach and is done with with good deal of experience. Are you CRNI and PICC trained?
Great Job! As you progress longer in the ICU, you will encounter many more patients that will deteriorate right before your very eyes! Especially those with a myriad of co-morbidities such as the patient you treated.
You went for subclavian vein for a central cath placement? I mean this is a blind approach and is done with with good deal of experience. Are you CRNI and PICC trained?
Kudos for keeping a cool head!
He probably meant an external jugular. In my experience the 2 times I placed an emergent EJ in a crashing patient the E.D. doctor gave the go ahead signal pending arrival of a central line kit.
RUmedic
89 Posts
You went for subclavian vein for a central cath placement? I mean this is a blind approach and is done with with good deal of experience. Are you CRNI and PICC trained?
Kudos for keeping a cool head!