RN-LOGIC 3,915 Views
Joined: Jan 30, '08;
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The newer medtronic corevalves seem to me to be more prone to causing asystole. Probably because they extend into the ventricle more and can depress onto the purkinje system more. To the OP, watch for a newly emerging left bundle branch block, that is a strong indicator that the valve is impinging upon the conduction system and is at higher risk for asystole. Bundle change should always prompt you to get a 12-lead
Great reply post....I always remember Albumin at a heart shaped molecule(a protein). It's job is to help control osmotic BP....or the fluids that can slip in and out of the blood stream...have you ever had a older pt that has "weeping" skin? Their skin looks thin as tissue with lots of soft wrinkles and it actually weeps a clear fluid. This is from low albumin. They are "leaking". Albumin also acts as a "taxi" carrying other proteins in blood plasma that are important to a post surgical pt like ipid soluble hormones, bile salts, unconjugated bilirubin, free fatty acids (apoprotein), calcium, ions (transferrin), and some drugs like warfarin, phenobutazone, clofibrate & phenytoin. Hope this helps you to understand Albumin. Remember this always.....never be afraid to ask a question or clear any confusion you may have.....learning never stops no matter how experienced or old you are!
Fresh hearts of often extremely labile for the first few hours after arrival in the ICU and sometimes longer. Generally if their blood pressure is wildly flipping from high to low the patient probable needs fluids. PROBABLY. Especially in the very early post op period. Get Swan set up, shoot numbers,. That helps determine care. High SVRI indicates vasoconstriction- body trying to keep blood pressure up in a shock-like state. Give a little fluid helps. Our patients usually get about 2-3L of crystalloid -plasmalite mostly. Our docs are now tending to avoid the use of albumin as much as possible --they say it does not improve outcomes and can be correlated with AKI.
Keep in mind that the body is undergoing and intense inflammatory response right after surgery, expect capillary leak syndrome and fluid shifts.
Re: the OP- I have never seen an OR record where they said 'unobtainable EBL'. Usually they have a pretty good idea cause they do the cell saver thing and give it back.
Agree with my fellow nurses MAP <60 is decrease perfusion to all your major organs. Remember the correlation between your aline pressures to get your MAP. Diastolic <60 can cause your MAP to drop.
I remember when i was in my critical care course (no going to tell you how long ago ) i was taught MAP >65 is all organs perfused , MAP 60 is brain only & MAP < 60 nothing perfusing.
Hope this helps
We all have the same article as a class...they just divide the work as a group and tackle each question depending on how your group wants to do the work. This week, we are answering questions 1-5.
I am here to tell you that where ego isn't an issue, title isn't an issue. NPs have had independent practice here for a long time. Physicians are accustomed to it and supportive of it. They have to be reminded it isn't the case everywhere and express surprise and wonder how the world even turns in those states, lol. When it comes to addressing DNP prepared NPs as "Doctor," they are likewise confused, only because they don't know who is and who isn't going to be addressed that way. The inconsistency is as jarring and confusing to them as it is to nurses.
In my office,when I meet a patient for the first time, I say "Hi, my name is Blue Devil, I am a NP." If they ask my what they should call me, and they often do, I say they should call me "Blue." (I find that a little curious, because I doubt they ask my physician colleagues what to call them.) However, even after I tell them to call me Blue, many do not. My colleagues (including the physicians) and the staff, when speaking to patients, call me Dr Devil. When they are speaking to me directly they call me Blue, of course. About 1/2 my patients call me Dr Devil and the other half call me Blue. Blue was good enough for my parents, so I am pleased to have my patients call me Blue. I didn't earn a DNP so people would call me "Doctor."
I will admit that I did use the title in a very stupid and egotistical way one time, because I was irritated at someone. My partner and I had a conflict with the principle at one of our children's schools, won't bore you with the details (except to assure you were we right and she was wrong ). We walked into a conference room with the principal, her boss the superintendent, the classroom teacher (who was on our side!) and a member of the school board that I'd asked to attend. Anyway, introductions were being made all around, and while my partner and I both hold doctorate degrees, we don't go around socially calling ourselves Doctor, lol. I was still trying to be nice to the principal despite our conflicts and said "Good Morning MRS Smith." She said rather hostilely: "actually Mr Devil, it's Dr Smith." She was unnecessarily snotty about it, when #1 I did not know she had recently completed her Ed.D (I did not get invited to her graduation or the memo with the update on her educational status apparently) #2 My tone had been very cordial and pleasant. I was already angry, hence the meeting. That tone/comment irked me, so I responded with: "well in that case, as a matter of fact, I am Dr Devil, and my partner is Dr Tiger (Princeton PhD)." It was childish and petty, and I regretted it the second I said it, as we usuallly regret the things we say when we are angry and frustrated, lol. To my recollection, that is the only time I have ever instructed someone to call me doctor.
Dumb story. Point being, the title is also dumb and isn't really important. I earned the degree because I wanted to and I enjoyed my NP education immensely. I believe in the DNP. I do think it improves NP practice. I do think it is important for leaders in the NP field to possess DNPs, and encourage others to pursue it. I do think the DNP is the future of NP practice. I don't think being called "Doctor" is a good reason to pursue DNP education, or oppose DNP education/practice for that matter. If there are DNP prepared NPs that really want to use the title and really want to hear people call them "Doctor" all day, well I wonder what that is really all about, but OK. You earned it, it is your's to do with what you choose. However, for me, it is not necessary to hear people call me by a title. I like what I do, I feel as though I do it well, and that's what it's about.
I reserve the right to throw it around next time I lose my temper with snotty bureaucrats. I am not perfectly enlightened 24/7/365.
I think a lot of nurses are going into the NP field due to the poor working conditions at the hospital. I don't blame them, sometimes I wish I had done this years ago. Floor nursing is very difficult, stressful and dangerous! Let's not kid ourselves!
NP's still are caught in the assembly line pace at clinics, but at least they don't have to do any heavy lifting and have a better quality of life, more pay and more prestige. Granted you don't have to be a primary care NP, many just work as an assistant for doctor groups, cardiologists, surgeons, etc. Not a bad gig, if you can get it, in my opinion.
Floor nursing is very frustrating, you are forced to work in understaffed, at times unsafe conditions, have no real control over your work environment and I'm sorry I don't see magnet status and shared govt really do much to change things. The bottom line is always money, there's no money in the budget, blah, blah, blah! It's very common for nurses not to get a paid break for lunch to be forced to work thru lunch, etc, etc.
It seems it will take an act of congress to get the hospitals to provide safe lift equipment to provide a no-lift environment when the patients are becoming ever more obese 200-300 to even 500+ pounds!
Why is it the hospitals always have money to pay the top dogs $100,000's to over a million when they say their non-profit or throw $400,000 away to the Ritz for customer service but never have the money to pay for adequate staffing ratios, equipment, lift equipment, etc, etc!
Since we don't have real control over are work environment, are overworked, overstressed, and put in needless dangerous situations to save a buck; I would advise people to consider going back to school for NP or something like that! If you have the money and time and ability, it would be a risk worth taking.
Know that you may have to compete and actively market yourself, let doctors know your avail, or be willing to relocate if necessary but it is a better choice than staying in floor nursing wondering how you'll make it and hoping you don't end up crippled with a disabling back/neck injury or suffering in chronic pain!
If you have a choice, its just not worth it! Once you are injured you'll be set aside and they'll just put a new person in your place. So I think NP is a good choice rather than staying in dangerous, poor working conditions!
I passed the CSC today!!! So happy! Just thought I'd share with everyone
To AMAC8487: "everything is compatible in the world of anesthesia"...sorry, that's my little joke! But you will find that it seems true! Although it may vary at your facility, generally, all the pressors are compatible together and can all go with propofol. Dilators go together usually. Insulin, fentanyl, propofol ok. Amiodarone and bicarbonate compatible with very little so best to run separate! We have an idiot sheet for drips, but hearts are managed differently. Hearts have a bunch of lines and ports; trauma surgeries have a 1 port cordis...so yes I do understand. Hope this helps!
This is going to sound awful, but in my experience, these patients do quite well when they self- extubate.
It takes 7yrs to be an CRNA? Why not become a doctor with that much schooling?
There are much easier ways to make 150k a year. .
but the salary should be the last thing you consider.
Every case is different.
An anuric end stage renal patient doesn't get rid of any great amount of fluid (insensible losses aside), so anything you give them stays there; you may not necessarily want them to have that fluid.
Some neuro patients just run low no matter what you do; Florinef, fluids, whatever, they might just live with a MAP of 45. Seen it a billion times.
They tell you cerebral perfusion pressure should be 70-100 or so. If someone has an ICP of 10 and a MAP of 60, CPP is 50. Sounds like you should be doing something about it, but if they're not broken, don't fix 'em.
It takes some getting used, not treating a low MAP. In orientation you're taught to flip out over it. Look at the overall picture and then decide if you need to flip out. Are they making urine? Arousable and appropriate? Are they in a deep sleep? The list goes on.
My advice is to ALWAYS work ahead. By this, I mean plan for the worst. Working ER, I don't have a clue what's coming in the door. So, as soon as I know what type of pt I'm getting from triage, I start the protocol in my head. If I'm getting a chest pain pt, then I know EKG, monitor, morphine, IV access, labs. I'll already have the EKG machine ready before I bring the pt back to the room. Abdominal pain, I know pee in cup, NPO, IV, fluids, Zofran, labs, CT. I have my supplies ready before the pt gets back to the room.
You have to stay thinking ahead and prepared for the worst. You never know when a pt may code on you. Sometimes, they wait until they get to the floor to code.
If you work the floor, I would see my stable pt first just to get them out of the way. If you are getting a new admit or have a pt that is a little more difficult, you can spend more time in that room with that pt because you have already spent time with your other pts. If a pt has 2100 and 2200 meds, try to pass them all at 2130. Group all tasks together. If you know you got to draw AM abs and do an assessment at midnight, then do them both.
Also know when to call the doctor. This will come with time. Not every abnormal lab is an emergency and can wait until the AM when the primary team makes rounds. Of course if you have a BP 210/120 and there is no PRN hydralazine already ordered, then call the doctor. If there is a critical lab value, then call the doctor.
Develop your nursing judgment. This will also come with time. If you have a pt getting Lopressor at 2100 and the BP is 130/70 but HR is 50, then you may want to hold the Lopressor. Understand how your medications work. Yes, Lopressor is long acting, but it also works on the HR as well as the BP.
Know when to ask for help and when to delegate to the next shift. Nobody wants to leave things for the next shift, but nursing is a 24 hour job. It's ok to say "I just got this new admit up at 0500 and the doctor ordered blood cultures X 2, but I just didnt get around to drawing them, so can you do them for me?"
Know not to take everything personal. When I first graduated, I thought I will come out of nursing school saving the world. However, I had a reality check when I realized not every pt wants to be saved. Some pts crave on the attention they get from being in the hospital, thus, will become that difficult pt just for the attention. Alot of pts are noncompliant. You can tell a drug addict that next hit of crack will give them a massive MI, offer social work for community rehab sources, offer Financial Services so they can get their BP medications, provide a bus pass so they can get home, and you know what? That SAME pt is back the next week with an active MI related to crack use. I had to realize it's not personal and just let it go. I've done my job by keeping that pt alive on my shift and that's all I can do. You can lead a horse to water but you can't make them drink it.
And another thing, not all pts or even you co-workers are gonna be "nice" or caring for that matter. Get use to it.
Alot of this stuff will come with time.
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