elfself25

My schooling used the concepts of nursing assessment, nursing diagnosis, then plan to intervene and evaluate the response to the intervention. I liked the way this made me think about the patients in holistic terms regarding what was going on with them medically/surgically/psychologically, their mind/body/emotional/spiritual response to all of that and how we as nurses could optimize that. I have greatly appreciated this difference in nursing compared to doctoring. The North American Nursing Diagnosis Association (NANDA) created the first list of nursing diagnosis in 1973. I encourage you to look at the NANDA website and perhaps you could encourage your school to teach from this motif. I did not become a nurse to be a doctor. I like how I see the big picture. Not all of my interventions involve the doctor and these interventions can make huge differences to the patient. Yes, we must have deep understandings of pathology and physiology so that when we assess the patient we can understand how that particular patient is experiencing that now. For example, I take care of same day surgery patients both pre and postoperatively. If I have some one who can't maintain their oxygenation saturations, what to do and why. If this patient is minimally responsive, maybe I need to bag that patient and have another nurse call for anesthetic or opiate reversal. Maybe I just need to rouse the patient and have them work out on the incentive spirometer awhile. Maybe this patient is very wheezy and needs a nebulized bronchodilator treatment. My this patient is fearful and painful and are splinting and breath holding. Maybe this patient needs more pain medicine to breathe adequately and coaching and education to help decrease the fear. Maybe my patient was fluid overloaded in the O.R. and the chart review corroborates that e crackles I am hearing in the lungs are because this patient has fluid volume excess and needs lasix. My assessments and nursing diagnoses prepare me to intervene and evaluate my interventions by critically thinking about the whole patient and their circumstances.

I have certainly been in that foley bind. The solution sounds doable and less traumatic than fishing around for Waldo. Anyway, it your description is brilliant and ever so funny.

I like Bernie Segel's (an M.D. who wrote book Love and Medicine) answer to this: Take an old car that is running poorly just as your body is now. Is the car's engine going to blow up today or much later. No one knows. We can spout statistics in situations like this, but who's to say what patient will be what statistic--then one who dies and the one who lives. If the prognosis is grim, I let the patient know. I also let the patient know that we will continue to support your body until you or your DPOA or legal next of kin, when you cannot speak for yourself, asks us to stop. After the emergency is handled , you can discuss living will, DPOA, thoughts and feelings on death and dying as you are able and you may get social work involvement and/or chaplan services. I also let the patient know if I think they are going to eventually walk out of there. i had a multi-trauma patient who had coded on the nursing floor the day prior. A parade of consultants came in and spoke about the systems that they were consulting on. When they left, I had an intuition that the patient needed to hear the big picture. I said, "All of us think you are going to walk out of here." The patient burst into tears and told me that he thought he was dying. He was 24 years old and had a son.

Here's how I think of withdrawal. 5 on the Glascow Coma Scale. If the persone is intubated and you suction, that person will grab the ETT and yank it out (o attempt to do so); the person may do what I call a head to hand maneuver because of restraints--sit up to get ETT close to the hand to yank it out; the patient may also try to push you away. The hallmark is that this movement has a purpose--remove noxious stimuli. 4 on the Glascow Coma Scale: Patient will start to raise arm to ETT but not complete the movement--as though too sleepy to do it. The hallmark of 4 is that it is semi-purposeful movement--either attempting to remove or get away from noxious stimuli--but it is typically elicited slower and the movement is not as vigorous as 5. 3 is flexion withdrawal: now the patient is posturing (decorticate)--to noxious stimuli--elbows flex, wrists flex, legs extend, feet plantar flex (look extended) and turn inward. This means that the corticospinal tract is interrupted at the level of the red nucleus. This movement is a reflex, it is not purposeful. Triple Flex Reflex is s spinal cord reflex. Patients may exhibit this reflex when brain dead. Flexion withdrawal, the red nucleus is responsible for the upper arm movements and the leg movements are a due to activity in the lateral corticospinal tract of the spinal cord. The motor assessment number of the Glascow Coma Scale is inversely related to prognosis with 3,2, and 1 having a grim prognosis. Triple Flex Reflex can occur with stimuli like air moving across the patient--the hips, knees flex and feet dorsiflex. Hope this helps. There are some good youTube videos on neuro stuff. There is a cranial nerve music video that is very helpful to remember cranial nerves.

Hi, Know your Glascow Coma Scale. I recommend reading about the scale. Memorize checking cranial nerves. When patients are intubated and unable to follow commands, the cranial nerves exams are corneal reflex (cranial nerve V), cough (cranial nerve X), and gag (cranial nerve IX and cranial nerve X). Use cotton wisp on cornea to check for corneal reflex. Know how to examine for doll's eyes aka vestibular-oculo relex (if no c spine injury turn head rapidly to one side, if this reflex is intact, eye will move to opposite side; if not, eyes remain midline. The MD can check for doll's eyes by instilling cold water in one ear at a time; if reflex intact, nystagmus is noted. Pupil checks are very important as one large pupil can indicate uncal herniation. Read up on ICP monitoring and ventriculostomy. With a ventriculostomy, the system is leveled to the external auditory meatus,i.e. ear canal. The MD chooses a level at which CSF wil drain if pressure is higher than the pressure of that level. There is 25 cc/hour of CSF made in the brain. You have to be careful when raising or lowering the head of the patient so you don't dump fluid. The skull encases the brain, the blood vessels in the brain and the CSF which is made mostly in the lateral ventricles, and the ventricles. Treatments to relieve high ICP (greater than 20 mm hg): remove part of the skull--craniotomy--allows brain to swell without getting squashed in the skull; allows for an evacuation of blood from epidural or subdural hematomas; CSF drainage via ventrix or lumbar drain; mannitol--uses osmosis to pull edema from the brain or 3% saline IV to shrink brain swelling. You need to use a filter on the IV with mannitol. Dexamethasone is used more often with tumors to reduce swelling--large amounts of it will cause leulocytosis. CO2 is a potent vasodilator. Its recommended to keep etCO2 at 35--lower can reduce cerebral perfusion and should be avoided--but can be a very temprary bridge if the patient is herniating--bag the patient to reduce etCO2 to reduce ICP. Treatment for subarachnoid hemorrhage is called triple h therapy (hypertension,hypervolemia and hemodilution). This prevents the vasospasm that occurs from irritation caused by blood. Vasospasm causes ischemia. The patient is also given nimodipine to reduce vasospasm. The patient will have routine bedside duplex studies to watch for vasospasm. The patient may be taken to the cath lab where the spasming vessel is dilated. Cushings triad is a harbinger to herniation: hypertension, widening pulse pressure, bradycardia, irregular breathing; also one or both pupils will become fixed and dilated (blown) and patient will lose cough, corneal and gag reflexes. Use strict asceptic technique with ICP, ventrix or lumbar drains. Fever and hyperglycemia worsen brain injury so goal is normothermia and blood sugar maintained within parameters set by the MD via an insulin drip. Fluid goals with multi trauma and head injury is to do the trauma fluid resuscitation as it is important to maintain optimal cerebral blood perfusion of 70 mm hg and perfuse major organs.. Cerebral Blood Perfusion is MAP mean arterial blood pressure) - ICP. Brain damage will occur with MAP 50 or lower, so ideal is between 60 and 70--if higher than 70 multitrauma patient is at high risk of ARDS. Lactate levels and/or base deficit/excess guide fluid resuscitation. Also early surgical intervention to stop hemorrhage is necessary. Cystalloids are used first, then blood products as necessary. Normal saline is started first when there is brain injury at saline content is higher with NS compared to LR. There are some great youTube viseos on neuro assessment. Sedation used in the ICU is often Precedex or propofol. Phenelephrine can be used to raise blood pressure with sedation induced hypotension. Dealing with family can be hard. I like open visiting during daytime hours. Family can be helpful too. Patients end up on tube feeding. Probiotics and fiber are helpful to prevent diarrhea. Also one of the things I always thought was difficult with neuro assessment is the fact that patients wax and wane, so you can expect a neuro exam to be worse when the patient is fatigued or during normal sleep time for that person. I sometimes had a hard time knowing if this change was a problem or a wax and wane issue. You already know a lot as a CVICU nurse, so this will just be a wonderful learning experience.

I agree with wonderpoints. Additionally I would like to discern the differences between 3,4, and 5 on motor assessment of Glascow Coma Scale. 5 is purposeful movement, i.e., patient grabs ETT or pushes you away. 4 is semi-purposeful movement. It is though the patient is too sleepy to complete the action, i.e., hand gets part way to ETT, then pt falls back to sleep. 3 is abnormal flexion; used to be called decorticate posturing. Hands go to the chest with centrally provided noxious stimuli like a trapezius squeeze; hips, knees and feet may all flex (triple flex). The Glascow Coma Scale defines coma as a score of 8 or less. Intubation is required with a score of 8 or less as patient has lost ability to protect airway from aspiration. The motor part of the Glascow Coma Scale is considered a most excellent prognostic indicator. I think describing the patient's behavior is more important than the distinctions between lethargy, obtunded, and stuporous as I have witnessed multiple misinterpretations of these terms. There is an interesting component of arousal when the patient's reticular activating system is working but the patient is unable to interact in any meaningful way with the environment--"The lights are on, but nobody is home."--often seen in patients with persistent vegetative states.

When I graduated, I stayed at home with my first baby for a year. When I went to get work (I thought I wanted med surg), I was told to go to a nursing home for a year. I did my time and I was able to enjoy the elderly people. It was most satisfying when I had time to hear people's stories. I really did not learn much that was transferable to hospital nursing. When I worked med surg, I really learned a lot about assessments, acting on the assessments when necessary, and priority setting. I also learned that doing a complete assessment, doing what I could before placing a call to an M.D. and also having lab values etc. on hand was essential before placing a call to an M.D., esp. at night.

This sounds like something to bring up at a staff meeting. I have always liked as much hands on with my patients as possible and consider that the CNA is there to help me. 2 is always better for a clean up, plus I could inspect skin, note the stool and see if the patient had some GI issue etc. I don't know anyone who enjoys cleaning up an incontinence, but I consider that it is my job and part of why I get paid. When I am too busy to help, I let the patient know that I need to get help for them as I am involved with something else. I hope to never trigger humiliation for anyone. I am what you call a seasoned nurse close to retirement baby boomer). Do you think this is a generational thing or is it floor nursing? I have worked mostly ICU and ER. ICU nurses clean up a lot of incontinence, esp. because of tube feeding etc. I rarely had to clean people up in the ER, but we always teamed up and did it right away as we always were interested in preventing skin breakdown. It would be interesting to do some kind of quality assurance on this to discover what the hindrances are, and to provoke improvement.

Ask to speak with the charge nurse. When I worked in the ICU, I did not mind having visitors. Some hospitals have a 2 person limit. The hospitals I worked at were pretty liberal during the day time (Seattle, WA). ICU nursing is intense and stressful. I liked to set limits with the family so we could function well together. When I had patient status updates, I would ask all the family members to come in the room. I would tell everyone there what was going on,what to expect, and possible outcomes. I could answer questions. This minimized questions I would get when I was delivering care to typically 2 very ill people. I never minded answering questions, but I asked people to wait till I completed my tasks because my major focus was on saving the life in front of me or providing comfort when life saving was beyond hope. I went to Miami when my sister was having a brain tumor removed. the visitation was 2 people for 15 minutes out of every 2 hours. Individual nurses would let one person stay longer as long as you stayed quiet as a mouse. I was appalled. I hope the charge nurse can help you and if not, some hospitals have advocates you can talk to. Also, you could talk to the nurse manager. Best wishes.

Hi, I can relate to the experience of not fitting in as my family moved annually when I was a child. I have some suggestions: Focus more on yourself and your patients. When you overhear something negative, ask yourself--is this really true about me? If so, is it something you'd like to change or is it your basic personality? If it is your basic personality, consider personalities that you don't care for. This reminds me that I don't like everyone either. Getting your certification in emergency nursing will help build your confidence. You mentioned that you have experienced not fitting in well before. This makes me wonder if you grew up in an alcoholic home. Having grown up in an alcoholic home myself, I have discovered that when I am feeling stressed, I feel as though I don't fit in and this experience can occur when I am surrounded by people I know love me. Al-anon is an organization that helps people who have been effected by the family disease of alcoholism. Al-anon helped me more with this and other issues of co-dependency more than anything else I have done to help myself feel better about myself. Try to base your self worth on your own measures of yourself. Everyone but me in my nuclear family--husband and children are introverts. I enjoy their quiet calmness. I enjoy their thoughtful responses. Trying to change yourself to please others is a losing battle--one that I have lost in the past. I also recommend avoiding joining in with gossip yourself. I was an emergency nurse for 14 years and loved it. I wish you well.