brdavis17

Thank you both! One question...when it comes to patients who are on CIWA and sleeping, you think it is best not to wake them? Say I give Ativan for a score of 10, and the patient sleeps. My hospital's policy is to wake them and reassess CIWA after an hour of giving Ativan, but last night I had a patient who was so agitated/angry when I woke him that it may have been better for his recovery to let him sleep. However, I am thinking for safety purposes should we assess them? Or is it better for them to "sleep it off?"

Hi psych nurses, I work on a medical floor but I thought you might be the CIWA experts. I had a patient last night who was on CIWA. I think his last drink was around 2 days ago. He had received Ativan three times during the morning/evening shifts (we work 8s) for scores between 8-10. I scored him 7 on the CIWA scale twice but wasn't sure if I should have scored higher or not. The first time I wasn't sure how to assess his tremor because I could barely feel it when I had him stretch his arms out and then when his arms went down he had a slight tremor but it was intermittent, so I'd didn't score him a "4" on the tremor. He was pretty drowsy but woke up after I asked him questions. He had a mild headache and mild light sensitivity. Overall he looked comfortable and wasn't restless. The second assessment, he was really sleepy and I could barely wake up to answer my questions. The intermittent tremor continued and he denied a headache. His vitals were fine the whole time. So, can someone explain how to properly use the CIWA? And what do alcohol withdrawal tremors look like? Also, is giving po Ativan safe for alcohol withdrawal to a pt who is very drowsy but has stable vitals?

In a pt who does not have CHF, is it possible for lungs to slowly fill with fluid if they have IV fluids running and have bibasilar crackles? Or is pulmonary edema more sudden? With bibasilar crackles that don't clear with a cough, is it possible that walking around will help clear the lungs? I ask because I have had a few pts with new-onset crackles lately and am sometimes hesitant to call MD to slow/stop fluids because my charge nurse has told me that you need to consider what they have fluids for (like if it's for the kidneys and they need the fluids)...though with ABCs perhaps the lungs would come first. She also said that it's important to re-assess to see if crackles have increased or there are any VS changes. But what I learned in school is ANY change, report to MD? I know nursing isn't always that black and white, but maybe it is for now because I am a new nurse (5 mos. in). And then another time an RT told me that crackles are not to be worried about unless pt shows other signs like SOB, O2 sat decreases, respiratory distress. I have been stressed about this lately and just need some seasoned nurses' thoughts.

Thank you all! Extremely helpful!

Ok, so if a fib is rate-controlled with amiodarone or other meds, will the heart beat still be irregular on occasion? Or should it be normal sinus? Would it be normal to hear occasional PVCs? Also, if a patient has a pacemaker, is it normal for them to still have an occasionally irregular heartbeat, like PVCs or something? I ask because yesterday I was listening to a patient who had a pacemaker, also was on meds for a fib. I heard groups of 3 beats (and also heard those while I was taking her BP) and then that went away, and then I heard occasional dropped beats or an extra beat like maybe a PVC. I was wondering if this is cause for concern.

I have a few questions for cardiac nurses. Is it normal for a patient to still have an irregular rhythm with a pacemaker? Are pacemakers ever placed for a fib? Also, if a patient has a-fib, is the normal treatment warfarin to prevent a clot, but is there a long term solution to help control the heart rate?

Okay, so I had her as a pt again last night and the crackles were gone. She also was saline locked. So perhaps the crackles resolved since they stopped the fluids? Also, that first night that she had crackles, her O2 sat was fine, as were her other vitals and she wasn't on any oxygen. So you still would've texted the MD with those considerations? It makes sense, since it was a new finding, but it was literally the only thing abnormal so possibly the crackles were the atelectatic crackles that are not pathologic?

Hi, I am a new nurse. During last night's shift (I work nights), I auscultated fine inspiratory crackles in my pt's lungs in their bilateral lower lobes. My pt was there for something totally unrelated-colitis, and has no heart/lung history besides HTN. She was gettting fluids at 100 mL/hr. Her vitals were stable and she wasn't short of breath. My charge nurse also heard them (I asked her to verify) and then a few hours later I checked again and they were still there. I asked my charge nurse if this is something concerning, and she said since the patient's vitals were stable, she wasn't SOB, and as long as the crackles didn't "increase" over night, it's okay and I can pass it on in report and possibly the next nurse can tell the rounding MD who could possibly decrease fluids. Also the crackles didn't clear when I asked her to cough. So I am wondering, were the crackles concerning? They were a new finding but I'm not sure physiologically how that could have happened besides the pt maybe being fluid overloaded. I guess I'm just confused about why my charge nurse was not that concerned. Maybe I should've text paged the MD to possibly turn down the fluid rate? Can I just say that it is challenging as a new nurse that so many things are gray, and it's hard to transfer what I learned in school to real life. :)

JKL33, by the admitting service do you mean the admitting MD? It was night shift so does that make a difference?

Those sound like good options. Thanks for the help! As for learning dosages, did you learn that with time? I'm sure Lexi-Comp has something in there about dosing if I ever encountered a similar situation like this and didn't know the dosing options. Or calling pharmacy.

Yes that makes sense. I don't recall the dosing. I guess I was concerned about dropping him too low but 167/90 is still pretty high and the order did say to give hydralazine for SBP >160. So is this something I should just learn from or could I potentially get in trouble for not giving hydralazine with the 167 SBP? I'm wondering if I need to take further action.

Thanks, klone. Not sure about the Sunday but I think I can do this pattern for now. :)

Hi, new nurse here. I had a pt with a BP of 194/105 last night, and pt had just been admitted to the floor for back/hip pain. Pt was asymptomatic. He had prn hydralazine for SBP >160 and scheduled clonidine due then. I gave the clonidine, per another RN's suggestion because giving the hydralazine could tank his BP if I gave him clonidine soon after. The pt told me his BPs run ~170/90 usually, even though he takes Clonidine bid at home. He also said he hadn't taken his meds that day (I'm guessing because of the pain stuff, being in the ED, etc.). So we rechecked BP and it was something like 167/90. I didn't even think about the hydralazine; I just thought it was close to his baseline and didn't give him anything else. He had clonidine scheduled for this morning (about 6 hours after the 167/90 BP). So, any suggestions about doing something different than what I did? Also, does anyone know when a good time frame would've been to check the BP again after giving clonidine? Would it be an hour?

Hi, I am a new grad working 8 hour night shifts, 32 hours per week. I'm going to start on my own soon and have a 5-day stretch of 8s for my pattern. I was wondering if people who have worked 8-hr nights have been able to find a schedule pattern where you work 4 nights in a row and still are able to have a stretch off. I think five 8-hr nights will be brutal... Here's my pattern: 5 on, 2 off, 3 on, 4 off. That fifth night in a row is a Sunday night so it goes into that next week so I get 32 hours that week. Anyone have suggestions? Or anyone have other 8-hr NOC patterns that have worked for them?