ark-two

Hello, I recently took care of a pt w/ this diagnosis. She was 26 and her 4th pregnancy. She was healthy up until her 36th week. N/v set in, but her other children were sick, so she thought nothing of it. She did have the edema, but it was in all her pregnancies. She came to the hospital and the baby was found to be in severe distress. A crash c-section performed and the infant released meconium in the uterus. THe baby was sent to Children's Hospital on a vent and survived with seizures and is on Dilantin. The mother came to us in critical condition when she would not breathe on her own after the section. She woke up in the morning and extubated. Liver enzymes were sky high and bili was up, but no jaundice. Ct of abd showed nothing and kidney failure set in. Also, DIC set in and supportive therapy started. 2 weeks later she was allowed out of the unit and to the birthing center to stay with her newborn. She ended up having surgery for infection of the uterus. The uterus was necrotic and sepsis had set in. We could not save her. Help me understand what happened. Did I mention she was a co-worker. We had never seen this at our hospital. We had experts from University Hospital, and she was recovering from the Fatty Liver. Mortality rates from this syndrome is not that high 18%. I just found out I'm pregnant and am scared to death. I know this is very rare. Has anyone seen it and what was the treatment? I know it was the infection that was the killer. The MD's attempted to do a hysterectomy earlier, but she refused. Sorry so lengthy.

I've been put on a clinical practice council and a request is for us to change our pericardicentesis trays. A doc complained about the bulb drain. Our trays now have what looks like an oversized JP drain. Our old trays contained accordian-type drains with a stop-cock to pull off so much fluid as ordered. These new drains are constant and there is not a stop cock. The other complaint is that the drains do not hook up to the tubing right and there have been problems. Do any of your units use the accordian-style drains, and if so, what is the brand? I'm going to do some research and see what other hospitals use, but any input is greatly appreciated!! Thanks!

Hello, my fellow nurses have volunteered me to try to change some things in our crash cart. We have Rapid response team, which has been great, but we are finding some things missing for code blue situations. We are trying to get versed and Diprovan loaded in our Pyxis for intubation. I've read some info about Diprovan and have had our anesthesia use it if they need to intubate in emergency situations. What I like about it is that it does not raise ICP in patients. We would also like to have versed in our respiratory box, we're trying to figure out how to do this. As you know, a pyxis is not always available where you code someone. We do not have combitubes either. The doc must intubate with an ET tube, but there are some patients the doc cannot intubate and anesthesia must be called. I feel it would be more beneficial to the patient if we used a combitube for emergency situations until anesthesia arrived, a combitube would only be temporary so breaths could be administered. Also, we have had some anaphylatic reactions. Inhale epi would be great. Any suggestions? What do you stock your crash carts with other than the regular code meds and iv fluids? Thanks in advance- Jessica

The cardioversion helped for about a week and then he converted back to afib, but it was more rate controlled. Guess they are going to coagulate him. Don't know what happened, since he left and went to rehab. What ever happened with your patient?

Had a gut who's hr was around 150 on amio @ 33 ml/hr. Tried dig IV and cardioversion. He was also a-fib. Had COPD. Amio did not touch his hr except around noon he would slow to the 80's afib and slowly rebound to the 140-150 throughout the day. We cardioverted him. I was really surprised they did it. He was in afib for a couple days before the cardioversion. He went directly to SR hr 70's. We sent him out of the unit. From what the floor nurses said, he went back into afib, but was rate controlled.

I've been told to place a cut onion on a burn to reduce the sting and swelling. Can't get near an onion without crying so never tried it myself. An old nurse told me to take a string and cut it in half. Tie one half to the wart and bury the other half. It actually worked on an old ex of mine.

There is a silent pulse ox. We use them. I'm not sure of the brand, but they are out there.

I work on TCU and generally have me the RN and 2 LPN (1 TCU the other Float). Oh yeah & 23 patients on monitors. Fortunately, I trust my TCU LPN's. The hospital has been working so that there are 2 RN's and 1 LPN all TCU. Unfortunately, the new hires are not out of orientation and 1 nurse is off on short-term disability.

I'm hearing impaired and have a Cardionics and the Litmann 4000. The Litmann 4000 is actually a really good stethoscope with the bell, diaphram and an awesome extended option. I can record heart tones and it counts the heart rate so I can concentrate on the sound. Keep in mind the price. I have to have an amplified stethoscope due to my hearing. I'm supposed to wear bilat hearing aids, which is why I have the Cardionics. With the Cardionics and the Litmann I don't need to wear them. I would suggest you go to somewhere where they sell stethoscopes and try them. I love both my stethoscopes, but do not recommend them if you are not hearing impaired. I also like the Ultrascope. It has really good sound quality and is one of the regular stethoscopes I can hear heart tones with. The Cardiology Litmann is also an excellent stethoscope. I'm just unable to use them because there is no volume control. (I'm tone deaf). Keep in mind price and quality. Try your stethoscope out before buying it.

had a nurse who signed off an order for IV Flonase. I went up to him with the Flonase bottle and asked how to inject and if one puff or two was sufficient. He got really mad! The order was for IV Furosemide. BIG DIFFERENCE. OH YEAH, he was our charge nurse, Scary!

I got the Starling's law and now it makes more sense. It was a complicated case and it was hard to watch a patient you have taken care of several times before be made a DNR for a condition you have treated him for before. I've been watching several of our frequent flyers become worse within the past couple of months and some even die. I felt that he was not given an option of aggressive treatment, but then again, the aggressive treatment is probably only a short term treatment to a long term problem. I enjoy asking questions on this site, because the people a very knowledgeable and willing to teach. It is always sad to lose the patients you get to know so well. Our hospital is a community hospital. Another one of my patients who was also complicated. I admitted her with CHF/ + triponins/pneumonia. She was started on heparin in er. She started bleeding on Heparin-HIT! Heparin d/c'd and 1 unit blood transfused and had a reaction. I believed it was pulmonary edema-I was not the nurse performing the transfusion. BP 210/110 and she desated to the 70's. She was placed on bipap and I had her the next night. The nurse on the shift before me called cardiology due to HR of 150 with breathing TX. Cardizem bolus of 20 mg with gtt of 10. When I was getting ready to start the bolus I called Cardiology because her HR was 65. I was uncomfortable. He told me to give it and watch her and gave parameters.-we don't tritrate. I made the suggestion that she probably has an adverse reaction to the albuterol and needed xopenex instead. The nurse who had her the next night said cardiology switched her from duonebs to xopenex and dc'd the gtt. Oh-with her, her urine output decreased also and she was given a fliud bolus on the earlier shift. I was wondering if the opposite wasn't happening with her. We decreased her HR to the low 60's and she was not perfusing. Her bp went down at first with the gtt, but by the end of my shift sbp was 165. She is getting her cath today- her EF via echo was 60% and she also had high bun and cr. On 80mg of po lasix bid.

I have a lot of trouble with background noise. I've found the in-the-ear canal digital hearing aids work wonders. They are adjusted according to your hearing loss. Therefore, only the tones that are weak are amplified and not all sounds. I do find them uncomfortable, my ears sweat! Because I was born with this, I did learn to read lips. if someone stands behind me and talks to me, I can't hear them. I find auditoriums impossible due to the noise bouncing I guess. I just know I cannot hear. Our professional disability office in our county paid for my hearing aids with a contract that I will work in Kentucky for two years as a nurse. Talk to an audiologist, they are a wealth of info and because hearing is important to your job, there is probably help out there.

No Swan's was done. He was in his 80's and a frequent flyer with CHF. No sepsis was involved because Blood cultures were neg, stool cult were neg, and sputum culture was wnl, along with ua nml. I understand the reason's for dopamine, dobutamine, Levapheed, not sure what neo is. We don't deal with these drips on our floor. I have had other patients who had similiar CHF problems. Ex: we had a 37 yoa male with cardiomegaly, frequently in for CHF with low bp. Usually they were put on a Bumex drip to diurese(spelling not right?) with a comb of lasix with BP parameters. THe only people I usually see on Natracor anymore, are not doing well at all or it is first time CHF. I've dealt with several Lasix drips and like them because of the diuretic effects, just watch K and supplement as necessary. I kinda feel I am at a disadvantage because I do work night and do not get to talk to many MD's and we do not have intensivists or residents at our hospitals. We do have house md's, but they get upset if you wake them up and ask questions. That is why I've put this case scenario here. I really want to understand. What both of you are saying is opposite of what I've been taught. Cardizem would make bp lower, but as Timothy said, not necessarily. I do like the Lasix/albumin gtt. Never seen one of these, but I do know albumin helps increase bp, they use it in dialysis all the time. Thanks and appreciate the input and learning experience. I'll look up the drugs mentioned. About the albumin/lasix- how does that work, are they mixed together and given in gtt form?

The Cardionics is rather pricey, but you do get a 3 yr warrantee on it. It has the headphones. You can find it at http://www.cardionics.com . The littman I purchased on ebay. Look up electronic stethoscopes on ebay and there are several to choose from. The dealer I purchased the Littman from also sold the Cardionics. Remember you can deduct the purchase on your taxes.

Appreciate the input. I didn't get to look any farther as far as lab wise or so forth, he was sent home with hospice. Thanks!! Just tryin' to learn!

Cardizem gtt would be nice if his bp wasn't so low. A fluid bolus with a BNP That high, BUN and CR, possible Dehydration? A Demadex gtt would pull the fluid off better, or even a Lasix gtt with possible dopamine? I'd have to look at his EF. He may of had a low EF and that is why they are not aggressive. Curious to see if he is still on our floor. The thing that really bothered me was the low urine output and concentrtion of the urine. More signs of dehydration. This patient was admitted to a med-surg floor before coming to TELE, but I think he would be more appropriately placed in CCU. DNR does not mean do not treat, unless the patient and family does not want him to be treated.

Hello, I'm heariing impaired, born with otosclerosis. I struggled through my first semester of nursing school, unable to hear some bp and heart sounds and breath sounds. I went to my ENT and he recommended bilat electronic hearing aids with a specialized stethoscope and gave me the route in which to persue to get the $5,000 hearing aids and stethoscope paid for. I then excelled in assessments. I now have 2 stethoscopes, one Cardionics Specialty stethoscope with the headphones. The sound is so clear, I don't need to wear the uncomfortable hearing aids, and I have the Littman 4000. The sound is wonderful and you have both the functions of a bell and diaphram. Plus, with the Litmann other peoole don't accuse me of listening to an IPOD while I work and I'm taken more seriously. Anyone else hearing impaired? What stethoscope do you use? PS- Some of the nurses have taken the Cardionics and used it as a doppler and claimed that it worked!

I recently had a patient who was started on Natracor gtt. His BNP was 4894!!! Bp in the high 80's and HR up to 200 for and steady in the 120-140. Cardiology was called and before the bolus of natracor was given and changed our standard parameters of hold for BP less than to to hold for BP less than 80. I didn't think Natracor worked for a BP of less than 90. After starting him on Natracor his BP actually went up and he started having v-tach and the increased HR. So, I kept a real close eye on him. He was made a DNR and cardi believed he was dying and would not make in a week. We gave him IV Dig for his HR only brought him down to the 110's. I noticed his urine output was decreasing and becoming concentrated. Any ideas as to what was going on with this patient? K- 5.5 BUN 48 CR 2.3 H&H normal. CXR-pulmonary edema and pneumonia. Was there any better way to treat him. I do realize that the increased HR was compensation for the low BP. I wondered if the po Digoxin would be better. Thanks, Jessica PS- When I said his BP was higher, SBP was 96-92 for me

Knowledge is power to a point. From what I've learned, you are best just to show your preceptor you are willing to learn. Ask questions and perform skills. Let the nurse show you and teach you and take on any skills you have not performed or are not proficient at. Let your preceptor know you have never performed these skills and so forth. When I have a preceptor, I like for them to ask questions and be honest, it is a value. The students who are too confident or are too knowlegeable, tend to not be trusted as much at our hospital. It is best to ask and learn than do and fail. Your preceptorship is a learning experience, not a chance to attempt to impress another nurse. Your instructor and preceptor will talk more about your job performance and consistency as opposed to your cardiac knowledge base. The knowledge base comes with experience. Study over your assessment skills, look at your drugs before you give them and understand why you are giving them and if you should give them to your patient. Look at labs and learn.

Our Tele floor we pull the Cardizem gtt anytime the HR sustains 60 or less and BP of 90 or less. Usually what happens is that the MD gets a call because the nurse had to pull the cardizem and the HR goes up and then we have to call again to reorder the gtt. Usually, when this happens, we get an order to decrease gtt by 1/2 if hr lower than 60. Isn't this somewhat of a titration? Anyway, the other week we got a patient who needed IVIG!!! They trust that we are staffed well enough to monitor that/ (IVIG in our hospital requires q 10 min vitals for the whole gtt!!) We are understaffed, usually 1 RN and 2 LPN's for 23 patients.

Our TCU floor does not titrated cardizem gtts. What is involved with the titration of a drip. It would be nice if we could and cut down on patient expense. If the cardizem needs to be titrated, they are to be transferred to CCU or ICU. Thanks in advance.

I work nights, graduated in April am in charge every night. Our charge consists of ER room placement and rapid response and code blue calls. I'm always on code duty, so I've gotten a lot of experience. The reason I am in charge is because of RN shortage. AT least I have good LPN's most of the time. As for day shift charge, a lot of new grads are charging the floor right now. Our hired charge nurse is off on maternity leave.

I work nights on a busy TCU. There are 2 TCU in our hospital and we generally have 3 nurses on each floor for 23 patients. I am generally the only RN on my floor, therefore, not allowed to leave. Our restrooms are nearby so that is not a problem, but sometimes the floor is so hectic, you just need a mental break. Due to cut backs and loss of staff, my schedule has changed from 36 hrs to 40 hr week. On night you really need 2 days off in a row to truly get a day off. I am working every other day, so I am burnt out. Not taking breaks or getting some r&r leads to burn out and dissatisfaction at work. Now I am being reprimanded for clocking out no lunch. The supervisor was upset when I told her that sitting down to check MAR's and shoving chips in my mouth is not a lunch break! We are now hiring staff to cover nights better. Jacho is having our staff fill out job satisfaction surveys and talking to the staff when they are on the floor, including night shift.

A discharge order I'd like to write: Chest pain does not mean that we will push 10 mg of MS q 5 min because you request it. The ER doc cannot refill your prescription of Darvocet, but he can admit you with a no narcotics order. Small animals are pets and not sex toys. Dropping your father (who's had a major stroke and cannot speak) off to the ER does not mean we cannot track you down (the family drops him off and leaves him when they want to go out of town.) This is not Hotel 8 we cannot guarantee that we will keep your mom for 10 days so you and your girlfriend can go on vacation.

Our hospital employs the RRT. We include TCU Charge RN brings defib and reads strips. ICU or CCU push drugs and assist md, respiratory therepist bags and abg's, and a pharmacist makes sure drugs are appropriate, plus house MD runs code with team assist. Lab draws all necessary labs ordered at bedside. It's nice at times since room is not overcrowded. And all input is advised. The RRT also responds to all code blues. It is a good idea to routinely have mock RRT calls and code blue calls so teams skills stay honed. I wish our hospital would do this. I'm relatively new and not sure what my place is. I usually write and run and read strips. Our RRT treats all RR calls as code blues because it can turn quickly.