telehead

"Vacation request- Denied. Next."

If you mess up administering an abx drip, it's not terrible... if you mess up a heparin drip, you very well may be looking at a large cobra waiting to bite... Edited to add that the CI is always present when a student administers meds in our unit... If there are too many students, they only allow "X" number to give meds so the CI can always be present..

Stick to your guns. I've been fighting this battle for the past year and a half. People complain when I'm charge because I spread patients throughout the four hallways we have but I don't care... I look at acuity... If they get angry enough (some of the nurses do, but then they are the same ones that complain about difficult assignments so they're going to be pissed either way) and complain enough to get me fired, so be it... I believe this is the proper way to do it...

I disagree with this line of thinking in general and specifically the part of your msg that I placed in bold... If nursing is expected to be a professional occupation, nurses need to be treated as professional and stop acting like we need babysitters. It's a culture that needs to be changed. The internet is an invaluable tool for finding information. With it, I can quickly look up interactive and dynamic information on the fly rather than stopping what I'm doing, going back to the conference room and searching through books to find an answer. There will always be people in all professions who abuse the availability of the internet while at work. The nurses who "spend all night on the internet" will merely find some other diversion to waste their time- magazines, sleeping or whatnot. Those people need to be weeded out for their lack of attention to their job, not for their use of the internet. Don't punish me by taking away a valuable resource because some lazy nurse who doesn't want to do his/her job can't be trusted.

We do insulin drips on our tele floor and I believe the plan is to move to the tight controls in the near future, but that's not why I called. We had a situation about a month or so ago. A particular nurse who is a real pain to everyone ("that's getting written up, this is getting written up, I'm not putting my pt on a bedpan, that's the aide's job- if they want me to do that, they can pay me nurse+aide pay", etc etc etc)... Well, she had a pt with glucs in the 400's so they started a drip.. 6 hours later she couldn't understand why her patient's gluc wasn't dropping despite the fact that she kept turning up the rate. Another nurse was curious as well so she went in and checked (then came to get me to verify the 'why' before going to the nurse).. and she found a puddle of insulin on the floor be the bed... The nurse never connected the drip to the patient... At which time she, of course, blamed the aide saying "she must have disconnected it or something because I know I connected it!!"... This nurse, by the way, has 17+ years experience...

It was actually the intern on call and she was going to sit with the patient while we increased the dopamine above the limit we're restricted to on our floor. Fortunately, a unit bed was made available shortly after we bumped the drip. Well, allegedly all other beds in the hospital were full and there were no nurses available. There are many factors at work here and I won't go too deeply into them because frankly, in the midst of a nursing shortage, I'm sure many others are dealing with it to. Long story short, our previous nurse manager insisted to the nursing supervisor that our floor was always open, regardless of staffing levels. So while other floors were capped by their managers due to staffing levels, admissions were directed to our floor, staffing level be damned. As such, float pool nurses (we're part of a health care system with 1 other inpatient hospital and 2 outpatient centers) started refusing assignment to our floor. Who wants to start a shift with 8 tele patients and then get an admission? The good news? We have a new nurse manager who is looking to deal with some of these problems. Anyway, on this night, the charge nurse already had 8 patients and the 2 other nurses had 9 each (and one of those nurses, I'm sorry to say, is incompetent). I'm not interpreting this as harsh whatsoever! I truly appreciate any and all thoughts on this situation, including criticism. Discussion from many points of view usually brings the optimal solution bubbling to the surface. So certainly, don't ever hesitate to bring agreement or a contrary point of view any time I post. I'm not easily offended.

My suggestion- take a deep breath, prioritize the priority tasks and ask for help... I've never seen every nurse on our floor busy with high priority tasks all at the same time. There is always someone who can help! Either the other nurse helps when you ask or they help in the code.

There have been a couple references to my gcs of 3. If I did it incorrectly, please, someone correct me! I'm used to heart problems, not head problems. Under "eye opening", the options were spontaneous (4), speech (3), pain (2), no response (1). I scored "1" because for the first few assessments, he would not open his eyes to anything. As a matter of fact, varying degrees of nail-bed pressure or sternal rub brought forth no reaction whatsoever. In the early morning, I entered a score of "3" when he would show even the slightest attempt to open his eyes on command. I likewise scored "1" to motor response because he did not follow any commands to move any part of his body nor did he move anything spontaneously. Again, during the early morning, he would attempt to open his eyes and he was moving his feet (even if in milimeters) so I entered a score of 6, attempting to note his highest level of function. As such, for a couple hours in the early morning, his score was actually 10. He had no verbal response at any time so that was always "1" 3+6+1=10 for a couple hrs (I believe I said, incorrectly, 8 in my initial post). Early in the shift and then again after about 4am, I had him back at 3. One thing I did notice but didn't know how to score/interpret- when the neurologist was evaluating the pt, he did have reflexes present. But he had no spontaneous movement. If I did any of this incorrectly, please inform me. Not that I expect to have many patients like this, but I want to handle it properly if I do. I also concur that he was comatose, per the GCS which considers anything below 8 as comatose. His respirations, however, were equal and normal in number and depth. He even snored a few times. Also, I agree that it sucks to have this patient + 7 others but I'm sure that's something many other nurses on here can relate to!

this would infuriate me. i can think of numerous times i've gone to our pyxis that has meds and had to override to obtain meds based on verbal stat orders. for example- i had to get dopamine the other night. i've had to get lasix for flash pulmonary edema, haldol to calm a pt who required 6 people to hold her down, iv lopressor... i couldn't imagine having to wait for a fax to pharmacy, then have the med sent/delivered before giving it. i'd like to think i didn't waste my time getting a bsn only to be treated like a child with excessive safety measures. as an educated adult, i'd like to be treated as one.

An abg done earlier that morning was wnl. He was in no respiratory distress, unlabored, regular rate, good depth. When I did my first assessment, I asked another nurse (who had 10+ yrs experience with brain injury patients before coming to our floor) to also perform an assessment after mine so I would feel more confident with my baseline assessment. I share your concern regarding no intubation tho. As I said, I thought he should be an ICU patient anyways (tough to have him along with my 7 other patients last night!). The neurologist consulted came to see him at approximately 2230 and evaluated him. He also agreed with my gcs=3 score. I'm sorry to say that I was unable to provide more effective advocation for him. I was swimming in uncharted waters. I spoke with the other nurse (neuro experienced) about him often throughout the night. Thank you for your thoughts!

Looking for general thoughts here. I had a patient last night on Q1 hour neuro checks (I'm a tele nurse! What the hell am I doing hourly neuro checks for?! ) and I know diddly about neuro. 82 y/o male had a ® ventricular-peritoneal shunt placed 2 days ago and was recovering on our med/surg floor. Initial neuro checks shows aaox3. Then he starts going downhill. Medically stable but his orientation left followed by decreasing LOC. Docs are thinking seizure and order an EEG and labs at 1320. Doc returns at 1600 to find the chart in the condition he left it and no orders taken off. Needless to say, he's livid and writes for immediate transfer to our tele floor (That's how he ended up with us). Unfortunately, it's now late afternoon on a Friday at this point and no EEG can be done (Don't ask- that will likely be changing now as well). Head CT showed no acute changes, guy had a stable subdural hematoma in the right frontal lobe. So- they order a gram of depakote and 1mg ativan and continuous pulse ox which the nurse before me did between 5p and 6p. 8p, 9p and 10p neuro checks show no changes- GCS score 3, pupils 3mm, equal and sluggish, O2 sat>98% on 2lpm, sinus rhythm, hr=70's with no pac's/pvc's, temp/resps stable, bp 90's-100's/50's-60's (hourly vs checks too). 11p-3a checks showed slightly improving LOC- Ativan wearing off? I upped his GCS to 8 (credit for trying to open eyes and follow commands). He fights me opening his eyelids for pupil checks, attempts to open his eyelids (unsuccessfully for the most part) on command, grossly moves his feet on command (a few mm, a lean) and can slightly grasp my hand with his right hand. 4am neuro check, he would still follow commands (I know, it's a loose interpretation) but he didn't fight me opening his eyelids. Aide said BP was down to 82/46 and I confirmed roughly the same number. ALL other data was unchanged from 3am check. Called IOC and was ordered to give 250cc NSS over a half hour to boost pressure. (pt had NSS running at 65ml/hr before). Pressure rose to 92/50. Doc ordered another 250cc bolus. Pressure dropped to 72/40. Sats/resps/temp all stayed the same. On monitor, there was NO CHANGE! Rock steady sinus rhythm, hr= mid-upper 70's. So we started a dopamine drip and ordered a unit bed. Pressure rose a bit, up to 80/52. LOC decreased further- no longer moving feet, pupils more sluggish. Still waiting on a unit bed. Doc offers to stay with patient until bed becomes available so we can double the dopamine infusion rate (we're limited to the "renal" dose on our floor). 15 minutes later, ICU bed is open- BP is now 86/56. Throughout all of this, there was no change on the monitor or the other vs. So I'm not sure what I'm asking, if anyone has even read this far... Maybe I'm just ranting about a difficult situation but does anyone have any thoughts on what was going on? Seems to me there was a disconnect in the autonomic system but I'm not really sure what all was happening...

Based on the info provided, it seems to me you did everything right... possibly could have taken the cardizem up a little quicker or higher (our tele unit limit for cardizem is 20mg/hr) but that doesn't sound like it would have done much. Agree with Dinith regarding a beta blocker- sometimes 5mg iv lopressor q5 minutes x3 works well (and often doesn't even require the third dose). Since the doc ordered dig, I'm surprised he/she didn't order a follow-up dose of that as well... Amio would have been a good choice as well... How old was the pt? Underlying cardiac issues? Renal status? Pulmonary status? Current EKG/enzymes? You can usually fix BP issues with a fluid bolus (or 3 )...

Welome to the wonderful world of cardiac nursing, bbuff! CHF and MI's will be enough to keep you going without the mix of fresh hearts, caths, etc... Rhythms, rhythms and more rhythms would be my suggestion... they can tell you a lot about your patient's condition, whether it's a need for some oxygen, an electrolyte imbalance or if a more urgent intervention might be necessary... In the end, it's all nursing so I'm sure you'll be fine!

I work tele also and I generally run blood at 75 for 15 minutes then increase per the patient's status. For the CHFers, I calculate the rate based on a 4 hour infusion. No sense playing with fire. Lowest H&H I ever saw was actually the night before last- I had a 36 y/o female with an H&H of 3.4/16.5 She drove herself into the hospital with a simple c/o "being tired all the time". Well NO KIDDING! On monitor, a simple sinus rhythm, 60's with pvc's that quieted as the 4 units of prbc's infused.

Andy, you are right. As I was typing the Beta 2 (bronchioles, breathe easier), I had one of those "wait a minute, that doesn't look right" moments but blew it off without thinking and kept typing. Thanks for catching that.

I haven't seen Afib with occasional PAC's because, as I work through this and try to understand it, the rhythm doesn't exist. I'm not trying to be confrontational. This is an open discussion seeking to answer the OP's question that has grown because of differing opinions. You stated previously that you love the how/why. I believe myself, Dinith88 and others have tried to describe, physiologically, the how/why afib with pac's is not possible, at least as I/we understand it right now. I've stated more than once that I'm open to where I might be wrong. Your responses have been, repeatedly, the same thing (ectopic beats without QRS complexes) backed with "that's what other nurses and cardiologists have told me". Additionally, within your explanation, you've stated things that simply aren't true (ie., a run of pac's indicate an attempt to convert to sinus). What many of us have tried to do, as you state, is also 'offer knowledge that we have learned' with explanation in an effort to further everyone's knowledge, mine/ours included. Actually, outside of the first responder, you are the only one. Everyone else has disagreed with your contention. As a fan of the old movie "12 Angry Men", I don't put any weight behind the number of people agreeing or disagreeing with me as evidence of the truth. But as others have added their responses, it does count towards building the knowledge base and contributing to the most likely answer. I suspect what you "saw" wasn't afib with pac's. Someone may have incorrectly interpreted it that way, but after hashing thru the physiology, it doesn't seem to hold much water. Nobody questions your credibility as a nurse. We're all (mostly?) nurses here. Some certainly have more knowledge than others in certain areas and some certainly have more experience than others. To be honest, you were the first to question the level of credibility, in an effort to "understand why this was such a hard topic for us (me?) to understand." The vast majority of this discussion took place before the question of age ever came up. This isn't nurses eating their young. It is an honest attempt at discussion. As I've stated, I'm comfortable with my understanding on this topic and the process of hashing it out enhanced it. The value of discussion. Don't ever stop asking questions and those people with the M.D. (or D.O.) after their names are right most of the time, but not every time. You may have the last word, if you choose.... unless it can lead to further discussion!

Agree with the others who state you should get an ABG. I've had pt's with sats in the low-mid 80's on the finger that registered a 96% on the ear! It would be a good idea to know exactly what the sat really is. The use of Coreg is said to be better for the CHF patient because it's not only a Beta-1 blocker but a beta-2 (bronchioles- breath easier) and alpha-1 (vascular arterioles- lower bp) blocker. From what I've read, it's preferred first line over digoxin with CHF patients... fib/flutter folks without the chf history still apparently respond to dig better.

You may choose to address these points or not address these points. No big deal. But to continue restating your points as if in a vacuum, condescension included, does not help you relate this concept to those of us who obviously "don't understand" as well as you. At this point, I feel comfortable stating plainly that you are wrong on this concept. Since the first post, I've considered it often, considered your post, considered other posts and have come to the conclusion that your point that you can have pac's with/in/around/below/above or in a parallel dimension to afib is incorrect. The simple appearance of a "p wave" (a faux p-wave because it only represents the last depolarization ((and very limited depolarization path)) of many that the AV node let thru) within irregular afib is not evidence of a premature atrial contraction. There are plenty of "p-waves" (the squiggly line between qrs complexes) that appear on a strip. They represent various attempts of the atria to depolarize in a singular fashion.. unfortunately, because the cardiac tissue is so irritable, it can't. Point A fires and can depolarize tissue over to point B but because point C also fired, the tissue around it hasn't repolarized yet meaning point A's wave can't travel any further... But D and E also fire at the same time, limiting how far the depolarization wave can travel for each of them as well. Those times that point A can depolarize all the way to point J before hitting presently depolarized tissue is when you get something that approaches physically looking like a p-wave in the midst of the squiggle. A PAC (premature atrial contraction) is a depolarization initiated by a point other than the SA node. However, for this to be called a PAC and not MAT (multifocal atrial tachycardia) or WAP (wandering atrial pacemaker), it must occur as a single occurrence or multiple occurrences within the structure of a normal SA initiated rhythm. ie., SA...SA...SA..PAC...SA..PAC...SA...SA... Additionally, to address another inaccurate point you made- there are no increases in pac's (since there are no pac's in afib) prior to conversion to NSR. As a matter of fact, I have never seen a conversion from afib to NSR that did not happen without a pause. That's necessary because the atria need a period of time to repolarize entirely. As such, there is no 'walk before you crawl' or 'reverse process' as you've described in a couple posts. In light of my explanation and my comfort/confidence in my position, I'm still more than willing to consider POV's contrary to what I've said and willing to consider that I'm 100% wrong. Discussion promotes understanding. However, I won't continue to discuss this with someone who offers nothing but the same point over and over without any consideration of the contrarian points brought up and essentially says "I'm right because I'm right and you're just not getting it." I actually find that to be opposite the notion of facilitating learning that you expressed earlier...

I'm torn between responding or allowing this dead horse to lie... But discussion is fun. :) With all due respect, I believe you have either interpreted what your cardiologist said incorrectly or taken the question to him/her in a vague manner. It was your previous response that leads me to believe this: PAC's in Afib? Of course not. PAC's with Afib. Yes, as was stated earlier by myself and a few others, you can have Afib with runs of PAC's or just frequent PAC's. There's is a difference b/c in Afib=no p wave=obviously not an atrial contraction of any sort. PAC's with Afib=a p wave occured from somewhere= there's atrial electrical impulses from somewhere trying to be recognized once again. So yes the underlying rhythm may be Afib, but once you see a p wave present (and it's probably best to be in lead II for this particular rhythm interpretation) you no longer can call this Afib. It has to be Atrial Contraction and obviously premature since the underlying rhythm is still irregular. This is, I believe, tho I don't want to speak for Dinith88, the stretch Dinith88 was referring to earlier and where I believe your argument falls into vague/lack of comprehension mode (lack of comprehension by me may also be the answer). "It depends on what the definition of 'is' is." I contend your use of with and in is simply semantics which raise a straw man in the discussion. By stating a difference between with and in as you've done, you've actually created two different rhythms. Your statement that "in Afib=no p wave=obviously not an atrial contraction of any sort." is precisely what many of us have been saying all along and it is the answer to the question originally posed. The strawman appears when you tried to change that to with afib. You present a definition that places the presence of p-waves as part of afib when it's actually only possible once the rhythm changes from afib to anything else, as I believe you (inadvertantly?) state here: So yes the underlying rhythm may be Afib, but once you see a p wave present (and it's probably best to be in lead II for this particular rhythm interpretation) you no longer can call this Afib. It has to be Atrial Contraction and obviously premature since the underlying rhythm is still irregular. The bold section, I agree with but I am unable to reconcile your statements in the first part- "may be afib" with the second part- "no longer can call this afib". The last part, I don't agree with either. If the underlying rhythm is still irregular, but p-waves are still present, then you don't have afib, under/over/between or otherwise-lying. If it's irregular, then you have sinus arrhythmia or you have sinus with frequent pac's. It comes down to this- a p wave on a strip indicates depolarization of the atria. The "quivering" of the atria occurs because there are multiple points in the atria (irritability) firing randomly, thus preventing the atria from fully depolarizing (or repolarizing). The atria hang, electrically, in the threshold region. The AV node, with its much slower calcium channel conduction system, allows much fewer atrial impulses through than are created. This is why you see irregularity. The first impulse that gets through might come from point A but the second one may come from point B or point C. Now when you consider the irritable atria may have 100 (randomly chosen number) points of electrical impulse origin, you can see why the resulting rhythm is irregular. What you don't ever have during this time is a fully depolarized atria and thus no full atrial contraction, therefor, you don't ever have a mature or premature atrial contraction during afib. That's my story and I'm sticking to it.... unless someone can change my mind.

I still disagree with your explanation. First, the ectopic beats are not typically indications of the heart's attempt to convert- just the opposite. The ectopic beats are indicative of considerable irritation in the atrial cardiac tissue. In actuality, it's typically a pause (a single pause or multiple 1-2 second pauses) that is seen just prior to a conversion back to sinus, not a crawl/walk series of pac's. Sort of the body's own adenosine treatment, but on a much smaller scale. Secondly, the very nature of afib, the 'quivering' of the atria, is due exactly to the many ectopic impulse origination points that you describe. As such, these multi-focal ectopic beats define afib rather than account for pac's within an afib rhythm. Interesting topic of discussion.

True Afib will NEVER have a true, distinctive p wave b/c the atria is FIBRILLATING, not contracting. So in Atrial Fibrillation with frequent/occasional Premature Atrial Contractions, look for distinct p waves to tell which are true PAC's. I won't presume to speak for Tweety, but I think this is where the confusion comes from. My interpretation is as follows: As you state, with true afib, you have no distinctive p waves- the distinct electrical representation of a single focus discharge. But unless the hr is 60 or below and you're running on a junctional or ventricular pacer, the discharges in the atria are present- they just occur as multi-focal discharges. As such, this ectopy can occur anywhere (and everywhere ) in the atria. With no regularity, it can't truly be a pac. In my mind, the only way I could note pac's on strip containing afib is if the heart is extremely irritable and you have brief flops from fib to sinus and back again. In that case, I could see a regular pattern, if even only for 6-10 beats and witness a pac within that stretch. That's my thinking... where are my holes?

Hi all, This looked like a good thread for my first post. I'm in PA on a tele/med-surg overflow floor. Day shift: 4-6 pt (charge has no pt) with 2-4 aides. Evening shift 4-7 pt (charge can occasionally have pts) with 2-3 aides. Night shift (my shift) 7-9 pts (charge has 6-8 pts) with 2-3 aides. I usually volunteer for charge at night so I can have 8 pts instead of 9 plus that whopping extra dollar per hour for charge!! We usually have a monitor tech for each shift. However, that isn't always the case. 2 weeks ago, the nursing assignment was 8-8-9-9 with one aide for the whole floor and NO MONITOR TECH! The nurses rotated through the MT station, covering for each other on the floor. We have an IV therapy team (1 person for the whole hospital on nights), a respiratory therapy team (1 person for the whole hospital on nights, 3-4 days/evenings). There are mornings I go to give report and can barely remember any details about the pts I "cared for" overnight. Mix in the cardizem/amio/heparin/dopamine/insulin/nitro/protonix drips, the c.diff pts requiring the iso garb each visit to the room and it's frustrating. This isn't safe health care by any stretch of the imagination. I've only been nursing this for a year and a half and I can certainly understand burn-out!!! Oh well. Sorry for the rant on my first post.