Artemis2

Thank You registeredin06! That is exactly the kind of information I am looking for!

Our saline is actually in a big bin in the supply room. Yes they have stickers so they are "charged". The problem is with reimbursement. Since they are considered a "medication" or pharmacy item they are not reimbursed by insurance without a doctor's order. This is the sticky part we are trying to fix. Although it seems logical to us bedside nurses to create the order under a set of ICU admission orders it was the request by our director to show evidence based practice saying that running a carrier for piggybacks was "good practice" that tripped us up. Is anyone aware of any evidence that a carrier line is better than having individual tubing for each antibiotic or piggy back? It seems like a no-brainer to those of us at the bedside but you know how directors can be....

What we mean is thae bags of saline you use for pressure bags, carrier lines and other misc. uses. Currently we don't have orders or policy to cover the use of this saline although everyone knows that you need a pressure bag for a central line CVP or an art line. Without an order the saline isn't entered into the computer and therefore there is not way to charge for it. We are looking into ways to change this. Do you at your institution have an Critical Care order set that includes standing orders for Saline for pressure bags? Saline for carriers? Speaking of Saline for carriers... Our usual practice is to run a carrier line with a secondary set used to deliver the multiple antibiotics typical for an ICU patient not to mention K+ & Mg runs and to provide a "push" line. Currently there is no order for this saline so it is not accounted for. In a discussion with one of our directors she wanted proof of "evidenced based practice" that shows a carrier is good practice. Our contention is that it is better to have one line connected to patient that is only broken when hanging a piggyback rather than hanging each piggyback on a seperate line and repeatedly exposing the hub of a central line by frequent connecting and disconnecting of antibiotic lines. Does anyone know of anything written about the use of carriers in the ICU? What is the practice where you are? How do you charge for the miscellaneous bags of saline? Are they included in a standard ICU admission order set? Thanks in advance for the feedback Chris and Linda on the nightshift

I have never had a formal report worksheet... the back of a progress note page works fine for me. I am in love with my colored pens, though. I can't start report without a highlighter, a red pen and a black pen. I recently bought a green pen but have yet to figure out how to work it into report. When I do though... watch out! I also love printouts from a computer with patient info and current orders. That is where my colored pens really shine! I highlight meds, circle allergies in red and some things like stat labs get both the highlighter and the red pen! Maybe I'll use the red for report and the green for the stuff that happens on my shift. Hmmmmmm...........

Thanks everyone. I am writing a proposal as we speak advocating a lower nurse-patient ratio than has been previously discussd, more equipment and all private rooms. You all are giving me plenty to go on. I'll be working on this for the next few days so anyone else that wants to add their description of what their unit is like please jump in.

Now that made me giggle! i know exactly what you mean!

Flex your visiting hours and allow extra visitation while keeping control of the situation for the good of everyone in the ICU. Wife or parents or children at the bedside as much as they want as long as it is not a crowd. Stress to the family that for the wellbeing of the other patients in the ICU visiting will have some limitations (no more than 2 other than the wife, etc) but that you will do everything you can to accomodate them. Most people are agreeable, understand your position and are willing to work with you as long as you are willing to work with them. Balance order with compassion and most of all communicate. A lot of customer service issues can be dealt with by compassionate, empathetic and clear communication.

Lets see... the one about my first day as an RN and the OD who threw his charcoal up all over me? No I can do better than that. Um the first case of HIV we saw when we didn't even know what it was and the projectile diarrhea was hitting the wall? Nope not that one. The maggots? Nope someone already told a maggot story. The piece of lint in your nice, clean, just bathed patient's hair that stands up and waves at you. Shudder, thats a good one but I think I can do better. Ok, here goes... There is a little known and rarely used treatment for a severe ileus that involves neostigmine injected sq into the abdominal wall. It is a little risky so you pull the crash cart up to the door (not a huge deal in the ICU). I hadn't done this before so my co-workers gave me the run down and explained that the results would be dramatic. So this patient is so distended she looks like she is going to blow. I gather plenty of towels and washcloths and give my injection. Very quickly the results begin...large amounts of liquid stool. Unfortunately I didn't fully understand the meaning of the warning that the results would be "dramatic". The next thing I knew there was a river of stool filling the bed! I'm throwing all of my towels at it, spare sheets whatever I can find but to no avail. Now it is running off both sides of the bed and onto the floor! By the time it finally quit the floor was covered with layers of blankets soaked in stool and the bed was... well I'll leave that up to your imagination. Fortunately in 25 years of nursing that is the only time I have had to do that!

Ditto what llg & mulan said. This cannot be tolerated. When these things happen I hope your first action (after stabalizing the patient of course) is to call your shift supervisor. It will help as you take further action to know that they are involved. As far as what the L&D nurses will think of you for writing her up...don't worry about that. I will bet that she has a pattern of sloppy care and that they will be happy that something happened to cause her to be formally written up.

Ok, here is my theory on gossip... Remember Maslow's hierarchy of needs? I believe that gossip feeds that need that everyone has "to belong". If you are standing around in a group talking about someone else then you get this warm fuzzy feeling of belonging... even if it is just an illusion and even if it is just for the moment. I think that is why gossip is so seductive and addictive. I think that is why people will turn on friends for the sake of joining in the gossip. Once people let go of this need to feel like they "belong" to this particular group or that they no longer feel the need to gossip. Otherwise it is very difficult to stop and you will find it everywhere because it feeds a basic, instinctive need.

You know, they are both such potent pressors I'm not sure it makes a difference which one goes first. I will be interested to see what everyone else says. Personally I think I would wean the vaso first just because I have worked with levo longer and am more comfortable and familiar with it.

Bwaaaaaaa haaaaaaaa haaaaaa haaaaaaa haaaaaa! :lol2::lol2:

I would have to agree that the cvp was a bit of an illusion. Your reasioning sounds spot on to me. Did you happen to know what his cvp was at the time of the BP drop? Making a decision like that based on a single cvp reading is a little too simplistic. For instance... I am wondering why this patient was on a lasix drip. Has he been volume overloaded and has some renal insufficiency? If so they may want to use the drugs to control his BP rather than fluids. Why is he on levo anyway? With only 50 cc/h UOP and BP instability my instinct would be to give fluids but the reference to the Lasix drip makes me hesitate. Did his lungs sound wet or was he dry? So many questions and Critical care is often like putting together a living breathing jigsaw puzzle. Oh yeah, how were his pulses? People hold their pulses better on Levo if there is a little fluid in the tank. Remember you can also use colloid to expand volume and wean your pressors. Hespan is 5oocc's but is hard on the kidneys. Albumin is often a good choice and is small in volume. There is also plasmanate and plasma protein fraction. If he has had volume overload problems and renal insufficiency then he may have plenty of fluid in his tissues that needs to be shifted into his intravascular space. Colloids are the intervention of choice here. Or is it possible that they have dried him out too much with the lasix drip as evidenced by the drop in BP and a UOP of only 50 cc's/hr. In that scenario the cvp is certainly an illusion and this patient needs fluid. This is where daily weights and serial daily fluid balance calculations come in along with your physical assessment skills. Determining volume status in a critical patient is rarely as simple as taking a cvp reading. When discussing the patient with a doctor (especially a resident) it is a good idea to have a handle on all of these issues. P.S. I don't expect an answer to my questions. They are simply food for thought.

In the old days (25 years ago) we only had IMV ventilation with PEEP. There was no pressure support, SIMV or any of the other modern vent settings. There was very little we could change on a vent when a person was not doing well. After you had maxed out TV, FiO2 & rate all you could do was go up on the PEEP. 25 is about the highest I have seen but in those days it was much more common and yes, we caused quite a few pneumos. Ventilators are so much more sophisticated these days that rarely do you have to go that high but every once in a while....

In the old days (25 years ago) we only had IMV ventilation with PEEP. There was no pressure support, SIMV or any of the other modern vent settings. There was very little we could change on a vent when a person was not doing well. After you had maxed out TV, FiO2 & rate all you could do was go up on the PEEP. 25 is about the highest I have seen but in those days it was much more common and yes, we caused quite a few pneumos. Ventilators are so much more sophisticated these days that rarely do you have to go that high but every once in a while....

Thanks Cat, this is exactly the kind of information I am looking for. Anyone else want to chime in?

Years ago I was working in a post-op open heart unit on night shift. The patients were in these 5 bed "pods" with curtains between the beds. It was one of those nights when a little old man decides that I am trying to kill him, won't take his meds, swinging and shouting at me. After I explain to him that I couldn't possibly be trying to kill him because if I were he would already be dead he startes shouting, "Fire! Fire!" When that didn't get him what he wanted he started shouting, "Patients! Unite! Don't let them kill you! Unite!" I called the doc and held the phone up to the patient's bedside... Haldol PRN patient rioting...

I posted this in the General nursing discussion forum yesterday but I wanted to make sure I tapped the wisdom of this group so I am posting it here too. Thanks for taking a look.... I have been hired to help with transitioning a med-surg unit into an Intermediate Care Unit and I could use the help of the nursing community. This is not a cardiac strpdown (we have one of those) but a stepdown from the general ICU's. Our floor already has a pulmonary focus so I am anticipating a lot of trachs, CPAP/BIPAP and the occasional vent. I'm curious, though,.... How many beds do you have? What is your nurse-patient ratio? Does it change on the night shift? Do you use nurses aids or techs? How many per shift? What does your patient population look like? What kind of diagnoses? Private or semi private? Bedside monitor or tele? Thanks for your insight. I need to educate and prepare my staff for what is to come as well as educate and prepare administration about how to do it right...if you know what I mean.

Thanks everyone for your reply's. I need to gather as much info as I can so that when I present my "Vision for Intermediate Care" to the hospital leadership it will carry some weight. Here is another question... Many hospital units increase the nurse-patient ratio during the night shift. Should the ratio stay the same in an Intermediate unit given the higher acuity of the patient demographic no matter whether it is day or night?

I have been hired to help with transitioning a med-surg unit into an Intermediate Care Unit and I could use the help of the nursing community. This is not a cardiac strpdown (we have one of those) but a stepdown from the general ICU's. Our floor already has a pulmonary focus so I am anticipating a lot of trachs, CPAP/BIPAP and the occasional vent. I'm curious, though,.... How many beds do you have? What is your nurse-patient ratio? Do you use nurses aids or techs? How many per shift? What does your patient population look like? What kind of diagnoses? Thanks for your insight. I need to educate and prepare my staff for what is to come as well as educate and prepare administration about how to do it right...if you know what I mean.

What does the unit's visitation policy say? I am a firm believer that a visitation policy must be adhered to even if you don't agree with it. You may not realize the problems it can cause if one nurse lets the spouse stay over night and the other nurses adhere to a policy that doesn't allow it. Remember that families do talk to each other in the waiting room and compare notes. Be aware of the problems it causes your co-workers if you allow the spouse to stay one night and the nurse the next night kicks them out. If you are breaking policy and the charge nurse is trying to enforce it then her position trumps yours. If you don't agree with the policy then try to change things at the policy level. As I said in my post to the other thread, I believe that whatever the policy is all staff must adhere to it to prevent problems. Remember that while you are thinking about what is best for you and your patient, your charge nurse has to do what she thinks is best for the unit.

Not all ICU's are the same. Some smaller-hospital ICU's have patients that would be on the floor or step-down in a "big city" hospital. Some have curtains between the beds or rooms with glass fronts and others have very private rooms. Some rooms have enough space for a family reunion and in others your have to be a contortionist to squeeze between the vent and the wall to get at your half dozen pumps. That said, I am in favor of more strict visiting hours. That may be because I usually work at "big city" hospitals where the patients are really, really, sick as are all the patients around them. That may also be because as a night nurse I really appreciate the time to bathe the patient, clean the room, straighten and untangle my lines and label my tubes in peace! Once upon a time I worked at a Catholic hospital with nice, big, private rooms in the ICU. The nuns in their compassion decided to change the visitation in the ICU and have "open" visiting hours. We argued with them and won the right to ask all visitors to leave from 0600 to 0800 and 1800 to 2000 obviously for shift change. I have never had more fights with visitors as I had in that unit. With the open visiting hours there was absolutely no respect by the visitors for the needs of the nurses. Every day there was a fight to clear the unit of visitors for shift change. I believe that grown up people, just like my children, do better when there is a clear and consistent structure. If you are too lenient you leave too much room for argument. Whatever the visiting hours are, I think that they should not be completely "open" but structured in a way that is appropriate for the setting. I believe that in only rare cases should a family member be allowed to spend the night...for their good as well as the patient's. And, I firmly believe that for any visitation policy to work it must be adhered to by all the staff with only very rare exceptions for compassionate circumstances. That's my

My favorite precordial thump: The scene is a large, round, inner city, 10 bed ICU with curtains between the beds. The alarm goes off, heads snap up and turn. One nurse heads across the unit at at run , slides to the bedside, fist in the air and THUMP! It was pure poety in motion. I was a very green nurse and very impressed.

24 years ago when I was finishing up nursing school I looked at what was happening on the floors and RAN to the nearest ICU. Fortunately I found one that was willing to take me as a new grad. In those days the ratio on the floor was more like 15:1! The last time I was pulled to the floor (it has only happened a few times and I go unwillingly) I nearly broke down in tears and I was only passing meds! I don't see how med surg nurses do it! I have had many nights in the ICU when I haven't stopped to even pee much less eat but on those nights I often feel the most satisfied...like I've given good patient care and had a challenge that was acutally fun. I will take the 2 sickest patients in any ICU with multiple drips and lines over any med surg assignment any day! I liked the comment another poster made about the ICU being "controlled chaos". Well, some days it is not so controlled but no matter how hard it gets I (usually ) only have 2 patients. I get to provide a deep and through level of patient care (usually ). I am also someone that likes puzzles and gadgets so the ICU suits me. When they want to float me to the floor I tell them that it is a big mistake... that I am incompent on the floor and it is true! My hat is off to floor nurses! They are my heros!

Nursenary, you don't recognize me here but I taught you the same thing once upon a time and a few other tricks as well. I didn't realize that levo had any beta effects. I thought it was pure alpha. Even us old dogs can still learn a thing or two. It is no wonder that you found that info since I have never known anyone to carry as many textbooks as you in their backpack to work. I have never known someone who enjoyed studying critical care as much as you and as hungry for the nuances of the subject as you are. Did you get my email?