mattcastens

I used to have that problem until I said, "you're an intellegent nurse -- read it yourself." I also broke the habit by simply not using the flowsheet to give report -- I do it all off the top of my head. If I'm not reading, they're not reading. Of course, it takes some practice, but working flight and EMS got my brain working.

Usually the neighborhood of 30mcg is the upper limit. If you get that high, watch for tissue necrosis in the extremeites -- you can be they aren't being perfused!

At our hospital there is no mandatory on call for us (unless a nurse works in OR, the cath lab, or other possible emergent areas). If the census drops we are asked if we would like to take call -- if everyone says no, then so be it. If we are on call we get paid minimum wage. Our hospital also gives pagers to all of the critical care nurses if they want one (cost to nurse is something like $2 per pay period). That way, not only can you be contacted if you're on call, but staffing also pages out all available shifts for the taking. If you want to pick up, you know what's available and can call in.

Here's another example: I was watching "Scrubs" last night and noticed that the Pyxis machines in the background had a huge "Pyxis" emblazoned on them. Honestly, who's this going to influence? It's not like I'm going to go out and buy my own medication system, and we all know that administrators are going to buy the lowest costing system rather than one they see in a product placement, right? I just don't get it.

Would it be used in conjunction with milrinone -- also used as an outpatient treatment for CHF?

I've only sort of heard about it. It's sort of a combination between MAST trousers and a balloon pump. The idea is that this inflatable suit (well... from the abdomen down, anyway) inflates rapidly during diastole to assist with coronary blood flow and then deflates just before systole to decrease afterload -- the same theory behind an IABP. As I understand it, it is only used on an outpatient basis. This is only what I've heard. I don't have any experience with it personally, nor have I done any research. Would it be used in conjunction with meds? What is this a treatment for?

Occasionally I have run across old ladies that say they use Tylenol to help them sleep (not Tylenol P.M., mind you -- the regular stuff). I would always blow it off, thinking that it was all in their heads. Now on some of our standing orders, the docs have Tylenol ordered at h.s. PRN for sleep! Since I have never taken anything to help me sleep (I do just fine on my own), I just gotta ask -- does it work? Has anyone out there actually used regular Tylenol as a sleeping pill?

Um, I don't know about you, but I find it very easy to not shine the laser in people's eyes. Or we can all wear sunglasses and be "Joe (or Jolene) Cool Nurse".

I'm currently doing the research on whats available. What I've been using in the meantime -- and might recommend to the unit -- is a $13 laser pointer from Target that I can easily place on the transducer manifold and shoot at the the patient. It takes about three seconds to set up, works perfectly, and fits in my pocket when I'm not using it.

Don't worry! You will get the hang of it. People learn at different rates, but eventually you'll be able to read a monitor or an ECG as easily as you're reading this. Start learning now! Get some books and start studying. While the books will only give you the "perfect" versions of the rhythms, at least you'll have a grasp of what to be looking for. Good luck!

Anybody out there use laser levels to level your PA catheters? If so, what company do you go through? I'm looking to contact some product reps, but haven't had any luck on the internet. Thanks!

Some of it is from experience, some of it is from studying, a lot of it is from asking questions. We are all continually learning.

Mario -- A couple of possibilities: 1. Transient heart murmer. Sometimes people get what are called "high output" murmurs. That is, when the heart starts pumping more blood than it is used to, the increase in volume creates a slight regurgitation through the valves causing the sound. (Pregancy frequently causes this with the extra circulating volume -- are you pregnant??) After waking, your heart is still in a relatively low cardiac output state which increases as you start moving around. Once the heart "awakens" to the new day, it normalizes with the increased cardiac output and the murmur disappears. 2. Transient gallop. Along the lines of the transient murmur, it is possible to have a transient extra heart sound (s3 or s4). Again, once the heart readjusts to the higher cardiac output state, it can disappear. 3. Pericardial rub. Probably not, unless you have had a recent infection, renal failure, or lung cancer. (Stop smoking, Mario!) 4. The stethescope. Occasionally, a cold stethescope diaphragm squeaks. (Sleep with it under your pillow.) 5. Since the squeaking clears when you yawn, it might be a little wheezing in your lungs that you hear when you breathe. The yawning wakes up your lungs and clears the squeaking. All in all, I think the chances are good that you're not going to die. Today, anyway.

I'd have to agree here, but i think it depends on your hospital culture. Where I work, no one is offended by an incident report, and much improvement has come of them from faster lab and pharmacy times to better staffing on the night shift. There is one nurse in particular who seems to be incident report happy, but we all (NM included) have learned to take them with a grain of salt.

You know, I attended a critical care symposium last week and listened to Tom Ahrens, CNS, PhD speak. (If you ever get the chance to attend one of his talks -- especially if you work in critical care -- I extremely highly recommend it!) He brought up the fact that perhaps instead of making everyone a full code unless otherwise ordered, everyone should be made DNR/DNI unless otherwise ordered. His point was that in terms of statistics, only about 15% of coded patients (hospitalized patients) are ever discharged home and only about 5% suffer moderate to little to no neurological damage. If more than one system is compromised, the percentage approaches zero. Seeing as how much pain and suffering this can cause to both patient and family, and considering that a leading cause of bankruptsy in the US is health care costs, we really should be educating patients and families better. Naturally, the patient or spokesperson would get the final say.

Sounds like you guys are setting up your unit for a huge med error sometime. We get all of our critical drips pre-mixed from pharmacy, and they're very good about getting them to us. In the rare instances when we need to mix our own (usally Nipride), we have a standardized hospital drip formulary that all of the critical care units follow so that all drips are mixed exactly the same.

First of all, don't confuse cellular phones with cordless phones. One of the hospitals I used to work in had all the nurses use cordless phones that looked an awful lot like cell phones, but they were tied into the hospital phone system. We would carry them to make it easier to make physician calls, etc. I have seen cell phones play havoc with telemetry equipment. There was also a warning about a year or so ago from the Baxter corporation that they discovered when cell phones were used near one of their IV infusion pumps that the machine would go from its programmed rate to a rate of 999 cc/hr until the phone was turned off.

I don't think it's "ACLS guidelines", but rather a change in teaching practice. ACLS is ACLS is ACLS, but the fact is (as indicated above) that nurses usually don't intubate. In a code situation there is usually an MD present or if not then a CRNA or even an RT who has more experience intubating than a nurse. It's not that the AHA doesn't think that nurses shouldn't intubate. Instead, I think the thought process is that since nurses generally don't, why not focus on what they in fact do -- push meds, defibrillate, make suggestions to the new residents, etc.

I agree about the food. Unfortunately, it comes with the territory of having to make so much in bulk. It's true, though, that improvements could be made. I am a firm believer in healthy food. Not a veggetarian, but close, and I try to eat organic, whole foods whenever possible. I have my fiancee and family sworn to bringing be home made (healthy!) food if I ever end up in the hospital.

I just wonder about the product placement I see in medical movies and on shows like ER. Not about things like soda or cars, but about things like stethescopes. I realize that 3M (makers of the Littman) and Hewlitt-Packard (Sprague) donate their products to these shows to add "realism", but my question is why? Do they think that I, as a nurse, or a physician will buy their product because I've seen it on TV? Has anyone purchased a stethescope because they've seen it on TV? I realize that I might be rambling, but it's late, and a slow night.

How many residents does it take to screw in a lightbulb? Just one, but an ICU nurse has to tell him how to do it. (Particularly appropriate after the night I've had...)

Good question! Since the population I work with is almost purely cardiac (both medical and surgical), this is what I've found: I love phenylephrine (Neo-Synephrine)! We have found this is the perfect drug post-surgery for patients with low SVR. Usually they don't need to be on it for too long because as their vasculature tightens up over the post-op period, we can wean it off very easily (short half-life). We use it mostly on the younger men who seem to dilate out after bypass. Now, of course, not every patient has a PA catheter, but a handy way to tell the SVR is low without a cardiac output is to look at the diastolic pressure relative to baseline. It's not what I would call a balls-on method of determination, but it helps in a pinch. I'm not such a big fan of epinephrine unless my patient needs purely inotropic support -- and even then I'd rather go with dopamine. Our surgeons seem to love it, though. I find it's fine to use up to about 1.5 mcg/min. Anything higher than that and I feel that the effects on the heart rate and O2 consumption are just too great. If you're trying to use epinephrine for vasoconstriction, do so only in an emergency and switch to something more efficient as soon as possible (Neo.). Dopamine is a fine drug, and because it's so flexible with dosing, you can do plenty with it. Great for inotropic support, great for less-intense vasoconstriction, and great for renal perfusion. Aparently there's been some discussion over whether or not there really is a "renal dose", but I figure that I see better urine output at lower doses, so it must work. Remember that as with any drug, different people have different sensitivities. I once had a patient who's blood pressure jumped 20 points on just 2mcg/kg/min! The doc said that it was impossible, that she was just on a "renal dose", so I had him turn off the drip to see for himself. The look on his face was priceless! (>sigh! ) Dopamine can be used very well with nitroprusside (Nipride) in those cases when you need inotropic support along with decreased SVR, but in that case, why not use.... Dobutamine. Dobutamine is also a fine drug. Wonderful for inotropic support. However, unlike dopamine, it vasodilates, instead of vasoconstricts. Dobutamine should not be used on people who have low SVR and need inotropic support! Dopamine and dobutamine are a great combination in cardiogenic shock. As (I think) the case is in most units, in ours norepinephrine (Levophed) is used as a last resort. Because it's such a powerful alpha-agonist it's great for septic shock when the SVR isn't responding to dopamine or phenylephrine. In fact, I've never used it on a cardiac patient. Only septic, renal, or septic-renal patients get the pleasure of "Leave-em-dead". I will say, though, that on the septic patients at least, it really helps pull them through the swamp until the toxins start clearing the system. I hope this all helps!

Don't worry! I've felt this way a lot since becoming a nurse three years ago. It happens! Two (or three) points: 1) I often felt this way until a I was recovering a patient who had just returned from open-heart surgery. A family member was watching me and my routine from the door of the room. I asked what he needed and he replied, "Nothing. I'm just watching you -- it's really cool what you do ... almost like a dance..." It made me realize that I'm probably better than I thought. 2) One way to deal with these feelings is to go home and journal. Write down how your shift went and what you think you can do better. Then forget all about it until you're ready to go to work next. 3) Another way is to find a mentor where you work. A nurse, or two, you really admire and respect. Ask a lot of questions. Also, before you leave, talk to them and simply ask, "How did I do ... what could I have done differently?" You'll be amazed that the answers (more frequently than not) are, "Good ... nothing." :)

I have always received compliments on how professional I look, and I don't wear white. I hate white! It's possible to look like a health care professional without white. Our hospital's policy is wear whatever scrubs you like. I wear: Black pants with black shoes (yes, black), a solid color top, and a short white jacket with my nametag. Professional dress shows pride in yourself and your job. I've also found that doctors, families and patients all stop and listen when I talk. I attribute some of this to my professional dress. Along those lines (and I might be starting a new thread with this), I find it hard to take seriously nurses who don't follow healthy living practices. So many smoke, eat junk, or are overweight ... what must their patients think?? I realize that these are hard habits or addictions to break. Even so, the best way to teach healthy living is by example.

The way to solve this is to do exactly what management says. I simply tell the family that I'm giving report, I introduce the oncoming nurse, and I give them a realistic time frame in which they can expect an answer to their question. I've never had a family complain about this.