Dyno

Hi Sharron, thankyou for your reply, only 4 years later but who's counting LOL. I am no longer in cardiac surgical now, transferred to cardiac investigations but the policy is still the same for pacing wire removals in our hospital. I never found any other info but best practice seems to be to contunue what we are doing. I am glad you also don't think it is over-kill, I think sometimes we are guilty of minimising risks for patients when we see the same procedure day-in-day-out but the potential is always there for tamponade, etc with removal of these wires. Same thing for CV line removal, patients up & out after 2 hour obs post biopsy (heart transplant patients). I always make sure they have our number close by but often they are independant & drive themselves home. Anyway, thanks again for your reply. cheers Dyno.

Thanks for your reply Bob, hope your wife has fully recovered from her surgery, she sure had some major work done. Maybe the extra precautions (vitals & RIB) are because we are over precautious if an incident occurs & the threat of legal action if duty of care is not maintained is always there? Maybe the extra precautions are because someone suggested it was done from the start & no one has proven, via research, that it is unneccessary? "We've always done it that way....." Or maybe, like you said, the precautions have slackened off because no incident has occured, on what best practice evidence though? Anyone with evidence of an event post wire removal & best practice based on research? Sounds like a project coming up! cheers, Lee

Doesn't anyone take out pacing wires??? Maybe they are called something different in the states?? Help??

Hi, I'm curious to know what others hospital policies are regarding removal of epicardial pacing wires post cardiac surgery Our policy requires baseline obs, remove wires, obs x2 30 minutes apart, pt to remain in bed 1 hour, watch for signs of tamponade (dec BP, tachy, SOB, pain) We aim to remove wires during 'office' hours (plenty of staff around), on day 4-5 post-op and while INR is Had pt last night: INR 3.4, day 6, due to be D/C next day, surgeon did round at 1900 hours & ordered wires to be removed now. Reminded Dr of policy & voiced concerns, Dr said to do it while he was on the ward.. this is fine but what about later if she tamponades? Made sure documentation was in order, & removed wires. No problems as far as I know (I am on a pm shift so hopefully she has gone home safely) Some nurse feel the policy is over-kill as nobody has seen a pt tamponade post wire removal. Thoughts please & what are others doing with this procedure?

I felt the same when I started on this ward but now see the telemetry as 'my friend' as it alerts me to changes. The first time I saw a pt convert to AF, I noticed nobody seemed too bothered, whereas I was thinking "hello, this pts rhythm is out of whack, BPM @ 160-170, irregular, etc, do you want the emergemcy trolley a little closer to them?', ofcourse it was treated quickly and the reason the staff were so layed back is because a high percentage of pts go into fibrillation. But now I see the benefit. I can spot one of my pts starting to change their rhythm, PVCs & irregular pulse is usually first sign & I can monitor them carefully, check electrolytes, as soon as they hit AF I can get them digitalised quick smart. I guess its all relevant to where you are working & how you approach things.

I agree with nilepoc, ICU bed is way too expensive. Use a 'sitter', nurse aide, or what ever you have in your hospital.

Scary stuff. If pt needs to be on visual obs & is a risk then they should be in a psych unit where one nurse usually takes responsibility for all visual obs. If this is unavailable then a special (1:1) for the shift or at least a lower pt/nurse ratio. Maybe a bed within view of the nurse's station would help but still a huge risk. Keep your documentation up to scratch and voice your concerns.

I work on a cardiothoracic surgical unit, 30 beds. We have 8 telemetry units (portable) plus 4 beds that can monitor pts via hard-wire & be transmitted thru the monitor in the nurses station. We watch our own pts (glance over as you pass the monitor), plus have the Team Leader (level 2) floating & watching. Most the time we are looking for AF post surgery (not hard to miss). Occaisionally we have a medical pt on telemetry but if they are a high risk for a ischaemic changes and/or MI they really should be transferred to CCU. It works well, the alarms alert us to immediate changes to arrythmias, rates, elevation, depression & we get to learn & read the monitor first hand. I do know of others working in hospitals where the telemetry units are not visible on their ward but I find it hard to imagine working like that.

In response to Ted, re what nurses wear in other countries.. In oz we don't wear scrubs unless we are in theatre/recovery. Most hospitals now have a corporate uniform although the traditional white can still be worn. In my hospital...for RNs Females can choose navy trousers, shorts or a skirt combined with the corporate top, ours is a choice of white with the hospital logo printed on it or a chambray shirt (denim blue/grey colour) or choose the traditional white dress. Black or blue shoes can be worn. Males can wear navy shorts or trousers with a chambray shirt or opt for traditional white shorts/trousers & top, blue or black shoes can be worn. Uniform allowances are given, also in the public system, the hospitals have to supply the uniforms (returned when no longer working in that hospital) & uniforms can be laundered free of charge at work. This has been union negotiated. The private system also has corporate uniforms, usually navy pants/shorts & the corporate top. I don't know their arrangements for allowances. Uniforms are also tax deductible in both systems. Paediatric wards sometimes have a separate brighter top but not always. ENs (LPNS) wear same corporate uniform but blue uniform instead of white if they take that option. Maybe we are 'behind' the times down under but it works well for us and we definately look professional. The trouser/top combination is comfortable & takes away the 'hospital' , sterile look. Patients can easily recognise the nurses apart from other staff. Hope that gives you some insight.

Glad I could help Debbye, Remember KISS it (keep it simple stupid!!!)

Sorry guys, guess I forgot not everyone works in cardiothoracic! A plerodesis is performed to create an inflammatory reaction between the lung pleura (visceral & parietal). This then encourages the lung pleuras to 'stick' together helping the lung to stay inflated. Patients present with recurring pneumothoraxes caused by a weakness in the visceral pleura (cyst or injury). Procedure is usually performed by a VAT (video assisted thoracotomy or keyhole surgery to the lung) ICC (intercostal catheter) or pleural drain connected to an underwater drainage system is often inserted. Analgesic is usually via patient-controlled-analgesia (PCA) with morphine or fentanyl Hope this helps, rest assured, I'd be lost in ER

Immediate post-op (after recovery): post-op obs, pain mgt (PCA, Paracetamol. Tramal), ICC obs/care (usually suction on), get up next morning if not night before to void, ICC usually in 24-48hrs, then PCA down, redress VAT & ICC sites daily, shower next morning (with assist/supervision), nausea issues, independant mobilisation once past effects of anaesthetic, home 2-4 days if no complications, often low-grade temp. immediately post-op (inflammatory reaction), follow-up CXR to check lung inflation. hope this helps

Interesting to see what others can & can't do. On our ward we take everything out: chest drains (retrosternal, pericardial, pleural), ICCs, epidurals, CVLs, belovac drains, pacing wires.. We have to show compentancy when first on ward ofcourse. Don't forget to be careful when taking out ICC to prevent pneumothorax, get pt to hold breath, pinch skin to seal, if no purse-string suture to close site put on steri-strips, always seal with vasoline-gauze & air tight dressing.