gradcare

Super glue is not a good substitute for lube. If you forget this and end up gluing your urethra closed, it is probably best to present to the ED early rather than wait until you have not peed for over 18 hrs..

Also it must be remembered that many medications used to prevent stomache ulcers including H2 blockers can alter the pH in the stomache so pH testing can be unreliable (false negatives) additionally listenting and pH testing do not give you a reliable provable placement for the tip. Radiographic proof is probably the best way to ensure correct placement for feeding and meds particularly since some fine bore NG tubes can collapse if aspirated.

No, insantiy is only relative anyway (your familiy drives you crazy.....just kidding) New Rn's in the critical care environment can and has been done well preveously however there needs to be a massive level of both clinical and social support available. It is not crazy to get med/surg experience prior to entering the critical care environmet and indeed amongst many critcare nurses the discussion regarding newly registered nurses in the critical care environment rages on. Short answer go with with what you feel is right and disregard the labeling.

Generally we need to remember that noradrenaline (or any other trope) is a poor substitute for adequate fluid reses. That said, in the setting of an adequately fluid loaded patient if you've hit 20 mcg/min with no result then you need to add another agent and look at their SVRI to determine what is the cause of the refractory hypotension (pump failure vs actual vascular depletion vs relative vascular depletion [vasoldiation]) If no result with 30 then perhaps some hydrocort plus a second agent, then a third etc. Been in the goo acouple of times where the clinical picture is muddied to see what we needed to do cia PICCO / SCVO2 /Swann / or some other cardiac measure. Guess my point is if your current thing ain't working it's time to see if what you were dealing with is what's happening and to add something else. Cheers.

To junebuggy re step downs using the "milk of human kindness". I'm presuming that these pts do not have an artificial airway and are not vented (that's what step down is to me). Thinking about how the stuff actually works, then using a substance with little difference between what "settles you down" and what "takes you down" can get a little hairy. (and I'm too old to do "interesting" anymore). Also last year there was a thead on neuroicu re propofol infusion syndrome which can cause things as benign as green urine or as bad as mycardial dysfuntion. To me these things rule out propfol for the non intubated pt (except as an induction agent). I think there was also a thread regarding propofol on the CRNA side of thigs too. Cheers.

What sort of ICU are you looking for? Medical / Surgical / Mixed? Once you get your stuff together on the ward environment you can make the switch. Both medical and surgical wards will provide experience that can be useful in the ICU. A CCU or telemetry rotation would also be helpful to get the basics on ECG interpretation too.

Have worked with 2 systems. 1 where the MET (RRN) nurse was included in the count but floating (no allocation). And the other where the Nurse had a case load. Response times didn't really differ what did was that the RRN with no case load could take over the care of the patient if it required transfere to the critical care area. Also they did not have their own caseload going to pot while they were away. Better for all if RRN has no caseload but try convinving the bean counters of that!!!

poor gerbal

How do I apply a fecal containment device (bum bag)? please note the instructions have pictures......... Should I call a code on this patient ??? (blue , no pulse no resps..was pink 2 min prior pt for full resus)

Attended pt who was crashing, me my doc ward staff etc with this pt when the pt opposite (in 4 bed bay) buzzes to tell us his obs wer 2 min late!!! Nice to be needed.:chuckle

"I'm feeling very discouraged with nursing after only two weeks of clinical. I'm in my 2nd semester of my BSN program. My clinical instructor thinks that I am way better suited for ICU so I'd love to hear what your day is like (in general) in the ICU. So far I've been on rehab, which I hear is the least acute it gets, and I'm SOOO bored. I NEED to use my brain more or I'm sure to go mad. I precepted last week and had three patients, was able to do all but pass meds myself (acuchecks, i&o cath, showers, vitals, all the charting, changed the beds) and was still craving more action. I'm thinking that's a bad sign as I'm "supposed" to be overwhelmed and nervous my first real week with multiple patients. We go back to only one patient this week. I'm not sure what I'll be doing the whole time if I was bored with three...." Just remember that the only time you will ever only have an allocation of 3 pts will be in CCU/HDU. Also try other specialties before you comit to ICU. You need not only basic nursing care but also a reasonable broad range of surgical and medical experience unless you end up in a pure surgical unit. If you can't pick up the number of patients, try looking at their pathophys, rehab plan and see if you can get a feel for why things are the way they are with them. Try writing some careplans, that sort of thing. The whole point of the first couple of pracs is to get the basics sorted and to gradualy step up the time management and clinical skills so by your final year you can really hook in and hit the ground running. So relax, the challenges will come but until then you may need to create your own.

All units i've been involved in ICU will do CRRT until the patient is stable and able to tollerate IHD (if it is going to be needed post discharge). If the patient is going to need IHD post ICU discharge then the renal people come and do it. So short answer for us continuous renal replacement from us Intermitent dialysis from the renal team. The Machines we use are different.

38 with ccf. bad karma from the get go. You do what you can with what you've got. what was the ecg like? any chance that this was pure pump failure cardiogenic shock)? Any SVO2/ mixed venous / subclavian gases to differentiate between sepsis/ cardio shock?. The other thing to remember is that you are only able to make the calls based on your experience and knowledge. I've been playing in the ICU for a while and would have had difficulty keeping this pt in the world of the living. One final thing don't beat yourself up. You gave the attending doc's the information you had, if they need more they ask for more. II'm hoping your shift coordinator gave you some help as well, they are meant to suplement your knowledge and skills when things get tough. Finaly I've run 200 mcg/min norad levo plus 85mcg/min adrenaline (epi) with Vaso, dobutamine and balloon pump before. They survived until we could get them on a LVAD but didn't make it to the top of the heart transplant list. Stick with it . You did ok with what you had. This pt has taught you heaps about ICU, nursing and yourself, don't waste it. This pt will live on (sort of) in the lesson's that you have learned. Sorry if post is scrambled but have just finished nite ending as it started with a code and a threatened airway. Cheers

Sounds like u need to either ban linnens or have a place for relatives to sleep. My current unit has 2 "slep rooms" for acute ie 1-2 nites only as we are the only unit with all the specialties for about 1200 km north south and west so many of out pt's are from out of town with no accomodation for a day or so. These rooms are also used for relatives of paliative patients occassionally. That said blankets and pillows in the general waiting area are a no no.

HIT(S) has been around for quite a while problem is you need to recognise and then test for it. Seen 3 cases in last 18 months, that said we tend not to use the low molecular weight heparins to prevent DVT's and tend to use heparin infusion to prolong CRRT filter life so we have a great deal of heparin ussage. Perhaps placeses that use low molecular weight heparins or danaproid have a lower incidence. Comments???

Of course that all hinges on the estimation of burned area being correct. Have left burns behind me now but started seeing goal directed fluid strategies with the goal being urine output of approx 1 to 1.5 ml/kg/min with parkland being a starting point. If u/o drops increase the rate... That said I left that area about 18 months ago so much may have changed.

We've been running on random vanc's for several years now used to to peaks and troughs now just do troughs approx 1-2 hrs prior to next dose. Though there seems to be an algorythm for bloods taken a little earlier.

Have yet to see a "standard rate" of TPN administration as nutritional needs can vary dependent on disease state, weight temp etc. Also fat percentage (eg 10 % vs 20%) can be altered depending on comorbitities and serum triglyceride levels

contraindication purely relative. No access = dead. Hey you get it where you can. Very poor chest so sub clav line probably out, IJ perhaps but sounds like the vena cava was getting a little crowded. Besides you didn't choose where to put the lines, you just asked for more access.

Some times you feel "dirty" because you are advocating for the patient knowing full well what that entails even if they don't (doing everything for the pt with GVH taking over their entire bodies, watching the disease process head towards the point of no return, knowing that their chances of survival reduce everyday), other times you wil feel dirty watching or assisting in painful procedures that may result in an improved chance of survival for the patient or that are necessary because of misshap or just bad luck. Sometimes you will feel bad because despite everything you do your patient is not comfortable, does not have a good outcome etc. What keeps me relativly sane is asking my self "have I done my best" if not then "what can I do to improve?" Finaly when all else fails I remind myself that everyone deserves the best chance we can give them to survive, thrive and hopefuly return to a state where they can again direct their lives. I guess the other thing to remember that you are not the cause for your patient being with you. You did not hit them, you did not inject dishwashing detergent into their arm, you did not ignore the wound that gradually ate away their arm. You were not the driver who ploughed into them, you did not suggest to them that they have their valves replaced. All you are doing is attempting to assist them to return to the best they can be. And if they are not going to survive then you are trying to provied the opportunty for their loved ones to say those things that need to be said but often cant be because time runs out. cheers

Have "walked Peep up to 35 cm H2O as part of recruitment manouver On pt with puritan bennet bilevel [hi peep lo peep]. Short term only however (couple min only) BP tends to go "bye bye" as pts tend to be a little vascularly dry and cant deal with the increased afterload and decreased preload due to the increased pressures.

Have "walked Peep up to 35 cm H2O as part of recruitment manouver On pt with puritan bennet bilevel [hi peep lo peep]. Short term only however (couple min only) BP tends to go "bye bye" as pts tend to be a little vascularly dry and cant deal with the increased afterload and decreased preload due to the increased pressures.

All fun and games till that slow leakin SDH hits critical mass effect then it changes. :chuckle

pa, I don't think anyone is being disrespectful of the individual who has coded. The common theme is that for those who feel challenged in a positive manner by being in a code that it is sad that someone else is in trouble. While we all strive to prevent codes they will continue to happen regardless of how good you and your team are. Why ? Simple people with irritable hearts will code, people with uncontrolled blood and fluid loss will code. people with massive electolyte shifts will code, simply becase they are so sick and these changes can occur more rapidly than even the best team can accomodate. Personally when in a code i'm beating my brains to think of probable causes and the treatment.... and wondering what the patient really wants.