bellehill

We obtain a pupillometer reading on admission for all our neuro patients. Our protocol is to call the MD for: NPi CV %change >1mm difference between pupils We also trend the NPi and if there is a difference between R/L pupils of >0.7 or if the NPi has decreased by 0.7 the MD is to be called. We use the pupillometer Q4h for GCS

We treat any stroke symptoms the same with the standard benchmark goals. Door to doc in 10 minutes, door to CT in 20 minutes, door to CT read in 45 minutes and door to TPA in 60 minutes if applicable. Our hospital uses a "stroke alert". The important thing to remember is a TIA is a warning that a larger stroke is going to happen. A lot of patients and physicians will ignore the symptoms and that is a big mistake. TIA patients still need to be admitted and evaluated.

Grab a textbook, preferably by Hickey and look at it then draw it. I always learned better when I drew the subject (like the Circle of Willis). I think I drew the COW a million times when I was studying for the CNRN. If you can draw it you can visualize and then when you need to discuss it just picture the circulation pattern in your head.

An update: we are seeing great success using the Flotrac. Our goal is SVV40 and CVP>8 for non-vented and >12 for vented patients. If two of the three parameters are not in range we bolus the patient. No more swans...YEAH! Just recently had a patient who spasmed for the full 21 days, several trips for IA Verapamil and she walked in to visit us completely intact. Really makes you feel good about what you do!

We have a Neo shortage as well, anyone else? We have been using Dopamine and Epinephrine.

Have you tried a bedside report? If you are having trouble remembering what happened during the day go in the room and talk about the patient. Chances are you will remember and the patient will appreciate knowing how thorough you were with report (if they are awake). Just a thought. Other thoughts, I go system by system. Head to toe and SBAR is always useful. Have the chart in front of you so you can go over orders, that will help to spark memory too. Your educator is right, it will get better.

Our unit has a shared governance with 4 different quadrants: customer service, quality of worklife, practice and research, and education. Each quadrant has a chair and co-chair as well as the chair and co-chair of the shared governance. Ours meets once a month for 2 hours. We have bylaws and a mission statement. The basic reason for shared governance is to bring decision making to the bedside, especially when it affects the bedside nurse. Some topics we have covered; weekend on-call for staffing, new education topics, social events for staff gatherings, signage for our visitor waiting room, new protocols for patient care. You really have to have a 100% commitment from the chairs and co-chairs for it to work. You also have to have a manager who believes in the process and is willing to let the council make decisions. Ideally, the chairs and co-chairs of each quadrant would engage the staff to be involved. All decisions are taken to the staff and decided by a vote so even if someone can't make it to the meeting their voice is heard. There are several great resources on-line regarding shared governance. It is very slow to develop but once you can get a strong base it will be worth it.

In our neuro patients it seems to work very sporadically. We were just inserviced on Precedex and it is not to be used for the patient when they are wild. Ideally, you would get the patient calm with Ativan/Haldol/Versed and start the Precedex drip while those are wearing off. Our rep recommended this especially for patients who are at risk of alcohol withdrawal. Start the drip BEFORE the patient becomes uncontrollable, not once they are. Personally, I like Precedex but it isn't for everyone. I like that the respiratory drive is not affected so I can use it on my non-vented patients and still do a good neuro assessment. Maybe your docs need to talk to the drug rep. Hospira makes it, just call them.

Is anyone watching "One Born Every Minute" on Lifetime? It was taped at Riverside Methodist Hospital in Columbus. I work there (not L&D) and I love to see the exposure. Even if you don't work at Riverside, what a great opportunity for Central Ohio. It is on Tuesday nights. Check it out!

I worked in a busy Neuro ICU my entire pregnancy. I was supposed to work the night I had my child. It is like any nursing job. You take normal precautions just like you would with any patient, even if you aren't pregnant. If you want to try neuro then do it. The worst part? All the sadness with those extra hormones in your body!

Thanks. We are going to be looking at the SVV, SVI and CVP. If 2 of the 3 numbers are below the parameters the patient will be bolused. This has worked well so far!

I agree with birdie22, go with the BSN and work as a tech. Nursing jobs are very competitive in Columbus.

One thing I see in new nurses on our neuro ICU is they do not understand the emotional toll they will encounter everyday. The neuro ICU is a sad place to work. We do have those cases that really lift you and and make you proud, but they feel far between. We recently had a 48 hour period where 8 patients died. Our new nurses had a really hard time with that one. Make sure you are mentally and emotionally prepared, neuro ICU is not a happy place to work but it can be very rewarding.

So what are you using to monitor fluid status and cardiac output? I certainly don't miss the swans, what a pain they were.

We recently started using the Edwards FloTrac for our Triple H patients. The first round went really well, the second round did not go as well. The problem we are having is the variability with the numbers. We are following the Stroke Volume Variation (SVV) instead of the Stroke Volume Index (SVI). I am wondering if anyone else is using this to monitor fluid status for your Triple H patients and what are your parameters for treatment? Do you follow the SVV or the SVI? I would rather not go back to our pulmonary artery catheters, but if we can't find a solution that will be what is necessary.

You did nothing wrong. I agree with the previous posters, 0.5mg of Ativan is like spitting on the problem. Neuro changes happen in seconds and you did everything you could for this young man. We always take patients like this home in our head, but put yourself at peace.

We use Propofol in our neuro ICU simply because it wears off so quickly for our hourly assessments. Precedex is tried and we have seen that it tends to work better on some than others (not sure if it is a brain thing). We just had the Precedex rep do an inservice and it is recommended to be started at the beginning of agitation or even before which never happens. We also use Fentanyl and Versed for our hard to control patients but we also saw an increase in ileus with the Fentanyl. Personally, I like the Propofol. It is quick and has a short half life for our neuro exams.

In our neuro ICU we do a neuro assessment together at the end of the shift. We are supposed to be going to full bedside reporting and I really don't see the harm. Of course there are some items that simply cannot be discussed in front of the patient or family but what a great way to include the patient in their care. We have family step out for report anyhow so that won't be an issue. I think it will be a great way to answer questions and make sure the patient understands what is going on with their care. Of course, we haven't tried it yet so my opinion might change. As a patient, I would like to know both of my nurses are on the same page.

I am on 8 committees plus teaching classes to our med-surg nurses, CC nurses and EMS occassionally. Plus, I am supposed to do bedside hours each week to stay clinical. Sometimes I feel like I am being pulled in a million different directions but what is really frustrating is that I start to focus on issues outside my department. I've been in the Clinical Nurse Educator role since May and I have had to pull myself back in twice and I also started sharing some of my responsibilities with other educators who were not on so many committees. My problem is being able to say 'no' but I am working on it! I think the most important thing you can do is make sure that whatever you are working on is going to benefit your staff and department, then work on the rest of it.

If you put your clothes in the dryer on high for 30 minutes you will kill the bed bugs from clothing and linen. I would do this automatically for your own safety, especially working in home health. Bed bugs is a huge problem for my city and the hospitals and this is how our infection control guru told us to get rid of them if we are exposed.

My hospital has a Critical Care Fellowship for new nurses and this is the only way we will hire new nurses to the NICU. I think the fellowship is a great way to experience every aspect of critical care and then decide which you want to focus on. Of course you can do NICU, it is no different than the other ICUs when you are a new nurse. Just make sure you take time and make sure you really want to work with neuro patients. They can be rewarding and frustrating at the same time.

Walk in, tell the doctor your symptoms and how you feel. There is nothing more to it. What would someone who isn't a nurse tell their doctor? You are human and normal.

1)c 2)e...if the patient is mechanically ventilated we do oral, non-vented we do nasal 3)a 4)e...enteral feeding should be started as soon as possible, it is best practice for the patient 5)a 6)a 7)d 8)b 9)e...we hold tube feeding one hour for residual >150cc 10)b 11)c 12)d

Our unit is open except for 6:30-8:30 and 1830-2030. This gives the shift coming in time to get report and an assessment done. I have mixed thoughts about open visitation, however, everyone has to keep the rules for all family members. That is our biggest problem; some nurses enforce them and some nurses don't. The nurses who don't enforce make it hard for those of us who do.

If you really want a hospital apply for any position possible....contingent, nights, rotating. Unfortunately you will need to shoot for the positions more experienced nurses are not interested in. Try specialty hospitals or rehab facilities just to get some experience. Hope you find one soon!