ghmccart

sounds like a protamine reaction that i have seen in the past, interesting that the epi was at just 0.2 mcg/ min, could have gone up to 10 eh>? and the vasso could be at 0.4.. interesting though

I wonder about using nicardipine for vasodilation, never used metop gtt, wouldn't, that night RN let it fly way to long, but good job dealing w it. thats why good thorough saftey checks always pay off!

it sounds like you are at one of those crossroads in life where you will be making a choice which will take you down two different paths. If you take the ethical stance in the sake of pt safety and safe practice for you it could mean your job at worst. If you just submit and go with the flow of an unsafe environment you will probably find yourself in a situation that you did not want to be in, pulling a sheath with unexperienced staff, with complications can go from bad to worse in seconds. You always have to choose how you will practice. If my leaders ears were that deff I would be looking for a new job. good luck, i applaud your energy

this positive inotrope is also a prodysrhthmic so watch for that! it vasodilates especially in the pulmonary vasculature, and is often used for folks who have pulmonary hypertension and are in need of a medication to help with contractility, lots of times levophed is added to increase the tone that is lost with the primacor. One important thing to know about this medication is that it has a long half life, so when you make a change to the dose, you wont know the effects for 1-4 hours after you do it, so watch out, they may drop after a while, even if you think they tolertated it well. Good luck!

we turn our patient with TVP's per policy q2 hrs, just make sure that their line is secure and locked, watch it close, and you know you dont have to turn them too much, just a little but to shift the weight of the pt, I learned that from our wound/skin nurse. hope it helps, we gotta turn folks lines or not.

if we have MT bleeding > 100 ml/hr x2 hr or >200 ml/hr x1 we call, then most likely check serial coags/cbc, consider underlying cause medical or surgical, then consider tight BP control, consider adding 10 of peep, focused med management etc. Our surgeon is a serious blood conservationist, we hate hate hate to transfuse patients so I am all over any signs of incresing mediastinal bleeding. Oh and always be aware of tamponade, get a chest film to assess for mediastinal widening! Proactive instead of reactive is my policy.

I pull mediastinal tubes in my OHS patients, not pleural tubes however. Try to pay attention to the difference on XR or communicate with doc.

I was A new grad into ICU two years ago, and have since trained into the CVICU, I use Bojar's manual of perioperative care in adult cardiac surgery, fouth addition. If you are looking for a complete cardiac ref. this is it. it is detailed enough for physician/ PA as well as for RNs. I swear by it.

what an experience, First off, if you still like being a nurse, and you want to, then dont let one experience where you DID advocate for the pt get you too down, but I too would have felt bad about that situation. All of the instict advice you got is right on. For me the point in which I would have been strongly advocating to get that pt what she needs is when she threw up and had to have 6L to be in the 80s, all though it is so different looking at things in hind site. with the s/s of CHF showing, and maybe some other acute event. sometimes it is the destiny of a nurse to be in a situation where they might be the only one to think that a pt needs something more or different ( including docs).

in one word optimize this pt maybe has an ef of 23 lets say, bad pump=all the things you listed. diuretic would be good as a part of the therapy, but this pt could possible benefit from an inotropic medication like dobutamine or milrinone. increasing the pump performance will increase o2 and uo, and idealy decrease pulm edema/resp distress. fluid restricions and a low na diet will help to. and another though. perhaps this pt heart has failed to the point that he is out of syncrony, meaning the electricity traveling through the r/l side of his heart is not hitting the ventricles at the same time so his pumps dont work in harmony. a biventricular pacemaker could give him the snyrony he needs and with the right meds he could be "optimized". but dont take my word for it, i only have one measly year under my belt and i know there is a lot more chf information around. maybe try a good text book, or ask a nice cardiologist would be cool to do. by the way, good question!

just like most things in real critical care, it depends on the situation. could be 1:1 if unstable, or 1:2, I would not do more than that

one bag w/three ring binder for educational stuff, couple crit care refs, chapstick etc, gum for bad breath, other things work in and out of the rotation. on my person I carry crit care ref. and very important to me is my little not pad that I write pearls from the experienced nurses " so what about this or what do you do when this happens" or when I learn something really good and want to recall it laters. every now and then I will read all the pearls I have written just to put them in my mind once again. two pens one sharpie in front L pocket, alcohol, caps in bottm L, tubex,calipers, and mini calculator in front R pocket(I calculate all my own gtts the old way), and thats it, dont forget to have a watch with a couple timers/alarms for odd situations

my concern is that you did not look up the medication and anticipate that before you gave it, it is a serious cardiac medication and should be given by knowledgable hands. asking us hear on this forum is ok, but man you need to empower your self.

msybe the pts MI allthough inferior maybe stable and not in need of so many fluids, and with the mitral regurg. preload and pacing are still good for RV MI's

It is important to know the physiological diff between cardiogenic shock, and septic scock, and throw in anaphylactic, hypovolemic, and neurgenic shock. taking the time to get these straight in your head is a good idea, even if you wont need the info regularly. we do know that the end result in any true shock in altered cellular metabolism and anaerobic happenings.