GatorRN21

I think it is great that your nursing unit prepares most your own infusions. Nurses on our unit have had little training in mixing infusions independently outside of the pharm--we do more training. So, this is a change from our typical everyday practice and training--I feel for the most part we aim for mixing the infusions to be not only the nurses role but a joint/collaborative role with the pharmacy. We aim for the pharmacist to be another check along the spectrum before a medication gets to the patient and also the pharmacist to best able to prepare the medication in an environment more geared towards medication preparation (more sterile, etc. compared to the unit because we don't have a designated area for medication preparation like the pharm does).

Know your code drugs inside and out. I work in a CICU so I know the correct dose and how many mL to draw up of epi (1:100,000 vs 1:10,000), atropine, Cal gluconate, and bicarb (infant vs adult concentration). I know this off the top of my head because as a new nurse I was drilled by my preceptors to write up the emergency drug doses and calculations for each specific patient until it became second nature and I could just rattle it back to them easily. I am grateful that my preceptors made me do this each time and I highly recommend new nurses especially in the critical care environment to make this part of your daily routine. Code situations are chaotic, be as prepared as possible.

In our CICU, we use the VAMP system on all arterial lines, which is a closed system. VAMP System Unfortunately, the VAMP is only supposed to be placed on arterial lines, so all other lines we still use the open system (stop-cock). But our team rarely follows the mixed venous sat so we commonly aren't drawing/wasting blood from the other lines--mostly drawing from the art line.

Great question! There is no right answer in this situation! Everyone will have an opinion! Thus, this is always a hot topic among the critical care team. umcRN, I found it good to hear that the nurses have a great deal of autonomy in titrating the sedation in your hospital. But, I believe the bedside nurse should not independently manage/titrate the sedation in a patient with impending cardiac failure. Oh Dex. . .some of the doctors are very against Dex because of its affect on the heart rate. Also, it is a newer drug and there isn't a large amount of evidenced-based data about how to use it safely (i.e. weaning off the medication and managing withdrawal). I just wanted to mention that I personally love Dex and think it is a great drug especially for short term use in the pediatric cardiac population. Of note, some anesthesiologists I have spoken with like to give Ketamine for situations like the one you described. But, we don't commonly give Ketamine for the most part. As already mentioned, never Propofol, it is a negative inotrope. Anyways, as you probably know, sedation for a patient admitted in cardiac failure can potentially throw them over the edge. Since their sympathetic response system is maintaining what little cardiac output they still have left, when you blunt that response with sedation this can lead to full-blown arrest. These are some of the scariest situations! That's why there is always so much discussion among the team about the "right" medication to use. But, bottom-line if we had to give a kid like the one described sedation/paralytic for a procedure (i.e. intubation), we would have an ECMO circuit/ECMO tech and open-chest cart outside the room and of course the surgeon up on the unit. If you don't have that available, they need to be sent to a hospital with ECMO capabilities.

Thank you for posting this info. I did not know so many drugs are going are going to be on short supply! At our hospital, I feel like every week that I have an e-mail about another change related to the drugs that we use frequently--it's down-right difficult to keep up with all the new updates. In our CICU, our pharmacy now specifically prepares smaller dose vials of ativan, versed, etc. Also, kids on drips of Versed or Fentanyl, will have each syringe prepared specially for them. We used to have at least a few standard concentration syringes of these medications available at any time in the Pyxis. Thus, this leads to another job for the nurse to add to her check-list-- reordering these meds and/or checking to make sure another syringe is available in the Pyxis. Also, during emergency situations specifically on night shift (i.e. pt crashing onto ECMO leading the pt to need a whole medication gang prepared); without the readily available standard prepared syringes the nurses now has to formulate his/her own drips in this chaotic situation. I am younger nurse with 5 years experience and do not have much practice in mixing drips unlike other nurses with much more experience, where that used to be a standard of practice. I personally get nervous about formulating drips and think this is going to lead to be potential medication mistakes. I feel this is more of a pharmists' job but the drug shortage has put this now frequently on nurse. Just another thing to worry about when you have an unstable kid

I just moved to Philly from Florida as well. I just moved into my apt last week so don't know many of the areas yet. It seems as though Philly is quite large. The cost of living is much more reasonable compared to other cities. I will be starting school in the Fall so I thought I should move near the campus. For a one-bedroom I'm paying $600, not including anything. So, I found the place online because with my work schedule I wasn't able to visit. I live in University City near Market Street and it's rough. I hear Center City near Rittenhouse and Old City area is nice. I was considering Center City but wanted to be able to sleep a little later in the morning so decided on somewhere close. Also, you have to pay for parking in Center City but in University City I am able to park on the street. Good luck with your move.

Hi! I am starting NP school this Fall so I don't have experience with calling consults. But, my boyfriend is a cardiology fellow and I hear him vent about this all the time. The consult service rotation is one of the worse for him- he just gets burnt out and admits to being short with people because of the constant calls for consults regarding patients with physiological bradycardia or to read ECGs. At the hospital, consults can't be refused as well. He has said when people call, some things that really bother him is when the other service calls requesting an ECHO or other type of cardiac procedure- they are not trained to make that decision but ordering it is up to the cardiologist or when the person calling doesn't seem to know much about about the patient or "isn't thinking it through." If he's short with someone he says that it's not because of them usually just the situation- so don't take it personal. Don't know if this helps at all

At our hospital on the post op heart surgery kids, we titrate the nitroprusside first up to 4mcg/kg/min for the systolic BP then once we reach that amount we add on nitroglycerine up to 4mcg/kg/min (not impressed with nitro though). Most kids come out on milrinone, sometimes on a low dose epi. Do other hospitals titrate like this for the BP? What other drips do other hospitals use? Thanks :)

Sometimes a kiddo will return from surgery without a NGt in place and is ventilated. The plan usually is to extubate the kid but when would it become time to put a NGt in a kid that hasn't been extubated yet? Last night I was working, the kid returned from surgery at 2p and wasn't extubated until 11p so should a NGt been placed? Abdomen of the kid was not distended.

Thinking about switching from surgical pediatric patients to HemeOnc speciality. Any suggestions? How long did it take you to get certified? Is working with this patient population very sad or more rewarding? I want to learn more and feel like at my current unit all I do is assess my patients, hang vanc, timentin, and gent, or do the occasional dressing change. I want to advance my nursing skills and learn more. Will heme-onc be a good way of going about that?

I've been working in an unit that gets many post op neuro patients that require q4h neuro checks. I find it so hard to perform neuro checks on the smaller kiddos and am so scared I'm gonna miss something some time. Little kids rarely let me check there pupils, don't want to talk, follow commands, etc. Any ideas on easy, kid-friendly ways to do neuro checks? Thanks!!:nuke:

Health care is not like fast food. People know where to get a good hamburger but don't know what type of disease/illness is ailing them. People are able to be customers when going to resturants, lawyers, dry cleaning, etc because they have a specific issue they are aware of and have knowledge of. Ex. getting a divorce see a lawyer, hungry go to a resturant. But in health care, things are much different and people come into the hospital unaware of what type of tests needs to be done, how to be treated, etc so they need to rely on the health care team.

I take care of a lot of post-op cleft lip/palate kids and post-op protocol is to have elbow splints on. No MD order is needed q24h for the splints. Well another nurse said they were restraints while she was auditing charts. We got to talking about this and could not find any policy on this issue, are they restraints and do children need the q2h restraint check documented?

I've taken care of a few infants in which the parents added rice to the formula becuase they believed their infant had GER. The parents believed it helped treat the GER. None of the infants were dx with GER. I was taught to not add it to formula until at least 6 m/o. Even if the infants had the dx of reflux, would it be ok?

Burns can always be prevented. Any kids with burns are always consulted with social services at our hospital.

Our hospital has starting a new program called Nursing Rounds, basically instead of giving report to the next nurse in another room, the previous shift RN and new shift RN walk into each room together. The previous RN introduces the new RN and then goes over the pt's history, problem, current issues, IVs, diet, etc in front of the patient and family! I'm not sure how I feel about this, I understand some of the pro's and con's such as noticing if the off-going RN didn't unclamp an antibiotic, etc or any questions such as "was the pt like this before" etc. But what about confidentiality of the pt and other's in the room and the nurses will be very limited in the questions they can ask without offended the pt and family. I wanted to know what other nurses thought of this new policy. . .