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TangoLima's Latest Activity

  1. TangoLima

    what are common times to run IV's in ?

    At our hospital: K+ infused at 10 mEq/hr even in the ICU. Mg++ infused at 2 gm over 4 hrs. This is per the pharmacy's recommendations. Maybe it COULD be infused faster, but I have never done it. The others I don't end up doing very often, so I don't know off the top of my head.
  2. TangoLima

    ICU visiting hours.. What is reasonable?

    Our official visiting hours are 1000 - 1800 and 1930 - 2030. We do not allow visitors to stay overnight unless the patient is dying. They are welcome to stay in the waiting room, and our hospital maintains a certain number of "hotel rooms" next to the hospital for family members who want to stay nearby. However, we have used nurse discretion for those with extenuating circumstances, like the family member works graveyard shift and wants to come in at an odd time for a few minutes. I don't like confrontation, and it is uncomfortable for me to kick visitors out right at 2030. But, then again, I like the fact that I work night shift and don't have to deal with the family all night long. ) I had a patient who was unstable yesterday, but by the time I came in, he was looking a lot better. I knew he was still very sick, but thought he was turning the corner. I reinforced the visiting hours, and the family drove home about an hour away. Then, the patient went into flash pulmonary edema, coded, and died at 2330. We notified the family, and they had to drive all the way back to the hospital. They were very gracious and stated that they really needed the time away from the hospital, but I still felt horrible!
  3. TangoLima

    Patients who are too unstable to turn

    Our beds have a rotation function built into them. You can set how much of an angle you want to turn the patient and what time interval. I usually always set the bed to 30-degree rotation each 15 minutes on all my patients, and then prop them on pillows as often as I can in addition. For my more unstable patients, I may use 10 or 20 degrees rotation at longer intervals. Nobody mentioned that here, so I thought I would throw that out.
  4. TangoLima

    DNR Status

    There seems to be a general disparity in how nurses in my unit view patients with DNR status. Most feel like a DNR being admitted to the ICU is inappropriate period, even if they are sick enough to be in the ICU if they were a full code. I've heard a nurse say...."Well, she's a DNR. I'm going to give the whole 1mg Dilaudid and not worry about the BP." Even my preceptor and other senior nurses whom I respect seem to have adopted this attitude. Our ANM has even refused to accept a patient to our unit who was a DNR. I just don't agree with this viewpoint. To me, DNR means if someone's heart stops beating or they stop breathing, we are not going to try to restart the heart or breathing. If the patient requires antibiotics, fluids, blood pressure meds, blood, etc., I feel those are reasonable treatments even if a DNR. Unless, of course, if the patient refuses, then that's their choice. If they're sick enough to be in the ICU, I feel like we should accept them. I know it's a fine line, but I guess I view this as an ethical dilemma and I don't really have a good answer for it. I'm also new (5 months) to the ICU, so am I just too naive? What is your viewpoint? What do you feel about giving blood to a DNR? Does your hospital have a policy on how to treat a DNR patient? Should I just accept this as the way it is? If that is the way DNR's are treated, I don't ever want me or my loved ones to become a DNR!
  5. TangoLima

    what are common times to run IV's in ?

    I have never seen Mag infused in less than 4 hours. Im not saying it cant be done, I'm just staying I've never seen it. Maybe that is our hospital pharmacy's policy. IDK. We run K+ at 10 mEq per hour unless we have an order to run faster. That includes being in the ICU. I just had a patient last night with a critical K of 2.6. The MD ordered 80 mEq over 8 hours. So, even with the critical K, the MD still ordered 10 mEq per hour. Don't have a lot of experience with the other ones, so I can't tell you for sure.
  6. TangoLima

    Who's to blame?

    Just to be clear, the patient came back from surgery at the beginning of day shift, and I inherited the patient much later after the tube feeds were already in progress. I was the one who STOPPED the tube feeds, and discarded the "residuals". I do realize that post-op orders are required, but that was at least 10 hours before I came in to work. It just seems like I walked into a big mess started by someone else, and I was too frazzled to put the whole picture together. I do feel like I stopped any further damage done to the patient, but I just know that he did not receive the best care. I wish the surgeon had written orders, and I wish the day nurse had been more proactive in requesting post-op orders, and not starting tube feeds without an order. I'm just wondering if I will have any culpability in this? Do you think I will be written up or disciplined?
  7. TangoLima

    Edwards Critical Care iPhone app

    Awesome! Thanks!
  8. TangoLima

    Who's to blame?

    This is going to be a long post, so thank you if you take the time to read it. I am concerned that this may come back to bite me at some point. So that you know, I have been a nurse 2 years, and been in the ICU almost 5 months. I had the same 2 patients for 3 nights in a row. Patient #1 was a 40 yo fresh post op. Hx of ETOH abuse, smoker, chronic pain, addicted to Xanax and Lortab. And did I mention he still hadn't cut the umbilical cord? Classic manipulator, babied by his mommy, enabled, etc. Diagnosed with unresectable pancreatic cancer, had a double bypass operation, poor prognosis. For pain, had a spinal Dilaudid epidural, Toradol 15 mg Q6, Dilaudid 1 mg Q4, Ativan 3mg Q8. Of course, none of this helped his "pain" and he was on the call bell every 30 minutes for pain, can't sleep, ice chips, mouth swabs, too hot, too cold, wanted to call his mommy, wanted his head up, head down, etc. etc. Oh, and he's going to have to talk to the doc in the morning about his pain meds because this is not what they agreed on. Patient #2 was a 76 yo with Hx of laryngeal cancer, trached, pegged. At some point, had a gastrectomy and PEG converted to Jtube. Had problem with repeatedly pulling out his PEGs and Jtube, ordered a new Jtube on-line and attempted to reinsert. Ended up with about 11 inches of bowel evisceration requiring resection and new Jtube insertion 1 week prior to my first night with him. No one liked taking care of him because he was constantly agitated, squirming around in bed, pulling at everything, required 4 point restraints. The first night I had him, he was on tube feeds via the Jtube, tolerating well, +BM, good bowel sounds, etc. Abdominal incision was draining A LOT of ascitic fluid, and had been for the previous 3 days, so I was just trying to manage keeping him clean and dry. At around 2 AM, noticed a small section of bowel protruding through the incision and around the staples. Covered with a moist dressing. Notified the surgeon, who said "Thank you" and hung up. About 3:30 AM, the OR called me to let me know he would be going to surgery at 6 AM, and had the surgeon notified me and give me orders? Well, NO!!! So, tried to get all the pre-op and anesthesia orders, paperwork, etc done. Patient was poopy, tried to clean him AGAIN. Then, he vomited and aspirated, suctioned his lungs, mouth. Gave pre-op meds. Critical bilirubin, notified surgeon and primary. All this while Patient #1 was on the call bell every 30 minutes, trying to keep Patient #2 from pulling his foley or trach out or falling out of bed, and the OR called me at least 4 times. Anyway, got the patient off to surgery, and gave report to a much more experienced RN. She had no patients at the time, but was going to receive the patient directly from the OR and recover him. She didn't even really give me the time of day, didn't focus on what I was telling her, wouldn't maintain eye contact, etc. A lot of the day nurses do this, and I find it very distracting, and makes me flustered. So, I get the patient back on the 2nd night, after repair of the evisceration, and he's vented via trach. The day nurse states she restarted the tube feedings at 20 ml/hr and to leave it there because "he said just leave it there and he would check on the patient in the AM". I'm assuming she was talking about the surgeon. I go to do my initial assessment and find that the tube feeds are going through the NGT. I think that was weird because he has a Jtube, but ASSUMED the surgeon didnt' want to use the Jtube for some reason, so I leave it running. At 2100, I check residuals, and find 200 ml of green/brown thin fluid. I talk to the charge nurse (because I'm new) and tell her I'm going to stop the tube feeds, return the residuals, and check again in an hour to see if any progress was made. So, I check again in an hour and find 225 ml. Oh, and I notice some of this same green fluid leaking out from his trach stoma. Suction his lungs, but no fluid in the lungs. I'm not about to return any of this back to his stomach and I discard the 225 ml. I asked the charge nurse if I should notify the surgeon, and she says not to call just because I stopped the tube feeds. But, I did notify the PA who was on call for the primary, and he just said to hold the tube feeds for the night. Did I mention that Patient #1 is still on the call bell every 30 minutes or so for his rediculous requests? So, I check him again at 3 AM, found he has another 200 ml residuals and I discard this. Did my chart checks earlier in the shift, but didn't do any of my filing until 6:30 in the morning, and of course the OR just stuffs all the operative documents in the front of the chart. So, I give report the the oncoming RN, yet another nurse who I can't stand giving report to, but that's another story. Anyway, I'm driving on the way home, and my mind finally has time to start thinking everything through. That's when it dawns on me the following: #1: I didn't notice any post-op orders when I did my chart check #2: Tube feeds were restarted very quickly following surgery, and if they were supposed to be restarted, should have been restarted via the Jtube, not NGT. The Jtube was covered by an abdominal binder, so wasn't visible unless you knew it was there, and the day nurse didn't pay attention to my report when I told her he had the Jtube. #3: The NGT was probably supposed to be set to suction, and the green fluid was stomach secretions, not true residuals. And did I mention they were backing up and leaking out of the trach stoma???? #4: When I was frantically trying to file the operative documents, I filed some orders, but didn't really pay attention to whether there was anything specific from the surgeon about post-op care So, I'm freaking out at this point, and I called the ANM and explained all this to her. I was so upset that I had a hard time sleeping. When I get back to work for the 3rd night, the first thing I do is check the chart to see if I missed anything. There are absolutely NO, NO, NO post-op orders from the surgeon. The NGT is now set to suction, and the patient is on TPN, not tube feeds. The patient is OK. So, patient #1 who hasn't slept for the last 2 nights and constantly on the call bell, finally passes out and sleeps, and I'm able to give patient #2 more attention, medicate him for pain Q2, and he finally settles down and rests, and I feel like I really did right by him. The ANM said she would talk to the other RN about what happened. I'm just so worried that this is going to come back and bite me in the butt somehow. While I do admit that I didn't put all the pieces of the puzzle together at the time, I DID stop the tube feeds. Thank goodness I checked residuals when I did and didn't let it slide until later!!! Plus, the day nurse obviously did not check for post-op orders, or else she would have filed them under the orders section. There was no order to restart the tube feeds in the first place, and if there were, I would have restarted them via the Jtube. And isn't it standard to set the NGT to LIS after abdominal surgery? Plus, the day nurse had the patient for at least 10 hours, and didn't have any other patients!!! I feel like I walked into a bad situation, but because I was so frazzled by patient #1, I just didn't have time to think through everything, and I didn't fix everything the day nurse missed. If I had put it all together, I would have called the surgeon and asked for orders. Anyway, how much should I let this bother me? Do you think I will be written up? Is this reportable? Am I a horrible nurse who doesn't belong the ICU? I'm so upset by this!! Sorry for the long post, but I felt like I needed to lay it all out.
  9. TangoLima

    Turning Patients

    I utilize the rotation feature built into our beds. Putting a pillow under these people is pointless since they just flatten the pillow anyway. Really, there's just so much you can do.
  10. TangoLima

    Holiday Pay Policy

    The only holiday our hospital pays holiday pay for is Christmas day.
  11. TangoLima

    Deciding to call MD

    I'm a little embarrassed to admit this.....but sometimes I have difficulty knowing when to call doc. I've been in the ICU 3 months and a nurse 2 years, so you would think I would have this figured out by now, right? It's not all the time, but sometimes, and it's aggravated by the fact that I work nights, and the docs at my hospital have complained so much about getting called at night that we have actually been told not to call unless we run it by the charge nurse/ANM first, and we must keep a "log" of calls to the MDs. It makes it very intimidating to call a doc at night. It's also complicated by some nurses telling me, "you don't need to call for this" or "wait until 0600 to call the doc". This is especially bad in the ICU where we are expected to use our "critical thinking". On the tele floor, we had NO autonomy, so calling the doc was an easier decision. Anyway, I get this little old lady right at shift change last night who was in septic shock. I get report from the day nurse that the ER says the BP is 80s/40s. Then, before they actually transfer her to me, the ER nurse calls and states her last BP was again 80s/40s. I specifically ask the ER nurse if any pressors are ordered, she states, no just fluids at 125 ml/hr. I roll my eyes, but say OK. So, she comes up to the floor, and of course her BP is still in the toilet......80's/40's to 70s/30s. I give her an NS 250 mL bolus per our ESO. She doesn't really respond to the fluid bolus. So, then is when I start struggling with whether to call the doc. I mean, her BP was in the crapper when she was in the ED. So, if he wanted pressors, why didn't he order them in the ER? Do I just watch her and if it remains approx the same as in the ER, don't freak out? She has a hx of CHF but lungs were clear. I didn't really want to give her another NS bolus, especially with fluids running at 125 ml/hr and fluid boluses in the ER. How much could she tolerate before having resp distress? I did end up calling around midnight and get an order for Levophed which worked great. I don't want to sound REALLY stupid. I mean, if it's an established patient, and it's a clear change from baseline, of course I call the doc. But, when the patient just arrived from the ED, isn't the doc aware of the pt's condition, and if he wanted a certain treatment, wouldn't he have ordered it? Or, why didn't the ER nurse ask for a pressor while the patient was down there with a crappy BP? Why didn't the doc write an order..... if MAP So, then this little old lady starts complaining of CP. Great! I ask all the pertinent questions......have you ever had this pain before? Where is it? What does it feel like? Does it hurt when you breathe? I immediately lower the Levophed dose from 4 mcg/min to 2 mcg/min. Of course, I just gave her Dilauded 45 mins ago when I started to Levophed because I knew her BP would be supported, so can't give any more pain med. I knew her next set of cardiac enzymes were due in 10 mins, so I wait on the lab to come draw those. I look at the side effects of Levophed and it states that precordial pain is a known side effect. Anyway, I call the doc. By the time the doc calls back 20 mins later, the little old lady states the pain is a little better and she really thinks its gas since her stomach is rumbling. So I tell all this to doc. I get an order for Maalox and 2 baby ASA. I ask if he wants to switch to another pressor, and he states no. Of course, 2nd set of enzymes is normal, pain resolves, the woman just had gas!! This same little old lady ended up having positive blood cultures this morning which were called to me by the lab. So, she already has an ID consult for today, and she's already on Vanco and Zosyn. So, do I really need to call the positive blood cultures? Our policy states all abnormal labs must be called to MD within 30 minutes of notification by lab, but REALLY? This is now the THIRD time calling this same doc. I guess CYA is the best policy in all of this. But still. Any advice is appreciated.
  12. TangoLima

    Sodium Bicarb

    I noticed this is a code situation as well. I also noticed that the HR increases when the bicarb is pushed. So, I had a nice conversation with another very experienced nurse afterward. Basically, in an acidotic situation, the cardiac cells lose their action potential, so the cells cannot contract and produce a beat. When bicarb is administered, the action potential is restored, and the heart is able to contract as it should, hence the increased HR. I am guessing this is partially explains the increased BP you noticed as well. The heart is actually doing it's job, cardiac output is increased, and therefore BP increases as well. At least this is how I understood it. I am relatively new to the ICU so I am seeing so much that I really have to stop and think about what is going on cellularly. Fun stuff!
  13. TangoLima

    ABG vs. BGE

    Can someone point me in the direction to find out the difference (if there is one) between an ABG and a BGE. I have done a quick google search and also searched allnurses, but haven't been able to find anything for BGE. We had a code last week, and everyone was trying to decide whether to run an ABG or a BGE, I guess because one of the results is faster. Thanks!
  14. TangoLima

    I use up all of my compassion at work.

    Although I don't feel "burned out" yet (I've only been nursing 2 years, 3 months in ICU) I do recognize that I tend to be a grouch to my family. In my case, I believe this comes from me being a natural introvert. I do enjoy talking with and taking care of my patients, but after acting as an "extrovert" for 12 hours, I am exhausted. So, when I get home, I don't want to listen to my family's problems, needs, don't want to talk on the phone. I just want to veg and be left alone. I'm glad to know I'm not alone.
  15. TangoLima

    Question: Give blood AND heparin?

    Thank you all for your replies. A few more pieces of relevant info: * No, I did not see any obvious signs of bleeding. * The patient's vitals did not indicate hypovolemic shock. * I don't remember what the PTT was. I don't even think I checked since I wasn't concerned with adjusting the gtt, but rather concerned with whether or not to continue it. I do see now how knowing the PTT would indicate whether the gtt was therapeutic or too high as to increase the chance of bleeding. Meandragon, Thanks for your comment about "risk vs. benefit". This is something I have to consciously work on. I tend to be a black-and-white kind of girl, when much of medicine is in the "gray area". One thing I find myself struggling with is knowing my boundaries in the ICU. On the tele floor, our hands are tied, and we don't do much of anything without first calling the doctor. In the ICU however, the nurses have much more autonomy, and do a lot of treating before calling the doctor, especially on the night shift. So, I'm having to learn to adjust my thinking and actions because of this. (By the way, hospital-wide we have been discouraged from calling docs in the middle of the night, so we often wait to call abnormal labs, results, etc. until in the morning unless it's something critical. We are going to be getting intensivists soon, so I think it will be better to always have a point of contact during the night.)
  16. TangoLima

    Question: Give blood AND heparin?

    I have just about 3 months experience in the MICU, and have a question about giving blood and heparin. I had a patient who had a Rt. IJ blood clot and was on a heparin gtt. I received report from the day nurse that the patient's H&H had dropped and she was supposed to receive 2 units of blood on my shift. So, I go in and do my assessment, notice that the heparin gtt is about to run out and called the pharmacy for a new bag. In the meantime, I start thinking, "why are we giving heparin gtt to a patient we're about to give blood to because of low H&H?" In all my previous experience (20 months on Telemetry floor), this has always been a red flag for me. I should have asked the day nurse about it, but I didn't think about it at the time. So, I start doing a little research. The patient had a history of anemia, but the most recent H&P stated that it had been stable. At noon the previous day, the Hgb was 10.1, now it was 7.7, quite a drop in 24 hours to me. The heparin gtt had been started the previous night based on the blood clot findings, but was not ordered by the attending physician, rather the on call hospitalist. There were no comments in the progress notes about continuing the heparin gtt while giving blood. Since I'm new to the MICU, I usually talk to a more experienced nurse before calling the physician, but this particular time I felt like I had thoroughly researched the situation, and that it was a legitimate, cut-and-dry question. In addition, the previous week I received a patient in the ICU who was on a heparin gtt and had developed a retro-peritoneal bleed. So, I call the hospitalist and get the on-call PA, explain the situation, including the fact she has a history of anemia and a blood clot, and ask whether or not to continue the heparin gtt. The PA gave me an order to hold the heparin gtt, do a U/A, guiac stools, etc. So, I inform the same nurse the next morning that he heparin gtt was on hold, she gave me a funny look but didn't really say anything about it. When I came in the next night, she basically chewed my butt saying the patient could have lost her arm or had a stroke, and I should have called her at home if I had a question about it. I told her that I just didn't feel comfortable running blood and heparin at the same time, and needed someone with more authority to tell me it was OK to continue the heparin. I have just felt really bad about this ever since. I know I have a lot to learn, but I felt this was a legitimate question. I have never continued heparin on a patient with low H&H receiving blood before. I talked to my former preceptor about this and she stated she probably wouldn't have stopped the heparin unless she saw obvious bleeding. Im just wondering if anyone else has any other thoughts on this. What should I have done differently? Do you routinely give heparin to patients with low H&H? Any input would be appreciated as I know I lack experience.