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TangoLima

TangoLima

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  1. TangoLima

    NaHCO3 lead to SVT?

    Hi all, Had a really rough/busy night last night, but I'll get straight to my question: One of my patients has a suspected case of necrotizing fasciitis. Her lactic acid on admission was 10.8, and had orders to start her on 1/2NS with 2 amps HCO3 at 100 ml/hr. The nephrologist also made rounds and ordered an additional 2 amps of HCO3 IV. I hadn't started the fluids yet, and pushed the 2 amps of HCO3. Before I was able to leave the room, she went into SVT with HR in the 180-210's. She was responsive, blood pressure stable, no obvious distress and would have brief periods where she would break and go into ST in the 120's which was her baseline. This went on for about 30 minutes. I called for stat EKG and notified the doc who didn't want to order anything until the EKG was obtained. By the time the EKG was done, it just captured her in ST with HR129. She came out of the episode and remained in ST the rest of the night with only 2 more short bursts of SVT lasting 30 - 45 seconds. I did call the MD the last time this occurred and she gave a 1 time dose of Lopressor 5mg IV. Since I'm new to ICU, my questions are: 1. I have seen NaHCO3 given in code situations where it raises the HR and BP almost immediately. Did giving this patient the HCO3 lead to her SVT? Is this an expected side effect, or was this a freak coincidence? 2. We tried to get the patient to cough and/or bear down to try to break the SVT, but while she was easily arousable, she couldn't cooperate with our instructions. Is there something else we could have tried to break her rhythm? 3. I feel bad about her being in SVT for so long (30-40 minutes), but I did ensure she was stable, called for EKG, and notified the doc. Per our ESO, we could give Adenosine, but I was hesitant to do this because she was essentially stable. She did end up converting back on her own, so I'm kindof glad I didn't take the risks associated with giving adenosine. Would someone else have done something different? What would your thought processes be? Thank you!
  2. 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.
  3. 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!
  4. 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.
  5. TangoLima

    Futile care

    I don't disagree that often times, the families aren't ready to let go and we end up basically torturing their loved ones until they die. I also agree that it is completely appropriate to present the facts to the family, the expected course based on our prior experiences, and discuss comfort/palliative care/hospice with them. However, it sounds like you are very aggressive in persuading the family to withdraw care to the point of getting the ethics committee involved. I mean you can only do so much, but in the end, it IS the family's right to determine care for their loved one. Also, how do you "refuse" to code a patient if that is the family's wish? I would think that could be interpreted as abandonment and/or neglect.
  6. TangoLima

    Leveling Art Line

    I'm sure this has been discussed many times on this site, but here goes...... I have been in the MS ICU for about 6 months, and don't have a lot of experience with hemo monitoring with A-lines, Swanz, etc. We just don't get many patients that critical who need them, and when we do, they go to the more experienced nurses. I have had maybe 3 patients who have had A-lines. I have asked the more experienced nurses for help in setting up, leveling, and zeroing the A-line, and have repeatedly been told to level the transducer to the insertion site rather than the phlebo axis. I really trust and respect these nurses, but tried to do some research to support what they were telling me. However, all I could find was to level all lines (Art, CVP, Swanz) to the phlebo axis. Last night, I had a post-brain biopsy pt who had an A-line that I leveled to the radial artery. She also happened to be laying on her side on that same arm with the BP cuff on the opposite arm. Anyway, her A-line and cuff pressures in no way correlated. Her cuff pressure was like 120-130 and her A-line pressure was 170-190. I'm assuming the A-line pressure was artificially high since she was laying on that arm, and her cuff pressure was artificially low since it was on the upper arm. And, as a theoretical question, if leveling to the A-line insertion site, I am assuming the pressure reading would be an accurate measurement of blood pressure AT THE INSERTION SITE. But, if leveled to the phlebo axis, the BP reading would be an artificial APPROXIMATION of central pressure due to the effects of atmospheric pressure on the transducer. Does that make sense? And, if so, why would we want an APPROXIMATION when we can have an ACTUAL? Thanks all!
  7. TangoLima

    The Dying Art Of The Physical Exam

    This is really not intended to bash ED nurses, and I will never claim to be super nurse, however...... Received a patient to the ICU with BP 40's over 20's and unarousable. Had been sent over from the nursing home, spent 5 hours in the ED, sent to a tele floor with BP 70's over 40's, then rapid responsed to the ICU soon after that. Soon after getting pt settled, fluids and blood started, I started doing my full head-to-toe assessment. As I positioned the patient to listen to the back of her lungs, saw a new nitro patch applied to the shoulder. No telling how many nurses, PA's, and MD's came in contact with this patient, but failed to notice the nitro patch because NO ONE listened to her lungs! I bet they all had stethoscopes around their neck though!! I actually saw this happen twice. Another nurse in my unit was receiving a patient admitted for PNA. When he asked the ED nurse about lung sounds, the ED nurse said, "I don't know, let me look at the chart to see what the MD wrote." Oy!
  8. TangoLima

    Highest temp you've seen?

    I can't remember precisely, but I want to say 107ish. They were suspecting some form of malignant hyperthermia, although, no recent surgery or anesthesia. If I remember correctly, they were thinking it was related to some psych meds she had been taking. She was on a cooling blanket for a long time, and we actually put ice bags on her. Don't know what ever happened with her. Will have to ask when I go back to work.
  9. TangoLima

    checking NG tube placement

    What is insufflation, and how would one do it?
  10. TangoLima

    What do you consider a positive troponin?

    I think our hospital considers anything over 0.1 as positive. However, these patients will usually go to a telemetry floor unless unstable or having an active MI. When I was on tele, we would routinely get patients on Nitro gtt. Positive troponins can be attributed to renal failure. I had a patient the other day that has chronically elevated troponins, although at this time I can't remember why, but every time he comes into the hospital, his troponins are high. No chest pain or other symptoms at all. Go figure.
  11. TangoLima

    How do you stay sexy in nursing school

    This was the best reply so far! Made me crack up! I take a shower before each shift, brush my teeth, and wear deodorant. I usually pull my hair back in some way, but sometimes wear it down. I wear natural makeup. My scrubs are clean and in good condition. I don't wear earrings anymore because I lost one while taking off an airborne mask. Actually, I only wear my wedding ring and my watch. NO FRAGRANCE! NO ACRYLIC NAILS! I like some others' ideas like wearing sexy undergarments, having a pedicure, etc. We have to wear all-white tops and either white or navy pants. So, I mix it up by wearing cute socks and/or cute shoes. This job is just too hard to be worried about being sexy. I just don't feel sexy after digitally disimpacting an old lady who can't poo, or cleaning up an old lady 9 times in one shift who has no problem pooing, or suctioning mucous out of someone's lungs, or running a bloody code, or dressing stage IV pressure ulcers in a septic patient, etc, etc, etc. At that point, the only thing I can think about is getting home, getting a hot shower, and getting in my bed.
  12. TangoLima

    Sugar for newborns does not relieve pain: study

    I will probably get flamed for this.... I will preface this comment by saying I'm not in NICU, so am not very familiar with what procedures would sugar alone be used as analgesia. For a simple heel stick, I would say that it's over really fast, so perhaps no analgesia is needed. But for other invasive procedures, such as circumcision, I think it is ludicrous to think that sugar = pain relief. There are too many other modern options for pain control to rely on something that has questionable efficacy. EMLA cream anybody?
  13. TangoLima

    Joined AACN, was it worth it?

    I just joined AACN too. I haven't received any of the publications yet, so can't speak to their usefulness. I find a lot of articles to be less than helpful. Like, I just read an article on ST segment monitoring (actually, I started reading it, got frustrated, then skimmed to the end). It talked about all the evidence/studies demonstrating WHY ST monitoring should be done as in timely detection of ischemia and decreased mortality, but did not discuss HOW to do it, etc. I just find that in this point of my career, I need more WHAT to do and HOW to do it, not a bunch of theoretical fluff. I read Nursing2010 and find that to be about the level of what I need right now. I hope one of the AACN journals will be along the same lines. I would be interested in getting access to AACN's ECCO online learning modules, as I think those would be useful. That is actually one of the reasons I joined AACN, because I thought I would be able to gain access. I was a little miffed to find out that even paying members can't access it. I will probably do some of the free CE's available not he website, even though I find a lot of those are too specific with a narrow scope of application. I do plan on getting CCRN certified, but I don't know if I'll renew my membership after that.
  14. TangoLima

    Critical Care Education Course

    Does anyone know of a good online critical care course perhaps similar to AACN's ECCO course? I am really annoyed that this course is not available from AACN, even for members. Our hospital has purchased this course for a new critical care residency program, but only bought 5 licenses for the attendants. I feel like I received a crummy orientation to the ICU and would really like to brush up on the fundamentals. I am not really looking for CEU's which seem to have a very narrow, specific focus, but rather something that is more general and all-inclusive. Thanks!
  15. TangoLima

    Was I wrong?

    I am considering going into HH on PRN basis for extra $$. Is doing dishes/laundry for the patients usually expected? I'm not above doing laundry/dishes, but I didn't envision going to nursing school to end up doing dishes/laundry. I understand the OP point that the family was requesting extra services, but that implies that dishes/laundry was expected to be done for the actual patients. Really?
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