TangoLima

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!

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.

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!

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.

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.

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!

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.

What is insufflation, and how would one do it?

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.

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.

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?

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.

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?

In our unit, CRRT is 1:1. I routinely have 2 vents, which in some ways I prefer over someone who is on the call bell every 30 minutes. The 1:1 vent sounds like a dream come true. Sign me up!

What do you mean by "cutdown technique"?

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!

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.

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?

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.

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.

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

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.

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!

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!

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.