KnittingRN7

Practice makes perfect, honestly you just have to keep doing them to get better. I had changed jobs and needed to get #18's in the Antecubital vein for CT's and I never used those veins before, it took about a month and i could pop them in almost everyone, if your having an off day which happens a lot someone will help you, our IV resource team goes to our ER too. You'll get better I say a little prayer before too seems corny but I think it calms my nerves.

You have to take exactly what you wrote above and put it in those objective terms and write him up. Keep writing him up, they are reviewed by their peers but at least your manager will have a copy too. You have to stand up to him and not allow it. Make sure the nurse who actually got yelled at documents in the chart when she called him when he came in etc. And she writes up exactly what he said to her. It isn't fun but you have to do it. It does help we have had to do it for several Dr's too and it does make a difference. I haven't had it happen lately but I stand my ground and give my explanation back, I might be shaking inside but I fight for my patients and myself.

I am sad to hear your facility is still using narrative notes, most with electronic records have gone to flow sheets for assessments, education and care plans. We write a narrative if there is a major change or Dr call. Most notes have some format template and we fill in the blanks making it faster. I have always used regular language instead of making sure I always use the medical term. Maybe your facility needs to check around and find a better system. Charting long open ended notes so many times a shift is way too time consuming for you and not an efficient use of your time.

Wow I work on a tele floor and our max is 4patients days/eves, and 5 at night which is still too many in my opinion. I have been nursing for 26yrs 23 on this unit. I honestly couldn't take care of 6pts. So kudos that you do. I am constantly prioritizing. I like to check my tele then go see everyone. I get bogged down because I like to do a full assessment, check labs, peek at last dr note and at least chart VS and IV status and then get their meds. This takes me 20min minimum per pt so with 6 no way. I am less worried about getting meds out on time as making sure they are safe to get the meds. Labs ok, BP, Pulse ok. I belong to the chronically late for break club so don't always get one but try to get 2. I use my charge a lot if I get really behind. They don't want overtime but I will not lose my license so take the time to chart the best I can. I do take the time to make sure care plans and education documenting is done. I think the people who get out every day on time and to break every time and still look like they have time during the day are letting some things slide. That is my opinion don't shoot me. But I would like to see their charting and I notice they are not always in their pt's rooms or have the aides do a lot of their cares. I have a different standard for my self. That is why we are fighting for staffing ratio lanuage in our contract and will probably be on the picket line in July. With all the things we are responsible for we can't go on being spread so thin. Good luck and fight for your patients and your license.

Jeremy, what did you mean by "Supposidly lower occurance than with adenosine. Interestinly adenosine increases flow 4x, this new agen is ony 2x. So it can not be used for endothelial dysfunction eval, also may not have as much PPV as adenosine with ekg changes." Can you just explain it better for me. Can this new Lexiscan be used with pt's with Asthma or caffeine?

Lexiscan is a new one for me, never heard of it. At our practice we have a Cardiologist quickly available but the nurses run the tests and administer the meds, we have Card Techs who run the EKG' and prep the pt's etc. Seems to work efficiently. We are not radiology nurses so that is all we do all day. Can Lexiscan be used for patients with Asthma? What did you mean by "So it can not be used for endothelial dysfunction eval, also may not have as much PPV as adenosine with ekg changes." What is PPV I didn't understand that. I am interested in hearing if centers are having their Dobutamine patients walk while it is infusing, sort of like how we have a walking Adenosine protocol where they walk at a slow flat pace during the infusion it seems to limit the episodes of brady. Walking the Dobutamine's might get their heart rates up faster, but I know lot's of patients don't feel well during the infusion. Anyone have a protocol they can share?

I think the peak is about 1 hour and the half life around 4hrs. If we give a small amount 5 or 10mg I usually just keep them our 15 min that we try and keep everyone. But we can give up to 40mg, so those people usually we keep longer, but it is individual depending on how they feel. It seems the one's we give a lot to are the ones already on a beta blocker and they don't feel it. I usually watch the ones that have never had it before a little longer. It is worrisome that by the time they are driving home they are at their peak, this worried me a lot but so far our patients have done well. I tell them not to do anything real exertional for a few hours and don't change positions real fast. If they feel tired after we encourage them to go home and rest. It seems that after the contrast and extra saline fluid their heart rates and BP's go up and they are usually back to their baseline. We hold the meds if their heart rate is less than 60 or BP less than 100, or their EF is less than 20. We have a dual source scanner so our heart rates have to be less than 70, 60 to 65 is perfect. Hope this helps.

We have a dual source CT scanner and still use IV Beta Blockers. The cardiologists say the images are so much clearer. 1. We hope if pt is on oral Beta Blockers or Calcium Channel Blockers that they will take them the am of their test but sometimes they get confused and forget. 2. If Heart Rate is >70 or irregular we give up to 40mg IV Metoprolol if initial BP is >90-100sys. 3. We treat each pt individually making a nursing judgment depending on their size, VS, how they are feeling, meds they are on etc. I usually start with 5-10mg given over 2-5min. We do not have to get them less than 60 HR. 65 is a good heart rate for younger or obese people, they can use a min dose radiation protocol, and on obese people the images are clearer the slower they are. 4. If the above doesn't work we keep going until the max of 40mg. In a few rare cases we have consulted with the ct MD and they have had us give some cardizem in addition, see case below. 5. If they have asthma we give Cardizem IV up to 25mg given over 2-5min adjusting to their response. If the heart rate does not come down with the full dose, we can give 20mg Metoprolol in addition (even though they have asthma). 6. If they have more than 2 pvc's in a 10sec tele strip we give 1mg/kg lidocaine up to 100mg, or 150mg in an obese pt. 7. If they have PAC's we are to try the max of Metoprolol that they can tolerate. 8. New this week if they still have freq PVC's or PAC's we call to see if the CT Dr wants to cancel the test. I guess they lose a lot of the images during those premature beats. Surprisingly most of our pt's have done well but it is scary giving all those medications then they go home. We have had a pt faint recently with a low bp and hr in the 30's after a full dose of metoprolol, cardizem and his nitro, he was a difficult case because of afib, but we got great pictures :) and they did find a lesion so I guess it was worth it. It seems like pt's already on beta blockers do not respond to the 40 of Metoprolol. Many days I feel like we medicate the scanner though, not the patient. The goal is always for optimal pictures, but as nurses we have to constantly advocate for our patients and stop with the meds when we feel they are at their max.

Are there any other resources for policies and procedures, the ARNA is $95 a year. I to am a new nurse to radiology nursing. We don't do interventions, just CT's and Cardiac CTA's and MRI's. I job share with another nurse but we have only 1 RN in the dept at a time and are creating our own P&P's. I too feel like we are reinventing the wheel, I know there are existing policies out there and usual meds given for coronary CTA's. Thanks for any suggestions you have for Lanedoescare, because it will help all of us.

I asked the same question about extensions and our CT tech said the injector injects at 300pounds per square inch (psi). According to her that could rupture the extension. It would be best if you contacted the manufacturer of your extensions and ask them the psi it can handle. Our facility does cardiac CT angios and rarely other diagnostic ct's so I don't have an answer about the oral contrast. It seems long. When I work the hospital I thought we have 1/2 bottle 1 hr before and the other 1/2 30min before and the dept gave a bit more when pt arrived. I hope that helps.

Thank you for your response. I just don't know logistically how we would do that. We would have to call every patient and every pharmacy for them for a script for lopressor. Then when we know their creat call them back for premed if needed. As I posted before we only have 1 nurse a day and can have 9 patients scheduled. We also look up every patient's history,their creat. and a recent EKG before they arrive. There would not be time to call every patient with a prescription. We also take add ons the day before or day of test if possible. Unfortunately we have not been consistently busy enough to justify 2 RNs every day. But that is what is needed. Thanks though because it helps to hear what other facilities are doing, that is the information we need. It feels like each facility ours especially are always trying to reinvent the wheel. I know there are places out there doing it successfully and efficiently. Any other suggestions would be appreciated. :typing

In our clinic in MN, we (the RN's) explain the risks of contrast and obtain a consent for the CTA's. We have been told by our physician what percent of risks to tell the pt's. Our adenosine MRI's have a consent, but I don't think our regular MRI's do even though they receive gadolinium. We are looking at starting them sign a consent in the near future.

We use tegaderm the 3M product it comes off easily, some of the techs use just the plastic tape. I like the occlusive dressing better, I can see and feel the site better.

We just worked on our protocol and are changing from creats to GFR. We use the NDRD for GFR. It is calculated by age, sex, creat, and if african-american or other ethnicity. I found that any woman over 65 with a creat of even a 1 or 1.2 will have a GFR under 60, men stay about 20pts higher as the ages progress. We were going to give mucomyst to any pt with GFR We standardized our protocol with what the Interventional Cardiologists use. If the GFR is We instruct for 64oz or more of fluids after, unless low EF then just drink slightly more than usual. Dialysis pt's no mucomyst or fluids just have to dialyze either that day or within 24hrs. If the GFR is We are still discussing IV hydration, because we are a clinic. Sodium bicarb and holding the pt for >1hr after probably won't be cost effective. We are discussing we may just run 250-500ml of saline in before and after the exam. Will need to adjust for chf pts depending on ef. We hold metformin for 48hrs after contrast, not before. The literature says to check creat before resuming but our cardiologists don't do that. If their GFR is poor, we as nurses have suggested to the pt to have their Primary MD check it again. It is interesting to find all the different policies.

I work in an outpatient cardiology clinic with a Ct scanner. We are currently using metoprolol for rate control. Some of the Dr's talked about trying esmolol because of the 9min 1/2 life. Another Dr said in other OP centers they use amiodarone. I would like to hear from anyone doing this and what their protocols are. I could imagine that their bloodpressure does not do well with these drugs and it would be more profound than metoprolol. Of course our pt population is 70% elderly with already compensated hearts and they are on a lot of oral meds. Any experiences?