Trauma

I work in a 32 bed CV Recovery/CVICU. Our IABP patient are typically part of a 2 patient assignment. Since we are the only unit in the hospital that cares for the IABP, we usually have 2-3 in the unit. Just a few weeks ago both of my patients had IABPs. Whether or not they are one on one ia all relative. It has been a long time since I just had one patient due to staffing issues and the inability to compensate for the nights we are short by possibly overstaffing others. As others has stated, it all the depends on the patient.

gratz on getting accepted. my advice is simple.3 words. follow your heart!

I have a different viewpoint than most. Our flowsheet is organized to chart by exception only. If the lungs are clear, just put a check in the box. If they present fine scattered rhonchi upon auscultation, then put an asterix in the box and write that in the narrative section. If its not an exception, I dont chart it. I prefer to be in my rooms with my patients to take care of them and their families. My philosophy is that if you provide great care to them, then there will be no need for a lawsuit. After 9 yrs, so far so good. I believe that charting vaguely can get you into trouble if called to give a deposition. For example, the nurse who charts "well perfused" how do you know, did you do blood flow studies to all organs and extremities? Sure, you and I know what they are talking about but a lawyer will eat that for lunch. You just have to be careful about what you chart and how you chart it. I'm not saying my way is right or the other ways are wrong. This works for me and I am comfortable with it. You have to find your acceptable levelof charting. Peace, Troy

We are a 30 bed CV Recovery/CVICU. Our 10 bed recovery bay is dedicated to all fresh surgical patients. We average 100 pump cases a month including CABG,Valve replacements/repair, AAA, Thorocoabdominal Aneurysm repair, TMR, and MAZE. Our pump cases are 1:1 for the first 4 hours and then if the patient is stable the ratio is 1:2. We have a extubation goal of 6 hrs post op that is achieved by RT/RN collaboration. Four hours after extubation, the patient, if stable, is assisted to a chair(lines and all). Chest tubes are pulled usually the 2nd day post op if CT output is less than 80ml during the last 8 hrs. Common drips include Dopamine, Dobutamine, Milrinone, Nipride, Cardene, NTG, Amiodarone, Epinephrine, Norepinephrine and Insulin. 99% come back with Swan, A-line, CT, Epicardial pacinf wires, foley, etc. Once the sun goes down. its just he nurses and the patients, no residents. I have been involved in about 25-30 emergent bedside sternotomies. I don't get the adrenaline rush anymore. After 9 yrs of seeing it, I am a lot more chilled and relaxed now. But I do remember the days! My attitude has changed over the last 5-6 years in that I would much rather take care of one of our chronics in the ICU than admit a fresh pump. Reason being for me is,recovery became routine. Writing down numbers every 15 mins. Extubate them and then its Morphine and Ice. I enjoy the multisystem complications that keep you on your toes in the ICU. Yes when a CABG goes bad, its a great learning experience, but there are more standard cases than unusual ones. For volume...give me isotonic normal saline. My rationale is that if I need volume for a dehydrated, hemoconcentrated patient, the last thing I want to do is give large protein molecules to further dehydrate the cells as colloid osmotic pressure pulls volume intravascularly. When they get normovolemic, I'll check a HCT to where I am now that the pressures are good. And Saline is way cheaper than Albumin or Hespan. Albumin has its place but I prefer Saline to start. It definately is interesting to see how other place run their units.

Shortness of breath (dyspnea). Initially, you may notice that you're short of breath only when you exert yourself physically, but eventually you may be short of breath most of the time, even when you're at rest. Fatigue. Dizziness or fainting spells (syncope). Chest pressure or pain. Swelling (edema) in your ankles, legs and eventually in your abdomen (ascites). Bluish color to your lips and skin (cyanosis). Racing pulse or heart palpitations. I take it your Pulmonary hypertension is secondary due to your CHF and COPD diagnosis? Are you being treated for those diagnosis? Secondary Pulmonary Hypertension is treated by treating the cause and not the PHTN itself. Primary PHTN(unknown origin,idiopathic) is treated with pharmacological agents aimed at reducing the pressure. Hope this helps. Peace, Troy

Augigi, Please forgive me if I have insulted you for that was not my intention. The phrase "does not prevent" was misleading to me to mean a definitive no. I had no intentions of insulting your knowledge as I agree everyone is here to assist each other. I thought that by my asking to "please review" would be sufficient to imply that I meant no insult. I was wrong. Please accept my humble apology, Troy

LanaBanana, Just to clarify to avoid confusion, the degree of regurge should be known. If it is insignificant such as trace, +1 or +2 then ususally there is no concern. However, if the regurge is +3 causing dyspnea on exertion then you may consider a surgical consult. The main thing is to prevent futher hypertrophy and demand on the heart. Chest pain is a very serious issue and should be thouroughly elvaluated. The MR could be causing the chest pain itself. Not trying to worry you, just offering my opinions from my experience. Peace, Troy

Augigi, Please review your information before you post. Trasylol does in fact help to prevent the bypass-related hiastamine release. Being a protease inhibitor, it inhibits multiple mediators including cytokine and kinin-kallikrein system. The only two things an IABP does is improve coronary artery blood flow and decreases the afterload on the heart by mechanical means and not the Windkessel effect. As the ballon deflates onces the aortic valve opens, it creates a vaccum therfore reducing resistance. To the original poster, Maybe this will explain the results you were seeing. Systemic vascular Resistance is determined by the pressure(MAP-RAP) divided by the flow(cardiac output) Since this is just a calculated number, a small decrease in your Cardiac Output by decreasing your Dobutamine would lead to an increase in your systemic resistance usually evidenced by an increase in your SBP and MAP.(Your RAP would likely go up also.) It will not take large numbers to skew the physiological changes you noticed. I may be off course as it is late and i just spent the last three hours learning about the sterochemistry and volume of distribution of pharmacological agents. Hope this helps, Troy

Premature ventricular contractions become more common the older we get. They can occur because of stress(both mental and physiological), pathology and sometimes without an explanation. The most important question is are these PVCs unifocal or multifocal. Unifocal meaning the morphology of each PVC is the same originating from just one place in the ventricle. They are multifocal if the morphology changes from one PVC to the next usually indicating a diseased heart. The reduction of cardiac output due to improper filling time from the regurgitating valve can lead to decreased blood flow to the coronaries leading to chest pain and ischemia producing the PVCs. The Toprol is a beta blocker thereby decreasing the contractility of the heart and decreasing the workload. Because of its negative chronotrope effect, the heart stays in diastole allowing for greater filling pressure to achieve an optimal cardiac output. In addition, the coronary arteries are filled in diastole as blood is pushed back toward the closed aortic valve so a slower heart rate>>>>longer diastole>>>>better perfusion of the coronary arteries. It may be time to evaluate the degree of mitral regurge and begin to interview CV surgeons for either tissue or mechanical valve replacement. Hope this helps. Peace, Troy

Well I guess you could elaborate and say the left and right atrium as well as the pulmonary artery. Other than those 3 things, I am stumped. Peace, Troy

Ill take a wild guess here and suggest that maybe he/she is asking for the location of the reference point. The junction of the fourth intercostal space and the midpoint of the anterior-posterior diameter indicates the phlebostatic axis. Exactly what is the question he/she poses to you? While looking at the entire question we can see something maybe you are not. Awaiting your reply, Troy

I was going through all the post and I can only think of a couple of tidbits to add that may or may not be responsible for the low DBP but I'll share my experience. The first thing that caught my eye was that this pt was on Dobutrex. Being a Beta 1 agonist stimulating the beta cells found in the heart, it also stimulates the vascular smooth muscle cells causing a slight vasodilation. It has been my experience that when Cardiologists order Dobutrex to increase B/P, I see the B/P remains where it is rather than increase. The second thing comes to mind is how long has this patient been out of surgery? As we know the Bypass machine triggers an acute inflammatory response with massive amounts of histamines,prostaglandins and bradykinins being released which lead to vasodilation and increased capillary permeability causing a third space shift and hypovolemia. It could be that the patient has lost vascular tone and the compensatory mechanism of a catecholamine release has not yet occurred due to the general anesthesia he is still under. This would explain the wide pulse pressure. I agree fluid would be my first suggestion, however, if true hypovolemia is the culprit(Hematocrit of 40 or higher) I would use NS instead of Albumin. The reason is Albumin works by increasing plasma osmotic pressure drawing fluid from the interstitium and the cells. The last thing we want is to further dehydrate the cells. Without a Swan Ganz catheter to monitor wedge and PA/RA pressures, fluid challenges will be a closely monitored process depending on the pre-op EF%.(Can the muscle handle all this volume?) One thing with valve replacements is that they all require extremely high filling pressure for the first few months until the muscle reverses the hypertrophy created in order to open the faulty valve.I have seen a PAD of low 30's needed to maintain UOP, CO/CI, and B/P. Off topic. Another reason I dislike using Albumin in post mechanical valve patients if their albumin level is normal is that Coumadin is 99% bound to albumin with about 1% in circulation. If we increase the patients Albumin levels above the normals then it takes a ton of Coumadin to get them therapeutic. Then when they go home, their albumin levels return to normal and all this Coumadin is released causing potential problems. That is all I have to add. I appreciate the knowledge that was displayed in the previous posts. Its nice to see other RNs out there who take their job serious and realize that the greater the understanding we have of the human body and its interactions, the better care we can give.

The book that I have used throughout my career for studying for the CCRN and whle finishing my BSN is AACN Clinical Desk Reference. This book will give you more than you ask for about any system and will provide you the majority of the answers you seek. It is not cheap costing me $140 several years ago, but I have not regreted the purchase.

We use a combination of all the drugs above at any given time depending on the circumstances. All of our pump cases are started on an insulin drip with Q1 hour accuchecks for the first 24 hours and then Q 4. I have to agree with TENNRN2004 about the volume issue. Preop, these guys required higher filling pressures to open the malfunctioning valve and post op we keep the PAD around the same as the cath report showed. We have to in order to maintain a decent stroke volume index and good UOP. Neo is ok but IMO it is very weak in its Alpha stimulation compared to Epi and Norepi. Almost 90% of the time if you start Neo , go ahead and mix the norepi...you're gonna need it. Just my 2 cents.

No matter what job you do, you will have negative people expressing thier negative energies. But only in nursing can the rewards be as sweet as making the critical difference in someone's life. No matter what the pay or the nurse:patient ratio, I will never regret becoming a nurse. It is not a job to me but a way of life. Troy,RN,CCRN [This message has been edited by Trauma (edited November 21, 1999).]