trvlngrn22

I just responded to a poster that submitted "how I stopped worrying and learned to love the monitor". It somewhat references alarm fatigue and I posted the words below. While I personally dislike joint commission on this one they did hit the mark but without any real message on how to. One pt stands out in memory. In for persistent V tach, she was going to see an electrophysiologist. Therefore she rang a critical value alarm continuously. But this pt had a pulse throughout her entire stay. As we were in a cardiovascular ICU with post op CABGs, post cath pts and generally sick pts, how do you safely monitor everyone else. Fortunately she had an arterial line and we were only going to treat her if she changed to pulseless vtach. So, I changed her alarm to aline to the critical value, greatly narrowed the parameters, and put vtach on message. Finally, quiet came over the unit. Everyone was told about the changes and I felt the pt was more accurately monitored for what we were going to and need to respond to. Imagine my disappointment when the next day I was called into managers office and told that this was inappropriate. Like we needed the constant reminder th pt had vtach with a pulse. Anyway my response to the other article is below. I find that a lot of people blame the monitors when they are only telling us what we asked them to. "I like the topic. I try to get my coworkers to love the monitor as much as I do. Alarm fatigue is a huge issue. So make the monitor work for you. Adjust alarms so they are appropriate. This might include limits or the alarm value. For example narrowing rate alarms,ie if I have a pt on cardiazem or amiodarone, raise the lower to 60 or 70 as the med might be *too effective * and lower upper to 110-120 after gaining some control so you know if med is ineffective.* Also know lead placement. Frequently I receive a pt who rings for asystole all day due to one lead reading that has such a low amplitude that it does look like that. Placement may have to go way off standard to get all leads to read. Remember the monitor reads all, not just the display lead. Also, pacemakers are sometimes challenging as leads may have to be moved to accommodate. You can go to your manual for the monitor to see the changes needed.* Review the limits, know the reasons for false alarms and how to fix them . Even frequent artifact can be and needs to be corrected. The wires themselves may be microfractured and need to be replaced. Sounds like you learned to always check the pt first in the case of alarm. I just want to say help the monitor work for you."

I like the topic. I try to get my coworkers to love the monitor as much as I do. Alarm fatigue is a huge issue. So make the monitor work for you. Adjust alarms so they are appropriate. This might include limits or the alarm value. For example narrowing rate alarms,ie if I have a pt on cardiazem or amiodarone, raise the lower to 60 or 70 as the med might be *too effective * and lower upper to 110-120 after gaining some control so you know if med is ineffective. Also know lead placement. Frequently I receive a pt who rings for asystole all day due to one load reading that has such a low amplitude that it does look like that. Placement may have to go way off standard to get all leads to read. Remember the monitor reads all, not just the display lead. Also, pacemakers are sometimes challenging as leads may have to be moved to accommodate. You can go to your manual for the monitor to see the changes needed. Review the limits, know the reasons for false alarms and how to fix them . Even frequent artifact can be and needs to be corrected. The wires themselves may be microfractured and need to be replaced. Sounds like you learned to always check the pt first in the case of alarm. I just want to say help the monitor work for you.

As far as I know, you will not be able to get on with a company without some experience. A new grad does not have the skill set to walk into a new hospital and be able to pick up and go. Orientation, if any, is usually directed at more of the administrative stuff, not nursing skills. You will not always know the specific hospital protocols and so will have to rely on good clinical judgement, sound practice, accepted methods, and most importantly experience. Sorry, but a new grad will not be able to demonstrate those things. My company asks for a work skills list ie, pulmonary catheters: 1. I am very experienced and would be able to teach/precept someone about them. or 2. I am comfortable with them or 3. I have a little experience but would need resourcing/help available or 4. I have no experience with them. It will be very hard to justify hiring someone who has a skill set of 3s or 4s. What would you have to offer a hospital that needs help when they are short staffed? I like travelling, but you have to be very self reliant. By all means pursue it if you want..after you gain some experience.

Dorimar, like you, I found myself becoming more negative and disappointed in my peers. Labelled as having a bad attitude by those that did not understand my frustration. Then a friend gave me this quote saying that she thought of me when she read it. "A cynic, after all, is a passionate person who does nto want to be disappointed again." (Benjamin Zander). Did it help, no- not really. But I liked that someone who understood me saw that passion in me. It does help to vent as you have here. I don't know why this is happening either. Nursing basics, answering alarms, common sense, all seem to be declining these days. I did change to travel nursing so that I answer more to myself, am less involved with staff issues, get to leave after I have had my fill. I might add that I am still looking for the place that I may be comfortable in. With travelling, I have worked at 3 Magnet Hospitals in the last year. Disappointed in the nursing attitude in all of them. Am trying a 4th Magnet Hospital come May, but think the answer is not in the status that the hospital achieves by pushing paperwork. The answer is most likely with the nurses like the ones who have posted here. We need to convey what is acceptable practice and lead by example. It is hard to change a work environment, but I think it can be done. Try to get some like-minded coworkers to help. Good luck.

michiganRN, too long ago to remember the specifics of optirest. The skin issues stood out in my memory because we talked so extensively with the rep and then had him do a 180 in regards to pressure ulcers. I believe the optirest was just a comfort mode, and while the bed is essentially an air mattress, I don't think it would do anything for relieving pressure in that mode...

When we started using these beds, we were initially told that they would prevent pressure ulcers if we used the rotation mode. However, we still experienced problems and went back to the rep. Then we were told they do not prevent the ulcers, and that any rotation less than something like 80 degrees was not beneficial..and that the timing needed to be almost constant. (not on one side for more than a minute or something ridiculous) Then to top it off, that we should have been using pillows. If you stand at the foot of the bed and watch the turn rotation you can tell if it is turning adequately. Most times the pillows are necessary at least for the coccyx area. Good beds for pulmonary therapy, not so great on the skin issues.

janfrn, yep, i''ve seen that too. gotta wonder what some people are thinking. one of my favorites was a nurse who had an IABP pt in reverse trendelenburg. the femoral transducer was on the pump, a good 6-12 inches too low, the radial one was hanging off the top of the bed, at least a foot too high and the cuff had fallen and was loosely around the forearm. and she couldn't figure out why the patient's numbers didn't correlate. at least with some sort of level (laser, carpenter, medical whatever..) you make a conscious effort to align things correctly.

I worked with 2 MDs of which one would have us wedge and the other would not.. Same RNs caring for their patients. Funny how you would not for one doctor's patients, but if the other was on call you ended up wedging on the patient anyway as the second wanted the numbers. Unfortunately, PA ruptures can occur. It is one of the reasons to go slowly on inflating the balloon and immediately releasing at the first sign of an overwedge. Too often nurses push the air in and then look at the monitor. The entire process should be monitored carefully and appropriate actions should take place. Even with extensive experience and very safe practice it is still a risk associated with swan ganz

I worked where they taped it to the forearm. Good enough for when the patient is supine, but they would never change (relevel) it when they turned the patient. So, on the left side, pressures were low and on the right pressures high. Not a very good job of monitoring.. As far as levelling by eye sight, you can usually get pretty close. But sometimes if you "estimate" and then level you would be surprised how far off you can be. A little bit off isn't so bad with the larger numbers of the Aline, but when it comes to the PA or the CVP, it can make a big difference.

not you 8flood8, just in general with the "no one is left behind" policy that has changed acls as well as compenticies. Really, my last class, and several before that, i felt that no one knew the material (actually many said they did not know what to do), were coached constantly (read this as they were told the answers) and yet we all passed. I have had MDs enter a code late and order meds after the patient was successfully revived. Feel for a pulse in a radial and claim they got it..the patient was asystole. I've arrived before respiratory therapy and found no one attemping to establish an airway much less breath for a patient. You sound as though you are a good student, and took the time to learn the algorhythms. I'm glad. Just saddened that it is not always the case anymore. ACLS used to be about training leaders who could run the codes and knew what to do. Now it seems to be more team approach, which can be good too...if everyone is not relying on others to come up with the basics. Again, 8flood8, not really you I was aiming at..you studied. Just venting..Please accept my apologies.

So, you have to call someone to come relieve you if you need to use the restroom or get a drink or eat. and like the others said, patient care goes out the window. When I have 2 ICU patients and am in one room, my other patient frequently needs something..that my coworkers take care of. zookeeper is right, this could lead to very expensive nonreimbursed problems. but that is hospital stuff. it also leads to poor patient care and they are the ones who suffer

Londaj is correct as far as needing an MD order. JACHO is changing how we nurse. We do not 'have the right' to hold medications...it is considered practicing medicine..unless we have parameters. But alas, JACHO wants it both ways. We also must question orders that seem unsafe. There are many reasons to give the medication. HR, Post MI, is it a new medication? a home med? the pts blood pressure may be 85 because he takes his meds. It is difficult to be a nurse these days. Sometimes darned if you do and darned if you don't. But you need to call the MD for orders if no parameters exist. Sometimes a compromise can be reached. Give when SBP is > 90, so that a med is not held for 12 hours. Or perhaps a lower dose...I myself have given antihypertensives with such blood pressures, or betablockers with HR's in the low 40s. Sounds crazy, but in each instance the patient needed the med and did fine. Do try to find out more on why. Know the peaks of your meds so you'll know when the patient is likely to develop problems if they do. Good for you to question the situation though

an old fashioned carpenters level works just as well. alternatively, you may look in hardware for a laser level used to hang pictures. probably less expensive than looking for one in the medical field.

Wow, I have been a nurse for 17 years, primarily in CVICU, and I still learn every day. I am a travel nurse and am surprised by the places I go where staff feels like they know it all... but can't read a Swan waveform properly, or adjust the timing on a IABP etc. If you feel stagnant, I feel sorry for you because you are missing so much. If medicine was always A+B=C I could see your point. But no one is the same, everything affects everyone differently and the number of problems and scenarios is infinite. Why is this patient on a small amount of epi with good results but the next bed doesn't respond to the max amounts? Why is this patient having trouble with oxygenation although they are vented on 100% FiO2? I have my CCRN and think it is a worthwhile test of knowledge, but know that many times even that knowledge base is not enough. I suggest that you start looking into a little more than just what you need to finish your shift. This may seem harsh, but no one should believe they know it all and have nothing left to learn. Some of the above had great suggestions, learn all their is about all of your equipment, all of your drugs, disease processes etc. The PACEP modules (available on AACN, SCCM etc) will thoroughly test your knowledge on Swans. And then the books, Bojar and Dvoric (sp?) are a couple of good ones. I still refer to them. Good luck to you at the start of your career. I hope that you take advantage of the learning opportunities available to you everday.