StayLost

I just stumbled upon this post. As a nurse manager in CT surgery, I have worked with the most amazing group of Clinical Nurse Specialists. I can speak for the ICU-- this is such an important role. Healthcare keeps stretching and divesting in Nurse Educators and CNS's. The status of our healthcare system is really sad when we don't value this VERY important role.

The gold standard for Cardioversion is Propofol Rapid IVP right before shock is delivered. There are times when a patient is symptomatic and can not tolerate the hypotensive effects of proposal, which we would give fentanyl and versed. And then there are times we shock because we can't wait or the patient will arrest.

I work in New York City. It's the norm here for ER nurses to oversee 16 or more patients.

We routinely use Amicar as well. If there are problems with bleeding, it's not uncommon for our patients to receive DDAVP in the OR.

It would be impossible to answer this questions without being there. Was there a proper waveform with diacritic notch? Were you able to draw back any blood? What was the difference between the systolic and diastolic - a dampened waveform will often give you absurdly narrow pulse pressures like 200/190.

The patient does not need to be flat for zeroing lines- in fact, the lines don't even need to be connected to the patient to be zero'd. We lay patients flat when we zero so that we can get the most accurate numbers, specifically the CVP. The 'flat and level' CVP is the most accurate. When I change pressure lines, I usually just kink the line before connecting the fresh line/stopcock. If you find it too stiff to kink, you can wrap a 2X2 and kelly clamp.

YES! IMO, this is how an experienced nurse gives report- don't need to know how long the bypass/XClamp time was for a patient going to the floor. If at any time I need to know about the patient's grafts (which has never ever happened) I can look them up in the surgical report. Just give me the major issues over the last 24 hours. Reports that drag-on drive me nuts.

Your patient does not need to be flat when changing the pressure lines to a swan What I usually do is kink the PA and CVP before inserting the new line, then draw back any possible air from the new stopcock. There are times when I use kelly clamps/hemostats by wrapping a 2X2 around PA or CVP before clamping it-- for instance when I am trying to detangle lines and I disconnect for some time. In order to Zero the transducer, the patient does not have to be flat-- remember, when zeroing the stopcock is off-to-patient. In fact, it doesn't even need to be connected to a patient to be zero'd to atmospheric pressure.For instance, when placing a swan through an introducer, the PA must be zero previously, as they use the various waveforms in each chamber of the heart to guide them for placement. I would suggest looking at the you tube video "Floating a Swan". Historically, the reason that we lay patients flat when we are zeroing because the CVP is most accurate when the patient is flat with the transducer level'd to the 4th intercostal midaxillary space.

I have worked with cardiologist that will run dopamine wide oven during a code, especially with asystole.

At my current hospital we do not get any compensation when caring for ECMO patients. In the past I worked for a hospital that would pay me an additional $8.00/hr for VAD/VA ECMO patients. Should an ECMO patient be 2:1 or 1:1 ? With any device, that depends on the patient. If a patient comes from the OR and is a train wreck, you may need 2 nurses to manage - one in the room, one out of the room. In my currently unit, I have never worked with another nurse to care for a patient receiving ECMO therapy. Although some may not agree, I believe ECMO patients are often one of the most stable patients on the unit- assuming the patient isn't bleeding or stroking out. This is because we have so much control over their cardiopulmonary function. It's very similar to managing centrimag BiVAD, and in fact we sometimes we use Centrimag with an oxygenator setup. In my current unit, perfusion rounds every few hours to check blood gases, change settings, & document ECMO values. If we have any problems we can call perfusion, who are only a few min away. Otherwise, its very nurse driven. There definitely should be some training course for a new program. There are a number of things you need to be aware of when managing these patients, (i.e. pressure changes in the circuit, chattering, flows dropping)

At this point it's time to consider either VV ECMO or discuss withdrawing. I would not attempt CPR while a patient is prone.

As a cardiac nurse, let me take a stab: Afterload is the pressure that the heart must pump against. SVR (System Vascular Resistance) calculated value we use to evaluate afterload. We calculate the SVR using the Cardiac Output, Cardiac Index, CVP, Arterial BP, & PA pressures. So, if a patient has high BP (let's say a systolic of 170 mmHg) the heart has to work extra hard to circulate blood agains such a high after load. We give medications, such as Lopressor, that decreases afterload, or the amount of pressure that the heart has to pump against. Now, lets look at your patient. The patient is tachycardic & BP is in the toilet because this patient is profoundly vasodiolated due to shock. A swan is placed & we got get a very high Cardiac Output of let say 10 and a very low SVR of 500. The CO will be elevated because the patient is vasodiolated. The heart has only 65 mmHg of pressure to push against, it's almost "pouring" flood into an aorta. We can concur the the afterload is very low because the SVR very low. As a compensatory mechanism, your heart will beat faster and faster, thus increasing CO(the amount of Bl ejected every min) to try to maintain a decent blood pressure. It doesn't matter how fast the heart beats, it just pours into the dilated vasculature and pressure isn't coming up. How do we fix it? Increase afterload - basically 2 ways: Give large amount of volume to "fill the tank". This will fill up the dilated vasculature, and help increase the afterload. Or start vasopressors to cause vasculature to clamp down.

TPN always needs it's own dedicated port Bicard should be run though it's own dedicated like, as its incompatible with virtually every med.

CT patients can go to sh** on you faster than any patient - extubated and sitting up one 1 minute & bleeding with a MAP in the 40's the next. I had a patient completely exsanguinate in less than 10 second through the chest tubes, with blood overflowing all over the floor. Some go back to the OR, but usually there is no time & we crack open chests at the bedside. Place bedside ECMO or IABP. The cases that come out of the OR at night shift are usually the sickest. The later cases the non-elective, emergent cases. For us, a typical 3AM admission is a train wreck: bleeding with REALLY long bypass times, vasodiolated, high-dose pressers/inatropes, multiple devices (I.e. BiVAD, ECMO), Nitric Oxide, open chest, and now.. not making any urine.

I much rather get paid less and have a better work environment. I was just talking about this last night with a coworker. My last job was amazing- New equipment, higher quality supplies, more staff, fast turn around with labs and medications from pharmacy - but these things came at a cost. I now get paid significantly more at my current job, but I believe having less stress and enjoying the 40+ hours I spend a week more important than the money. shouldn't have left :)

Same here - 1:1 the whole time

Unlike teaching hospitals with a ton of residents, I have worked in private hospitals where it's not uncommon to run pressers through a PIV- like when it's the middle of the night and there is no provider to place a central line. My question to the OP is this: is it's really necessary to assess the patency of a PIV if you are maintaining a blood pressure with your drip running & is it a good idea to interrupt the drip to flush it? I agree with MunoRN running vasoactive medications through a manifold/carrier line is the best, as you and not only titrate the medication but also the rate that it's delivered to the patient.

What I am speaking about is not a summary provided by an EMR. It's a separate form that has fields for every body system where you pencil in key info

The unit always comes up with new forms for us to fill out, some that make me uncomfortable and some that take up my time & annoy me - BUT ALL OF WHICH are NOT part of the legal chart. One of these forms is a hand-off sheet, were the nurse highlights info about a patient, and initials it with the nurse from the next shift. When something goes wrong, the management immediately goes to the hand-off to check . For instance, if a vanc through is missed and they nurse blames the previous shift for not reporting I personally refuse to fill out this form because I believe it sets you up for trouble. It's not in our hospital policy to fill out such a form. I told this to another nurse, and her response was, "that's why they have everyone sign the education form when they introduce it" When I sign this form, my understanding is that I am signing that I was present and heard it, not that I am bound to do it. My question is, am I wrong? When we sign those education forms, are we agreeing to abide ?

Amio bolus of 150 mg IV over 10 min and then started on a drip at 1 mg/min X 6 hours, then decreased to 0.5 mg/min continuously. When transitioning to PO, the drip is turned off after the second PO dose.

My hospital's practice: Lines are pulled by the department who placed the (i.e. Cathlab tech). This is because the nurse needs to be free to manage the patient. 1) Verify ACT 2) When the sheath is removed, manual pressure is held over insertion site for 20 min, and if no A-line is present, obtain NBP q 5 min. A Nurse must stay at bedside while tech holds pressure. 3) After pressure dressing is placed, the nurse inspects site with tech - notes any hematoma. 4) Vitals and Vascular checks q 15 x 4, q 30 x 2, then hourly until bed rest over 5) If not indicated in the order, One our of bed rest for every french ( i.e. 4 hours of bed rest for a 4 french sheath) 6) We only place a femstop with an order when oozing continues after manual pressure is held, starting at 50 mmHg, making sure to check pulses on limb it's placed on.

Sometimes we transduce a CVP just because we can.. a patient has a central line or even a PICC, so ... why not? In this patient population, I probably would leave it open to CVP, DRIP, & PT. I would intermittently check an accurate CVP by turning the stopcock off to Drip. Since your patient was on Oxtreotide, sounds like he/she may have had a GI bleed. This is a clinical scenario the CVP is very important- we need to monitor fluid status. Using the CVP for IVPB infusions is no big deal, but I would try not to use it for Continuous IV infusions.

#1 - There is a ton of stuff involved with a transplant work up. It's very complicated and there are many rules We used to give Isuprel to increase HR in Sinus brady, but not with post-of heart transplant patients. Taking care of a Post-op heat transplant is much like a CABG with a few exceptions. Anti-rejection meds are priority - you need to have an understanding of what types of induction meds your center uses. It's important the the anti-rejections meds are delivered on time. Otherwise, you really want a new heart transplant to have a HR 100-110. Our patients usually have pacing wires- I have had to pace them to keep their HR up. I've had a few new post-op transplant patients acutely reject, after which we will usually place ECMO for BP's refractory to pressors. #2 - An impella is a short term VAD, so it may be used in place of an IABP for a patient that needs extra support. The impella is not used as much in the units I've worked because it requires an Echo to verify placement. The older models could very easily migrate. One of the perks is that it can be placed in cathlab. In my unit, since I work in Open Heart, if a patient requires extra support, we will use centrimag as an LVAD or BiVAD. Heart Mate II is long-term VAD for support as a bridge-to-transplant & one of the only devices that is approved for destination therapy (no transplant). Usually indications for a LVAD is EF Every LVAD has different Pro's & Cons. Heartware is becoming more popular, but works best for smaller people. HMII is still the most popular device. The Cetrimag is still our go-to device for RV Failure. #3 - Some on here may disagree, but POWER FLUSH! Most importantly, its important to develop a culture of taking care of your lines. If you can't get a good waveform, sometimes slightly inflating the balloon will float the PA back into place. THat's my magic fix. 4) Their PA #s are always extremely high and rarely anywhere near normal, and the MD directs the nursing staff to titrate up/down on milrinone on what can appear as on a whim. If it's dobutamine/levo combo or just dobu, it's usually RN directed and parameters are set in our MAR which is easy enough to figure out and follow. It doesn't help my past experience with milrinone is limited on textbook knowledge that is a inodilator etc. #4 - We tend to try to keep out PA pressures out of the high range in heart transplant patients. This is because of the RV. If PA's are high, the RV will have to work against that increased pressure. We usually give Nitric Oxide or Ventavis gas to help dilate the pulmonary bed. #6 - Some units I've used chlorhexidine for oral care, others I have not.

I have a Master Cardiology and it's AWESOME. Where is it? In my closet. My current unit puts a cheap disposable one in each room, and they work just fine. I agree, save your money and get one down the road.

I disagree. In my experience, nurses who transfer to the Critical Care from tele often have a difficult time adjusting their priorities, which in the ICU translates to bad habits. Besides, after 3 years of working in the ICU is there really a distinguishably differences between a nurse who started as a new grad or one with previous experience in step down? I don't think so.