TexRN08

More about IV drip management! Titrating/bolusing/weaning (esp. drugs like propofol, versed, fentanyl, levophed, nitroprusside, dopamine, vasopressin etc), ideal ways to set up multiple drips (when you have more drips than ports), how to prepare for common bedside procedures (intubation, a-line insertion, central line insertion, Swan-Ganz insertion, TEE etc), external pacemaker set up/use, reading ECGs, Swan-Ganz catheter readings (what they mean, how waveforms should and shouldnt look), how to properly write nursing notes (what to include, HOW to say things correctly etc)... im sure I can think of more, but these are things I really felt unprepared for as I started my first nursing job..... some of these topics were taught but not emphasized and others I may have seen a couple of times in clinicals but not nearly enough (think I may have titrated a nitroprusside drip and thats about it during school).. Other things were neglected simply because they were not utilized at the hospital where I did clinicals/went to school (ie. Swan-Ganz and narrative-style nursing notes)

I work at a large level 1 trauma center so they are hiring the LVNs as support staff instead of CNAs (which we currently have). The duties of the CNAs/techs are primarily accuchecks and recording urine outputs, so from what i took from the discussion is that by replacing CNAs/techs with LVNs our support staff will be able to carry out a broader range of functions, thereby allowing the RNs to focus more on other tasks. In addition, as I mentioned earlier, they will also be able to take over care of the stable patients who are awaiting transport. We're guessing this is a way of freeing up an RN when a new admit comes in without having to call someone in. So far they haven't given us exact details about how it will all work, but they have started the process of hiring LVNs to one of our ICUs. I suppose they want to try it out in one unit first and work out the kinks before implementing it throughout the entire ICU. We shall see :-)

Our director of nursing spoke with us the other day about the hospitals plans to start hiring LVNs to replace the CNA's and techs in our ICU. The reason being is they are planning on turning over care of our ICU patients who are stable and awaiting transport to the floor over to LVNs, allowing the RNs to maintain true ICU patient assignments. While this makes sense we were discussing today whether or not the RN still remains legally liable for that patients care after the LVN assumes care of that patient. I know that this probably varies from state to state, but I'm just interested in anyone whose facilities have implemented a similar plan and how it seems to work for them. Personally I think it sounds like a great idea, but other nurses in the unit are pretty skeptical about how it will all work out. Thoughts?

This is why I find it so counter-intuitive when people say that withdrawing life support measures is wrong b/c it's "playing God"

I'm a pretty new nurse as well, but this is how I recall learning how to do this (someone correct me if I'm wrong)....The stopcock should be turned off to the injectate syringe if you want to get the CVP. The injectate syringe (at least here) is connected in a straight line to the Swan port and the CVP line is connected perpendicular to these. So if you want to get a CO you turn the stopcock toward or "off" to the perpendicular tube (the CVP) to close off that connection and allow the saline from the injectate to run through. When you are done turn the stopcock toward the injectate syringe to open back up the CVP line and resume CVP monitoring. The reason you want the stopcock open to the CVP line when monitoring CVP is because the transducer senses the pressure as its transmitted through the saline in the CVP line and translates this into the number readings you see on the monitor. That's why things like air bubbles and kinks in this tubing can distort the accuracy. I hope this doesn't sound confusing, but this is how I understand it to work.

In my nursing school we were assigned one preceptor to work with through our entire class of hospital shifts and as part of our clinical requirements were we told to write our preceptors a thank you card on our last shift with them. I doubt that if this were inappropriate that we would be told to do this, and some people even brought gifts (nothing fancy just brownies, cakes or candy for our preceptor and the rest of the nursing staff to enjoy). So i say go for it, just don't go too over the top, at the very least I don't think you can really go wrong giving someone a thank you card :-)

Haha yes I do realize that "happy nursing school hospital" does not = real world hospital... my preceptors are often amused by the things we were told in school lol... However, this was a hospital-wide view, not just that of my nursing professors.... And thanks for the website I'll definitely check that out... practiced shooting some COs today and do see how it can be particular. Had to do it a few times before my numbers were close to what everyone else was getting, but I'm going to work on getting it down... Thanks again for all the help :-)

The TV was decreased to 400 (i gave you his pre-ABG settings).... And yea everyone involved knew this pt. was probably not going to survive very long, we were just doing everything until the family could make a decision. Just found it to be a great learning experience with so much going on, and I really want to start understanding the objective/goals of treatments and what types of outcomes to expect from all the interventions. I really have enjoyed reading everyone's responses because it challenges me to look at the bigger picture. Thanks all for helping me think through this :-)

I see... I haven't had orders to do that yet, so I guess I will get a better grasp of it when it happens.... I guess I'm just having trouble coming around to them since I've been groomed during my education/school clinical experience to believe that PA catheters are the devil and now working at a place where they are king lol

I guess that's my question about them. Anytime I've mentioned that my old facility did not use them, everyone would ask well how did you get CO/CI? So then I ask well what are we using those numbers to do? How much does it impact the course of therapy?? I honestly have no clue, because I have so little experience with them. As far as the types of patients, other than CABG, its been so variable that I can't recall off the top of my head, but I will start paying more attention to that. How do you incorporate those numbers into your nursing care?? So far in my limited experience I haven't used them for anything, bc honestly I don't know how to, but if I'm missing something I definitely would like to know :-)

I have seen neo, but haven't had a chance to really work with it yet. And yes, they recently changed to weight based dosing for levo so many of the nurses are getting used to that (many of my preceptors have had a calculator on hand to calculate the mcg/min because that is what they are all still used to). We eventually did hook up a CVP monitor and on avg he was~12 and the pt. had terrible ascites (liver failure) so the doc had put in some sort of abdominal drain (i forget what he called it) which we were replacing every 2 L drained with 25 g of albumin. By the end of the 24 hr period we had drained ~8L from the abdomen (which had pharmacy upset because they said we shouldn't be pulling off more than 6 L, but the docs goal was 10L before clamping -- we called to clarify b/c pharmacy was reluctant to give us anymore albumin but the doc confirmed that 10L would be fine) We also had D10 IVF running but I can't recall the rate (I want to say 150 ml/hr), because when they had turned off the D51/2NS drip our next blood glucose was 22. The pt. had gotten dialysis a couple of times during day shift since his UO = 0 for 2 days (i think they pulled ~500 mL the first day and ~1000 mL the second day), but not sure of the details other than that. The pt was ventilated and I believe the setting were A/C with TV = 600 R= 14 PEEP = 5 and FiO2 60%, but his RR was was 30s-40s which we were trying also get under control with our sedation drugs. We were doing Q3H x 3 ABGs which initially showed metabolic acidosis, we gave bicarb, and the next ABG showed respiratory alkalosis. I thought that this was because of his respiratory compensation for the metabolic acidosis, but the doc said something about having 2 separate unrelated processes going on (he was kind of hard to understand so maybe some of you can help me fill in the blanks here).

The max rate we can give vaso is 0.04 units/min and we his levo was on avg 0.5 mcg/kg/min and dopamine around 17 mcg/kg/min (max for this here is 20 mcg/kg/min)... I am still not really good at knowing whats high, low and avg doses, but when I asked my preceptor if this was alot she just said he was on fairly high doses.

I'm a brand new nurse and the hospital I did my clinicals in did not use these. I don't want to say they NEVER did, but the general consensus at that hospital was that current research does not support their use, therefore they were pretty much phased out (we didn't even keep the supplies for them in our equipment room). However the hospital I am at now uses them all the time, and many of the nurses are not happy about how often one of the docs here will just put them in everybody (including non-cardiac patients). So my question is how often (if ever) are they used at your facility and what sort guidelines are in place for their use? The docs at my old hospital seemed to do just fine without them, so it confuses me why the doc here is so into using them with all of the risks they pose. Also, in your personal opinions (especially those of you have been nurses for a long time and greater amount of experience using them) do you think that the benefits outweigh the risks??

I forgot to add this as well to my thought process, and let me know if I'm going in the right direction or not: As far as sedation I should probably start with the propofol or versed and leave the fentanyl b/c the fentanyl will handle pain, propofol doesn't. Also I think I remember reading that longterm use of propofol isn't really desirable, and versed/propofol are more alike in terms of what you add them to achieve. (like most pt.'s i've encountered will start with fentanyl/versed or fentanyl/propofol, adding a 3rd when 2 isn't cutting it). As far as the pressors I was thinking maybe starting with the dopamine or vaso and leaving the levo alone. My reasoning behind this was i know dopamine can cause tachycardia (and the night before when I was with this pt. I had my first run in with SVT, but IDK if the dopamine had anything to do with this??) and also the vaso was maxed out so if something were to happen we couldn't increase it's rate to correct it. Then from there I think I narrowed it down to starting with vaso because the pt. had 0 urine output for about 2 days, and I thought I remembered that dopamine is good for renal problems b/c it vasodilates the renal artery (but then someone told me that they are currently questioning if dopamine is really THAT effective for renal problems) Also, in my experience so far levo seems to be the 1st pressor many docs will start (I think I remember hearing that its more specific for alpha receptors than the others so is less likely to cause undesirable effects on the heart through B-receptors), but other than that I don't really know why its the one they usually will start first. Another thought I was thinking when deciding to keep the levo around is because unlike the dopamine or vaso, there's not as defined max dose like the vaso and dopa so I can usually always go up on it if necessary (but I also was told that after going past certain dose that its not really effective anymore, but we were far from that on this pt.) I think this pretty much sums up my thought process while I was staring at the pump at the bedside trying to make a decision. So critique away pleeeeassseeee :-) , especially if some of my thoughts were totally missing the mark. Better to be wrong now than later when these decisions are completely left up to me

I really appreciate all of the feedback. I guess my main problem when they are on 3 pressors (levo/vaso/dopa) and 3 sedation drugs (fentanyl/propofol/versed), and deciding for example well x,y,z ALL cause this effect, but which one is most likely to be causing this and I should probably try decreasing first. Or the other day I had the doc say we need to start trying to get this pt. off of all of these pressors. The pt. was maxed out on his vaso and was on fairly high doses of dopamine and levo (from what my preceptor told me) and was sedated with fentanyl, propofol and versed. His MAP was not super stable (dropping below 65 and sometimes even below 60 throughout the night), his SBP was floating in the 90's, HR was usually between 85-100 and he was showing signs of poor perfusion in his ear and fingers. Since he was more than adequately sedated my thoughts were well lets ease up on the sedation and work on weaning one of the pressors. But thats as far as I can get. I know that all of the sedation drugs can cause hypotension, but I don't know which one is MOST likely to cause it. I also know that any pressor can cause poor perfusion to the extremities, but which one is MOST likely to be responsible for it? Again thanks for all the help, I really want to start getting the hang of this :-)