ambersky004

Has anyone encounter this term Hepatopulmonary syndrome due to liver cirrhosis? There was a patient situation where he came in due to ascites, generalized edema, had pmHx of TIPS, +meth/cocaine on urine drug screen. Stable vital signs and mentation wise though look drunk. Inpatient lactulose and rifaximin bid given. The next day, crea went up from 1.6 to 1.9, ammonia went up from 118 to 130. Lactulose dose was increased and given IV lasix. Pt gets SOB on sitting upright and standing and look comfy when laying down. Not sure what happened but, pt coded after given another Lasix, Ativan, Albuterol/Duoneb breathing treatments due to some agitation and SOB though lungs were clear, VS, SpO2 wete fine before but drop to 60s after those treatments. I heard pt started to develop stridor. Pt then got intubated. I wonder if the pt develop that term Hepatopulmonary syndrome? Pt declined pretty quick. Not sure if he was not able to protect the airway due to facial and periorbital edema and grogginess and was given Ativan? What do you think might your theory? Or anyone had an experience with liver disease?

Thank you dianah

10 hrs Post pci, pt develop a vfib but was self limited when night nurse check on her. Night doc said it was torsades though mg level is normal. Still was given 2 gm of magnesium. Now, cardiologist said pt needs a life vest. Due to 40% LVEF. Has anyone encountered this situation before? Let's talk about it. ?

How does retroperitoneal bleed develop after post pci? What are the possible causes of it developing? I was assisting in removal of arterial sheath with my co-worker, I was not able to monitor the patient constantly on our medsurg floor but was there during pt arrival. 5 or 6 hrs after the procedure, my co-worker was removing the arterial sheath on the left femoral artery. She held it for about 12 or 15 mins then she asked me to check on the pt abdomen because he was complaining of belly pain. I checked his lower belly and he said it is tender to the touch on a certain spot and I feel a hard lump. His BP started to drop to 80s systolic as well as the HR to low 50s. I called the cardiologist while my co worker was holding pressure. I thought she did great because I did not see any significant bleeding or hematoma below pt's thigh or around the groin area. So we thought he had a vasovagal episode. we did a ct of abdomen and it confirms a moderate RH. Pt was was stable but his bp drops especially when pressure is applied to groin. H and H drops from 11 to 9.1 and the next day to 8.6 with ongoing abdominal pain. he eventually got a unit of blood in ICU and air lifted for a vascular surgeon. I thought about the scenario, I am not sure what had happened? Was it a slow bleed during and after the procedure and coincidentally we just noticed it when we were removing the sheath 5 hrs after? what do you think are your thoughts on this? I am now anxious if pressure was not held correctly on the femoral artery or it was a high stick puncture by a cardiologist? But why did it happened so fast during removal of sheath?

Thanks for that description! Pt was tender to the touch in her inner thigh area while she pointed the site. Do you think the venous sheath was causing it? Anyway, I pulled arterial sheath then the venous sheath after when her aPTT was about 51. The oozing stopped after both sheaths are removed. I am about 90 lbs. I usually bring my step stool and lower the bed, supine the patient and spread and rotate leg and foot away the midline. It always work for me when I locate the pulse. We usually hold pressure for 20 mins. I have learned not to occluded the pulse totally more than 3 or 5 mins because it is not good. My other co worker on the other end who is bigger than me, her pt develop a hematoma and site kept bleeding after sheath was removed. The pt had a peripheral angio. The cardiologist came and said to put a fem stop. So nurses tried to apply it. While I was on the Pt's foot, using a doppler to hear any pulse. I told the doc, I could not feel or hear a pulse. Doc remove the pressure on the fem stop. ? it was quite a rough time during shift change. I was off the next day. So I hope my patient did well all night.

Thank You wedgepressure. What is retrograde and antegrade stick? Can you describe it? I always feel doubtful when I pull sheaths because I am small but if I do have obese patients, I let a larger nurse pulled it. We pull sheaths on our cardiac-stepdown floor when we get post cardiac cath and peripheral angio patients. It has been 3 mos I have not pulled sheaths so yesterday, my patient keeps on bleeding around the arterial and venous sheaths, ACT was 367 and she was on Aggrastat drip for interventional stent. I did not feel any hematoma or swelling around groin areas but she reported of tenderness upon palpation on her inner thigh. I did not feel any hematoma or swelling. The cardiologist came and he said she is very low in pain tolerance. I applied pressure for 5 mins and she still moderately oozes. I keep reinforcing dressings. Until her PTT came back and it is 174. I know that sheaths needs to be pulled because it keeps her bleed. But cardiologist said wait to 2 hours. We usually hold manual pressure for 20 mins. she did fine. but I keep thinking she might loose like 100 cc of blood I her. :D

What are your techniques in removing femoral arterial sheath removal? If you are about 90 lbs in weight, does it matter or not when applying manual pressure to the femoral artery? Do you all have certain techniques on how to ace femoral sheath removal?

Libra nurse Thank You. I do enjoyed being at the bedside. But for the past 2 yrs I have been more depressed. I have never tried changing jobs. So this is my first time moving to a different department. More of a specialty. I am just worried if another pandemic hits us, outpt and input surgeries and procedures are going to slow down or get shut down again. Last year, many nurses were furloughed.

Libra nurse Thank You. I do enjoyed being at the bedside. But for the past 2 yrs I have been more depressed. I have never tried changing jobs. So this is my first time moving to a different department. More of a specialty. I am just worried if another pandemic hits us, outpt and input surgeries and procedures are going to slow down or get shut down again. Last year, many nurses were furloughed.

I have worked for 6 yrs now in cardiac stepdown/tele progressive care unit. 2 yrs ago, I posted about my burnout. But I thrive and stick with it again for couple yrs. Last yr covid pandemic, our floor was shut down, floated to med surg floor then back to our floor. I just started as a charge nurse and preceptor last year. It feels like I have another meltdown this yr and have no desire to work bedside nursing again. More tasks for charge nurses to do, need to improve patient satisfaction, etc. I did not get a pay raise for 5 yrs until this career ladder started last yr but I have to accumulate hours in order for them to give you a raise and advance to the ladder. But this year, I feel more not in touch with what I do as a nurse at bedside. I know Hospitalists and cardiologists trusted my assessment skills. But it is not being there for them and teaching them. It is more passing meds and waiting until snf placement. I applied for another position in our hospital. And it is in OutPatient surgery/GI lab unit. This unit last yr became our covid unit. The work setting is different. I need ideas on what are considerations I need to think about, pros and cons from transferring to a cardiac stepdown unit that enhanced my nursing skills but feels like I am not growing there professionally even though, precepting and charging are now part of my duties last yr. But I feel numb and unable to function as a bedside nurse that I was before the first 2 to 4 yrs there. Need some ideas from ya'll. Appreciate it.

I am also going for an interview in GI las/outpatient surgery. I have been a nurse in a cardiac stepdown unit for 6 yrs now which I enjoyed and enhanced my assessment skills. But I am feeling rot in that place. I am concerned of giving up my 12 hours and more days off than 5 days a week but shorter time. How was your application?

I have worked for 6 yrs now in cardiac stepdown/tele progressive care unit. 2 yrs ago, I posted about my burnout. But I thrive and stick to my unit again for couple yrs. Last yr covid pandemic, our floor was shut down, floated to med surg floor, ICU and covid unit then back to our floor where we isolate possible covid. I just started as a charge nurse and preceptor last year. It feels like I have another meltdown this yr and feels like I have not able to focus more on my patients but more on the tasks, and management expectations or even co workers expectations of me as the charge. I will understand if they are new nurses but they are not new. Then I need to know the flow of patient's # on our floor and more. But in our unit, charge nurse takes 3 to 4 patients I did not get a pay raise for 5 yrs until this career ladder started last yr but I have to accumulate hours in order for them to give you a raise and advance to the ladder. But this year, I feel more not in touch with what I do as a nurse at bedside. It is more passing meds, waiting until snf placement for the elderly, make sure we charge supplies to pts, etc. I applied for another position in our hospital. And it is in OutPatient surgery/GI lab unit. This unit last yr became our covid unit. The work setting is different. I need ideas on what are considerations I need to think about, pros and cons from transferring to a cardiac stepdown unit. This unit enhanced my nursing assessment skills, acute and progressive care, collaboration with doctors and other staff but feels like I am not growing there professionally. I feel numb and unable to function this yr as a bedside nurse compared to before the first 2 to 4 yrs there. Needed someone to give me their perspectives and views. Appreciate it.

I have worked for 6 yrs now in cardiac stepdown/tele progressive care unit. 2 yrs ago, I posted about my burnout. But I thrive and stick with it again for couple yrs. Last yr covid pandemic, our floor was shut down, floated to med surg floor then back to our floor. I just started as a charge nurse and preceptor last year. It feels like I have another meltdown this yr and have no desire to work bedside nursing again. More tasks for charge nurses to do, need to improve patient satisfaction, etc. I did not get a pay raise for 5 yrs until this career ladder started last yr but I have to accumulate hours in order for them to give you a raise and advance to the ladder. But this year, I feel more not in touch with what I do as a nurse at bedside. I know Hospitalists and cardiologists trusted my assessment skills. But it is not being there for them and teaching them. It is more passing meds and waiting until snf placement. I applied for another position in our hospital. And it is in OutPatient surgery/GI lab unit. This unit last yr became our covid unit. The work setting is different. I need ideas on what are considerations I need to think about, pros and cons from transferring to a cardiac stepdown unit that enhanced my nursing skills but feels like I am not growing there professionally even though, precepting and charging are now part of my duties last yr. But I feel numb and unable to function as a bedside nurse that I was before the first 2 to 4 yrs there. Need some ideas from ya'll. Appreciate it.

Thank you.

Thank You.

I worked in a busy cardiac step-down unit/progressive care unit. For some reason over the weekend our unit was closed down due to low census. I came in the next morning and started my routine. We have ICU overflows, Post cath/post pacemakers, transfers. That time it was only me as the charge nurse that day and a brand new nurse on our unit. We started to get 3 patients that morning. There was a situation that day where one of the family member asked me if we could keep an eye of the pt's spouse who has Alzheimer's while they are looking for a nsg. home placement for that spouse. To cut the story short, I disagree with the family member to have a "responsibility" of the pt's spouse who has dementia. With 2 nurses on the floor that time and both could be in their pt's room, could not keep an eye on her if she wanders off. I explained. The family member told the other members that we cannot be "responsible" as she qoute the word i told her initially. I felt guilty because as a nurse, you want to take care of the vulnerable patients, you want to help your patient as a whole. His spouse is part of his life. I felt that i should have use a different words to say to the family members. Have you had this situation? What should I say or how should i communicate better with the family?

Here is the steps on application by examination in California Board of Nursing. Maybe it will help you start the process. ? https://www.rn.ca.gov/pdfs/applicants/exam-app.pdf

Have you visited the CGFNS website? It They help you do the credentialing of your nursing transcripts from the Philippines. You do not need to take the Philippines NLE if you plan to work as a nurse here in the US.

My Easter Sunday at work was unfortunately quite challeging. I came in to work that morning, had a patient that became lethargic and in respiratory distress even with bipap support. She was given a low dose of Ativan to help her relax and a 1 unit of PRBC 3 hrs ago per night shift. I assessed her lungs and heard rales and crackles, HR-125s. BP normal. O2sats were falling below 90s even with bipap support. I called the RT to help assess her respiratory status and check the bipap. Had the chance to talk talk to the hemodialysis nurse and made her aware on the patient case and patient may need an urgent hemodialysis. I called the Hospitalist and Nephrologist, and finally transferred the patient for hemodialysis room. O2 sats went up but she is still on Bipap support all shift. Patient and family has been informed that she will need to be in hospice or comfort measures, however patient does not want to give up her dialysis and she does not want surgery of her AVS. Is there anything else we could have done differently on this patient with known severe AVS, recent AKI w/ placement of tunneled hemodialysis catheter and now with worsening respiratory distress and might be Bipap dependent??

Don't be too hard on yourself. I know it takes a toll on you or might even feel like a nightmare. It is hard when your patient dies on your shift. You have questions. Instead of ruminating those thoughts and feelings, learn from it and let go of those thoughts and feelings. Forgive yourself. Stay strong. You cannot always save everyone. We are all going to die here on earth. What matters is your values, your compassion and service to human kind.

The topic of workplace incivility calls to mind. Our beloved profession can be taxing on the body and spirit. With all of the pressures we face in our units every day as we take care of patients with increasingly complex comorbidities, there is no room for the added stress of lateral violence. Some co-workers are not really aware of how to communicate well. They feel insecure and jealous and started bullying you. What we permit, we promote, and it is incumbent on all of us to draw a line in the sand and say “enough” when it comes to workplace incivility.

Nightnerd, what you wrote just summarizes about what I am feeling and thinking. Sometimes, I come to work happy and confident, sometimes I come to work questioning my worth and feeling like I am not supported or feel like not part of the team. I tried to delegate and follow-up the tasks with my co workers but when I do I feel that they get upset so I think to myself if I'm bossy. I work in bedside nursing now for 5 yrs. There are just like these days and this year had me reflect really hard if I should be staying in bedside for next 5 yrs.

I feel the no tolerance sometimes on their unrealistic expectations. I am trying to use some of my PTO hours for some break away from work.

The QT interval is the time from the start of the Q wave to the end of the T wave. From the time taken for ventricular contraction and relaxation. How fast the ventricles recharged for the next cycle. While the QRS duration is how fast the ventricles contracts. It's not always that way. But both prolongation of these two will cause a lethal arrhythmias.