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ICU nurse

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  1. BelgianRN

    bolus w/o order....yes or no?

    What's wrong with speaking to the RN herself? Why run to management. If you felt the need to spy on her patient care at least have the courtesy to go head on with her as well. There is too little direct communication nowadays.
  2. BelgianRN

    Registration Typos

    "PEP", so i figured hmmm profylaxis. Turns out it stands for "poepen en pech" which is Dutch for "unfortunate sex", the guy had an STD. Or when the patients talk too much some secretaries summ it up to "sick". Also had "ITP (no clue what this is...)". Or "secretive patient".
  3. BelgianRN

    GCS of a quadriplegic?

    The GCS was designed with the mindset of neurotrauma evaluation. It gained popularity for other usages and pathologies. But i think the point is moot as to what their GCS is if you have signs he is oriented. You can't properly use the GCS to determine consciousness in patients with disabilities influencing your GCS and the GCS as such has no value in the evaluation of these patients. Also get in the habit of reporting GCSs by their individual components. In my documentation I'll report a GCS like: GCS(EMV): 11(3-5-3) or if tubed/trached GCS(EMV): 9 (3-5-T).
  4. BelgianRN

    Effectiveness of IABP

    IABPs are great. There used less nowadays in light of the alternatives that are getting easier and easier to implement (impella, L/R/Bi-VADs, ECLS). But an IABP is very effective if used in the right way and we can place them right at the bedside without having to leave the ICU or having our lovely VADs bleed out in front of us. And I like the sound it makes!
  5. BelgianRN

    audible brachial pulse

    You can only hear audible arterial pulses when the bloodflow is somehow obstructed. There are multiple reasons: pressure from your stethoscope on a superficial artery, partially clogged artery, aneurysmatic deformation, AV-malofrmation to name a few.
  6. BelgianRN

    What's your patient load?

    For every ABC-unstable patient we go 1:1, means the other nurses go up at the same time taking over your load. Medsurg anywhere from 3:1 to 6:1 depending on available staff. Peds generally 3:1. Small surgical cases: task oriented nursing, everyone with available time pitches in, assessment/primary diagnostics ordered by the triage nurse or dedicated ER physician. In general our patient load is very variable throughout our shift since we are involved in prehospital care as well. So if all other nurses have to go out on prehospital assignments and/or in-hospital codes, the ER falls back on 1 - 2 nurses for everything and everyone. All remaining patients fall under the responsibility of the remaining nurse, including ABC-unstable ones that get dropped off in the mean time. Luckily we have pretty amazing ER docs that will do many of our tasks themselves if we are too busy.
  7. BelgianRN

    Working long hours to buy gifts for everyone...

    I used to do this for years, but somehow felt unrewarding as some members in my family can be really ungrateful. But last year I decided to work Christmas, escape from my extensive family (the easy part as they live abroad) and spent my entire christmas bonus on myself and a few selected people. And you know what I loved it, doing it again this year!
  8. BelgianRN

    Simultaneous Electrolyte Administration

    The only issue that we keep having with our new people is simple chemistry problems. Like you can't infuse potassiumphosphate and magnesiumsulphate together since it forms the insoluble magnesiumphosphate and things like sodiumbicarbonate and calciumchloride. It's easily overlooked when someone (esp. inexperienced residents) wants to supplement several electrolytes and is inexperienced with the solubility of different salts.
  9. BelgianRN

    BiV pacer question

    It is possible to have two ventricular spikes if your pacemaker activates the two ventricles separately and out of sync to some degree.
  10. BelgianRN

    atrial ecg

    Indeed, an atrial ECG requires atrial pacing wires. The policy in my hospital is that we connect the extremity leads as they should and use V1 and V2 or V3 connected to both atrial wires. I generally use V3 if my complexes are too large and start overlapping with each other. The remaining precordial leads are not always connected. Just remember because your view point for the atrial leads is located in the atrium you'll probaly have large QRS-complexes but also very large P-waves that can easily be confused for QRS-complexes making atrial ECGs harder to interpret. I'm not sure which pacing ECGs you are taking. But when I have a temporary pacemaker (and I know there is an organized perfusing rhythm underneath) I disconnect the pacing wires from the external pacemaker unit and take an ECG without pacing spikes. I don't use the pause button because our pacemaker units just don't pause long enough to complete an entire ECG without pacing spikes and i'll end up with pacing spikes at the very end of my ECG. When we take ECGs on people with internal pacemakers we generally first take an ECG in the resting state (e.g. if the pacemaker is pacing we'll take an ECG of that if it isn't pacing we take one of that). Then the pacemaker technician will either mandate the pacemaker to start pacing or switch off so we can redo the ECGs and compare them. It gives great signs of failure to capture etc. But this takes coordination with a pacemaker technician and is not always needed for every pacemaker patient. Just remember when people have been paced for a while your unpaced ECG might still show abnormalities in repolarisation (e.g. altered T-waves) and can have ventricular conduction abnormalities just because the heart's own conduction system has been bypassed for so long by the pacemaker function.
  11. BelgianRN

    Blood cultures from old CVC

    Standard Practice in our ICUs is when spiking a temperature we draw at least one blood culture peripherally (or
  12. BelgianRN

    Primacor and Dobutamine running @ same time?

    It is a very common combination for our severe heart failure patients. Both drugs have a different pathway to stimulate the inotropy of the heart. Dobutamine works via your beta receptors stimulating the enzyme adenylate cyclase to promote formation of cAMP from ATP where cAMP will increase the intracellular calcium concentration that leads to inreased contractility. Milrinone is an PDE3-I (phosphodiesterase inhibitor class 3) that will inhibit the enzym phosphodiesterase so it no longer breaks down cAMP and as a result contractility increases. So both drugs can work synergistically. In my experience milrinone will cause more afterload reduction as compared to dobutamine therefore hypotension is more of an issue. At the same time milrinone is less proaritmogenic than dobutamine. And milrinone will have a more profound effect in decreasing pulmonary hypertension as compared to dobutamine. So usually the last two effects are what prompts preference for adding milrinone as opposed to increasing the dosage of dobutamine.
  13. BelgianRN

    ECG Question Need help ASAP

    The thing that came to mind is that half sensitivity refers to 5 mm/1 mV instead of the standard 10 mm/1 mV. You'd change this value in the light of left ventricular hypertrophy or conduction abnormalities that cross into your other leads obscuring the view of those leads. This is generally most prominent in the precordial leads. If I translate roughly from Dutch we'd call it "half calibration" or "half gain".
  14. BelgianRN

    anxiety/desats when repositioning intubated patient

    As other posters have said preoxygenation is helpful. But you could see if you have orders to give a bolus of a sedative for an already intubated patient. This will decrease the oxygen consumption by avoiding anxiety altogether an also prevents excessive moving/struggling from the patient while turning him/her which in turn will help with minimizing oxygen consumption. I'd like to stress too that it's important to check all connections in your ventilatory circuit before turning a patient where derecruitment is a potential problem (e.g. ARDS) to prevent even greater desaturation when performing a manoeuver.
  15. BelgianRN

    What to do in family emergency situations?

    I remember a few years ago a colleague called around 22 pm she wouldn't be in for the nightshifft. She came home found her husband drowned in the tub together with her 1 year old. As she called us the EMTs were still coding her child. I'm still amazed she called in at that time. Long story short I stayed for her nightshift. Even though I had morning shift the day after, we decided the morning shift would do with one person less. I got chewed out by my manager even before asking how our colleague and her child were doing. Some people have just lost all compassion.