hellonurse36

I can only speak for Datascope (now Maquet) as that is the one I use. If a pt codes you DON'T CHANGE ANYTHING with the machine...focus on the pt. As soon as the machine no longer senses an EGK to use as a trigger for inflation/deflation it will AUTOMATICALLY switch to pressure trigger. Once you start compressions the machine will pick up the pressure changes from the compressions and will time the IABP appropriately. Changing to pressure mode is not wrong, but there is no need as the machine already does it. Key is to focus on the pt....same if you need to defibrillate...ignore the machine.

Our criteria in Eastern NC is a pt presenting to an ED with STEMI (ST elevated MI) should be on the cath lab table with balloon opened in culprit lesion withing 90 min of presentation. If pt presents to facility without ability to do interventional cath, pt is transported to nearest facility (us). If the distance to us is far enough that pt can't reasonably get here and on the table in 90 min, then they get thrombolytics (unless they have a contraindication - ie recent stroke, bleed etc). It's all about time. . . time is muscle. Hope this helps, Terri Greenville, NC

I spoke with our medtronic rep last week about this scenario. This is what he told me. All the newer MEDTRONIC pacemakers have AICD components (he stressed that this was how medtronic devices worked, but he couldn't vouch for other brands). If a pt has this AICD/pacer then we use the magnet to TURN OFF THE DEFIB aspect of the device so it won't shock pt - ie pt with runs of VTach but is being made comfort care (withdrawl/no shock). The magnet will flip a switch so the device can not read/respond to shockable rhythms. Once you remove the magnet the switch flips back and the device can shock. But it WILL CONTINUE to pace. Magnet does not affect pacing ability. In our hospital our policy is to call the device rep and s/he comes in and turns off the pacemaker if that is needed (ie. withdrawing care). Hope this helps. Terri

I have a whole setup that new RNs can "play with" and practice setting up. I also have a display board with the inside of the heart on it that I have glued a swan catheter in the correct position. Below I have a pict of the stages of the swan being floated in. At each stage I show a pict of the balloon and the waveform. It is great for helping people visualize things. Terri

[ How long does the AICD have to be exposed to the magnent before it stops? I am not sure how long the magnent has to be exposed before the AICD stopped.] I believe it stops immediately. "The reason for this is because there is a small magnetically activated switch built into the electronics of pacemakers and implantable defibrillators. This internal switch is designed to close when a magnet of enough strength is placed over it. . . Removing the magnet returns the pacemaker or implantable defibrillator back to its previous, normal programming." (from Medtronic website) Terri

I work in an ICU and we do report at the desk and then go into the room for bedside rounds. I agree that bedside report is not approriate...although I will repeat something to the oncoming RN in front of the pt if it is something I told the pt I would pass on. ie. "I just gave Mrs X a lasix pill and she is concerned about incontinence, I told her when she rings her callbell we'll answer quickly to get her a bedpan." On my bedside rounds I check- dressings, chest tube/drains - both the dressing and the amount/colour of drainage, length of transvenous pacer wires or swans, groin sites if pt has arterial sheath/IABP or had a sheath pulled on that shift, swelling/edema, LOC/responsiveness on a sedated pt or pt with altered LOC. ALWAYS check your pump set up on any infusions. Make sure the pump is set up for what is hanging - ie. Dopamine 400 mg/250 ml bag hanging but pump is set for 800mg/250 bag! Once you assume care of the pt you are responsible for that error too. I also review the MARs so I can ask the day shift RN about any unsigned meds - did they give them and forget to sign them off or did they forget to give them. Also, if family is at the bedside of a very sick pt or one that is comfort care (withdrawing on a DNR pt), I make sure I ease the transition to a new nurse with them as well. ie for a really sick pt: "Mr Z's wife will be sleeping in the waiting room or at hotel ABC and the ph number is in the chart, I told her that we'd let her if anything happened and keep her up to date on things." For a comfort care pt I make sure the family knows that they can stay at the bedside and that we are there for them as well, reinforce to not hesitate to let us know if there is anything we can do for them. I think for many families shift change is a stressful time. If they've built a rapport with the nurse and have gained confidence in the care their loved one is receiving, they worry about who is coming on next and how things will go. Hope this helps, Terri Greenville, NC

Tazzi, I went to a woundvac class and it was great. It was a lecture about skin breakdowns, staging pressure ulcers, treatment for different stages etc. Then there was a hands on part where we go to play with the machines - even practiced putting dressings on each other. It was neat to feel the suction. The WounVac is made by KCI. Here is their website http://www.kci1.com/35.asp lots of stuff. Terri Finney, Greenville, NC

My hardest week ever was 5 on, 1 off then 4 on! Night shift! Not fun. Great paycheck! Terri

Yup. I am sitting at home today enjoying call pay due to low census. Not sure what's going on, but here (Eastern North Carolina) we have had several beds closed for over a month now when usually we are pushing to move pt's to an intermediate bed so we can take new ICU admissions. Terri in Greenville, NC

Our protocol states that a pt with 2 consecutive FSBS > 140 be started on an insulin gtt managed by the glucommander. "The Glucommander is a computer based system for controlling blood glucose by directing an intravenous infusion of insulin in response to the measurement of glucose at the patient's bedside". Basically the computer chirps (audible beep that sounds like a cricket) when you need to take a FSBS, you take it, enter it in the computer and it tells you what to program your insulin gtt at based on how the FSBS is trending. Pt's that are on the glucommander and NPO are on D10 @ 80 ml/hr. I asked one day about this as I thought it was strange that we were giving a DM pt D10, I learned that since the pt was NPO we need to provide some glucose source so the pt doesn't go into ketoacidosis. If the pt is eating or has tube feedings, we don't do the D10. Hope this helps. Terri Finney Greenville, NC

What kind of complications are you looking for? Do you mean how can things go wrong? What are bad outcomes? Are you speaking about in hospital or in general public CPR? -broken ribs/sternum are just about a given if CPR is done correctly. -pt's heart beat returns but there is brain injury from decreased oxygen, anything from mild injury to complete brain death -I suppose you could get some minor mouth diseases (ie herpes) from someone doing mouth to mouth on you without a protective shield....but if I was the person, I'd take the herpes over being dead. - and of course - death. The way I see it, if a pt is needing CPR they are already dead, so, any complications are worth the risk. Terri Finney

Beth, These goals look good, I can't think of anything better. I forgot how the "Nursing School Instructor's mind works!!" Boy am I glad those days are over...sounds like you are pretty close to being through with it all to!! YEAH!!! Good luck. Terri

Hmmmm. Not sure I agree with your instructor. The time spent in clinicals INTRODUCES a student to all of these things, but one can always continue to improve them - in fact....that is what most new nurses are working on during their orientation! What unit will you be doing your independent experience on? Maybe if I knew what area you will be in I could think of some better examples. Terri

Not sure what you are looking for or what type of unit you will be on, but I'll give it a try. 1. Learn how to program and run pumps, including (if they have this), using programable features for different medicines. 2. Learn how to do an effective head to toe assessment in a timely manner. 3. Work on communicating goals of care and plans for the day with pt/family. 4. If you are on a monitored unit, learn how to read basic rhythm strips. 5. Improve or do x # of specific skills - IV sticks, lab draws, NG tubes, Foleys. 6. Improve communications with other health care professionals (care partners/aids, MDs, OT, PT etc) 7. If you are on a critical care unit or happen to work with an RN caring the code blue pager....go to a code, help with post mortum care, if trained- do CPR. Learn about the paperwork that needs to be done after someone dies - do they have an organ donation program? 8. Learn to read ABGs. 9. Improve understanding of different vent settings/modes. 10. Have someone show you how to use the defibrillator, pacer, look through a code cart. 11. Observe placement of an arterial line, central line, swan line etc. Hope this helps get the brain started! Terri

Here is a simple explanation (sounds like you have it all figured out now, but thought I'd add my 2 cents). To help you understand what is the systolic vs diastolic it helps to know how a BP cuff works and understand WHAT you are hearing and WHY you are hearing it. As you inflate the cuff you are exerting pressure against the artery, the number the needle points to indicates the pressure being applied. When you inflate the BP cuff beyond the pt's systolic (highest pressure in arteries - occurs during systole or when the heart is contracting) it occludes blood flow and you do not hear a pulse. You slowly let the air out and once the pressure of the cuff EQUALS the systolic pressure, blood flow is no longer occluded and it rushes past your stethoscope, hence you hear the sound. The number on the gauge at this point is your systolic or top number. As you continue to let air out of the cuff, eventually the pressure in the cuff will be lower than the pressure in the artery during diastole (when the heart is at rest) and you won't be able to hear the blood flowing by....this is your diastolic or bottom number. I think most nursing students have problems learning how to take a manual pressure. Keep practising - it's the only way you really get confident. Terri

We have a palliative care team (MD and several FNPs) that are consulted. They review the case, meet with the family and try to establish appropriate goals of care. Most families find this very beneficial as these experts know how to communicate about end of life issues very well. We are very lucky to have these experts as any health care providers don't communicate well when discussing end of life issues. For example MD discussing code status of loved one: "If your mother's heart stops working do you want us to do everything to save her?" What son/daughter would feel comfortable saying no to that questions? vs. MD "If your mother's heart stops, do you want us to do CPR, (make sure they understand that this could result in broken ribs), shock her, give her drugs to try to start the heart again? Would she want to be on a ventilator? How does she feel about life support? What quality of life is acceptable/unacceptable to her?" I have found it very useful to make sure the family understands their role. I tell them that they know the pt the best and know what they would/would not want. I make sure they know their job is not to make decisions for their loved one, but to communicate to us what that person would want. I have had several family members tell me they appreciated being told that as it felt like it took some of the burden off. That being said, some families just can't let go. It is very hard to see the pt struggle, but all we can do is continue to provide education, support and care and hope that the family will make the best decision. Terri Finney

British Columbia has a program called Cops for Cancer http://www.cancer.ca/ccs/internet/standard/0,3182,3278_367929__langId-en,00.html "What is Cops for Cancer? The Canadian Cancer Society's Cops for Cancer is a partnership between the Canadian Cancer Society and police officers, RCMP and local military police from across British Columbia. Each fall, Canadian law enforcement personnel cycle a pre-designated route in their region, raising funds and awareness for pediatric cancer research and programs that support kids with cancer, such as Camp Goodtimes. Cops for Cancer began in Edmonton in 1994 and has grown to include many other Canadian cities and areas. In British Columbia, there are four Cops for Cancer Tours, including Vancouver Island, Greater Vancouver, the Fraser Valley, and in the North." My sister is am elementary school teacher and her school challenged the students to raise money and if they hit a certain goal my sister would have her head shaved in front of the whole school and if they met a second, larger goal, the principal would have his head shaved. Needless to say the kids were very motivated and both of them ended up with shaved heads. Some of the students even got to do the shaving!! Terri in Greenville, NC

I believe it is a risk benefit decision. Most patients who receive thrombolyitics get it because they have ST elevation and present to a facility without a cath lab. They get the lytics and are sent to a facility with a cath lab for higher level of care (per RACE protocol). In our facility most STEMIs are met in the ED by the cardiologist who then reevaluate the pt/situation and decides if they are admitted to the unit or go to the cath lab first. I have seen both. I have also seen pts who have received lytics who don't go to the cath lab because of it, they come to the unit and then have an increase in chest pain and end up going to the cathlab for an intervention. The MDs continually evaluate and reevaluate the pt and as things (ECG, pt's report of chest pain etc) change, so does the plan of care. Of course, the pt receiving lytics is taking into consideration and becomes part of the risk vs benefit analysis. Terri in Greenville, NC

I went to an excellent class on IABP put on by a Datascope rep. They have a great website at datascope.com Click on cardiac assist at the top, then on the page that appears click on Educational Resources on the L column. then E learning resources and finally on COUNTERPULSATION OVERVIEW. It is very good. Terri

Jen - There is a top and bottom for both males and females. Our garments are a constant reminder of the promises made with the Lord in the temple to live righteously and strive to follow His example, as well as a symbol of our modesty in dress. There is nothing secret about our garments, but we do consider them very sacred, and thus don't really write/talk about them in detail. Terri

Good question. I am an endowed Latter day Saint (Mormon who has been to the temple and thus wear the garment you speak of - there are several styles/fabrics). I would say to leave it on if possible, if not, remove it and put it in a patient belonging bag, perhaps give it to a family member. If the pt is alert, make sure you let him know what you are doing so he knows that you are not going to throw them away, maybe something like "We need to remove your garments, I will place them in this bag and put them up in this cupboard so you don't lose them." By the way, there is a top too. It is considered a sacred garment so should not be placed on the floor. It the garment is soiled (blood/body fluids etc) and you think it should be thrown away, put it in a bag and give it to a family member for them to dispose of it. Other things a LDS (Mormon) may need during a hospital stay. 1. If pt is there on a Sunday, 2 or more brethren from church may bring him the sacrament (bread and water). Hopefully the pt is not NPO. 2. The sick are often given a special blessing/laying on of hands for healing purposes by brethren from the church. 3. You may get a lot of visitors...maybe even couple of missionaries! Hope this helps, Terri

Dear BlueEyedRN First...I am sorry for your difficult night! Hopefully you are processing this. Do you have chaplains at your hospital? Our chaplains are available for staff too, what about employee counselling? Next, you did NOT kill your pt!!! You allowed her to go quickly to a place of peace. While it was undoubtedly hard to watch her struggle...at least it was short. I admire pts/families who can make this difficult decision when presented with the situation. I work in a cardiac ICU and we code far too many people for far too long and keep them "alive" for even longer. I always figured if the family was in the room during a code most would beg us to stop long before we actually do. I guess you can take some comfort in knowing that your pt's last few minutes, while difficult, weren't chaotic resulting in broken ribs/sternum from CPR, burn marks from shocks, and massive drugs being given. I think the fact that you are struggling with this is normal and shows that you are a caring person who will make a GREAT nurse! I hope today is a better day for you!! Terri

I just logged on and it opened up. Are you trying randylarson.com/acls Or try this http://www.randylarson.com/acls/start.html Also, here is another good site. http://students.med.nyu.edu/erclub/ekghome.html or http://medinfo.ufl.edu/~ekg/TOC.htm Just remember that what you are seeing is a representation of electricity moving through the heart. The horizontal plane represents time and the vertical plane represents voltage. With the leads placed in a certain pattern (either a 3 lead, 5 lead or 12 lead pattern) we can see how the electricity is moving through the heart and thus how the heart is working or not working. For basic rhythm interpretation ie. is the pt in sinus brady, afib, having frequent PVCs etc we look at lead 2, for indications of ischemia, injury, MI (active, old, new etc) we look at a 12 lead as this allows us to see WHERE in the heart the problem is. If I were you I would focus on the rhythms first then try to figure out the 12 lead. I am surprised you are doing 12 lead as it is pretty complicated. Do you have to diagnose where an MI is occurring or just know some basics of why we use 12 leads? Basically a 12 lead allows you to look at the heart from different angles. Since we are looking at conduction of electricity through the heart we expect to see certain patterns. Injured or dead heart muscle does not conduct the electricity the same way and will result in ECG changes. The lead(s) these changes show up on tell us where the injury is. In the clinical setting we use the 12 lead along with pt's report of chest pain and results of labwork (cardiac enzymes) to help diagnose an MI vs angina when pt presents with chest pain. When a pt presents with chest pain we draw cardiac enzymes (CKMB, troponin) q 6 hr x 3 sets and do an ECG. When there is active heart muscle damage, enzymes are released from the heart tissue and show up in the blood (thus these enzymes are often called cardiac markers). If the enzymes come back positive (especially troponin as it is specific to the heart vs CKMB which is released by skeletal muscle as well), the person is dx with an MI. Problem is, these enzymes take time to show up in the blood (hence the need to have 3 negative sets to rule out an MI). Since we don't want the person sitting around having an MI while we wait for the enzymes to elevate, we can do an ECG and look for any changes. Q waves would indicate an OLD MI while T wave inversion, ST elevation or depression indicate active injury. For all of these WHAT LEAD it shows up in on the 12 lead tells you what part of the heart is being damaged and thus which coronary artery is the probable culprit. Off the top of my head I cannot remember them all, but here is an idea. If you see changes (Q waves, ST elevation etc) in leads II, III and aVF you know it is an inferior issue. Changes in V1-V4 means anterior problem. A Q means an old MI of unknown date in this area, ST elevation means an active MI in this area and the pt goes to the cath lab where they can see what is causing the problem and fix it (balloon, stent, consult with Cardiothoracic surgery for a bypass!!). Hope this helps, Terri

I have always loved blocks (well, only on paper...don't really care to see third degree up on my pt's monitor!!). I had a great ECG teacher who made it really simple. First degree heart block - PR interval is lengthened (> .20) and consistent. She likened it to a renter who pays his rent late, but consistently....it is due before the 20th but he pays it on the 24th every month...he is late but consistent. Second Degree heart block, type 1 ( aka Wenckeback) - PR interval is increasingly longer until a QRS is dropped, then it starts up at the original length again and starts over. Think of it as the renter pays later and later each month, then misses a month (no QRS), then starts back up paying rent but pays it late and continues to pay it progressively later until he again misses a month. Second degree heart block, type 2 (Mobitz 2) - PR is CONSISTENT but a QRS is randomly dropped. I remember it by the saying - Mobitz 2 out of the blue drops a Q. Third degree heart block - no synchrony between P waves and QRS complex. Call it the divorce rhythm because the P and QRS are ignoring each other. The Ps are consistent but do not create a QRS, QRSs are consistent but are not stimulated by a P. If you see a P in a QRS you pretty much have 3rd degree. Hope this helps. Terri

One of the best sites I have found for learning ECGs is - http://www.randylarson.com/acls/ He explains things very well. Good luck, Terri Finney in Greenville, NC