Bec7074

I'll speak to the second question. Read up on lactate, lactic acidosis, and base deficit. Those are related concepts especially in sepsis or after a cardiac arrest. It has to do with anaerobic metabolism (lack of O2 to tissues when you code). As a result, lactate builds up causing lactic acidosis. Fluids help flush out lactate and may also improve perfusion and cardiac output. Base deficit is a great way to know a patient's fluid status. Hope that helps!

It's hard to say....I think I would wonder the same thing. His SvO2 was 50 the day before...not fantastic so maybe an early indicator that he was going to get worse regardless of whether or not you took him to IR. I'd imagine all his body systems were under stress after the arrest. On a side note, I know what you are getting at. It seems that sometimes we (aka the doctors) get a little too excited and do things that don't make sense and possibly result in patient compromise. A few weeks ago, my unit had a multi-system trauma on the Rotoprone bed. His sats were in the 70-80s even prone. He had only been on the bed for a day. The docs talked to the family and we emergently transferred him (yes prone) to the CVICU for Ecmo. They had to supine him to insert the large catheter for Ecmo and he dropped his sats, coded, and died while they were working on it. When we found out about it, we were shocked. Clearly they knew they were going to have to supine him for the line. What was the rush? We've seen many people suck on the Rotoprone and then make a turn in a few days. He hadn't been on the bed that long and he wasn't getting any worse. How many ppl live with sats in the 80s? It just seemed like a gamble and an unnecessary rush. Thoughts???

I'm kinda perplexed by a few things in this scenario. First, why does someone who got only 1 cardiac stent need Neo???? Was this a cath-lab patient? He sounds super stable given that he's eating and peeing and reading his Kindle....not the kinda patient I would expect to need a pressor especially after such a small procedure in which many ppl are D/C'd the next day. Had he had an MI? We're his troponins elevated or was this a scheduled thing after a positive stress test? Also if he was bradycardic all night i would have thought Neo wasnt the best pressor. Maybe dopamine or levo could have helped. It just seems strange to me. Regarding the sugar, maybe his body was in a higher metabolic state given the recent procedure and ?MI and therefore his body just handled his usual dose of Lantus differently.

Nothing says 'Happy Nurses Week' like a few close calls with bodily fluids.

I worked in a Level 1 trauma center and we have all NPs at night and one attending in house. The NPs who work with the trauma service are all ACNPs (acute-care nurse practitioners). There are 4 of them at night and more during the day, so yes their degrees are put to use. If you're interested in trauma, go for your ACNP. On the downside, most ACNP programs won't let you in until you've had at least 2 years of ER or ICU experience. Work on that for now

Medical staff and patients, and patients and their loved ones need to have clear ideas of the pt's end of life wishes whether the patient is coding or is just unable to make decisions on their own. I give kudos to all families/patients that know what they want, either way, from the start and aren't afraid to do it. If patients haven't talked about those kinda decisions with anyone before its too late, then that's just tragic. Had a wife once say, "we didn't put our dog with cancer down, I'm not going to do the same to him.". I disagree that making someone a DNR is "putting them down" but at least she knew what he would've wanted."

Not that it's a good answer, but did the lasix increase her UO? If so, then it was the right choice for her. I look at your patient Ike this...she was severely hypotension in OR. Kidneys are the most susceptible organ to hypoperfusion. Her kidneys took a hit during that. AND, not only did she have poor perfusion, but her hemoglobin was also probably low after the EBL of 4500 (holy crap) leading to poor oxygen delivery to her kidneys. Now you've hit 2/3 things that lead to organ damage. If she had any oxygenation issues, you'd hit a 3rd. Once damaged, sometimes the kidneys take a few to reflect the damage and no matter what you do, the kidneys need to heal and the only thing you can do is maintain good perfusion, oxygenation, and O2 delivery (hgb), and play the waiting game. Lasix is good for vascular volume overload as you know, which it appears this patient may have developed given the high CVP. I'd assume they would also check her I&Os (she has gotten like 15 blood products and has damaged kidneys so I would assume she'd be positive). So yeah, Lasix doesn't sound like a bad idea although it's not going to do much for the kidneys.

CaCl is also a buffer for acidosis if that's what they think part of the problem was. It's a typical part of the "high K" cocktail that coincides with acidosis. I had a patient so acidosis/hypotensive once that her pressure would bottom out the second the CaCl finished infusing (we use IVPB unless in codes).

I worked on a med surg that took insulin gets with 1:4 ratio. Insulin ggts we're more common in the PCU I worked in with 1:3-4. I think it's very much facility specific.

Diminished lung sounds are what we call it when we don't hear much air moving. Lungs can be both clear and diminished. Are you sure you are placing your stethoscope the in correct location? Try listening to their back if possible...sounds are usually louder from the back as the diaphragm and/or distended bellies aren't in the way. Also, have you tried Googling lung sounds? I used to have an iPhone ap when I graduated that played a small sound bite of a variety of conditions. Just give it time. Soon those will be easy and you'll be moving on to something else...like heart sounds :) Also, sometimes I find myself comparing sounds. For example, if I've cared for a pt for 8 hours and upon my last assessment I find the lungs are the clearest they've been, I have to remind myself they are still diminished just clearer. I usually chart a comment that says something like "increased air movement since previous assessment." you could ask a professor or respiratory therapist for more help.

This sounds awful for pts and nurses. Part of your assessment is assessing the rhythm. The ICU nurses are not caring for these patients and can't quite possibly know or have the time to see if something like frequent PVCs are normal or abnormal for the pt. You need monitor techs!!! Just curious...is this the way it's done around the clock or only at night??

The pt may have been a symptomatic at a rate of 130 only temporarily. In afib > 120, the heart loses its "atrial kick" (the small portion of blood ejected from the atria to the ventricles) and thus, cardiac output decreases. I've seen it take a while for pts to become symptomatic (SOB, restless). If it was me, I would have called because of the rate. Live and learn :)

We use inhaled Flolan in our ARDS pts as a last-ditch effort. Usually they are on Bi-Vent (bi-level or APRV) and a prone bed already. To me it makes sense. ARDS causes pulmonary edema which surely can cause pulmonary hypertension.

Critical thinking skills, motivations, and the ability to admit you don't know it all and aren't afraid to ask for help.!

I did med surg to PCU to ICU in 3 years. I love ICU and will never go back. I admire the med surg nurses who juggle all those patients. I did it, but not very gracefully. You need confidence and experience. You'll know when you've gained both of those. For me it happened around 1.5 years of nursing...I swear I just woke up one day and realized I hadn't had a need to look up something in a while and even knew what to do in certain situations. For the purpose of your job record, I'd say don't leave before a year. Finally, to be a good APN, you're going to need experience. Just remember that there's no rush, and the more experience you have as an RN is going to make you a better NP.

Sure. I wrote Thank-You's to all my preceptors at my current job just thanking them for their help. I got my main preceptor a $5 gift card to the coffee shop in our hospital. I didn't feel like spending a lot of money was necessary.

Here are my thoughts (although to be clear I fully disagree with this facility). 1. It cannot be an IV compatability issue since we all know Mg and KCl are compatiible. Hell, they're both in TPN. And this facility says 2 separate lines is not ok even. 2. Therefore, I believe the issue has to be with the effect of administering 1 electrolyte has on the other electrolytes. For example, have you ever heard that if you have a low Mg, your K will never come up? It has to do with the electrical charge across the cell. Calcium and Phos have an adverse relationship. Administration of one will typically make the other go down. Phos binders may help calcium to come up, etc. However, if this is their rationale, they should be asking you to check electrolytes in between IV administrations. 3. I have never had a problem with treating electrolytes at one time and have never heard of such a thing. What if they patient has many critical values? Let's just watch their K of 2.6 while we treat their Mag of 0.8 for 4 hours. And what about if they patient has K constantly infusing through IV fluids?? Doesn't make too much sense....

I am of the opinion that there are many things worse than death. Anoxic brain injury combined with STEMI sounds like one of those things. Death does not mean you failed. It means the family made a decision (and to each their own) and it's your job to support that decision regardless of your personal beliefs and give the patient a dignified, peaceful, pain free death. Once you see the families that put patients through hell and back, you will learn to appreciate those that aren't afraid to call it quits or who are confident in saying they know what the patient would have wanted. Just recently on my unit we coded a man for over 2 hours. He had a carotid dissection and we knew there was nothing we could do. He was a ticking time-bomb. His wife sat and watched us code him the entire time. She told the doctors "I wouldn't put my dog down, I won't do the same to him." That's fine if that's what she wanted or thought he wanted, but if I were that patient I would have rather died with my wife holding my hand without people pounding on my chest.

Just came across the thread but wanted to add: I don't think more than 1 anti-hypertensive prn is weird. If the pt is having sinus pauses do not give any beta blockers!!! Scheduled or prn. This can create more pauses By slowing the conduction. Without pauses, I would have chosen the beta blocker first because of the high HR and bc they were in fib/flutter. In this situation beta blockers help to break up the chaotic fibbing and slow conduction down sometimes converting to sinus.

You could just tell the new managers you don't want your current manager to know. They should get that. Are there any peers that could serve as references that would keep quiet for you? Any professors? Previous employers? Or, be honest with ur current manager. I've left 2 jobs before due to location and I think managers take it easier and are more understanding rather than if you were leaving cuz you hated it. Chances are, you'll eventually find a job elsewhere anyway right?! Don't feel guilty.

I think it depends on where you work and how you get your assignment. I work in an ICU. We are split into teams. Each team gets a group report and hears the basics of each patient on their team. We get a small spreadsheet of information on all the patients that includes their docs, what they were admitted for, drips, vital sign info, and frequency of some labs. From there, a team leader makes the assignments and we pick or are assigned by the team leader. Then, we go and get report from the previous shift for our patients. Combined, it rarely takes longer than 30 minutes, but we also have 1-2 patients. At the end of our shift, we update the spreadsheet for the oncoming shift. Here's an example of info on the spreadsheet: J. Smith, 35M Full Code Truma-Dr. Ortho 11/12-to ICU L pneumo/rib 3-8fx's, open pelvis fx, OR-ex fix on pelvis, intubated 11/13 BLE dopplers (-), 10 beats VT 11/14 trach'd at bedside, start feeds HR: ST 110s Temp: afeb BP: Keep MAP>60 Resp: Vent Foley OG to LIS IV: Fentanyl, Precedex, Levophed, MIV q4h H&H, q4CVPs History: hyperlipidemia, OSA (CPAP) Then say at the end of my shift, my patient had a temp and went for a CT, I would change the sheet to reflect that. I really think the sheet is great and makes going through report much faster. The sheet is saved on one computer so everyone can always see it. Then you never lose the medical history or what the patient has had done during their course of stay. Makes things SO easy!!! :)

I passed the CCRN first try doing lots of practice questions. I did the Pass CCRN CD and the cardiac was hard. I prob did 50%on the CD and 85 on the legit exam. Remember they make the CCRN for ALL types of ICU nurses so they aren't going to go too crazy into a IABP. Search "CCRN" in iTunes and some free podcasts come up. The cardiac was ESP helpful. My advice: schedule it!!! Once I did I studied on and off for 3 months and passed!!!

"Scrub the hub" for 15 seconds with alcohol, change IV tubing and caps q4days unless it's propofol (q12 hours), change central line dressings q7days unless there is a gauze over the insertion site then the gauze must be removed within 24 hours. How is your units hand washing compliance? How do you draw cultures? Assuming you know they aren't coming back just contaminated.

I think being a PCT in an ICU makes you competitive enough. Stay in touch with you manager and let her know you want to work there. The CCRN is hard and you will likely need actual hands on RN experience just to be able to pass regardless of how good a student you are.

I work in a trauma ICU and MRIs are fairly frequent. We have to change the leads once we get to MRI to all MRI compatible EKG patches and wires. Also, we don't change tubing, but we have to use extension tubing because the IV pole must remain outside the MRI suite and the IV tubing must be long enough to reach the patient (10 feet or so). This way, the RN who accompanies the patient can titrate drips, bolus, etc all while not interrupting the procedure. We also change temp sensing foleys to regular foleys and fill out a pre-MRI checklist. Maybe that will shed some insight. If a patient has a good pressure (or hell a low one but is obviously mentating enough to tell me they want a bath) they are getting a hefty bolus. We bolus freely using our continuous drips. The docs know how much we are giving by clearing the pumps and charting it. Renal disease has nothing to do it other than some of the drugs may not be cleared as easily. But it doesn't sound like that pt was going to be extubated anytime soon so who cares. And my guess is the renal failure is from rhabdo second to burns. So with copious fluid/bicarbonate administration, the kidneys should hopefully kick into gear.