sunnybabe

I practice questions I found in various books from Kaplan to Barron's. I thought Barron's CCRN book was really good.

Speaking of vents (sorry OP to jack your thread), how much is too much for your patient to be breathing over the vent? I've had patients who were vented and did not look agitated yet were breathing upwards 30-40x a min when their respiratory rate on the vent was set at around 20-30. I once had to page a provider about giving better sedation because the abg for one of my patients came back terrible. We usually use PRVC mode here if anyone is familiar with that mode.

I used it. I thought it was great! The review series is really thorough but doing lots of questions and focusing on my weak points was the biggest help. I also listened to Laura G's videos but found Med Ed to be more detailed... I made 91% on the test

Thanks offlabel! That makes it very simple to remember. And you're right, in real life, its a mix of both. I think that's where I get messed up with understanding at times because I try to relate everything I read to the patients I have (especially the sicker ones who have a bunch of issues going on, its hard to pinpoint exactly why they are hypoxemic). Sometimes, I put these patients in the CCRN study box, but I see now that they're much more complex than that.

Is COPD considered dead space or shunting? I understand that dead space is ventilation without perfusion and examples include lack of blood flow to the lungs, pulmonary embolism, since the aveoli is getting air but there is a problem with circulation to the lungs. Shunting is good perfusion, but bad ventilation and this can happen because air is having trouble getting into/through the aveoli for ventilation. I'm thinking this is where COPD lies. Examples I read for this was atelectasis, ARDS, mucus plugs, pneumothorax, and pleural effeusions. Am I on the right track? Thanks :)

Thank you all! You guys are awesome.

So if CVP is not an indicator of preload, then how do we determine preload. I've been asked over and over again, "What's the patient's CVP" to see if they are dry or wet (whenever the number was too high, they wanted to give lasix or low, some fluid...) but if CVP isn't an indicator of fluid status then... what is?

Hey all, I had a patient who cardiac arrested and they thought he was in ARDS given his Pa02 compared to his FiO2 and we were increasing his PEEP upwards to around 14 until he finally started oxygenating in the 90's (he was in the 80's before on 100% FiO2). I heard the RT discussing that his blood pressure would probably be affected. I have three questions: 1. How can adding PEEP drop a patient's blood pressure? He was already acidotic (so on a bicarb gtt) and on multiple pressors but vary labile with his blood pressures. The RT assumed that him being on this additional PEEP could make this situation worse. I've been reading and I read that adding PEEP decreases the venous return to the heart, but if that is so, then why is the CVP elevated (isn't CVP an indicator of the venous return to the heart-aka preload)? 2. I don't quite understand the relationship between PEEP and urine output. When I've called providers about a patient's low UO and their intubated, they ask me how much PEEP they are on. Does the extra pressure compress blood flow to the kidneys??? 3. Also a side question, why the patient was dropping his O2 sat, the provider also wanted to know his peak inspiratory pressure. Once she knew that, she went up on the PEEP, so does that mean the PIP was low or high to make such a decision.

Thanks a lot for the video. That really helped!

I had to comment on your post because it sounds exactly like my experience, except I am a new transfer to ICU. I have a year of nursing experience on a observational med surg/tele floor which is less acuity, but it's always stressful to be a new grad and I feel like new grad all over again. In my last job, I use to think what could go wrong in my shift, how I was perceived by my coworkers, calling doctors [i work night shift as well], and dealing with changes in patient condition. And here I am, on my second week of being off ICU orientation, and I have had the same feelings as well. When you ask about how to not feel this way, it really struck me because I don't think we need for the feeling of anxiety to necessarily disappear. It may keep us on our toes, keep us from making mistakes, and create conscientious nurses out of us, because we care to be good nurses. However, I think we have to recognize the fear and then determine what is truly causing the anxiety about the job. For me personally, I placed a lot of emphasis on how my coworkers felt about me- if they thought I was a good nurse. Not to mention I had in the back of my mind, that I couldn't make mistakes or else I was stupid. I thought that I had to perfect or else I was not a good nurse. So, in general, its the thought behind the feeling of anxiety that matters. Here are some things I have used to cope with my current transition and also where I started as a nurse. #1- Journaling: When I look back on my entries from my journal from when I started nursing a year ago, I realized that I am having the EXACT feelings as I had back then. I see how one entry talked about how nervous I was, how I didn't want to be a failure. But then, I would read entries from weeks later that said how I enjoyed my job, how confident I felt, all the good things that happened on my shift, and even the lessons I learned without the self-condemnation (like, calling myself an idiot). It was very encouraging and it's something I still do, especially with this new transition to the ICU. Usually when I get off work, on my way home, I'll just think about things that went really well (like maybe I finally got something for my patient who I thought really needed something) and things that could have been better (ex:next time, I'll remember never to ___________ because _____________ can happen). I try to avoid beating myself up and going around and around my weaknesses ( which includes talking to physicians and staying calm and being able to think in bedside emergencies). I'm aware of things that could get better, but we have time on our side! That's why they say its takes a year to feel comfortable in your unit ( they say two years in mine ). Be patient and kind to yourself. As long as you care to learn, you will be fine. #2- Get a hobby!-I think every nurse (well, everyone) should have a healthy outlet. We are nurses but it doesn't have to consume our lives. You have to take care of yourself. I'll admit that I think about work a lot, more so a reflection of things that happened, but I have to aware of that and snap of it and remind that I need to take care of myself. I think working nights may make it a little harder because you spend time sleeping during the day, but find something you like to do during your night owl hours. Do something that you enjoy and helps you not think about work as that next shift will come when you finally do have to think about it. When dealing with people, my best advice is to not take anything personal. I used to be the nurse who would send a physician who was sitting next to me a page to his cell phone to call back rather than just speak up. But since going to ICU, I realized that I cannot afford to speak up, or else the patient suffers. And I just think that it's wrong that my patient didn't get the care they needed because I was afraid of ______________. Most MD's/PA's/NP's are very reasonable to speak with, however, we also have to communicate well about the situation because sometimes they don't know anything about the patient ( in my experience). I noticed that I tend to rush my conversations with them and that's something I personally want to work on, so they have a better picture of what my patient is going through and may need. And if you encounter anyone who is rude to you, just remember who's its about- as someone once put it on AN: The dude in the bed (the patient). I'm learning that we have to check our egos out the door. And at the end of the day, everyone who works with you is just human with flaws and all. As far as getting stressed out when your patient's condition changes, that has happened to me several times at work. You passed the NCLEX, you can do this. I am very used to task nursing from my old floor, so a lot of anxiety comes from a lack of critical thinking, which can only come with time, patience, and learning. Your orientation was only the beginning of how much you have to learn. When something is going on with your patient, pause and think back to what you have learned (I would encourage you refresh yourself on concepts you don't totally understand when you have downtime or for your leisure- sometimes we fear because of of our own ignorance, so if you educate yourself on the side, you will feel a little more prepared). And if you just don't know, then just ask someone whose opinion you respect. I usually ask the nurses who have been there forever about patient situations that is frustrating me or I'm scared about what to do. They have seen enough to think more outside the box than I am and my favorite thing is that they are calm. Sometimes, they just say call the MD, but at least that is better than nothing. It's even better if you find a nurse who you notice loves to teach, so you can be around them and soak up all that knowledge. I know this is an extremely long post, but I really do hope you find more peace and contentment in this field. The point is, even if it feels uncomfortable, whatever it is, if you know it's the right thing to do, you have to do it. You know you have to do it. And when its done, anxiety has lost its battle with you because you still did the right thing. It's a long journey to feeling comfortable but once you feel totally comfortable, you may be ready to move on to the next challenge. Good luck :) You're going to make an awesome nurse.

Thanks everyone for their response. When I returned to work, I was told that because the patient had severe valvular disease (particularly the mitral/triscupid valve), his DBP would be low. This was considered his baseline. They didn't focus on his MAP as much as his SBP. They took off the dobutamine and used levophed instead.

There were other nurses who advised me to talk to the doctor. The patient looked stable but his bp was low so that was my primary concern.

Hi, everyone. I've on my second week of off orientation in a CCU. The other day I had a patient who had multiple issues: pleural effeusion w/ chest tube ( the effeusion was resolving however), improving septic shock, AKI, moderate valvular disease. Initially on admission, he was on dobutamine, levophed, and vasopression- the dobutamine because he was in cardiogenic shock, levo and vaso for the sepsis. They first managed to get him off the levo and vaso and then I see that the dobutamine was weaned off to "keep SBP >90 or MAP >60"- this is according to an order I saw. During my night with him, I noticed that his SBP was over the 90's, but his DBP was consitantly in the 20's. This made is MAP in the 40's-50's. I looked at his trends and it seemed that his DBP has been mainly in the 30's-40's during prior shifts. I got concerned and noticed that the dobutamine drip was still on standby on the pump and this order was still active, so I started him on 2 mcg. I contacted the cardiology group and they mentioned to start Levo at 8 mcg. I didn't notice a significant difference in his pressure until I went to 7.5 of the dobutamine and stayed at 8 of the levo. And by the morning, his DBP returned back to the 20's unless I went up on the levo. And his MAP stayed around the high 50s but struggled to hit 60. I was confused on how to titrate between these two gtt's and what would most benefit this patient. I think I am most confused about the role of dobutamine. I know its a positive inotrope but does it really increase blood pressure or decrease it because I know it will decrease SVR. I have heard one RN tell me it decreases BP while another says it increases BP. With a cardiac patient whose blood pressure is tanking does it really help them in the short term or should I just placed him first on the Levo instead? His EF came back at 55% which is why (according to the notes I read) they wanted to wean the dobutamine gtt. BTW, I was told he had received dialysis the day I got assigned to him, so perhaps he really needed some fluid instead? The oncoming RN also mentioned that perhaps he needed to get re-cultured again. Maybe he was still septic? I'm just thinking there was another way I could have handled it. It's been difficult to adjust to feeling comfortable with what to do as far as making critical thinking judgments.

I know this is an old thread, but I wanted to mention that I too am struggling with developing critical thinking skills as I am focused on tasks in a busy ICU on day shift. I'm still on orientation and I have until Christmas till I'm on my own (I get 12 weeks since I have a year of floor experience). The tips in this thread were great.

Hi, terri8 When you said dropping off your resume, did you mean dropping it off to the unit manager or to HR? Also, were you able to apply to non-residency programs too because I realize that not all of the hospitals have residencies and some hospital residencies are full. I graduate in July so I was trying to get into a new grad residency but it's difficult right now. Thanks in advance :)

I just wanna give you a hug. And I'm sorry to hear about your parents' health. You are definitely being put to the test, but I hope you overcome. I am in the same situation except that I have my practicum in the summer. I'm writing 20+ page papers, I'm trying to work ( I work in the hospital too) to pay my bills, and have time consuming projects + that dreaded ATI. I've learned that when I feel heavy, I'm carrying too much. Yes, I can't change that I have to do these things but I can look for ways to find balance. Is there any way you can work less. I am PRN and don't get vacation time either, plus sometimes I'm called off. I've had to survive off of loans. Find some peace. If you're spiritual, tap into that. If not, get into something that will help you decompress. Peace is available, you just got to find it amongst all the chaos. Best wishes to you, your career, and your family.

This was very nice to read. It's sad how our circumstances lead us to settle instead of thrive.

For ATI, I was able to use the review manuals for each class. I am in OB-Peds, Mental Health right now. I read these books practically front to back and it was really much more helpful than taking practice exams.

Hi, I am in Pediatrics class right now and I love learning about cardiac. In my notes and lecture recording, it says that increased pulmonary blood flow (which in children are usually caused by congenital defects like VSD or ASD) will cause impaired myocardial functioning. As a result of this impairment, the heart has to work harder and the patient will be tachycardic, weak, and tired. My rationale for all of this is that since the blood keeps going to the lungs, the body is unable to get enough O2 into the lungs since the lungs are filled with blood/fluid. Is this correct? Also I was thinking that the heart keeps doing the left to right shunting that it can't keep enough blood to send out to the organs so it keeps working hard to get and keep blood from the lungs to send elsewhere. I was also thinking that the continuous left to right shunt increases pressure in the pulmonary artery and the heart is working hard to overcome this pressure and eventually begins to fail ( backup of blood occurs as a result of this as well--> heart failure). I also have in my notes that left ventricular hypertrophy occurs as a result of increased pulmonary blood flow. Is it because of that large amount of blood going from the lungs into the left atria and then left ventricle? I was wondering if anyone could let me know if I am on the right track. If you could put in terms that would apply to both children and adults, that would be helpful. I want to make sure I understand how blood filling up in the lungs makes the heart "work harder". I know it should be common sense but I want to understand the patho part of it. Thanks!

1. Brush up on your A/P, thenit will be much easier for you to understand disease processes because you know how the actual body system is supposed to work. So definitely know your functions. I found Endocrine and Respiratory to be the hardest. 2. A NCLEX book would be helpful for you. I never bought one but my friend used Saunder's Comprehensive RN and I would always look at it before my tests. Alot of med surg questions are related to 1. Do you understand the signs and symptoms of this disease (Ex. pneumonia vs. COPD) 2. What are the key complications and things to watch out for (Ex. If someone is a diabetic, what's the worst that can happen) 3. What can the nurse do to help the patient with his disease? What can the patient do (goal)? Try not to memorize, but instead understand why the patient has this disease, how he looks with this disease and the treatment that is supposed to be used for it. I got an A in the class. I also think I got an A not only because I studied, but I also work on a med-surg floor and I saw nearly every disease that I learned about in class. When learning, think about a patient ( real or imaginery) so that the situation makes more sense to you and you can answer the question properly. GOOD LUCK!

I am in KSU's nursing program. I have several classmates who have gotten externships with Wellstar. I believe they prefer actual nursing students. I really wouldn't rush trying to get in Wellstar right now until you are actually in the program. Trust me, once you are actually in the program you increase your chances of actually meeting one of the WellStar recruiters ( they come to our school to speak all the time). Try applying elsewhere, maybe a nursing home or as a sitter, if you need to work as a CNA (for money purposes). That will put something on your resume until you are ready to apply as an actual nursing student. Good luck.

Thanks so much. I am so much happier!

Hi, I sent this email to my teacher. But he has not yet responded. I work on a med-surg floor and I did consult with one of the resp. therapists but I just want to know what you all think as well? I don't post here often, but I would love to know the answer to this question [h=1]A few weeks before our respiratory lecture, I had a patient in the ICU who I observed was becoming very tachypnic and restless. She was an elderly woman. I told the nurse and when she noticed that the patient saturation ( I know you said those aren't the most reliable was going into the 70's and the patient was clearly distressed, she bumped the O2 from 2-10. In short, they were able to avoid intubation and keep her on a CPAP machine ( or PEEP? I know it was just positive pressure being put into her lungs, not 2 different pressures. I'm still not sure what the right term for it is. The nurse said it was to assist her with ventilation, not make her ventilate). Upon a chest xray, it was determined that she had pneumonia and I think it was causing sepsis. They also got an ABG and I believe it was respiratory acidosis ( the textbook says that pneumonia can lead to resp. acidosis). I also had a COPD patient who demonstrated the same signs of my first patient (increased RR, increased HR, very distressed) I understand that respiratory acidosis is clinically manifested as respiratory depression ( this is what they say happens with drug overdose). But is it that sometimes, the first signs might be a hyperventilating patient ( like mine who RR was going up, HR was going up) and if we did not quickly intervened, they would have eventually hypoventilated? I am just thinking of the compensatory mechanisms that pt's demonstrate when they have resp. acidosis. I might be confusing hyperventilating with tachypnea. But to me they look the same! How can you tell the difference especially since you have to treat the underlying cause? Thanks, Sunnybabe. [/h]

Hey, I'm a tech too, but on a med-surg unit. I possibly want to be an ICU nurse too as I have floated there before and I loved it. Even though I'm PRN on my floor, I have been floated to other units, including ICU, when census is low. I plan to go into the float pool either later this year or next year before I graduate. That way I can see other units. I thinking going into the float pool will be in your best chance or tell your manager that you would like to apply to the ICU and see if she can put in a good word for you. I rather the first option because not all managers are that receptive to transfers. Also, it may help to get your senior practicum in ICU so that even if you only see med-surg you have some sort of ICU experience

I find that many patients are difficult because there is a misunderstanding between the nurse/cna and the patient. I have had to tell patients (those who are alert and oriented), that they should tell me how to help them because I can't read minds. Goal setting and being on the same page from the start of the shift is a good way to develop trust. Hourly rounding helps and just spending a little more time in the room more than usual helps too. Family members tend to annoy me the most because my main focus is on the patient and they are taking that focus away with their antics. I just recognize their concern and just tell them how it is and what can and cannot be done. Right now, I'm a tech but I see even the best nurses get complaints. Sometimes, you just can't win and I always look at whether the customer service at hand is even worth trying to remedy because some people just can't be pleased and will not change their mind.