LCRN

At my facility we document the following routienly: full assessment Q4 hr lung sounds Q2 hr vitals Q1 hr I/O Q1 hr hemodynamics Q4 hr (also w/ every change in vasoactive meds) This is all subject to change depending on the patient and the circumstance- if a patient has an IABP pulse checks are done Q1, if neurosurgical patient neuro checks done Q1 and so on.... LCRN

Hey- Were you running all these meds via a central line or swan? I know you said you had no cvp...Was it via a PICC or peripherals?Do you use neosynephrine at your place? I would probably used that first due to the preference at my hospital. Seems to cause less peripheral ischemia then others. We use NEO as a 1st line pressor for our "cardiac patients" and CABG's and then add a little NTG for coronary dilation even while patients are hypotensive. Then I would add Levo with the tachycardia I would stay away from dopamine and epi. As for the dobutamine I would hold as well being that it can cause hypotension although it is an inotrope. Without a swan I think it would be very difficult to manage this patient. What were you using as parameters to titrate epi? Did you at least have an art line? What ended up happening to the patient? LCRN

Hello- At my place we run Dopamine mcg/kg/min...Our max is 20 mcg/kg/min. We usually titrate up and add another agent for blood pressure support at around 15 mcg (of course every patient is individualized), other vasoactive meds we commonly use are...neosynephrine, levophed, vasopressin and epinephrine. If we have to add multiple agents to sustain a Mean Arterial Pressure of 60 then we place a swan so we can optimize the patient with additional meds. I've seen a change over recent years with pressors...dopa seemed to be first line for hypotension and the 2 hospitals I work at now seem to go to levophed first which was a last line drug that earned the nickname "leave 'em dead". Anyone else seen a trend? LCRN

As an ICU RN I'd love an OB RN to come down with their patients however it's not realistic with staffing. When we get patient's on mag infusions we check reflexes Q1 and mag levels Q4 usually. We do this while we are addressing their other issues at hand...htn, bleeding, resp insufficiency LCRN

peripheral vascular disease, aneurysms, thrombosis, some autoimmune diseases cause decreased perfusion to periphery... I'm sure the list goes on but their a couple off the top of my head

The difference in the hospitals that I have worked at is basically as the above poster had stated...when patient's no longer meet ICU criteria but may require closer monitoring. In my ICU our patient-nurse ratio is 2:1, on our step down unit it is usually 3-4:1. These patients need frequent chest pt, may still require some vasoactive meds and central line monitoring but are no longer intubated. If they are post-op may require frequent drain I/O's as well as urinary output. But also usually have pretty aggressive rehab if they are able to tolerate it. I hope this helps. LCRN

Hello- at my facility the for patient's who are hyponatremic our goal to correct is 12 (mg/dl) in a 24 hour period due to the severe complications of correcting too fast as were mentioned by other posters. We usually never infuse 3%saline for more than 1 liter before switching to a less hypertonic fluid. We check lytes every 4 hours to make sure that we are not correcting to fast. For our patients that are chronically low NA we usually give them NaCl tabs with each meal and at bedtime. Hope this helps- LCRN

The policy at my hospital is that all narcotic continuous infusions are to be run on PCA's however all of our benzo's and paralytics are just on regular pumps... \ LCRN

Hello- Routinely we have a ratio of 1 RN: 2 patients for most of our assignments. Post-op OH are 1:1 the 1st 8 hours and then unless they are considered unstable (requiring 3 or more pressors/dilators) or have open chest with IABP another patient is added to the assignment. At the hospital that I work in we have a POD system so each RN has a desk computer, phone and 2 patient rooms directly in their visual field while sitting at their desk. We have a total of 30 beds between the MICU and SICU, all RN's are cross trained to work in both units. This system works well unless both patients in your "pod" are SICK....traumas, crani's with ICP's, AAA repairs, etc. We always have a charge RN and a resource RN to assist newer staff members, take the MET Team calls, Codes and place IV's on the floors that are difficult sticks. We (in the unit) also assist with conscious sedation for bronchoscopy's that are on the floor and triage patient's with the ICU Resident. The charge RN and resource RN rotate on a weekly basis and are essential to the daily flow of the unit because they do not have patient assignments and are able to assist with a crisis that always arises. Hope this info helps!

We have a "skin care protocol" and if a patient is having loose, incontinent stool and is at risk for skin break down or already has skin breakdown we use appliances--> let me explain. 1. Recal Pouches do work if applied correctly...at our place we usually get about 3 days out of them but we are tedious in application with skin prep and the smallest size tegaderms in the areas that tend to lift up for added security. We tend to irrigate them q 12h to make sure their patent. We only apply pouches if the patient has NO breakdown, No redness and skin that will be able to withstand the pouch adhesive. 2. My personal favorite is the ZAZZI- this is used for bariatric patients as well as uncontrolled stool. With some bari patients we intentionally liquify their stool by giving them lactulose so they can use this device which is similar to a rectal foley but rather than having a balloon being filled with air inside the rectal vault it is filled with air so it's soft and flexible and can remain in a patient for up to 28 days per the company. You can provide retention enemas and medications right through a stopcock that is provided, there is also a water flush port. Our facility likes it. We also use it with patients that have sever decubitus ulcers/c-diff with breakdown/colitis/and for strict I/O at certain docs requests. (the zazzi is contraindicated with any lower intestinal surgery or resections) 3. The rectal foley which at our facility is the good ole standby, we use this for short term use. The 30cc balloon is filled with water. Usually we only insert this if the patient is already having loose stools, we wouldn't intentionally liquify someones stool just to insert this because is it a short term solution. This is because the balloon filled with water in the rectal vault can cause necrosis after time and practitioners adding a little more water to stop the stool from leaking :) I know how you feel because I am also quite short at 5'0 and am familiar with the bed that you are talking about. I hope this information helps you- If your facility is going to take patients over a certain weight they should provide you with mechanical lifts or the staff to be able to safely lift them. I would definetely bring this up to upper management. Above all your concern is the patient as you pointed out! Good luck with your concerns!!!! For our skin care protocol we also start patients on MVI/Zinc/Vit C (if renal dose adjustments are made) Once again I hope some of this info was helpful it has seemed to make a difference at my place!

I make 90k with working around 40-44 hr/wk including my double (at my facility you make 1.5 pay for doubles) with under 10 years experience. I work primarily days but I do pick up nights. I live in CT and some of the senior experienced RN's that are capped (I'm talking 30 years experience)with all certifications and levels are making 115-130k. Hats off to them because they deserve every penny and MORE! The more certifications/differentials/ and levels that you have add up as well as what shift you work...those evening and night differentials add up! LCRN

In any situations that I wear a mask which for myself are few and far between if ever a patient insulted I usually let them know it's for their own protection when I'm cleaning them if they have any areas of break down so that I do not get any of my "germs" on them because I have a "cold" at the time. This usually prevents any embarassment and avoids an uncomfortable situation. LCRN

I don't know what you're going through and can't imagine it but I'm assuming that there's no way that you can safely take care of an assignment that large...let alone do assessments on a 1/4 of them!!! You need to find a different position that respects you and your quest to provide good, safe care so you can make a difference. I work in ICU where I have a 2 patient assignment- somedays I feel like I can't handle that when I've been performing cardiac massage to relieve a PA's hands whose are numb or have a patient on so many gtts I don't even know where to start untangling the web of spaghetti of IV lines...but know that you are an assett to your hospital and it needs to treat you that way! LCRN

In my unit--> We have one Charge unit without an assignment and one resource unit without an assignment this is because as ICU RN's we are responsibile for multipile tasks throughout the hospital--> MET team, Code team, bronch team, conscious sedation, difficult IV's on floors, and we assist the unit residents in triaging the patient's to come to the unit. Having said that we do not have any aids or techs in the ICU. We rarely have patient's that are 1:1 unless they meet specific criteria. Our open heart fresh from OR are 1:1 for first 8 hours and then go to regular staffing. If we have a really sick heart with open chest and sternal retractors still in with balloon we'll keep them 1:1. So basically there is a nurse that has just one patient that day and helps out the RN that has the 1:1 patient because our pods are setup with 2 rooms. If one of our patients have to be transported to CT or something we ask one of our "podmates" to watch our other patient for the 1/2 hour usually this does not cause a problem. Most of the time we take our breaks very close to our pods so we don't need to get someone to actually sit at our pods for the entire break. Usually we do not have the luxury of having experienced critical care RN's float into our unit. When we our short and we have RN's float into our unit they may be vent proficient but are not used to gtts, cvvh, balloons so we must change assignments to assure that thay receive the most stable assignment at the time. Believe me we are happy for any help! However the most stable patient...can turn at any moment as I'm sure you may know. We opened the pod system up in our new ICU a little over a year ago and I love it. I have my own little work area with my chart rack, a phone, and a computer. This provides a work station for the docs to come and speak to you regarding your patient's and for you to chart rather than in your patient's room. I hope this helps, if you have any more questions please feel free to ask! Lisa

I work in a 2 unit ICU-->medical side with 16 beds and a surgical side with 14 beds. So all RN's have to be cross trained for both units. Each of our pods have 2 beds. When you're seated at your pod you have both of your patient's in view by the windows in front of you. I'm not sure how it would work if you had 4 beds in a pod...would you have 2 nurses? or are your patients "stable" enough to have an nurse patient ratio of 1:4? We also have multiple main master monitors that show all patient's readings on the walls in the hallway. What do you men by # of hours worked per patient day? LCRN

I had a PICC line when I had to receive Vanco for osteomyelitis for 6 weeks. My homecare RN also had a lot of difficulty drawing blood from my picc. I routinely flushed with additional saline and hep saline. I ended up having to always hold my arm above my head and take deep breaths and cough to get an intermittent blood flow. I received alteplase 2cc in each port which did not help (picc flushed easily just difficulty was in aspirating blood). It was decided it was just a very positional line...I was drawn peripherally for p/t's. Does the Picc have claves? After each blood draw and dressing change they should be changed...they can cause a sluggish or no blood return at all. Sometimes these lines do not cooperate... LCRN

Anzemet if the patient has IV access or Marinol PO has been a solution for intractable N/V with the other suggestions that posters have suggested

Synvisc will not STOP your knee from developing effusions necessarily. The etiology of the effusions needs to be determined. I had synvisc injections in 2001 --> the intra-articular injections regardless of the practictioner's skill level do cause pain. I had the series of 3 injections and found that within 6 months I was no better off than prior to the injections. My physician put a "freeze" spray to help with the pain at the injection site...this did help some. Do a search about synvisc and you can find some good information. Unfortunately for me, my results were not what I wished they were. Good Luck!

I think we need to know more about the specific situation. If the above poster is calling respiratory depression resp=7 after morphine administration before narcan is given an oxygen saturation maybe should be checked. If the pulse ox is fine with decreased respirations I would not clinically push narcan. Then we can get into another discussion as to the patients co-morbidities such as sleep apnea, pleural effusions, lung ca, brain tumors/ bleeds, abdominal ascites which can all alter your respiratory rate. Before you can give an answer to this question I think you need to know more about the situation.

I work in a split unit medical and surgical ICU--> we have to be cross trained to work in both units and a level I trauma center that can entail any type of patient any day. I love my job, I feel I am blessed to hold people's hands as they pass, to share memories with loved ones, to help patient's get better and console patient's when they do not. Don't get me wrong I have bad days that I feel like are impossible assignments and wonder how I got through them afterwards but I can look back as a reflection upon my character to say that being a nurse has made me a stronger individual. I remember a post-partum woman who was carrying triplets and at 21 weeks went into early labor, a crash c-section and a severed bladder and repair later and i was taking care of a woman who was expecting 3 healthy babies and ended up with one baby in NICU fighting for his life. After I extubated her and provided mouthcare I offered to "clean" her up. I asked if I could shave her legs..she accepted and then broke down in tears explaining how she could not thank ME enough for doing something extra to make her feel better. All I could think about was what else could I do to make her more comfortable but that act of caring (as odd as it may sound) went farther than anything else I could've done for her. I am fortunate to be a nurse...

I agree with the above poster...at my facility we have to types of DNR--> one is a comfort and one we provide supportive care to such as vasopressors/treatment of cardiac aarythmias/blood products. If a patient is a DNR comfort and is receiving morphine for exactly that ->comfort then giving them narcan would bring them into immediate withdrawl and a painful state. I don't know the circumstances

I guess it really depends on what dept. you want to work in. Being that St. Vincent's has just opened a brand new state of the art 30 bed ICU...if that's what you are looking for I would reccommend that. I cannot comment on St. Raph's because I do not or have not worked there but I think it's bold to suggest working there over another facility when you do not work there yourself and are relying on what you've heard from you're friends. Just my opinion. I guess it all depends on what you are looking for in a job and environment.

I'm at a loss about the pacer beside mode could've been changed or augmented by being interrogated. About the senior RN referring to being refractory to the meds...to be on 1mg/min of amio for more than the usual 6-8 hours (then you're to reduce the dosage in 1/2) can cause amio toxicity. Have you guys been running labs on this patient?

I can only comment on St. Vincent's...I love it. There is very much a family feeling in that hospital. What type of position are you looking for ICU? ER? med/surg? Although Bridgeport is not the greatest area it's easily accessible from I95 and Route8/25 connector. I had heard the same thing upon applying to St. V's...it's in a bad neighborhood. I've had no incidents or any problems while I've worked there. They offer a lot of incentives...gym, credit union, leveling, pay for educational courses and when you sit for exams (if you pass). The list is long compared to other hospitals that I've worked at. As far as the cost of living...from what a lot of people say single bedroom apt. go from 750-1100 and you can get a 2 bedroom for 950-1400. The surrounding areas of Bridgeport are nice regardless of the above posters comment. Look in Milford, Stratford, Fairfield...it all depends on how far you want to commute. Good luck...if you have any questions feel free to ask.

Also you need to think about patient's co-morbities that could've caused a "false" high cvp such as any right sided heartfailure or issues with valves. In some patients you have to use the trend of the cvp to measure volume status rather than necessarily the actual number. For example the normal cvp depending what source you look at is about 2-6 but since cvp is the reflected value of the Right atrium someone with Right heart failure might have a cvp of 18 and be on the "dry" side. It's important to understand your hemodynamics inside and out. I hope I didn't confuse you by adding this tidbit.