Catchall_RN

I'm not actually sure if we have a medical librarian... I'm sure we have to--I'll have to go search around on the intranet about this. Thanks again for the comments!

Which monitors do you use? I have found some monitors are better than others. Nihon Kohden never gave me apnea alarms but gave me the sinus asystole alarm alllll the time. On the other hand, Phillips tends to give me apnea alarms pretty frequently, but much better with the rhythm alarms. Definitely also change your leads/electrodes if you're getting a lot of alarms. q24hrs is best, there is a huge difference sometimes just by changing out your electrodes (and double check placement, they jump around or sometimes someone brain farts and puts the white over the left and the smoke over the trees!).

Places I have worked have similar VS policies as is listed here so I won't go into that, none of the places I have worked specifically say we have to stay in the room Places I have worked have had different blood infusion rates for ICU in particular, and a couple have given us another set of rates we can use in emergencies (specifically wide open). I have found bigger ICUs that have higher acuity pts have more liberal policies for us for obvious reasons (if a pt is bleeding out and I'm getting the level 1, that policy is useless anyways) Generally speaking, what I usually see in the ICU and what I also do with starting transfusions: if it's a pt's very first transfusion and they're stable, I'll start at a slower speed and turn it up 10-15 mins after. I try to stay near the room, or at least in eye and ear shot. There are situations where I cannot do this, but I will still listen up for it. I will tell the pt and/or family (if pt is unconscious for example) some of the signs to call for me, like itchiness, rash, back pain etc. If it's a pt's 3rd or 4th, I'm usually more liberal with the speeds. I'm happy to say I have NEVER witnessed, or heard of my units, having blood transfusion reactions. A very very small # of pts got pre-medicated with benadryl. On at least 3 occasions I can think of off the top of my head, blood bank did send us the WRONG BLOOD .. one of which was a few weeks ago where that error was terrible, as we were using the level 1 ... We caught it immediately on double check, but still, that time is precious :\

These are some excellent responses, thank you! I'm not completely sure who, or which, educator I would direct questions to. At previous facilities they had like 1-2 educators that kind of did all the ICU stuff, granted previous facilities did not have this type of variety. We have like the ECMO CNS, cardiology CNS, cardiovascular surgery CNS's, transplant CNS, etc etc. that act as educators and quality improvers. They often teach the classes that will train for their various specialities, so I have 0 idea who the ECMO CNS is because 1) I'm not day shift 2) I'm far off from being able to take the class yet, for example. I think it's unfortunate that we do not have the educators like at my previous facility that are easy to get in contact with, but I can also see why my facility has gone the route it has. The clinical manager will frequently send out articles, fliers, and AACN online classes for education on certain things or updates that the CNS's pass to him for easier distribution. I do learn a lot from my charges and other experienced nurses, as well as the residents. I have been fortunate to teach them too recently, as we have had an upswing in brain bleeds which a lot of my coworkers are not comfortable with, but I know those in and out.. I did ask my clinical manager a bit ago about how I can learn more on these newer patient populations, and he responded I'll pick up the basics by just helping nurses with the pt, and further trained in classes when they open up again. That's fine and all, but it doesn't satsify my curiosity as it is now. :) It probably doesn't help that the particular topics I want to learn about are considered very advanced specialities even for critical care, so AACN rarely runs a journal article on these specific topics it seems [truth be told I've been busy with a ton of OT and moving to a new apartment, so I haven't kept up on the articles in the past 4 months]. Just to make clear, they didn't simply drop me w/o skills into a high acuity ICU with 1:1 type pts (I can take some 1:1's, like brain dead donors, severe sepsises, paralyzed for severe ARDS--but not the VADs, fresh hearts, ECMO etc).. A majority of the pt population I know very well, but the exposure to all the new stuff makes me excited and curious! edit: Forgot to say, a lot of the "paper" protocols and policies were taken "out" simply because the facility feels it can better implement them using order sets via EPIC. This is fine, except sometiems when I'm having a slower night, that's how I learned as a new nurse about patients I hadn't had--I'd look up the protocols and piece together the why's and how's of the treatment and management process. Also, I'm getting the feeling that some of the questions I asked are possibly not as delineated as I might have thought... like the transplant work up question--I had a patient just the other shift where she had to go through quite a bit more than normal (according to my charge) because they really needed to rule out extra crap (her liver enzymes were normal, but hep B antibodies came back positive [but no prior immunization] so she needed a whole load more tests and a biopsy) that most of our patients don't need to endure. The PA catheter with medicine management (I don't know what to call this? my facility usually calls it the milrinone or dobutamine test) is standard as is gastroparesis testing, but from there it seems to vary. I'm thinking I might learn more if I was on day/evening shift where I could see more of the testing and thought process of the day time physicians rather than just reading their notes (which are not often detailed--many of them are new to EPIC heh) if I have the time.

Long story short, I spent the last 3 yrs working with almost every type of ICU patient except day 0 open hearts, transplants, burns, and anything under the weight limit for adult ACLS. The hospital I worked at was excellent trauma/neuro but lacked a lot in .. everything else, as I have found. I got my CCRN with flying colors, and quickly got offered a job in a fantastic area at a very large, extremely high acuity hospital that deals with all transplants (including hearts), ECMO, high risk cardiac patients, neuro, etc etc just no trauma/burns. I was given a short (5 days) orientation to the basic population I'm expected to take w/ no extra training and that's cool, 95% of that I understand every intervention in regards to disease management etc. I came here to see if anyone is able to provide me a starting point to better understand those 5% I don't feel as strong with and also some starting points for better understanding the patients I will want to take as I progress in my new facility. (I am also currently on night shift, and the residents do most of the noc work so their understanding is often not 100% either--or they are afraid to explain. I try to ask experienced co-workers when we have time, but there's not always enough time considering the acuity of our patients) 1) WTH is all in the heart transplant work up? I asked a bit about why we do some of this stuff and ppl kind of give me a blank stare cause a lot of us TRULY don't know why we do gastric emptying studies and so forth. [[specifically post transplant: There's also a lot of drugs ppl throw around I have only heard of in CCRN studies or briefly see in pharm books like Isuprel that get used frequently that I am not sure as to why. A starting point for me to read on the aftercare of heart transplant and ECMO in a clinical setting would be fantastic!]] 2) All the different VADs. Where I worked, if you needed more than a balloon pump, you hoped you could make it 2 hrs to the nearest "higher acuity cardiac center" or you went on comfort care. Here, we have like 5 different VADs at least. Why do we choose a heartmate over an impella? How about the one a patient went home on for like a year? How does the work up actually work (kinda got some answer that work ups generally use a PA line and either milrinone or dobutamine and possibly other pressors, see how much support is required, and from there if a pt needs a VAD right now, soon but can wait with medication management, just needs a different medication management, or your heart is **** get a new one). I am not expected to take these yet, but they are usually one of the first to get trained into (along with CRRT). 3) PA line troubleshooting. Where I worked, we didn't use them. Almost ever. Now I get them on daily basis. The new ones are fantastic, beautiful wave forms, wedge perfectly, etc. The ones that have been in for >72 hrs? Start to have problems with dampened waveforms (primarily), "catheter is sitting up against the vessel wall", etc that simply flushing doesn't seem to help but some of my coworkers seem to be able to fix with magic fingers. This is barring the pressure tubing/NS levels cause I have learned in my very long experience with alines and CVPs how often those get overlooked and are usually my first go-to point. Also, is it coincidence, or do morbidly obese people and PA caths usually get questionable waveforms? I honestly don't know how body mass affects the catheter. 4) Possibly because it's been transplant work ups, and also because its very MD directed, I'm not always sure what we are titrating gtts to in particular with the PA line in severe CHF. Their PA #s are always extremely high and rarely anywhere near normal, and the MD directs the nursing staff to titrate up/down on milrinone on what can appear as on a whim. If it's dobutamine/levo combo or just dobu, it's usually RN directed and parameters are set in our MAR which is easy enough to figure out and follow. It doesn't help my past experience with milrinone is limited on textbook knowledge that is a inodilator etc. 5) Is Natrecor used anywhere anymore? 6) Is peridex/chlorhexidine qshift for oral care for vented pts a standard in your ICUs? For some very odd reason, this is the ONLY issue I've run into with my new place, they don't believe in ordering it for all vents. I have always known it to be a gold standard in VAP bundles etc. Any ideas for reading for general transplants would be awesome too, granted kidney/panc/VERYSTABLE livers are not that complicated, there's just a few things that we do that don't make sense--and I have asked our ACNP why we do them, and the answer is, "We always have done that, I have no explanation I'm afraid". Can't just take that for an answer, of course. It's kind of a lot in this post, thanks for reading. :)