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Speaking as an ICU nurse, i can tell you that not all are ocd's but a lot are. You really kinda have to be, because you have 1 or 2 patients and then if you pass it along to someone who isn't so nice, we'll you'll hear about it the next day, actually the manager will hear about it the next day. Is this what you're going through? I mean the next day you come in and the previous nurse will berate you about the little things you ''forgot'', I'm not talking about important things, but like some not so important things like when they come in there's 50 cc's of urine left in the foley bag that can accomodate over 2 liters, and which you also emptied an hour before when you did your I/O? There's really nothing you can do about it, you just have to shrug it off. But then after awhile it does get to you and you become anal retentive about your patients, making sure everything is pretty much perfect. Then once you start to orient a new nurse, they will also think that you're pretty much OCD.....So the best thing is just leave your work when your shift ends and forget about it. Good luck!

Thank you both, Gauge and Siri...You've cleared things up for me...There's a dual program Adult/Geriatric NP that I'm really interested in pursuing with the hopes of seeing patients from clinic to inpatients to nursing homes. Thank you both.

Yes thank you, I guess I was thinking of a specialty in a way where you can see your patients thru the whole continuum, clinic and inhospital, and was wondering if you need to be dual certified. Thanks a lot!

I had a question on another thread that's similar to this, and no one has answered yet, so I guess I should pose it here...My question is if you're an FNP or an ANP practicing well care in a clinic and your patient becomes acutely ill. Now I know IM physicians do consult specialists left and right, there's no question about that. Though what I would like to know if anyone would like to answer is, working in a clinic, is it a common practice to have hospital priviliges so that you can follow your patients during their in-hospital stay, or would you need to be a dual cert ACNP for that? Meaning as ANP or FNP's with acutely ill patients that you sent to the hospital from your clinic, would you then be able to round on your patients off clinic hours to see your patients in the hospital and still be this patient's primary HCP, order lab tests/meds/treatments etc? Is that even possible? And I understand the notion of putting consultants on your patients such as pulmonologists/cards/nephro depending upon your patient, but I guess my question is, is it common place to have single certified FNP to follow a patient from a clinic to hospital thru discharge, as the primary HCP, or would you have to give up your patient to have a different attending like an attending physician assigned by let's say the ED to manage the patient while they're in the hospital. I guess it's kind of like the same as an IM/FP physician having a critical care patient and giving up that patient completely to the Intensivist group, and them seeing and rounding their patients everyday with the attending physician in the background while the patient is critically ill, but in the case of ANP/FNP it's from well care to acute care. Would dual ACNP/FNP help to have continuity, or it doesn't matter? Sorry if this sounds confusing, but I'm looking at programs such as ANP and I'm wondering if I would need ACNP to follow your own patients thru their whole stay, which really appeals to me. Thank you very much.

LOL this made me chuckle and made my day, too funny.

A solution for missed orders that is used by a lot of nurses so that they can cover themselves is the end of shift chart audit with the oncoming nurse. Therefore a nurse can go home knowing that when she checked off with the oncoming nurse, all the orders throughout the shift was taken care off. It takes only a minute.

Hello, to all practicing NP's especially the one's in primary care. I just have a question...If you're an FNP or ANP who functions as sole Primary care provider for your own patients in a clinic for well care, and then your patients become acutely ill, does that mean you would have to consult an internist to manage the patient and maybe do an admission? Or are most ANP and FNP usually have admitting priviliges that they can manage the patient in the hospital? If not, and you're an ANP or FNP, then would you need to be certified as an ACNP to have admitting priviliges in the hospital, handling the patients hospital stay, rounding on your in hospital patients? Is that within a scope of an ANP or FNP, how bout if they're dual certified as ACNP, would that be within their role? Or is that encroaching upon the role of Internal Medicine Physician?

Yes, per oxyhemoglobin dissociation curve, a right or a left shift depending upon the temperature. Source: http://www.ventworld.com/resources/oxydisso/dissoc.html Here's an interactive module where it shows the change in oxygen saturation when the only variable changing is temperature. http://www.ventworld.com/resources/oxydisso/oxydisso.html

Here's a video of a student who made the error of picking up the cellphone in the middle of a lecture...

PRN med I would, if you push the 1cc mso4 and leave it as is then it will take time for the IV solution to push it in, and your patient would be in pain for awhile. I guess I'm being anal.

po here, x 18 doses usually, then patient can be transferred to the floor. Some attendings prefer to keep their patients in the ICU until the 18 doses is finished, with tylenol overdose, but some physicians transfer the patients after 36 hours or 9 doses depending on the labs.

One can say that pulse palpation can be dependent upon the skill of the person performing the palpation. Sometimes, during a code there's a lot of chaos, and a doppler could be another aid. There are times when you have flow with less than palpable pulses, and at these times, when you have a weak pulse that's not palpable but is evident thru the doppler, then your interventions could change - for example not doing extra defibs on a patient with a weak pulse that's found only by a doppler, as oppose to defibrillating a person because the staff couldn't palpate the weak pulse. Technicality I know, but can be helpful at times.

If the pt's already on lisinopril, you can safely say that he's at a higher risk for incidence. For the warning, research non selective cox inhibitors.

LOL sorry that annoys u augigi, I was giving her an incentive. To tell you the truth, and as of course you know, it's difficult to get people in without ''bait''. I for one, love inservices from the drug companies, it takes me away from the chaos of the unit, I could sit down and have a nice and quiet for a few minutes. Even if it does sound crude, it is a great form of advertisement. It becomes a symbiotic relationship between the two. As a lot of nurses in the unit knows, ''food and gifts'' are what the companies use to get them in the conference room. You'll see a lot of them by the nursing station and say, ''guys we have food in the kitchen, and an inservice'' I'm not saying it's a bad thing, actually it's a good thing, the companies get their points across, and the nurses learn at the same time. Again, I apologize.

That's what I heard about community hospitals that don't have fellows or interns, they pretty MUCH are more autonomous because they don't have residents that would be there in a minute, so I heard typically the RN's from community hospitals would have to be pretty fast, and can function well alone.

Same here, only balloons i worked with up to this point are datascope 98, and 95(but i haven't seen those in a long time). The Arrow one Tenn is describing sounds nice. Tenn, when you say fiberoptically zeroed in the OR, does that mean you don't have to zero the balloon periodically anymore, for instance at the start of your shift? PB7200 was my first vent...For some reason even if they were much bigger than the dragers I see now, I seem more "at home" with it. For some reason i like this... http://www.pulsebiomed.com.au/images/7200.gif than this http://www.ovc.uoguelph.ca/news/images/ventilator_2c.jpg

LOL I second that, those kinds of assignments are just heaven...

We also "manage" our IABP's ourselves, thur orders and protocols. Inserted either in the CC or OR, but rarely can be inserted in the Unit when the patient is way too unstable to be moved about. I believe that an RT is capable of taking care of an IABP, given the inservices and all, but like everyone has said, you practically should have someone be there AAT. What I mean is yes, putting an IABP on auto and letting the machine manage its own timing is what we pretty much do all the time, but sometimes there are other factors that go with it such as adjusting gtt's and stuff, using pacer or ur pressure for trigger, going to CT with the balloon, and other things like that. My question is, why would this done at other places? Do you guys think it's a way for administration to be able to justify not having an IABP patient as 1:1? That because RT ''manages'' the balloon, does that mean the pt's acuity is lowered? With regards to insertion, personally I've never heard of an RT inserting an IABP. Meaning, if a certain patient needs an IABP placed, you can basically pretty much bet that the cardiologist would be there because the patient is sick. Maybe what RT's do at these institutions are pretty much the same as what the RN's do when they come in, meaning checking the machine, you know enough helium and such, the right ratio on the balloon, and maybe zeroing the aline. My concern about this is that most of the RT's I've worked with have enormous patient loads already and they bounce from unit to unit, how would they able to manage the other vents. Even if you have an RT dedicated in the ICU, you still have multiple vents in the unit which would make this a bit hard for them. Quick question for you guys, are you guys allowed to draw blood from the balloon line at ur facility? Some places I've worked at allow it and some don't. There are times when you might have a TLC and an extra Aline, but the TLC pretty much is full and you can't really disconnect what's going there cuz they could be pressors and the patient is unstable, or you have that extra Aline but it won't draw blood, are you then allowed to put the balloon on stand by and draw blood instead of peripherally sticking the patient?

I haven't recovered patients who's had this procedure than as well. More info from experienced nurses would be great.

My advice is try to check your hospital's schedule for GRAND ROUNDS, and try to schedule your lunch time when they have it. A lot of hospitals provide free food and it's a great way to learn and keep up with new things. Go to every Grand Rounds as you can...They welcome nurses there, well at least at all the hospitals I've worked at.... Try to see if your employer provides you with an annual budget that you can use for extra classes, besides the critical care/acls/telemetry one which they usually provide anyways. I was able to deduct the cost of CCRN review, and books from the educational budget for the year. Try to go to as much inservices you can, from drug reps, not only do they give good information, usually they provide great food, and tons of free stuff, like books and equipments with their logo on it. Develop a great rapport with your preceptor so that even when your orientation is over, you have a resource. That being said, after orientation, still try to follow your preceptor's schedule so that she/he can be there on the days you're working and be there to assist you. You might not need to buy a lot of reference books, if you have a Clin Spec for the unit, you might be able to borrow materials from them to read, and use them on your down time.

Tenn, This sounds quite interesting, and I'm just kind of thinking about it. I kinda skimmed thru your post, I'm not sure if my brain is working right, but here goes. Since you don't have the numbers, I'm just assuming here, it'd be nicer if you had the swan numbers, so I won't make a fool out of myself. Assuming you didn't touch the ratio on the balloon all night, cuz I'm not sure if you did or not, and let's just say that the balloon ratio was constant all night, and we're just talking about the dobutrex. You said your CI was okay, and your SVR was kinda high in the beginning? Was this when you started dopa? I think probably starting the dopamine was what started helping you at night and leading them cut the dobutrex dose in half in the morning, by increasing you CI more, but since you don't have the pre and post CI with dopa then I'm just winging it here. So that in the morning when they decreased the dobutrex to half, then you still had dopa on board. I'm also assuming you didn't touch the dopamine and you kept it a constant rate. That's one of my theories. Second one is a little far fetched, meaning, what was your HR at 5mcg of dobutrex, I doubt you were tachy, cuz if you were you would have mentioned it. Just in case though that you were tachycardic, maybe that's why your pressure wasn't that good, but of course you'd have to be mighty tachycardic before it can make much difference, so maybe when they decreased the dobutrex to 2.5mcg, your HR slowed down a little, giving you more time for filling, and thus increasing your CO, maximizing your curve, and stabilizing your BP? Again maybe I didn't read the details about your post, so forgive me if I'm way way way off. I'd be interested in what other thinks as well.

Wow, amazing the patient did fine. The first time it happened to me, I was sitting down in front of the patient, and the patient was labile, and u just know something will happen. CT output was pretty high the last two hours, transfusing blood, maxing out the drips, then the patient dumped, as in dumped huge amounts, I call the surgeon and he said he's gonna take the patient back to the OR and he'll be there in 15 minutes. I hang up the phone look up the patient went into vfib right before my eyes as I was looking at the monitor. Called a code, defib the patient, nothing happening, the cv fellow comes and tried everything, then he says, ''get the kit, get the kit''. Opened up the pt, suctioned about 2 liters out, the surgeon calls ''bring her in the OR now" CV fellow jumps on the bed started internal compressions with his hands while he was on top of the bed, about 8 people pushing the bed to the OR with the CV fellow compressing...Finally got back to the room, it looked like a tornado touched down, couldn't chart, couldn't do anything, soooooo exhausted...unfortunately the patient never made out of the OR. Second time it happened, the patient was awake but looked real real real crappy, then just crashed, this time there was no chest tube, CV fellow says "he's tamponading, tamponading we need to open up" same thing happened, opened up, we had about 3 saline bags on pressure bag, called to have O negs be sent up, was taking forever, and just pushed as much hespan and albumin we could, finally patient was taken back to the OR, came back, stabilized, and was able to go home about a month later. IF these things happens a lot, I prolly would be burnt out after the first year, luckily most of the time it's smooth sailing.

Do you guys routinely culture tips all the time when discontinuing central lines?

I remember, psych was the best rotation, hands down.

LOL yeah tenn, usually if I run into problems it would be with the younger folks, the 250pounders, six foot something guys. They don't wanna get up, they don't want to walk, some want to smoke, some don't eat their ''heart'' diet and will have their gf's bring in mcdonald's. Sometimes I get slightly mean, but you have to be forceful or else some people won't get up and walk and you're the one who would get an ear full when the surgeon comes. If they don't do their IS, I just suggest IPPB, and sometimes they don't like that cuz our RT comes in when they're napping and they'd have to be woken for it, then they won't have a choice but do their IS. Sometimes bargaining works, sometimes you just have to get PT involve cuz u just can't do force them anymore, and you hope someone else can.