papawjohn

Brett has a good answer. I would only add that you should be thinking that you are going to work in both MICU and SICU sometime and in a CCU also. There are lots of things to learn from all the 'specialties' and to be the best nurse you can be you should experience them all before you lock yourself into one unit and plan to stay forever.

Well, Username33, that's a simple question that actually covers a huge am't of ground -- how would you tell a seizure from a stroke? There are similarities of course. Changes in consciousness, deflections of gaze, loss of speech. A seizure is always followed by a period of (at least partial) unconsciousness. This is called "post-ictal period". A stroke does not A seizure you or I will witness is virtually certain to NOT be this person's first seizure. Look in the chart, evaluate the meds he gets. If you're giving anti-seizure drugs there's a big clue there. A seizure will almost always involve the entire patient. There are some that we used to call 'absence' seizures that might just give facial twitches and then a fade-away with a 'thousand-meter-stare'. But if one leg is twitching -- or one arm -- then probably all 4 extremities are also. With a CVA, things are pretty clearly different. No 'post-ictal' unconsiousness. Effects might be dramatic or subtle but they're usually on just the one part of the body controlled by the brain-part that suffered the 'stroke'. The most common CVA is this: A 'mural thrombus' from the wall of the Left Atrium breaks off and travels through the L Ventricle into the Aorta. The first really large artery it gets to is the L Carotid. Up into the brain it goes. It follows cerebral arteries until it gets to the L Middle Cerebral Artery and there it can't go any further so it lodges there and clocks the flow of blood to the language center ('Broca's area') and the motor area that controls the R side. You find your patient dysphasic and hemiplegic. But strokes and seizures come in all shapes and sizes. Stay very alert and when you notice a neuro change in your patient -- gets lots of help!!

I will admit that I am a TERRIBLE delegater! In ICU where the usual 'load' is 2 patients, I find I can focus down on just my two patients and develop a scheme for meeting all my expectations. When someone stops me and says 'what can I do to help?' I really, actually, literally cannot think of a thing. I have all these steps planned for myself. Adding a helper means I have to make new plans. It's usually easier to just hurtle thru the shift. Of course when a patient's condition changes and my plans are all trashed -- THEN I need help and I'm glad to have someone to lean on.

I've noticed over the last few years that the field of Case Managers and the like has expanded amazingly. In my little ICU the last 5 RNs to move on all went to Computers and phone-conference type work instead of "bedsides". Makes sense in this "managed care" world. But I'd find it interesting to look into, just out of curiosity. How much has the field grown? How is it linked to this whole internet thing? Does it actually produce measurable improvement for the patient? You could take it from there.

My sister tells this story on herself and I'll pass it along. She was a new RN working in a CCU and a patient was admitted with an irregular atrial rhythm and a peculiar heart sound. She called the Cardiologist and was trying to describe this. He said, 'what does the heart sound like?' She said, 'you know when you have just one tennis shoe in the drier? It sounds like that.' Her patient had new onset atrial fibrillation and was treated correctly. What you can describe accurately to the best of your ability really is the best you can do! SBAR and fresh vital signs and lab results and current meds are important, YES! But don't be afraid to tell the MD what you hear and see and smell. You are his/her ears and eyes and nose.

Well KSL777, I'm trying to imagine the situation that has you posing this question at like 0100. (Of course -- where you're at, maybe it's 4pm! But the time-heading says 0139.) And I imagine you've just finished your shift and you had a push to give to a patient who really needed that med -- but his only access was a Triple Lumen Central IV. You looked at the meds and fluids flowing thru that line and said to yourself 'where do I put this?' Because you had labeled the lines, right? That's basic! Don't stand at the bedside and wonder 'is that the Norepinephrine?' Very important! And because you'd made yourself aware of incompatibilities, eh? You said that and I'm very impressed! I've stood before that huge chart with all the drug names along the top and along the left hand side and tried to find the right intersection to see the C or the I or the X. It's not easy when your patient needs the med and it's in your hand and there are like a million little boxes on the chart and you want to be right! Then you walk over to your patient and each lumen of the TLC has one IV line running to one pump. Each pump might have a med (Norepinephrine, Diltiazem, what-have-you) or it might have maintenance fluid with piggy-backs. OMG!! Is the med compatible with Zosyn? Or Mag Sulfate? Such a world of decisions!! Here's what I've done. First, be sure of the maintenance fluid and it's compatibilities. Run that into the DISTAL Port (which is the one "DISTAL" to you -- the port farthest from you and farthest from the patients skin). Then all the drips that are compatible with that, hook to a stop-cock and put them between the maintenance fluid and the distal port. If there are 2 or 3 or 4 drips, put the 2 or 3 or 4 stopcocks in a chain with the distal port at one end and the maintenance fluid at the other. This actually has a name; it's called a "manifold". Anesthesiologists use this system in surgery. It's whats between the fuel injector of my car and the intake valves of the cylinders. You're not doing anything new or amazing. But you're making everything clear and organized. You will find that you will know exactly what is going into your patient and where -- which is a real accomplishment, believe me! And you will find that all the compatible things are flowing neatly together and that you might have a 'hep-lock' port on that Triple Lumen to use for nothing but 'pushes'. So you have all the vaso-pressors running into one 'manifold', say. And all the maintenance and antibiotics running into another. OK? And you have the third port for pushes. And you have a push that is NOT compatible with the other meds hanging. So you're uncertain -- should I push this med in or do I need to stop the incompatible ones -- even flush the lines! -- and then give the push? Ahh -- stop and think: what is the major buffering system of the body? When I was in Nursing School (and dinosaurs roamed the earth) it was the BLOOD. So you are actually 'pushing' this med into a BUFFERED mixture of (incompatible) meds and blood. Believe me, the blood will take care of it 9,999 times out of 10,000. The 'incompatibility' issue occurs in the IV tubing. Not in the central venous circulation. So label your lines and put them into compatible 'manifolds' if necessary. And do not be afraid to mix them in the blood of your patient. So says your old Papaw.

Well Stacia, I'll give you a bit of advice -- bear in mind that things that worked for me might or might not work for you. You say you work with Tele. Use your monitor skills and try to get all the pulls to the Unit and pick up whatever overtime the CCU in your present facility allows. Also take a critical care course. They're commercially available over long weekends. When you've pulled a few ICU/CCU shifts and have the certificate of completion from the course, shop like crazy in whatever city you wish to move to. I bet you'll find a job you want. PapawJohn

My personal favorite. Young pregnant gal contracts Guillian-Barre, ends up with paralysis to her ears -- worst case I ever saw. Vent and TPN and the whole 9 yards in our Neuro ICU. Part of assessment was documenting fetal heart tones. Whenever I found them I'd put the earpieces of the steth into HER ears so she could listen to her baby. Her face lit up like sunrise when she heard that. She recovered completely and about a year later actually walked into our unit carrying her little girl. We all got hugs and there wasn't a dry eye in the place! PapawJohn

Joe, my friend, I didn't bother to check on all your other posts but would I find something on the order of 'What a great experience I had at work today!' if I looked? I've occasionally put that sorta thing here. Three nights ago I was pulled from my ICU to a med-surg unit. Usually a horrible experience for all concerned! One of my Pt's was a retired Nrsg Instructor. We had a wonderful time together! It was swell! Last night I had a Pt who'd been admitted yesterday with 'water intoxication'; his Na was 107 in the ER. Vent, propofol -- and in our little community hospital, only peripheral IVs. For me he went into acute renal failure, produced no urine for 12hrs! Was 'shocky' all night -- diaphoretic, ventricular arrhythmias, BP down to 70 @ times. I was juggling him with norepinephrine and propofol and getting lab-work and starting IVs and talking to MDs all night long. I s'pose he's not likely to survive but by golly he got everything I had to give. And it was with a great feeling of satisfaction that I reported off to the Day-shift folks this AM. After 30yrs, I still love my profession. Many times I hate my JOB. But when I'm at work it's usually a great time to be me. Maybe we should have a special place to go here to say "what a great shift I had!" I'd like to contribute to it. Yer old PapawJohn

Sounds like you're working in a Hospital with very slack management. But so are a lot of us and it's likely you'll be doing it a lot in your future. So as aggravated as you (justifiably) feel....get over it and do something on your own. Here's what I'd tell my daughter (a newbie RN herself): find the 'good' preceptor. Ask that person to become your personal mentor. Promise them anything! You'll walk their dogs, cook their breakfast, do their laundry!! Then go to the person who makes out the schedule and announce 'So-and-So is my preceptor and I have to be scheduled on the same days she/he is working!" Insist upon this. If the nurse manager gets involved, remind them that they hired you contingent upon training.... I bet if you stand on your own hind legs (as we say in the South) you'll go far... and good luck to ya. And remember -- the person who makes out the schedule is ALWAYS your friend!!! You'll make SURE of that. PapawJohn

Hello, fellow ICU nurse!! I've been at this over 30yrs now and still find that giving (and to some extent, getting) report is sometimes the most stressful part of the 12hrs. Isn't that nuts!! Think about it for a minute. You've watched your patients rhythm for an entire 12hr shift and there's not been a single ectopic beat. Then the AM labs come in and his Magnesium is 1.4. OK, so how serious is that? Your person experience says -- not so serious. Eh? You place a call (maybe -- and if you don't, so what?) to the answering service @ 0630 because you have to report 'critical' labs. You don't get a call back.... And soon you're giving report and mention that the next RN will be giving MgSO4 so you've gotten the 'Protocol' out and put it on the chart but the MD hasn't called back. And that next RN makes you feel like you've been leaving your patient in grave danger all night long and what the H#LL do you think you're doing leaving up to them to correct that horrible electrolyte imbalance!? Let me tell you -- the problem is the expectation of that next shift nurse. Our patients are badly broken people. You, doing the best and most work that one person can do in 12 hours, cannot 'fix' them. We always pass 'broken' patients to the next shift. That's why they have ICUs and that's why they keep them working 24hr/day. ' If you had IDENTIFIED a particular problem for that next nurse -- THAT'S the important thing!! You have assessed and treated and re-assessed and you are giving them the distilled knowledge of 12 hrs of dealing with the patient and you're alerting the next RN to sudden problems that have turned up. That is your job. It is NOT your job to turn over to the next shift a Pt without problems. Keep up the good work and Stay vigilant You'll do fine. PapawJohn

Well, I'll chime in. I'm a lot older than you but let me be boring, as grand-pa's tend to be, and explain that I was a military Medic (think--EMT) in the early 60s. I became a 'para-jumper' (think Para-Medic but in a helicopter) in VietNam (there was a war there -- maybe you've heard of it?). This was in 1965 -- when dinosaurs roamed the earth. The very first Coronary Care Unit had been established in 1963. That was the very first time that nurses were given the responsibility of reading cardiac rhythms. Before that, only MDs were thought to be able to interpret monitors. Suddenly in '66, I was taught to put wires on some poor SOB's chest and to actually SEE HOW HIS HEART BEAT!! It was amazing. Today, 45 yrs later, I've never gotten over it. There's this line on the monitor. If you know the code, you can actually read the electrical activity of a heartbeat. Like an alphabet -- suddenly you're reading Don Quixote!! Only -- there's a human being on the end of the wire. He or She has family and feelings and a past and a future! And you are reading their heartbeat. A never-ending amazement!! Since then I've become an ICU nurse. I've "read" Cerebral Pressures and Right Pulmonary Artery Pressures and Electro-Encephalography and calculated cerebral oxygen uptakes and I never quit being so amazed that I -- just John -- could actually look inside the working of the human biology as a work-a-day, ho-hum, monitor-is-stable-I'm-going-to-lunch way. It has always been as if I were to look into LIFE ITSELF. When I was a student RN, I worked as an orderly. Probably "orderlies" don't exist anymore as a job description. I was the male CNA who could be counted on to turn the heaviest patients, give enemas-til-clear to male patients and similar 'Y-chromosone' related activity. I got to see the whole spectrum of the hospital. And what fascinated me then -- and fascinates me now more than 30 yrs later -- is seeing that heart rhythm. Knowing I'm seeing INSIDE somebody. May you find something just as fascinating and amazing! Good Luck to You PapawJohn

Ms Do-Over, you are correct and wise. People do NOT die from CO2 narcosis; they die from lack of Oxygen. And the Ambu-bag is your and their best friend-in-need. PapawJohn

Well, as you can tell I've had to think about this quite alot lately. I already belong to Medicare. I pay a lot of attention to politics (comment regularly as JohnMcC if anyone reads the same blogs I do) and worried extravagantly about the economy during the recent debt-ceiling debacle. I take this seriously, in other words. And I'll assume this is a serious question. I'm going to take the SocSecurity at the earliest moment I'm eligible for full-benefit retirement. There are two reasons I made that decision: First, every plan to decrease SocSecurity benefits exempts already-retired people from the cuts. The fastest growing demographic in the US is us old folks; we are the 'Boomers' after all who re-shaped society as we moved thru the life-cycle. The political party most interested in 'cutting entitlements' gets a very large (and growing) share of their votes from older voters. Older people vote in larger numbers than any other demographic. So I do not fear politicians will do away with the benefits of already-retireds; since I'll need the SocSecurity eventually -- I should get it while the getting is good. Second, retiring at 'full retirement age' means I can earn roughly $34,000/yr above the SocSecurity check. If I earn more than that, my SocSecurity earnings are taxed in order to 'take-back' $1 out of $3. (If that seems odd, remember that SocSecurity was a Depression-era program and encouraged people to retire so that younger people could move up into those jobs.) On the other hand, taking early retirement (age 62 - to - 66 @ present) means the IRS takes that $1 of $3 on everything above $12,000. In otherwords, I can earn $22,000 more by waiting til age 66. My annual earnings will be essentially unchanged, but I can work only 6months/year. Sweet!! I'll finally get to hike the whole Appalachian Trail. Or sail around the Bahamas for an entire season. Or I can work 3 X 12hr shifts each pay-period and play in my workshop that much more!!! What's not to like? PapawJohn

If your workplace doesn't allow you to do EKGs yourself, or order them stat prior to calling the MD -- which I guess is true, you did exactly what your Facility planned for this sort of thing. Nurses have great responsibilities and tend to obsess over them. Planners of institutions and administrators establish the rules and standards and policies that nurses have to follow and they sleep well every night because they hire nurses -- who obsess over their responsibilities. You did not make the rules. You followed them very well, sounds like. Relax and go easy on yourself. PapawJohn

You should pay attention to CanesDukeGirl (with the very nice avatar, by the way) and get tested ASAP. You indicated that you practice somewhere besides the US. Here, your delay would be a serious problem for the Facility you work for (there are regulations about this kinda thing) and also for you. You see, here our insurers could possibly say that the delay in testing makes it reasonable to assume that you got HIV from some other source than the needle stick and attempt to deny they should pay for your treatment. Probably you don't believe that, but unfortunately there are health-insurance-companies just that horrible. So American nurses would be ON FIRE to get a complete panel of cultures and titers and such. Again -- good luck to you PapawJohn

My friend Do-Over. I agree completely that students are given a huge jumble of numbers and -- sadly -- not enough organization of those numbers to find real information. Numbers are NOT the same thing as information. So I try to help by using little vignettes that exemplify how treatments affect results, how to prioritize numbers, what to be careful of. We really ought to try to make things as simple (in the sense of well-organized) as possible. Thanx PapawJohn

Had a frightening needle-stick back in the mid-90s. Working @ level 1 trauma center in large eastern city. Pt brought to my ICU with head injuries (beaten with pipe). Pt was young African-American male and is very androgynously dressed, skin and hair carefully made-up, nails polished. To a cynical old b#st@rd like me it said 'male prostitute' in large letters. I was starting an IV to draw some early labs and to replace the EMS line, using the familiar 'angio-cath' with the spring loaded inner stylet. At that moment he had a seizure and drove the stylet into the septum of my left thumb. There it hung with his blood filling the flash-back chamber and mine dripping down the length of the stylet. DAMN, I thought. I'm never going to have sex again. (Actually -- that's the honest truth. Didn't think -- I'm going to get AIDS. Thought --- sex is over.) Amazingly, that young man turned out to be negative for anything!! No HIV. No Hepatitis. Nothing. And after being tested for 18months, I had nothing also. But here's what I thought you'd want to know, NewlyGrad. There turns out to be a secret 'club' of people who've suffered needle-sticks and similar. Many nurses and also many Lab and Resp people. Very very few people actually 'convert' to positive status. It turns out that it's actually NOT so likely that you'll get HIV from a needle stick. You should of course be tested. I understand there are anti-virals you could get as prophylaxis -- and I would advise you to pursue that vigorously. And the pt should be tested. But you don't need to have extreme fear or depression. Lots of us have had worse needle-stick injuries and never got sick. Hope this helps. Good luck to you. PapawJohn

Hello, PayItForward. I think that your question is kinda non-specific which makes it hard to help you out. Let me give you a couple of examples of people presenting in resp failure and how we'd help them, OK? Worst situation: Sadly debilitated person, bad nutrition, COPD suffers a fall @ home and isn't brought to us until a day or two later. They've suffered tissue damage that has harmed their kidneys (called Rhabdomyolysis). And their COPD has gotten worse (no meds while down, no inhalers, O2 runs out). This person has lost both channels that the body uses for getting CO2 out of the body. The ABG might have a pH of 7.1 and a CO2 up around 100. (You or I would likely be dead with numbers like that -- but our Pt has compensated over the years and is awake but obviously in danger of dying pretty quick.) So there's you UN-compensated ABG: ph 7.1, pCO2 100, pO2 50, Sat 60. The first priority is to move large flows of high-oxygen air through this poor soul's lungs. You want the pO2 up in the 90% range or better (because as bad as high CO2 might be -- it is a failure to get OXYGEN to the cells that kills our patient). We want rapid deep breaths and a tidal volume/minute volume as high as we can get it without injuring the tissues of the lung (AVOID excessive 'peak pressures' on the vent). You will simultaneously be giving large am'ts of IV Fluids to help the kidneys. One potential problem is that that fluid will move into the pulmonary circulation and cause Pulmonary Edema, so your listening to the lung sounds frequently and keeping diuretics on hand. OK - so that person, before they fell, had 'compensated' ABGs. They took bronchodilators and inhaled steriods and had home O2 and didn't sneak TOO many cigarettes. And their kidneys worked. Don't forget that the renal excretion of H ions is a primary way that folks with limited respiratory function keep their pH in balance by lossing acid-causing ions thru urine. That's their COMPENSATION mechanism. So this compensated person gets pneumonia. (More accurately...gets pneumonia AGAIN...cause the ER staff will know this person well.) He gets to be your patient and he has ABGs like ph 7.35, pCO2 70, BiCarb 45, pO2 65, Sat 88%. The correct interpretation for that set of numbers is 'compensated respiratory acidosis' -- because altho the CO2 is WAAAY HIGH, the combination of high bicarb and renal excretion have keep the pH within the 'normal' range. Obviously, this person is finely balanced and might 'buy a vent' any time. You'll probably put him on a BiPap machine and give a lot of respiratory treatments. You'll evaluate for productive coughing and make sure that mucus plugs don't close off any airways. There will be cultures to collect and antibiotics to give. You'll worry that when this Pt sleeps, it will be because of CO2 Narcosis -- because when the acidosis reaches abnormal levels the first tissue it affects is the Brain and the Pt become sedated, breaths slower, acidosis gets worse and soon you're hauling him off to the ICU to be intubated. Because he became UNCOMPENSATED. Hope that helps. Good luck to you PapawJohn

Hey!!! OMGosh. As much as I love my computer, it drives me crazier than my cat does!!! Try this: http://drhelen.blogspot.com The 'defibrillator' threat is from June 30th. It's worth it if you have a warped sense of humor like I do!!! P-J-

Hey!!! Ran across this. Had to share!!! "He has a defibrilator...he is out partying with 2 hookers and his brother..." http://drhelen.blogspot.com/2006/06/fun-with-defibrilators.html Papaw John

Hey KR!! I applaud your determination to do what you thought was right. I bet you guessed that the Dr was gonna be p@#%ed off; so your decision was particularly admirable. Those are really weird results. I can understand why you wanted them confirmed. Treating results like that would be--in a way WORSE than giving a K-rider to someone without any Labs to go by. Before I completely endorse your actions, I'd have to know more about the Pt and his history and--to some degree--the relationship between the Pt and the Dr before he got to the Hospital. As a Nurse who has 2 bro's-in-law who are MDs, I hear both sides. It may well be that there is some background condition or history of prev admissions that the Dr knew about but you didn't. Of course, the communication barriers between Nurses & Docs (which are in part traditional and in part status-related...and which mostly consist of MDs not wanting to talk to US instead of we not wanting to talk to THEM) is the real problem. Let me ask you a question: What would you have done if the Dr had calmly and politely said something like, 'Mrs KR, I've had this Pt in my care for years now. He was in the office just last week and we drew blood then that made me think this situation might be developing. I appreciate your caution but I'm not surprised that these levels have showed up and we really need to start the therapy right away.' Now wouldn't THAT be cool? I bet you and I would have jumped right on those K-riders. Papaw John

Hey Angelique!! #1. You are correct, this is in a 'normal' person. But remember that the Pts you will see with PACatheters have had a long time to develop heart/lung disease and to compensate for it. There was a Pt in a Unit I was working in a year or two ago that had PAPressures like 65/25 and Wedge of 25 to 30. She was not in distress with these numbers. She'd had vascular surgery, had known pre-op Cor Pulmonale and was vulnerable to quick decompensation if anything went wrong--therefore the 'Swan'. #3 You are correct again. There is a sensitive little pressure-sensor at the end of the catheter. When it just sits there in the Pulm Circulation, it senses that. When you inflate the balloon, you 'trap' a column of blood between the pressure-sensor and the Left side of the heart; for convenience-we call it the 'wedge' pressure. It would be more accurate to say Left Atrial Pressure. #4 I'd vote for PCWP. When you give lasix (IV of course) you get a quick dilation of some of the arterioles in the kidney. So the kidneys sort of 'open up' and reduce the SVR. There is a 'lag-time' before the urine starts pouring and the actual volume of fluid starts to decrease. There is also a short 'lag' before the reduced SVR results in the Pulm Edema Fluid is absorbed into the blood stream and the 'crackles' go away. (This is one of those silly questions that turn up in textbooks and such. Cause if the lasix is going to work it'll work pretty darn quick.) Hope that helps Papaw John

Hey Barkley!!! I bet there's people who can help you better than I can but I hate to see a post like yours get to the 2nd page of the '24hr' forum without a reply. So let me try my best. I had a BA degree, was totally broke (it was a long time ago, the 70s, stagflation etc) when I decided to go to NursingSchool. So it was not a sacrifice for me to look for CNA-level jobs to support my family while I was a NrsgStudent. This was in EastTenn--not an area noted for high pay scales, OK? Still, I was surprised that being 'just' an 'orderly' actually paid fairly well. Now I'm at the end of a pretty neat career and I meet young guys who are 'PatientCareTechs' while they're in NrsgSchool--and they're not doing to bad. I knew a young (20s) fella who worked his butt off as a CNA/PCT here in the TampaBayArea (also not noted for high pay scales) and made more than $40K in the '04 tax year. Now I repeat, he worked his butt off to do that, but he also saved enough from that year of hard work so that he got his LPN while working part-time in the next year. So--my advise, check out certification as a CNA or EMT through the public schools (adult education, whatever it's called) in your hometown. Then get the best job you can doing that. Once you have reached that point, evaluate ALL the different ways you can reach your goal. You could start by continuing the public-school program to LPN. That would take approx one year to 18 months and then you get a big raise. From there you could find an LPN to ADN program, again--they typically take a year or 18m. There are MSN programs that would take you on the basis of your BS and the ADN--and there you are!!! Maybe this won't work out for you quite as neatly as I've written it here. But the basics are completely possible without starving to death or having your car repossessed. Good Luck Papaw John

Hey Maryln!!! Hardly any of us have a vast encyclopedia in our heads with the norms and the effects & treatments for all the labs you'll see ordered. So relax and do not spend hours memorizing them. An example: I always have to look for the normal ranges of things like T4 and TSH and AST and so on. But many nurses who (for example) work with liver-transplantation could rattle all the liver enzymes off and tell you lots and lots about what they mean and what to do about 'em. If I was precepting a baby-nurse and they knew the Chem 7 and Magnesium and the 4 basic numbers for a CBC (WBC-Hgb-Hct-Platelets)--I'd think that was being VERY well prepared. And if they had a 3 by 5 card that they pulled out to check on--I'd STILL think they were well prepared. Hope that helps Papaw John