Receiving a open heart patient

commonsense · Feb 7, 2015

Hello, I am new to the CTICU, on my 10th week with a preceptor (have had 6 different ones) there is a lot of movement when a new open heart comes out, so far I have one receive under my belt but am still working on my own system to perfect if anyone has experience and could toss a critique I'd love that.. we are a cardiac hospital so the patients are really sick, we do CABGs valves bentalls ECMO CRRT Balloons.. everything you can imagine except transplants).. anyone who can throw more stuff that I need to consider or something I'm missing completely.. thanks!
PRE ARRIVAL
Ensure all supplies are in the room
-suction connector+ splitter
-glucometer + strips, lab tubes abg
-bp cuff
-dopplers in the room
-blood warmer in the room
-body warmer in the room
-Vigelio, A LINE/PA LINE/CVP LINE ECG cord
to do
-Enter pt info in Vigelio (ht/wt/gender)
-Patient history (past medical history) on cardex
-Page Respiratory Therapist
-take current bed out of the room
UPON ARRIVAL
(assisting)
-transfer from transport to SICU monitoring (A Line/PA Line/CVP Lines/ECG/SPO2) plug in patient bed
-connect drains to suction, empty foley, clear pumps, draw labs/blood sugar/ABG
(receiving)
-check out patient rhythm/BP, pulses, assess lungs while pt still being bagged, check out surgical sites, check drains, urine output, write down the drips vs lines
(Anesthesia Report)
ask if there were any major events? dysrhythmias/arrests? what lines does the patient have? any trouble with the lines? last abx time? easy intubation?
(Next) 12 lead ECG, CXR(review ET tube/Swan Placement/Chest Tubes/Opacities/OGT) talk to physician about corrections and ask for orders
(when you have time after)
untangle all the lines, label all the drips with times, start morphine protocol, determine if you can extubate patient (check Vt/NIF/follow commands FiO2 40%, lift head) turn off propofol drip if they can be. start Aldrete score 15 minutes after, check labs & correct electrolytes
Screen for major events (excessive bleeding: give volume/PLTS/FFP/PRBC. abnormal ABG:adjust vent settings/give bicarb/adjust ET tube. Tamponade: high CVP, Low Diastolic pressure.

Sounds much more efficient than me. I typically just look at the patient and scratch my chin a couple times while saying hmmm. However, that's receiving, if assisting I run into my patients room and try to act busy so that I don't have to do anything.

Esme12, ASN, BSN, RN · Feb 8, 2015

PRE ARRIVAL
Ensure all supplies are in the room
-suction connector+ splitter
-glucometer + strips, lab tubes abg
-bp cuff
-dopplers in the room
-blood warmer in the room
-body warmer in the room
-Vigelio, A LINE/PA LINE/CVP LINE ECG cord
to do

Here I would also make sure there are pacers ready (surgeon preference or based on report what wires are in place) with new battery.

Enough pumps and depending on report new gtts ready to go (like Epi dopa levo)

-Enter pt info in Vigelio (ht/wt/gender)
-Patient history (past medical history) on cardex
-Page Respiratory Therapist
-take current bed out of the room

DO you pre-make your OR post op beds? If you do I usually will double make mine in case they are unstable and I make a mess there is a layer that is fresh for the famliy.

Zero the bed.

if you double made the bed just when you weigh them again put those linen on the bed for the weight.

UPON ARRIVAL
(assisting)
-transfer from transport to SICU monitoring (A Line/PA Line/CVP Lines/ECG/SPO2) plug in patient bed
-connect drains to suction, empty foley, clear pumps, draw labs/blood sugar/ABG

What kind of monitoring do you use. It is important to never take these patients off one monitor and not have them on the other monitor. Do your patients have NGT's? verify placement.

(receiving)
-check out patient rhythm/BP, pulses, assess lungs while pt still being bagged, check out surgical sites, check drains, urine output, write down the drips vs lines

Heart tones listen to your heart tones. and pupils.

(Anesthesia Report)
ask if there were any major events? dysrhythmias/arrests? what lines does the patient have? any trouble with the lines? last abx time? easy intubation?

EBL! Crystalloid and colloid amounts so you get a general idea of where they are.

(Next) 12 lead ECG, CXR(review ET tube/Swan Placement/Chest Tubes/Opacities/OGT) talk to physician about corrections and ask for orders
(when you have time after)
untangle all the lines, label all the drips with times, start morphine protocol, determine if you can extubate patient (check Vt/NIF/follow commands FiO2 40%, lift head) turn off propofol drip if they can be. start Aldrete score 15 minutes after, check labs & correct electrolytes
Screen for major events (excessive bleeding: give volume/PLTS/FFP/PRBC. abnormal ABG:adjust vent settings/give bicarb/adjust ET tube. Tamponade: high CVP, Low Diastolic pressure.

Listen for you heart tones. shoot your cardiac output when ordered/or as per policy. Remember tamponade is narrowing pulse pressures and pulsus paradoxus....you can sometimes see it on the a-line wave.

Nice job! Who watches your balloons/ECCMO? Anesthesia or the nurse

dah doh, BSN, RN · Feb 12, 2015

Wow! That's really detailed! Strong work! I guess I've been doing them so long I don't plan it anymore. I just listen as I set them up, then ask for the plan: keep them sedated & intubated overnight, extubate, keep BP in this range, transfuse, etc. I can figure it out from there if it's my patient or help stabilize & run for stuff if it's someone else's patient.