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Topics About 'Icu'.

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Found 23 results

  1. commitmentphobe

    Is ICU worth the stress?

    Is working in the ICU all it's cracked up to be? Part of me has always wanted to work there--I won't really feel like I've "made it" as a nurse until I can take care of the sickest patients. I'm thinking about making the switch to my hospital's MICU. They get very high acuity patients, all the other hospitals in the area send their patients to us. I know I would learn a ton. But then again, I currently have a pretty cushy procedural nursing gig. Low stress, day job, no weekends. Sure, I might not be fully actualized as a nurse, but maybe that's okay for the sake of my mental health? I know the ICU job would be much more stressful, probably even once I've overcome the learning curve. And what if I can't do it? It's scary! Should I do it and push myself? Or should I stay at a job that makes me mostly happy, if not deeply fulfilled? I'd appreciate some advice 🙂
  2. Hello, I recently graduated and my goal at the moment is to land a job in the ICU. I have two job offers both from a nurse residency program. One being surgical PCU or Med-Surg. But if I accept the surgical PCU position I have a 2-year commitment and no commitment to Med-Surg. I am uneasy about the 2-year commitment. I have applied to ICU jobs but have not gotten any response. Any advice on what should I do or what steps should I take to get into the ICU?
  3. adelina207

    New Grad ICU Burnout from COVID

    Hi everyone! I'm a new graduate nurse that has been in the ICU since April. I'm experiencing alot of stress related to COVID. We're in our 2nd wave of COVID now and the amount of death I'm seeing is almost too much for me at this point. We are coding people everyday. On Thanksgiving, we had 4 COVID patients code during just my shift. Not to mention my hospital is also not allowing visitors anymore so all the communication with family is via the phone. I understand providing emotional support to the family and patient is part of my job, but I am just so overwhelmed with how powerless I feel in this situation. I love the ICU population in general and I love the critical nature of the care, the critical thinking, the independence, everything, but I do not know how to deal with this much death and suffering. I know this is largely due to the pandemic and in the normal ICU environment, deaths are not quite this frequent, but with no end to this pandemic in sight, I don't know how much longer I can deal with this. Nurses on my unit are burnt out. Some are leaving the bedside permanently to go into administration/case management, some are just out sick with COVID for weeks at a time. It's not even just caring for these critically sick COVID patients that bothers me, it's also the way my community is treating it. I am seeing patients die every day at work, but then I go onto social media and see that half of my friends and family are posting that this virus is fake, that we're faking death certificates for financial gain, that nurses should just keep quiet because we "signed up for this". I literally feel like I'm being gaslighted by my community about this pandemic. I'm just looking for advice. How are you guys dealing with it? How do you get back into the right headspace after a code? How are you staying healthy and keeping your stress down among all this craziness? How do you prep for a shift dealing with critically ill COVID patients? I would appreciate any advice. I
  4. I'm curious. Most of the people I went to school with want to be ICU or ER nurses. They've never worked in the ICU or the ER but that's all they want to do. I told one girl who refused to work anywhere else other than ICU to go into a nursing home if she needs a job. She refused it and it took her a few months to finally go into a nursing home. She quit after a month because of her standards. It's the same thing when it comes to med surg and psych nursing. It feels like many newer nurses look down upon any other nurses other than ER and ICU. Another girl I know said she's wanted to work as a psych nurse forever, but when she was offered the ER position and psych position she took the ER position. I asked her why she chose ER over psych and she said she knows ER better. Now she complains about the work load from a trauma 2 hospital. I asked her why she didn't just transfer into psych since it's what she wanted and she didn't really give me a concrete answer just basically that she's stuck. Does it feel that way to anyone else? When it comes to ER/ICU it feels like they only respect those specialties. Thanks!
  5. So I am working back in psych where I have a state pension (not 401k, 403b, etc), but I just left neuro ICU where I worked for 3 years. So my question to all of you is how long can a nurse be out of the ICU and working in psych before the nurse is seen as "just a psych nurse" and not a good candidate for the ICU anymore? Thank you all in advance!
  6. allnurses

    NTI: Pain Management Challenges

    Hospitalized patients often experience pain. In the ICU, most patient experience pain to some degree. As more invasive and painful procedures are performed, pain escalates. Add in intubation, multiple lines and your patient experience a wide variety of painful sensations. How to manage this pain? What is the best pain regimen for the opioid naive and opioid-dependent patient? Principles of Pain Assessment Pain is a subjective complaint based on many factors: Procedures being performed Patient past medical history History of opioid use Perception of care received Just to name a few. Assessing pain can also involve many avenues - for the verbal patient: Wong-Baker Pain Scale Faces Pain Scale Verbalization from the patient It becomes more difficult to assess pain in the unresponsive patient. Patients can be unresponsive for various reasons: intubation, sedation, paralysis, dementia, psychiatric disease. However, here are some tips: Grimacing Tachycardia Irritability Decreased interaction with the environment Opioid-Tolerant Patients There is no exact formula to follow to ensure adequate pain management for your patients that already take opioids. The first task is to obtain information regarding the patient's past/current opioid use. Do they have cancer and take escalating doses? Are they on maintenance suboxone for past opioid addiction? Do they use street drugs? Not always easy questions to ask. If the patient is unresponsive, asking the family in a non-judgemental manner is essential. Emphasize that you want to provide optimal pain relief and in order to do so, you need to know if the patient takes opioid medication/drugs frequently. From the Society of Hospital Medicine: "Patients with chronic pain present a special challenge. When they have pre-existing pain and undergo an operative procedure, it becomes important to differentiate pre-existing chronic pain from new acute postoperative pain. Additionally, patients already on chronic opioid therapy may require a 200 to 400 percent increase in preoperative opioid requirements.24 Thus, it is important to establish preoperative analgesic requirements to create a postoperative pain management plan, not to mention a keen awareness of comorbidities that may preclude the escalation of regimens due to patient safety concerns." The Stepwise Approach is recommended - this involves the use of non-opioid medications such as NSAIDs, Cox-2 Inhibitors and non-pharmacological options also. However, in opioid-tolerant patients, "always start off with an immediate release medication. Long-acting opioids are not appropriate to be used to treat acute pain and for initial dose titration. The route of pain medications also makes a difference in the frequency of administering pain medications. Short-acting oral opioids peak in 45-60 minutes. Intravenous dosing will peak in 10-15 minutes. Knowing these parameters makes it easier to dose medications sooner to achieve adequate pain relief in acute pain. When dosing medications for acute pain, it is appropriate to give an additional dose if the pain is not relieved by the expected peak time. As an example, if a patient in acute pain is given an intravenous dose, then it is appropriate to give the same dose again or double the dose (depending on the clinical situation) if there is no relief in 15 minutes once peak onset of action has been reached." (Society of Hospital Medicine) Opioid Naive Patients Patients that do not take opioids merit consideration also. "When using a patient-controlled analgesic (PCA) in opioid-naïve patients, only patient-controlled dosing should be used initially. Starting a continuous basal dose on an opioid-naïve patient is generally not appropriate. Once steady state is achieved with patient-controlled bolus dosing in 24 hours, then starting a continuous basal rate can be considered if the clinical judgment deems it necessary to use opioids for a longer time period." (Society of Hospital Medicine) Other Considerations Always be mindful of renal function as this can adversely affect pain control. Also, due to many factors, renal function can deteriorate while hospitalized. Dose adjustment must be considered. NSAIDs and Cox-2 Inhibitors are usually precluded for the patient who has decreased renal function. Patients on dialysis or CRRT also pose special pain management issues and it will be important to bring on the care of the nephrologist. References: Getting Out of Your Comfort Zone With Opioid Tolerant Patients Multi-Modal Pain Strategies for the Post-Op Patient - Society of Hospital Medicine
  7. Monitoring the hemodynamics of your critically ill ICU is so important. Use of the Swan-Ganz pulmonary artery catheter is one of the ways to quickly assess the cardiac status of your patient, make interventions and improve their care. However, the monitoring systems for Swan lines aren't that intuitive. Until now, that is. Edwards Lifesciences has a new monitor, the HemoSphere advanced monitoring system, which was just recently approved for use in the US which is both intuitive and user-friendly. As an ICU nurse, your monitors are your pathway to your patient. Having a small, portable, easy to use monitor makes your shift just a little easier. This monitor has an interface similar to a tablet and can continuously assess flow, pressure and the global indicator of oxygen saturation (CCO, RVEF, RVEDV, SVO2). Allnurses staff recently attended NTI 2017 in Houston and spoke with the Edwards staff about the HemoSphere on the exhibition floor and got a demo of how intuitive and easy-to-use the HemoSphere is. Would you recommend this to your hospital?
  8. I am always hearing step-down unit and am afraid to ask anybody what it means. I thought it was ICU "a step down from med-surg" but I know that it sounds stupid. Can you tell me the difference between Step Down Unit and ICU?
  9. Chancub

    Through the Eyes of An ICU Nurse

    Everyone copes with things differently, but often times I write to help me cope with the difficult woes of my job. I often don't share, but this time I thought, why not let some of you guys have some insight into the life of an ICU nurse? If it wasn't for the outpouring of love and emotional support from my coworkers, I often don't think that I could do it, and I think as a team they are incredible and mean so much to me and have taught me so much, so thank you. 10/8/16 You'll never know how much you affect me. You'll never know that I had to step out to get some air and call my own mother, just hear her voice, and be thankful that I still have her in my life. You'll never know that I went home and cried my eyes out in my shower thinking about the struggle and loss your family is going through. I bring you water and tissues, you thank me.... it's the least I can do. I stand by you and hold your hand, and hug you as you sob. Your selfless decision to let your mother go peacefully is the most beautiful and difficult decision you could've ever made...I wish you could believe and understand how incredible and courageous that act of love looks like from the outside, even though you're broken and shattered on the inside. You stand by her side as we turn off life support. She was loved. You'll never know how much that sad look in your eyes and the glisten I notice on the verge of tears, eats me up inside. You offer me food, with a cracking voice, because you're incredibly selfless and have no appetite. You sit next to your son and read him a story knowing this may be the last time. You beat yourself for not being there, blame yourself for his disorder. I tell you it wasn't your fault, it's genetic, as you look away from me with tears in your eyes. You ask if he will ever be able to breathe again on his own, I wish could tell you yes, but his muscles are deteriorating and his disease is unforgiving and undeserved. You hold his hand wishing for these final moments to last forever, you try to cherish them. 8/16/16 Your youngest daughter was rolled onto our unit unresponsive. She was pronounced brain dead by the attending; you fall to the floor, a blubbering mess, demanding to have the test redone because you swear you saw her eye move; it didn't. I help you off the floor as you are bawling into the blanket that she used to sleep with every night. I am left there by the attending to pick up the pieces of families' and friends' broken hearts. You have a large family, I keep explaining what just happened to each person that re-enters and asks questions. They are all so thankful for the honesty, even though it's the last thing anyone wants to hear. You so desperately want to understand why she is dead if her body is still functioning on life support. I re-explain, but you can't comprehend, you keep asking yourself why? Each time a little piece of my heart is with you, I wish desperately that she could just wake up and be your baby girl again; but she can't, she never will be. I watch you as you stroke her head gentle as tears roll down your cheeks; "just one more day," you wish you could talk to her just one more time. You yell at her to "Wake up! Please, please wake up", you beg and plead. I give you your space, you need these final moments with your daughter. I secretly cry in the bathroom for you. I am there for you, I support you, and my heart hurts for you. I will never forget you. You'll never know how much you affect me. You'll never know how privileged I feel to be your ICU nurse.
  10. traumaRUs

    Shhhh...Quiet Time in the ICU

    The American Association of Critical Care Nurses recently published a study regarding the noise level in an ICU and ways to decrease patient and staff noise stimulation. Noise stress is a concern for both patients and staff. "In one study, it was found that making a unit quieter increased patient and staff satisfaction by 60% to 80%. In a study conducted in a neurosurgical ICU (NSCU), 54% of patients experienced sleep disturbances and the most common sleep interruptions were at night to monitor vital signs, conduct neurologic examinations, and reposition patients." According to patients in the ICU, the most bothersome noise is at shift change, particularly in the early am. The patients often hear things they should not hear: the patient next door to them is going for a procedure and "we aren't sure how its going to turn out", the other patient on the other side, "can be shipped out to the floor today." Taken out of context much confusion and stress can occur. This study took place on a neuro-surgical ICU that is part of an "806-bed, level I teaching hospital. The NSCU is an active unit with an average daily census of 15 and approximately 1800 patient admissions annually. This translates into 3 to 4 patient transfers out of the unit and 4 to 5 patient admissions daily." They collected data and decided on quiet times from 1500-1700 and 0300-0500. They designed signage, achieved buy-in from administrative and ancillary staff stake-holders and began to consider what steps needed to be in place in order to implement quiet time. One of the lists they developed was to be proactive with care BEFORE quiet time began. Here are some of their initiatives: Quiet time checklist Routine medications administered Pain assessed Bedpan/urinal/commode offered Blood drawn/intravenous catheters placed Vital signs taken Neurological check performed Television off Lights off in patient room Family aware/involved Door closed Multidisciplinary rounds completed Lights dimmed in nurses' station Alarm parameters customized to patient Minimize conversations in common areas No overhead paging Respond promptly to alarms No physical/occupational therapy sessions during quiet time Move equipment quietly Cell phones/pagers on vibrate Remind colleagues "Shhhh" There were some limitations to the study regarding the ability to rearrange infrastructure of the unit. Some beds were closer to doors which increased noise. In addition, as this was a teaching hospital, there was simply more talk among providers and interdisciplinary team members. The providers that came to the unit to see patients did observe a guest mentality where they talked quietly and decreased their ambient noise as much as possible. However, as one researcher pointed out that with 5-6 people in a group, even if they are talking quietly it can get quite loud. Although the staff verbalized feeling less stress and having quality time to reflect on patient care, they did not conduct qualitative data collection by surveying staff about their perceived stress levels before and after quiet time. Because of the high level of cognitive impairment of the patients, examining Confusion Assessment Method scores before and after quiet time may have yielded useful data. In conclusion, the neurosurgical ICU nurses were successful in changing unit practice and enhancing awareness about excessive unit noise. Registered nurses, clerical support associates, patient care associates, and unit leadership viewed the quiet time initiative as important, leading to adherence and buy in across the multidisciplinary team References: Narvaez R. Quiet time project improves patient satisfaction. Ugras GA, Babayigit S, Tosun K, Aksoy G, Turan Y. The effect of nocturnal patient care interventions on patient sleep and satisfaction with nursing care in neurosurgery intensive care unit. J Neurosci Nurs. 2015;47(2):104-112.
  11. Sisig12

    Is progressive care unit like ICU?

    Do graduate schools accept experience from PCU?
  12. I have been an ICU nurse for about a year now. I have learned a million and one things and still have a lot left to learn. I just wanted to offer a little help to new grads trying to get into the critical care scene and newly hired nurses in the ICU. First.... If you want to be an ICU nurse go for it. It is one of the biggest learning curves you can take on but if that is your passion don't let anyone shoot your dreams down. Second.... Apply to a large teaching university hospital. Usually those hospitals will have an internship program that lasts 4-6 months which includes one on one patient care, constant supervision by a preceptor, and critical care classes to teach you critical care medicine. Third.... Study on your own time. Pharmacology, pathophysiology, A&P, ect. This will all be things that help you tie the whole picture together. Fourth.... When in clinical (students) or once hired as a new ICU nurse, participate in everything you can if your patients are stable. If they are intubating a patient, ask if you can record or push meds. When coding a patient be the first one to hop on the chest and due compressions, bag the patient if needed, record everything that is going on ect. Watch the nurses place lines with ultrasound and ask them to teach you. Basically, as long as your patients are taken care of and stable, go around and ask if you can watch and learn or help out with procedures. Finally.... You have to love what you do. You will see more death then any other form of acute care nursing. Some of the things you will see will tear your heart out. You have to go into this career path knowing that there is a very high turn over rate in this field because of how stressful it can be. That being said, there is nothing more rewarding that seeing the 19 year old girl who should have died, walk out of the hospital with a full recovery. It is the "little miracles" that keep you coming back for more even though the day to day can be gut wrenching. I hope this helps, ICU nurses are a breed of their own. It has been the only job that I have ever had that I truly wake up in the morning and am excited to go to work. You will either love or hate working on a unit and you will most definitely develop a dark sense of humor. I wish all of you students and new grads the best of luck in your nursing careers and always remember, there is a lot of people out there that are "dream killers." Don't listen to the negative people out there. You can accomplish anything you want as long as you put everything you have into it.
  13. walk6miles

    This Is Intensive Medical Care!

    You get a report on your two patients (rushing through the assessment as quickly as possible) and just as you go into the empty room assigned to your third patient, the phone rings and it's for you. You put the phone down after the report and look up at the call light flashing brightly (of course, it's one of yours). You finally finish with patient number 2 just in time to see patient number 3 being wheeled into his room. Oh, joy! You promise yourself that you will make it to the restroom AFTER you get him settled in. It's okay, you're a nurse and we all know how big a nurse's bladder can be. Now let's focus on your third patient: a 70-year-old gentleman with end-stage HIV. He weighs exactly 80 pounds (actually, he resembles a survivor of the concentration camps) very bone and tendon stands out. It is painful to look at him. You finish up all the essentials (assessment, consents signed, history filled out) and you give him the call light/ tv remote. Once you have regrouped and organized you are ready to deliver medications, change dressings, etc. - all those things that contribute to the comfort and healing process. Once you get the ball rolling, you have it made. Unless there is a blip on the screen, a glitch in the plan, a problem with the plan! Prepare yourself: the call light goes on and you're off - the race has begun. Now let's add to the equation. You walk into your first room and notice that your patient, a 78-year-old female with a long health history compounded with more than 20 visits to the ER, now needs some serious attention. Her Lasix has not kicked in and you can hear the gasps as she struggles to breathe. A simple Lasix "chaser" is not going to help at this point. You page respiratory, an arterial blood gas is the thing. Next, you page the physician and stand by the patient with the insane hope that your presence can somehow assuage her shortness of breath. Twenty minutes later and your patient is on the ventilator but, you have to fight with the physician to keep the patient sedated on Diprivan (he prefers 2 mg of Ativan every 4 hours). In order to get the drug most suitable for your patient, you must get a pulmonary consult for ventilator coverage. You clean up the patient, the room, and, oh yes, the husband's belligerent attitude ("she was fine when I left her") and hand him the box of salty snacks he slipped into the patient's delicately balanced diet because, after all, food is love and he felt the need to "spoil" her a little. The call light beckons you away from his angry accusations. Your second patient has been on your mind, and in your prayers for the last 2 hours ("dear God please let her stay stable while I take care of my other two patients"). The poor woman needs a bedpan; the other nurses have been great about helping her out while you are stuck in the other rooms and hopefully she can understand. She does. This is her third hospitalization since that horrible day she found a lump in her breast while checking herself in the shower. She is here this time because her first round of chemotherapy made her too ill to be at home, alone. She refuses a foley catheter and you respect her wishes despite the difficulties her refusal create. We laugh and joke while I help her get comfortable in bed. I have removed the surgical bandage and examined the skin surrounding the stitch line. It looks pink and flat and healthy, "edges approximate" gets tucked away in your brain for documentation later. She tells me her story while I help her move around a bit and give her a quickie bath and linen change. She is hopeful that she will beat this "thing". I help her with her gown. I am prayerful for her. I will miss her because tonight she will transfer to a step-down unit. I tell her to expect it (even at 0300 hours) because that is the way it is: one patient leaves or expires and a room opens up. Now I can try to sit in front of the computer and chart. That has to be the one thing that can become harder and harder. You organize your paperwork and your thoughts and begin entering the information for each patient; a call light or alarm goes off and there you go flying down the hall. The minute you finish with that business, you sit in front of the computer and realize you cannot remember what was next. This night I count the times I am called to the room by call lights, not just my patients, but call lights and alarms. Seventeen times by the time we have been on duty four hours. My 80-pound patient's call light goes on and I am filled with disbelief: he is gasping for air. He has brought with him an advance directive. It is a piece of paper which states that he does not want "heroic measures" done. When you can't breathe, however, you change your mind quickly. I offer him several options and he makes his choice. Respiratory places a device which is intended to deliver the maximum amount of oxygen to this patient's lungs; I explain to him the next step. We both hate the bipap device but together we make an agreement. I will keep him comfortable tonight and tomorrow he will speak with the physician about further treatment options. I have experienced physical pain. Serious, unrelenting, mind-numbing pain. I understand pain and the patient who finds they are imprisoned by pain. You must find relief for them as completely as you can; the physician must understand the patient's needs. Sometimes the collaboration between the patient, the physician, and the nurse runs out of fuel. Sometimes it is the physician and sometimes it is the nurse. My belief that no one should suffer needlessly was born as a result of an injury. I now make it my business to see that my patient remains if not pain-free, then at least in "control" of their pain. If the medicine can be given every four hours, I give it. I find that this attention to "control pain" benefits the patient. They don't wait so long for relief that the pain gets ahead of them. I have lost my temper only once and that was with a coworker who did not give a cancer patient ANY pain medication on her shift, "she didn't ask for it" is not an excuse - some patients are stoic unnecessarily. Now I am given a bed for my post-surgical patient. I dare not drag my feet on the transfer because I have another post-surgical patient waiting in PACU. This patient had open heart surgery (coronary arterial bypass grafts) more than three weeks ago. He noticed a slight redness at the base of his sternum a week ago. He says he chose to ignore it; now he has a high temperature and a sluggish green drainage at the site. Oh yes, the site is bright red and swollen. In report, I am told they evacuated more than a half cup of secretions from the now seriously infected incision site. Whether he knows it or not, his life is endangered. He will stay in ICU for several days so that the intravenous antibiotics can get a foothold on the infection. Before I can accept my new patient, the patient in the assigned room must be transferred. This means paperwork, calling report (and finding the nurse willing to take the report at the time you are ready), packing up the patient and their belongings, and finally, carting the patient off to their new room. In the hospital where I currently work, the cleaning group is so good that the problem of cleaning a room quickly doesn't exist. Finding a tech to transport the patient out of one room to the next can be tough. Techs are few and far between. We overwork our techs, but what choice is there? Sometimes it feels like we are on a treadmill. We get the patient in, treat them as best we can and then we get them out. Get 'em in, get 'em out! Many nights I stand at my workstation and look down the hallway and wonder if there is some way we could get things under control so we could have more contact on a personal side with our patients. By this I mean I would love to find time to sit in a chair in the patient's room and listen to them. I don't have that luxury now. When I need information, I just want to scream: just tell me yes or no; now just sign the consent! Eeek! I try to get everything done in a timely manner. Most often, it's done and that's the miracle in itself. Timely? Ha-ha! I have worked night shift all of my nursing career (except for one summer when things were really slow and I needed any shift I could manage) and nights are somewhat less chaotic but nevertheless challenging. The young in our intensive care unit have not learned to say NO to bullying family members; this causes heartache and lots of anger. Two weeks ago I had 3 belligerent family members who planted themselves against the empty bed in a two patient room. They placed their chairs directly in front of the bipap machine and dared the staff to eject them. Their dad was struggling with pancreatitis. He had a Dilaudid PCA which they pushed to deliver the pain med until I came in and could not awaken the patient even with sternal rub. After consulting with the physician and presenting him with an ABG incompatible with life on this planet, I removed the PCA pump. I was screamed at by the family (thank God Charge backed me up). I explained everything to them and asked them for their cooperation. They begrudgingly helped me by cooperating with a plan of care that WE developed. The patient did well on bipap that night; his pain was controlled by me, and the family actually went home to rest. In our unit, whether the family stays at night is "nurse's decision"; a weak and demoralizing rule of thumb which often cripples the nurse's ability to care for the patient. So, now you've seen a night within the intensive medical unit. Like so many jobs, there are many facets. Sometimes the hospital you work for cares for the nursing staff and their ancillary support. Often times it is hard to see that. Especially when the things they do confound its employees. We are all alike, that is, we work for a living as well as personal satisfaction. As nurses, we want our opinions to count; we want to be part of the team. We need to support each other; I am very fortunate to work with the group of nurses that I do.
  14. Ruby Vee

    Managing 24/7 Visitors

    A brand new ICU patient, whether they are crashing with cardiogenic shock, fresh from the ER in septic shock or just back from the OR, is a busy patient. There are assessments to be done, labs to be drawn and body cavities to be accessed . . . IV, NG, Foley? Intraaortic balloon pump? Chest tubes? But often times family haven't seen the patient since they kissed them goodbye in the pre-op holding area or at the front door this morning. If possible, it's good to have the family back briefly to see the patient and to get a quick update of all that's being done to help them. If the bedside nurse is too busy, overwhelmed or crazed to deal with family right now, perhaps the charge nurse or a neighboring nurse who isn't caught up in the admit could show the family back, answer brief questions and then give them a time frame for when they can come back and stay for a spell. When we tell families that they can stay however long they want, even overnight, we're creating an expectation. They believe that the loving thing to do, then, is to stay overnight. If they don't stay overnight they don't love the patient enough. When families expect themselves to stay at the bedside, they often overlook taking care of themselves, skipping meals, delaying bathroom breaks and forgoing sleep. So one of the first things I tell family is that it's OK to go home. When the oxygen masks drop in the aircraft, you put your own mask on first, THEN help others. Family members of critically ill patients need to be encouraged to take care of themselves. It doesn't hurt for the patient's nurse to check in with them . . . did they get enough sleep? Have they eaten? The cafeteria is on the first floor and they serve awfully good salads. (Or ice cream or whatever.) It's OK not to be here every minute because I'll be at the bedside -- they can call me anytime. Family members who are told that while visiting hours are 24/7, it would be a good idea for them to go home for the night are more likely to actually GO home than family members who are simply told they can stay. I usually tell the families of my fresh post-op patients that "There's nothing you can do for him tonight -- but tomorrow he's going to have to get out of bed to sit in the chair or go for a walk, he's going to need help with his meals and reminders when it's time to cough and deep breathe. That's when you can really help him. So go home and get some rest now, so you'll be fresh in the morning when he needs you." I follow up with a card with the phone number for the unit and the message that they can call any time they feel the need and the nurse will give them an update. It is helpful if there is someone besides the bedside nurse who can screen visitors -- and usually that falls to the first person they see when entering the unit. If that's a secretary, keep the secretary updated when visiting is going to be a problem. Let them know that "we're putting a line in Mr. Smith, and it will be at least 20 minutes before the family can come back," or "Mr. Jones' family can come back, but I need to talk to them about the isolation procedures first, so call me." If the unit is so poorly designed that the first person they see is likely to be some random staff person running between rooms (and my old ICU was exactly that way), it's far more difficult. If you're that random person they see first, direct them to the front desk, to the patient's nurse or even to the charge nurse or a Clin Tech who can help them -- don't just rush on by unless your patient has just arrested. Family are more likely to pay attention to a closed door, a drawn curtain or a sign advising them to please come back later if someone has given them a heads up earlier. I try to give the family some expectations for the shift the first time I see them. "We plan to put in a central line sometime today. If you come back to visit and the door is closed or the curtain is drawn, please give us 20 minutes or so, and then come back again." Be sure to give yourself a generous time frame. If you tell the family they can come back in 20 minutes and it takes an hour to finish, they'll be understandably worried. Most critical care units have some sort of rules for visitors -- ours are posted in the waiting room and spelled out in a brochure visitors are handed the first time they visit. Please follow the rules. If you don't adhere to the rules for visiting, the nurse who follows you and tries to enforce the rules is then the bad guy. It's a poor nurse who sets up her colleagues to be the bad guy, but we see it all the time. Someone just wants to get through their shift with a minimum of discomfort, and so lets the visitors do whatever they want without speaking to them about it. The next nurse is then treated to a struggle and potentially a nastygram from the family to the boss. Don't do it! Just stick to the rules. They can always be relaxed if it's a special case (Grandma is about to die or grandson just got off the plane from his deployment to the middle east), but if you DO relax the rules, make sure you TELL the family that you're relaxing the rules just for right now because it's a special case. Don't create the expectation that it's always going to be a party in the room at 3 AM.
  15. Well...it is not in your kitchen.... Counterpulsation : count-er-pul-sa-tion (kown'ter-pÅ­l-sÄ'shÅ­n), A means of assisting the failing heart by automatically removing arterial blood just before and during ventricular ejection and returning it to the circulation during diastole; a balloon catheter is inserted into the aorta and activated by an automatic mechanism triggered by the ECG. (Farlex Partner Medical Dictionary) The intra-aortic balloon pump (IABP) was introduced the in the late 1960s by Dr. Adrian Kantrowitz as a simple yet effective device to increase coronary perfusion. The IABP is a balloon that sits in the aorta approximately 1-2cm below the origin of the left subclavian artery and is inserted via the femoral artery. Because it is easy to insert, the IABP is the most widely used form of mechanical circulatory support. Dr. Kantrowitz not only invented the intra-aortic balloon pump he also invented the L-VAD and an early version of the internal pacemaker. He also performed the first pediatric heart transplant in 1967. Inventions: Intra-Aortic Balloon Pump | Thayer School of Engineering at Dartmouth The principle of the IABP (intra-aortic balloon pump) in simple with the primary goal is to improve the ventricular performance of the failing heart by facilitating an increase in myocardial oxygen supply and a decrease in myocardial oxygen demand. The first uses of the IABP were used for surgical patients; the pump can now be used along with interventional cardiology procedures and medical therapy (medications). Some indications for its use include Failure to wean from cardiopulmonary bypass. Cardiogenic shock. Heart failure. Acute heart attack. Support during high-risk percutaneous transluminal coronary (balloon) angioplasty, rotoblator procedures, and coronary stent placement. The balloon inflation in diastole and deflation in early systole causes 'volume displacement' of blood within the aorta, both proximally and distally. The intra-aortic balloon, by inflating during diastole, displaces blood volume from the thoracic aorta leads to a potential increase in coronary blood flow and displacing the blood distally increases blood flow to the distal extremities and organs. In systole, as the balloon rapidly deflates, this creates a dead space, effectively reducing afterload for myocardial ejection and improving forward flow from the left ventricle. There are several contraindications to using the IABP. For example: patients with aortic regurgitation because it worsens the magnitude of regurgitation. IABP insertion should not be attempted in case of suspected or known aortic dissection because inadvertent balloon placement in the false lumen may result in extension of the dissection or even aortic rupture. Similarly, aortic rupture can occur if IABP is inserted in patients with sizable abdominal aortic aneurysms. Patients with end-stage cardiac disease should not be considered for IABP unless as a bridge to ventricular assist device or cardiac transplantation. http://ceaccp.oxfordjournals.org/content/9/1/24.full.pdf Accurate timing of the pump is imperative for maximal assistance. ICUFAQs-Intra-Aortic Balloon Pump Review Correct timing of balloon inflation and deflation during the cardiac cycle is vital to ensure optimal effects of counterpulsation minimizing potentially harmful effects related to mistiming. Most commonly the ECG waveform is used to trigger balloon inflation and deflation. The arterial pressure waveform is an alternative technique that may be useful if either the ECG trace is poor or there are cardiac arrhythmias. Present day machines allow either method to be easily selected. The balloon starts to inflate at the onset of diastole. This corresponds to the middle of T wave on the ECG waveform and the dicrotic notch of the arterial pressure trace. As aortic valve closure has occurred balloon inflation causes a sharp upstroke on the arterial pressure waveform followed by a tall peak which represents the assisted diastolic pressure. Deflation occurs at the onset of systole immediately before opening of the aortic valve. This corresponds with the peak of the R wave on the ECG trace and the point just before the upstroke of systole on the arterial pressure trace. As the balloon deflates, the assisted aortic end-diastolic pressure dips down to create the second deep wave, usually U shaped on the arterial pressure waveform. IABP timing in relation to the cardiac cycle is monitored by display of arterial pressure waveform. Principles of intra-aortic balloon pump counterpulsation The intra-aoritc balloon pump may appear to be a sophisticated video game, with pretty colors on a screen, but is a life saving adjunct in the care of the sick and failing heart. Counterpulsation is a valuable method of temporary mechanical circulatory support that attempts to create more favorable balance of myocardial oxygen supply and demand by using the concepts of systolic unloading and diastolic augmentation that saves cardiac muscle by allowing it to rest and increasing coronary perfusion by increasing the blood flow down the coronary arteries. Resources Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL Jr. Initial clinical experience with intraaortic balloon pumping in cardiogenic shock. JAMA. 1968 Jan 8;203(2):113-8. PubMed PMID: 5694059. Unverzagt S, et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD007398. doi: 10.1002/14651858.CD007398.pub2. Review. PubMed PMID: 21735410. Thiele, H. et al. Intra aortic balloon support for myocardial infarction with cardiogenic shock. NEJM 2012 Oct 4;367(14):1287-96.
  16. It is a fact that many people will either personally experience a critical illness or be impacted by a critical illness by a friend or family member (Gavaghan & Carroll, 2002). The concept of family-centered care and open visiting hours in the intensive care unit (ICU) has recently come into light as health care professionals, family members, and researchers seek to examine the benefits of a more liberal policy for visitation. According to Farrell, Joseph, & Schwartz-Barcott (2005), visitation regulation has largely gone unchanged since the U.S. Public Health Service published visitation recommendations for the intensive care unit in 1962. The research on the subject matter remains limited and far more research is necessary for an effort to acquire empirical data relating to patient responses to a more liberalized visitation policy that is focused on family-centered care. This article seeks to examine the literature available to answer the compelling question as to whether open visitation policy within the critical care environment provides recovery benefits to the patient. Adjunctive to this question is the need to recognize the family as an extension of the patient and determine their needs and motivation. This paper will explore five comprehensive studies in an effort to develop information on the compelling question. Further, each study will be critically reviewed to determine commonalities among the research as well as differences. Finally, the results of the review will provide conclusions that support a change in practice and provide strategies for hospitals to develop a visitation policy that is consistent with the research and focused on family-centered care. Literature Review The first research article is a study conducted by Gavaghan & Carroll (2002) with a purpose to integrate current knowledge about family-centered care as a means to develop nursing interventions that promote a family-centered approach to care in the ICU. The primary thrust of the research was focused on family-centered care theory, where the family is viewed as a "social unit that has a significant effect on the patient's outcomes" (Gavaghan & Carroll, 2002, pg. 65). Gavaghan & Carroll (2002) hypothesized that family members have needs that must be recognized by nurses in the critical care environment. Further, the authors set out to clarify these needs through the development of the Critical Care Family Needs Inventory (CCFNI). The CCFNI focused on five conceptual areas that researchers felt were important to the family and included: proximity, assurance, information, support, and comfort. According to Gavaghn & Carroll (2002), psychometric testing of the CCFNI supported appropriate measurement of the data collected by the tool. The study sample consisted of forty family members that completed the CCNFI (N=40). The results of this inventory revealed that family members often felt that their needs for information as well as proximity were met. However, the study revealed that visiting hours, support and comfort were often inconsistently provided by nurses and medical staff. Of special interest is the notion that while the hospital had a posted policy for visitation, nurses were inconsistent in their application of the policy. This inconsistency often made the family feel a sense of distrust to the nurses. The final conclusion of this survey provided for suggested recommendations to improve family relationships in the ICU and improved satisfaction. Nurses are the primary means of information and support because they are the health care professionals that have direct and constant access to the patient. The study suggests that as a means to improve satisfaction, hospitals develop a visitation policy that embraces family in the care of the patient. Further, the facility should develop a brochure about family-centered care and visitation that provides the family with an orientation to the activities of the ICU. Lastly, the author suggested that the use of volunteers to engage families in the orientation process provided needed relief to the nurses and actively involves a group of people that have the time to spend nurturing the family needs. Another research article written by Farrell, Joseph, & Schwartz-Barcott (2005), focuses on the need to balance patient, visitor and staff needs in terms of open visitation in the ICU. This phenomenological qualitative study was driven by the need to answer the question about nurse perceptions while working with visitors in the ICU. The study focused on a sample of nurses (N=8) that work in the ICU and have voiced concerns over balancing the care of the critically ill patient while attempting to meet the increasing needs of family members. The tools used for this research included observation, questionnaire, and interviews with the sample participants. The measurement and analysis of the data included host verification, where the researcher validates the quotes from the sample participants and allows the participants to verify their answers (Polit & Beck, 2004). The findings of the survey demonstrated that nurses are central to access of the patient. Nurses hold the key to the gateway and depending upon their needs for the day can deny or grant access to the patient by family members. The major concern with this responsibility is the general lack of consistency by the nurses. One nurse may grant family access while another nurse denies access creating a disparity in the nurse-family relationship (Farrell, Joseph, & Schwartz-Barcott, 2005). Central to the nurse-family relationship is for the nurse to understand that family members have a need for information, and access to the patient. Likewise, families need to understand that nurses must balance the critical care of the patient, safety and have the ability to complete the nurse's work while the family is present. The study also focused on how nurses manage family visitation during the patient's routine care and when it is appropriate to ask a family member to leave. Study participants overwhelming cited that they asked family members to leave during the provisions of personal care (Farrell, Joseph, & Schwartz-Barcott, 2005). Further, nurses were conflicted as to whether family members should be present during codes. The study suggested that family presence during a code is very individualized and should be left to the discretion of the health care team and the family members (Farrell, Joseph, & Schwartz-Barcott, 2005). In comparison to the first study reviewed by Gallaghan & Carroll (2002), Farrell, Joseph, & Schwartz-Barcott (2005) suggest that the ICU appoint one individual that can effectively manage the complex needs of the family, thereby allowing the nurse time to care for the patient. While Farrell, Joseph, & Schwartz-Barcott (2005) do not suggest a volunteer can manage this function, it is interesting to note that both studies made this recommendation. Another study conducted by Livesay, Gilliam, Mokracek, Sebastian & Hickey (2005) detail the experiences of nurses that work in a Neuroscience Intensive Care Unit (NICU). The purpose of this study was to examine nurse's perceptions about open visitation, determine if the nurses believe the policy needs to be changed, and how the actual policy in place impacts their patient's recovery. This quasi-experimental research design had a participant sample of registered nurses and patient care technicians (N=30). The measurement tools employed were questionnaires that were distributed to study participants. Of the thirty participants, twenty-six responded (Livesay, et al, 2005). According to the study, 85% of the sample were aware of the visitation policy and provided this information to family members when they inquired about visiting hours. Nurses were more likely to be liberal with the visitation policy (10 of 25) if the patient's condition was serious. Most of the nurses in the sample indicated they would ask family members to leave the ICU during normal care routines. The majority of nurses would recognize caregiver fatigue on the part of the family member and would suggest that the family member take a break to get a cup of coffee or go for a walk (Livesay, et al, 2005). An interesting point to note here is that the nurses studied most often recognized the family members need for information concerning the condition of the patient. Many family members were reluctant to leave the bedside if there were not some assurances from the nurse that they would contact the family member if the patient's condition were to change. Another point of interest is that fact that when nurses provided the family with assurance that they would monitor the patient closely; the family member would leave the unit for a rest period (Livesay, et al, 2005). The conclusion of this study resembled the conclusions of the two other studies reviewed. This study recommended that clear policy is established on visitation and that nurses apply the policy consistently across the board. In addition, the development of educational material and perhaps a contract for care is made between the family member and the nursing staff. This study identified the educational material be used as a means to provide the family with education about the patient's needs, the nurses' responsibilities and ways in which the family can be engaged in the care of the patient. Finally, like the other studies, this study also recommended that support personnel be included in the units of staffing in an effort to relieve the nurse from the responsibility of meeting the complex needs of the family. Support personnel can provide the family member with needed information and contact during the critical care stay and increase the family's satisfaction with the hospital (Livesay, et al, 2005). The next study reviewed was one conducted by White (1994) that randomly selected 125 hospitals that had an intensive care unit (N=125) and to compare and contrast visiting policies for each hospital. 40% of the sample responded to the survey conducted by White (1994) during the study period. Of this 40%, all participants had a visiting policy in place for pediatric and adult ICU. Visiting hours ranged from 8 hours to 14 hours with few having any form of visiting hours after 9:00 PM. The general premise of the study was to determine if there were physiological reasons for more liberalized visitation as well as to describe the legal and ethical considerations for a more liberalized visitation policy. As has been true throughout this literature review, most of the studies, including this study by White (1994) speak to the fact that the nurse is considered the gatekeeper. Use of this term employs the understanding that nurses are often the professional responsible for applying the policy of visitation within the critical care environment. In addition, the nurse directly impacts the family's ability to have access to the patient or be denied access to the patient (White, 1994). The major difference in this research is the focus on ethical and legal considerations for visitation. According to White (1994), patients and their families have the right to be together through an acute illness. White (1994) suggests that as patients are isolated and in some cases forced isolation, this can and often does cause a general sense of distrust with the staff and increases the recovery period of the patient. Patients need the support and nurturing of their family during times of acute crisis or illness. The conclusion of this survey suggested that nurses need to have a wide depth of understanding about the policy of the hospital in terms of visitation. Nurses often denied access to visitors if the business of the unit required such actions. Most often cited was the increased acuity of the patient or the staff limitations (i.e. shortages of staff members) (White, 1994). The final research study that was reviewed was conducted by Eriksson & Bergbom (2007) and was designed to answer the question of whether family visitation actually helps the patient during recovery. While there is much discussion about family visitation, there is very limited research to support or deny the claim that increased visitation by family actually is beneficial to the patient. Eriksson and Bergbom (2007) used a prospective, explorative observational study design to answer the referenced question. They surveyed a sample group of 198 patients and their families during the study period (N=198). The nature of the study was longitudinal because it provided a study review period of eight months. The primary thrust of the study was to examine the results of family visitation on the clinical manifestations of the patient and whether these clinical results were related to increasing family support. Data was collected over an eight-month span of time and reflected a total of 198 patients. The data was analyzed via the Statistical Package for Social Sciences, Version 12 and deemed reliable (Eriksson and Bergbom, 2007). At the completion of the study, the data revealed that there is really no conclusive evidence that increased family visitation had a direct positive or negative impact on the patient's overall clinical performance. In fact, the researchers suggested that more research and study is needed in an effort to provide further evidence on the subject. The authors made reference to the fact that patients in the study that had no visitation during their stay in the ICU had a better mortality rate than those that had visitations (Eriksson & Bergbom, 2007). This result might lead one to believe that family visitations do not have any correlational relationship to clinical performance and recovery. Discussion Each study reflected a reasonable design and analysis methodology. Some studies reflected the perception of nurses with open visitation policies, while other studies focused on the patient's clinical performance with increased family visitation. In each study, the data was compelling and revealed that family members have a need for close proximity (access) to the patient, a need for information, and a way to be engaged and involved in the patient's care. Further, most of the studies reviewed suggested that educational material be developed in an effort to provide family members with an orientation to the critical care environment and the stated visitation schedule. Nurses were recognized as the gatekeeper for access to the patient and when there is disparity among nurses in terms of enforcement of vitiation policies it can negatively impact the nurse-family relationship. Some studies went so far to suggest that when visitation policies are not consistently enforced that it can cause a distrustful relationship between staff and family members and reduce overall family satisfaction with care. Some inconsistency with the studies center around the overall influence open visitation has on the clinical performance of the patient. The study by Eriksson & Bergbom (2007) provided empirical data to refute the hypothesis that increased family visitation actually improve patient's overall mortality and decreases the recovery process. Evidence from their study is contrary to the new age assumption that open visitation makes a real difference to the patient. While the results of their data may be true, the authors of the study suggest that more research be conducted to in an effort to analyze more data on the subject. Conclusion Open visitation in the critical care environment is being widely discussed as a means to improve patient outcomes and provide families with proper access. Research on the topic continues to be very limited. However, there is enough evidence to suggest that family-center care theory can be used as the cornerstone of this foundational understanding into human dynamic. Families are evolving and changing and health care professionals must recognize that people who are important to the patient must be considered family members (Gavaghan & Carroll, 2002). While the industry adapts to the changing family unit, there are several strategies that nurses and hospitals can employ in an effort to better meet the needs of patients and their families. Some of these strategies include: the development of consistent and fair visitation policies designed to address the needs of the family, educating nursing staff about the need to fairly and consistently apply the visitation policies across the board without the need for disparity, and the development of educational material designed to orient the family member to the critical care environment as well as provide them with written information about stated visitation schedules. Further recommendations suggest that a member of the volunteer staff be appointed as a family liaison and conduct the family orientation. Also, the development of a family engagement contract was suggested by one study in an effort to involve the family with the provisions of care. Finally, in an effort to provide ample access to the patient and allow fatigued caregivers the opportunity to take reasonable rest breaks, one study suggested that the hospital invests in beepers that can be assigned to family members that leave the ICU for breaks. Beepers provide the family member with a peace of mind that if they are needed or if the patient has a change in condition, the nursing staff will have ready access to alert them of these changes. As hospitals and critical care environments develop their policies, they must keep in mind that nurses play a critical role as gatekeepers for the patient. The primary concern must always be for the well-being of the patient, but the family and their complex needs must be met as well. The challenge faced by today's professional nurses is truly in the balance of these two different priorities. References Eriksson, T. & Bergbom, I. (2007). Visits to intensive care unit - frequency, duration, and impact on outcome. British Association of Critical Care Nurses 12(1). 20-26. Farrell, M., Joseph, D., & Schwartz-Barcott, D. (2005, January). Visiting hours in the ICU: finding the balance among patient, visitor and staff needs. Nursing Forum, 40(1), 18-28. Retrieved January 29, 2008, from CINAHL Plus with Full-Text database. Gavaghan, S., & Carroll, D. (2002, March). Families of critically ill patients and the effect of nursing interventions. Dimensions Of Critical Care Nursing: DCCN, 21(2), 64-71. Retrieved January 29, 2008, from MEDLINE database. Livesay, S., Gilliam, A., Mokracek, M., Sebastian, S., & Hickey, J. (2005, April). Nurses' perceptions of open visiting hours in neuroscience intensive care unit. Journal of Nursing Care Quality, 20(2), 182-189. Retrieved January 29, 2008, from CINAHL Plus with Full-Text database. Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.).Philadelphia: Lippincott Williams & Wilkins. Verhaeghe, S., Defloor, T., Van Zuuren, F., Duijnstee, M., & Grypdonck, M. (2005, April). The needs and experiences of family members of adult patients in an intensive care unit: a review of the literature. Journal Of Clinical Nursing, 14(4), 501-509. Retrieved January 29, 2008, from MEDLINE database. Whitis, G. (1994, January). Visiting hospitalized patients. Journal Of Advanced Nursing, 19(1), 85-88. Retrieved January 29, 2008, from MEDLINE database.
  17. Chancub

    ICU - not for the faint of heart

    I am just trying to hold myself together, often I am in pieces, and I feel like I am scrambling to keep everything in one piece. Is this what life is like? That was a question I asked myself last Thursday night, it was the second night that I had this patient, and his family was amazing. Often times it's the good ones. Of course it's the good ones that always lose the ones they love the most, and it seems like ones that are terrible nasty and mean stick around forever. You think that in two nights you wouldn't get to understand and know another human being, but you would be wrong. In my position as a nurse we really get to know people, possibly it is because it is when we meet people, in their most vulnerable moments. In the middle of my week I admitted a patient who had had a cardiac arrest, he was being flown in, as I've mentioned before we get patients from all around the state, the sickest of the sick. I get report from the nurse from where he's coming, and I knew this was going to be a bad one. What I did not apprehend is how incredible his family was. When I left that next morning, he was on a couple medications to keep his blood pressure up....but no big deal often times people are on that unit, when I came back the next night he was on three blood-pressure medications, and he was not able to keep his pressures up, and I knew it was over. It was only just a matter of time, now my job was to support the family. They were such a great family, I knew that they would not hesitate to make him a DNR if they had known that there was no hope, and in his case there was no hope. Why as the human population, do we continuously try to expand the lives of the people we love to the very end of time, even if it is not possible? We beat ourselves up for these people that die, when in reality we do not know if they really do die? Their souls can continue to live on, but we are so scared of death that we cling to them, even if they're willing to go. We will save that topic for another day, I have plenty of stories. Well his family was not like that, they were willing to let their loved one go, knowing there was no hope, but they were going to be there and love him until the very end which was soon to come. Throughout the shift as I got to know the family, I learned this hopes, his dreams, how many kids he had, what he did for a living, what he wanted to do with life, where he was coming from and why he was here. I learned his family's hopes and dreams, the ages of the children, his siblings, how his parents passed, anything else you can think of that you want to know about a human. Throughout the night the daughter, the son, the sister, and the ex-wife, never left the bedside. I have an odd name, but they sure did remember it from the night before when I admitted him, I felt so grateful that they would actually remember my odd name in their time of chaos and dismay. As his blood pressure started to trend downward, I knew it wouldn't be much longer, but the thing about that is, we never quite know when they're actually going to go. He had a son who lives in LA, who was attempting to get there, and you never know if that's what they're waiting for. Well he lasted my entire shift, and passed right before shift change, and an hour before his son was about to land. People choose when they want to die, he chose that he had wanted to die and hour before his son had got there, we will never know why. At one point in the night the daughter had continuously tried to be closer to him, I grabbed another coworker of mine who helped me scoot him over on the bed, and told her that she could lay next to him if she would like, she was so happy with tears in her eyes, knowing her father would soon pass. Thankfully he had just walked her down the aisle a month sooner, she had placed little crystals on his chest, I asked her what they were for? She said; "to keep him grounded, keep him with us." She was beautiful, there was tears in my eyes I had tried to hide, and I smiled; he will always be with you - I didn't say it, but thought it. She did not leave the bed again, until I was long gone and he was long passed. I will never forget that morning, I had given report to the nurse that had had him the day before, suddenly his heart had gone into a rhythm that was lethal, I notified the family and told them that it was only a matter of time now, he was no longer perfusing. They all stood around him, crying, and letting him know it was ok to go, and he was loved. I stood in the back, there for support, if they had needed me, or any other questions they needed answered. Before I left, and after he had passed I hugged them, and cried. They told me, which is a moment I will never forget; "you were our angel last night" ....their angel, wow...As she hugged me with tears streaming down her cheeks, and thanked me for everything. The one thing I've realized about this job is how much love their is in the world, and how people can always be thankful for anything you do, even if they're in the worst circumstance. I guess I never really realized that, I was just doing my job, but my job isn't normal...my job entails being there for people in their most raw and vulnerable state, people are so humbling. I left that day in tears, crying for this amazing family. I also realized how incredibly grateful I was for being able to be in their lives for that moment, for the moments when they needed someone the most, I was thankful it was me. I am grateful I met you, even in these circumstances, thankful for you, for changing my life, I will never forget these times, even if I don't do this job forever, so much will never be forgotten.
  18. ICU patients are sicker than ever. Many patients in the ICU are intubated and getting them extubated can sometimes be problematic. Delayed extubation or re-intubations are costly in terms of healthcare dollars but more importantly in increased mortality and morbidity. A recent study conducted in a large neurocritical care unit (NCCU) explored stridor as a predictor of unsuccessful extubation. "Some degree of laryngeal edema develops in all patients undergoing prolonged intubation. In serious cases, the tracheal lumen can narrow by greater than 50%, impairing ventilation and necessitating reintubation.3 An objective marker used as the clinical indicator for severe laryngeal edema is stridor, an audible high-pitched inspiratory whistle caused by increased airflow velocity. Postextubation stridor (PES) affects 1.5% to 26.3% of patients after extubation.4 These patients require monitoring and rapid intervention, leading to increased care needs and associated nursing time." This study encompassed 43 extubations in an urban NCCU. 12 had post-extubation stridor and 9 patients were reintubated, 6 of these were due to post-extubation stridor. "Risk factors that require the consideration of prompt treatment include female sex, age less than 18 years, duration of intubation more than 5 days, body mass index greater than 26.5 (calculated as the weight in kilograms divided by height in meters squared), prehospital intubations, and difficult intubations requiring multiple attempts. Additional risk factors include previous self-extubation, recurrent intubations, and extreme agitation." With a screening tool involving the above criteria, it was determined that a single dose of methylprednisolone 40mg IV four hours prior to planned extubation. "Additionally, someevidence15,16 supports the use of inhaled budesonide immediately before extubation, although larger studies are necessary to support these findings." The "aim was to affect institutional practice, not to create generalizable knowledge. Implementation of the pathway was successful in reducing rates of post-extubation stridor and reintubation; however, these findings are limited by the short implementation period and small sample size." "Research on risk factors for PES and appropriate prophylactic treatment is limited. A few studies focused on trauma, medical, and surgical critical care patients. No studies focused on NCC patients. The latter patients are associated with a unique set of challenges and require further investigation. Additionally, research findings have long supported the use of steroids in patients at high risk for PES, but consensus on the definition of high risk has not been achieved.17-19 Further research is necessary to better aid in understanding patient characteristics and practices contributing to PES prevalence in NCC patients. The clinical pathway we implemented incorporated the best available research to create consistency in evaluation of patients before extubation and to guide management. Multidisciplinary input into the creation of the pathway was critical to obtain support from everyone involved in its implementation and was key to the success of the quality improvement project. The pathway was safe and effective in reducing rates of PES and reintubation in a single NCCU. What is your experience extubating patients successfully? Do you find the use of steroids in one dose or multi-doses to be helpful in reducing the risk of reintubation? What is your ICU doing to reduce reintubations? Here is the link to the study discussed in this article - it will be available October 15-25, 2018.
  19. Trissity

    Who's afraid of the ICU?

    I won't say that I always wanted to be a nurse, but it is a near thing. Even when life got in the way, and delayed my career for several years, nursing was always in the back of my mind. When I finally did get into nursing school, I was ecstatic. It was grueling and stressful, but never scary. I breezed through tests and clinicals, and I knew I had made the right choice for a lifelong career. I was made for this! I worked on a busy Med/Surg unit as a nursing assistant and unit secretary during school (which despite being an ADN program took four years due to an extensive waiting list for the nursing program). I believe the experience I gained from that job made me a better nurse, and I encourage all perspective nurses to be a nurse's aide first (trust me, you can tell the difference from those who don't have that prior hands-on care). Needless to say, when I graduated and started orientation on that same unit, I felt well prepared for what was expected of me. I was nervous, but not scared. My education and previous experience did not leave any room for fear in me. I quickly got the hang of things and was soon comfortable in my new role. I had my time management skills well honed, and was never late with medications or charting. My patients were well cared for, and my call light volume was low, despite heavy patient loads. I just couldn't understand why it took some nurses so long to chart and get their tasks completed. I completed one full year on Med/Surg before I wanted to spread my wings. I had always been very interested in critical care, and as luck would have it, a spot had just opened up in our ICU--not something that happened very often. I took a chance and applied. Happily, I was accepted. I went into this job, one year fresh out of school, brazen and cocky. Of course I belonged there--I had done so well in school and out on the floor. This would be a piece of cake. Oh, how quickly I was knocked off my horse! The ICU was worlds--galaxies--away from Med/Surg. Even though I felt like I knew everything, my coworkers wasted no time in proving me wrong. My preceptor, and ICU nurse for more than twenty years, bombarded me with questions constantly, about things I'd never had to think about before. Not just the "how" and the "why" of things, but the "what else", "what if", and "what do I need to do to change this". These are critical thinking skills that I thought I was using already, but clearly was not. It is hard to critically analyze your patient's care when you're busy completing tasks. I quickly learned that we don't do tasks in the intensive care unit, we manage patients. And it is an absolute must to know what you're talking about at all times. There usually isn't time to look up references when you're not clear on something. And I knew next to nothing. I would leave every morning after a long and stressful shift in tears. I wasn't good enough, or smart enough, or fast enough for this job. Doubt started creeping in about my life as a Med/Surg RN, and I begun to fear that maybe I wasn't even as good at that job as I so arrogantly believed. There were many days during my orientation that I had to talk myself out of quitting. How could I be trusted with patients' lives? Slowly, but surely, it got better. I immersed myself in critical care textbooks and journals every day. My eyes would go cross-eyed reviewing my patients' charts making sure I knew everything that could potentially go wrong with them. I asked questions. I practiced. I survived. It's been three years now, and I look back on that time with embarrassment. It was my own over-confidence that made for such an awful experience. No brand new nurse would be expected to function on the same level as seasoned pros. And a 3.9 GPA doesn't prepare you to recognize minute changes in your patients as an impending disaster...only experience can do that. I still don't know everything, but the difference is, I know that now. I know more than I ever did, and I'm learning more every day, which is the beauty and the point of nursing--that endless supply of new knowledge. I am eternally grateful for my preceptor, who saw right through me, and believed enough in me to make me change and grow. I hope to someday be a tenth of the nurse she is. My advice to prospective ICU nurses is to be afraid. Something's wrong if you're not scared, and you're most likely not ready. Learn. About everything. Listen to the nurses that have been doing it for years. Stick with it. Nothing is more exciting or rewarding than balancing on that thin line between life and death, and these patients need good nurses. Welcome to the club!
  20. hollyhockstorm

    Midas' Touch

    Appreciate....my daughter had a hard time enunciating that word before....one word that touches a heart, tries a tear, gives a lump in the throat. As we walked from the school bus towards home, she asked, "Mom, how's work?" "Oh, it's not that good, I was too busy last night." Then, she said, "That's alright, Mom, I know you've done your best." Oh, how encouraging and wonderful were those words reverberating in my ears coming from a 6-year old. She has a sense of maturity. Whenever you feel down, she's there to give you encouragement. So, as I pondered how my night really was, I was blinded by the tasks...too many things to do, too little time. But one thing for sure, words of encouragement could just let you go on and on and let you carry on with your tasks as you try to catch up on things. And it's good to hear that from anybody, from a co-worker, and most especially from your patient, even if she's just using the sign language. My co-worker last night said, "Naomie, what have you done? You have a magic touch!" (I was then thinking of King Midas). Me too, was so thrilled with my patient last night. She's been with our care for a long time in the intensive care unit. She's an End-Stage Renal Disease patient, with a multiple medical history and issues, who had surgery, became septic, was intubated and got trached. I had her when she was so confused, getting out of bed, on fall precaution and on Levophed drip. She wasn't on the ventilator yet. When I had her, she really had exhausted me. She had no restraints on and so I made careful, close observation on her. Then, I had her again, last night....she's on the ventilator already, with a triple drip-Levophed, Insulin (meaning I have to do blood sugar monitoring every hour using our Portland Protocol), and the Amiodarone drip-my favorite, using all the ports of the right internal jugular central line. I received her really febrile with a temperature of 103.3 F and had bouts of diarrhea. She has also a nasogastric tube with a Glucerna going, and with a new right above knee amputation that's oozing. (Did I make a mistake of choosing Bed A over Bed B?-they forgot I was pregnant and they wanted to give me Bed B- a very, very heavy patient and 6'6" in height and on a ventilator and all...with special participation of multiple organisms needed for Isolation Precaution). Hmmm, anyway, I'll just take this (Bed A) as a challenge..."whatever" was my word for the night. And so, she's on restraints...not a favor....but more observation and monitoring and documentation. I started my night the hard way....febrile, poop, the drips....assessment was forever. Good thing, my other patient, which was on the other side of the unit wasn't that bad, she's more stable(?) maybe, because she's alert and oriented by three...but then, the blood pressure was fluctuating, in and out of cardiac arrhythmia, give the trigeminy a five with an underlying rhythm of Brady, and with a whooping Troponin level of 9.81! Hmmm, she's alert but an acute one while the other one on the vent is chronic. But both of them were critical, that's why they were in the intensive care unit. Okay, first things first....titrate that needs to be titrated, address the febrile issue...Tylenol needs help at this time, I needed to order a cooling blanket-another temperature monitoring to prevent hypothermia, needed to give way for my antibiotics, too...creating double ports to one of the triple lumens....we couldn't use her right arm for venipuncture since there's an AV graft for her hemodialysis. Think, Naomie! Then, after the important ones were addressed, started cleaning her up. I thought this one's hopeless....we've seen people, come and go...but then, she started waking up....it's like she heard my thoughts....she started to communicate with her lips...I could hardly understand... I tried to make some humor to uplift her....then, I asked her, " Can you smile for me? "...she smiled....that was amazing! It's like I didn't believe she could follow simple commands...she was too confused before. And then, she started to talk again, but without sound, of course, she has a tracheostomy. I tried to understand her...but maybe I am just poor with reading lips. I told her to wait while I try to find the communication board where she could just point things so I could understand...I also tried to let her write the words...but she's too weak...until I figured out she just wanted to take the restraints off from her wrists. I explained to her the importance of restraints at this time since she's not totally oriented, she's in and out of reality, and she signaled to me, she understood why she had to be on bilateral wrist restraints. From then on, she's trying to communicate, asking for ice chips was one of them...I indulged her with that, so little, just to keep communication open. For me, it was fulfilling to see her come out to some consciousness...I was wrong after all. Hope is still there. Before my shift ended, her temperature went down to 98.7 F, she converted to Sinus Rhythm from Atrial Fibrillation, she's communicating, the blood pressure was stable, and her morning labs were not critical. That's why, my co-worker said, "What have you done to her? You have a magic touch!". And then, I realized...I've done my job after all! And I was on time. And it was fulfilling and amazing. I was just preoccupied with the number of tasks I needed to do. But then, I had done it, I mean everything and it's well done. And that just made me smile.
  21. Ruby Vee

    How To Be A Great ICU Colleague

    Welcome to the ICU. We're happy to have you here, and we know you want to be a great ICU nurse. That's going to take a long time, but you can be a great colleague in the mean time. When you encounter someone new - or anyone, really - smile, say hello and introduce yourself Do this as many times as it takes. Some of your new colleagues will remember you the first time. Others aren't so blessed with name/face memory. Some will remember your name or face but not what you're doing in the ICU. Introduce yourself to the secretary, the tech, the housekeeper, the pharmacists, the providers and the consulting services. Those who are shy or find it difficult to introduce themselves will be grateful to you for making the first move. Be up front with what you know and what you don't If you're transferring in from Med/Surg, you already know how to put in an IV, NG and Foley but may not know how to set up the monitor. If you're transferring from the SICU across town, you already know how to take care of a patient but may not know how to document in this hospital's clunky computerized chart. If you're brand new, you may not know anything, and that's OK too. What isn't OK, is for you to pretend you know something you don't, or not to know something you do know and could help out a colleague by doing. Watch the monitors If someone else's patient has a systolic blood pressure of 42 or a heart rate approaching 300, DO something. Grab the nurse, alert your preceptor, tell the provider. Don't just hope that someone else will notice so you won't have to. If someone else's patient is coding, help out Even if you're new, you can run specimens to the lab, pick up blood from the blood bank, corral the visitors in the area, answer call lights for the nurses in the room, jump on the chest to do CPR (the best place to be to see everything!) or watch the monitors on the rest of the unit. In fact, a study done when I was a brand new ICU nurse concluded that other patients in the unit are at risk of dying or complications while their nurses are helping out in the code. So you can help out by just watching the other patients. (IF it's your patient, remember Samuel Shem's rules from "House of God": The first pulse to take in a code is your own.) If a patient is being admitted, help out Even if the only thing you can do is plug in the bed and the IV pumps, take a set of vitals and I & O on the admitting nurse's other patient or update the visitors. Manage your alarms No one likes to listen to someone's patient alarm over and over because they're in A Fib with RVR and the upper ECG limit has been set at 80. If your patient's heart rate is usually 120, set your limit 20% higher. (Or whatever your unit protocol may be.) If his systolic blood pressure typically runs around 80, set the lower limit accordingly. Silence your art line alarms BEFORE you draw blood. Change the ECG patches, leads, cables -- whatever you need to do to get a clear picture and no extraneous alarms. Manage your pumps Learning how to titrate drips is a skill. But most ICU patients have multiple IV pumps, and managing them is a different skill. They can all fit on one pole rather than having three poles at the bedside. Label your channels and your tubing in the unit-appropriate manner. Set your volume to be infused to a reasonable amount -- you don't want the IV to run dry, but you don't want the pumps alarming constantly either. Before you go on break or sign out to another nurse, make sure there's plenty of fluid in your bags. Order the new bags in plenty of time. Make sure your pumps are plugged in -- a battery that dies takes up to 24 hours to recharge, and some of the pumps cannot be silenced except by Biomed. (If that happens to you, get the pump off the unit or bury it under blankets and pillows until it's inaudible from more than 20 feet or so. Then call Biomed.) Manage your own visitors Don't let them wander up and down the hall peering into other patient's rooms. When you ask them to step out, direct them to the family waiting area and tell them how approximately how long it will be until they can come back. Don't just leave them standing in the hall even though it's only going to be "a minute". It's far too easy for them to see or hear something that is HIPAA protected if they're just standing there. Visitors standing in the hall create obstacles to be negotiated and can get themselves into trouble. I once watched (from my patient's bedside, where I was holding pressure on an arterial squirter) a group of visitors pull the tops off every lab tube on the supply cart and switch them around. Another group discovered an unlocked computer at a charting station and were navigating through a patient chart when I happened upon them. And one group amused themselves by staring at other patients in the unit. So don't let them hang out in the hall, the nurses charting stations or near another patient's bed. Ensure that visitors know and follow the rules Most ICUs have some sort of rules for visitors -- things like only 2 at a time, no eating or drinking in the room, no cell phone use -- whatever. They're written down somewhere (and if they aren't that would be a great project!). Know what they are and follow them. When you don't manage your visitors and ensure that they follow the rules, you're setting up a bad situation for the next nurse. If you've let the visitors do whatever they want and the next nurse wants them to follow the rules, you've made her a bad nurse in the family's eyes. Yes, it's easier to get through your shift if you don't insist upon follow the rules, but it's going to make your colleague's shift worse. Don't do it. You don't have to LIKE or AGREE with the rules; just follow them. Follow the rules for nurses Follow the dress code, even if you don't like it. Be on time. If you're not supposed to carry your own private cell phone, don't. If you're only supposed to eat in the break room, don't eat at the nurse's station. Hide your beverage. Whatever the rules are, follow them. That especially goes for self scheduling if you're allowed the privilege. A new employee who tries to slide an extra weekend off past the scheduling committee or slough off on their night shift requirement may not get counseled the first or second time it happens, but someone has noticed and is not impressed. That person may be quicker to jump on other minor offenses, and is less willing to like you or give you a break when you need one. Be accountable If you say you'll watch someone's patient while they go on break, watch that patient. If you say you'll clean the balloon pump that has just been removed, clean it. If you're supposed to be hand washing monitor, be hand washing monitor. Pay attention to your skills checklist and be alert for opportunities to learn new skills or practice older ones. Fit into the unit culture Talk to people. ICUs are stressful environments, and ICU nurses are often possessed of a very dark sense of humor. There may be a list in the break room of 47 ways to say "the patient is about to die". Circling the drain, waiting for the Jesus Bus, high Vulture index -- and many, many more. You're not going to make friends by being offended, even if you ARE offended. Add your favorite saying to the bottom of the list, and be prepared to think of a dozen new ways to say your patient lost consciousness. Or threw up. We joke about things that aren't really funny because often times things are so serious that if you don't laugh, you'll cry. Understatement is the hallmark of a true ICU nurse. The patient that just ripped off all his ECG leads, pulled out his central line and is running down the hall naked and screaming for the police may be described as "a tad lively" and the one with a blood pressure south of 60 and a heart rate north of 160 may be described as "a touch unstable." Sinus rhythm with PACs, PJCs and PVCs is "cardiac salad" and a loud murmer may be called "the Maytag sound." I am sure I've forgotten dozens of things, and hopefully someone will remind me.
  22. Old-school RN here. Studied for Boards (before they were called NCLEX) while traveling West in a wagon train, fighting dinosaurs along the way. Cut my teeth in several ICUs, when Swan-Ganz catheters were becoming all the rage. Have seen trends and treatments come and go, the pendulum of nursing practice swing first one way then the other way. Background: I worked in IR (Interventional Radiology, which included staffing the Cardiac Cath Lab) for 21 years. Most recently (past 10 years) I work exclusively in Cardiology: Cath Lab, Stress Lab and Cardiology Case Management. Current Issue: Two recent encounters blew dust off a few dendrites, and got me wondering about the practice of transporting cardiac patients from either the ICU or tele unit to various procedure areas. Encounter One Patient with NSTEMI (non-ST-elevated MI, the "less" dangerous form of MI) and +chest pain in the past 24 hours arrived via bed to our Cath Lab. He is not on a cardiac monitor. Say what??? Repeat: He is not on a cardiac monitor. His accompanying nurse reported "the doctor said he could go unmonitored." Encounter Two Waiting for my next patient to enter the Stress Lab, I heard a familiar beep-beep-beep and turned toward the door expecting to see a gurney roll through, patient attached to the monitor, RN in attendance. What rolled through the door: Nuclear Med tech pushing a wheelchair, on which sits a patient with the transport monitor in his lap. Beep-beep-beep. No RN. My question: WHO is monitoring the patient??? And now I ask you, gentle readers Do you know your OFFICIAL hospital policy regarding transporting cardiac patients (or any ICU or telemetry patient, for that matter) off the unit for procedures? How old is the policy? Is it reasonable, sensible and sustainable (i.e., is there sufficient trained staff to accompany a monitored patient off the unit for two hours, while other nurses cover the transport nurse's patients)? Do ALL tele patients and ICU patients require RN attendance and monitoring for transport for procedures? Is it time for re-evaluation of said policy? I offer food for thought in the form of four articles my newly-dusted dendrites found when I did an online search for "monitoring patients going off the unit." First is a short thread from our own allnurses.com, in which members describe a wide range of policies and how they are implemented: Transporting Telemetry Patients off the unit - page 2 Next I found a 2004 article - a statement of practice guidelines! - from the American Heart Association: Practice Standards for Electrocardiographic Monitoring in Hospital Settings (make some popcorn and settle down for serious reading with this one) Patients are divided into three classifications according to diagnosis and condition, to determine the need for monitoring. Lots to consider and ponder. I was pleased the website search revealed a wonderful small article outlining how one facility empowered nurses to formulate an algorithm to use that "enables safe patient transport without an RN or monitoring." The article is written by Nancy J. Mayer, MBA, BSN, RN, and published in the AJN Nov 2009. The algorithm is simple to use, takes a lot of guesswork out of the decision-making and requires a second nurse's (usually the charge nurse) approval for the transport plan. Look up Transporting Telemetry Patients -Aligning Forces for Quality (pdf) And finally, a short article about, well, exactly what the title says: Telemetry monitoring during transport of low-risk chest pain patients from the emergency department: is it necessary? Targeted mainly for patients being transported from the ED to a tele or ICU unit, this is a thoughtful study. Lots of ideas here. Oh, and the encounters I described earlier? Encounter One I respectfully requested the nurse re-evaluate each transport situation. Patient with NSTEMI and chest pain within 24 hours who is going to the Cath Lab (which means, we don't yet know for sure the extent of coronary disease but he just had an MI, so it is quite possible he has cardiac disease!), no matter what the MD writes --- I will transport him on a cardiac monitor! Encounter Two Think about it: Yes the patient was sent on a monitor. However, is sending the patient on a monitor, without an RN in attendance to watch the monitor, really carrying through with the intent of the policy of monitoring a patient during transport? IMO,either send him on a monitor with an RN or obtain an MD order to transport without monitoring. Ah, my old dendrites are tired now. Hopefully your patients who need watching (to paraphrase the Bard, [mis-]quoted in the article title) "must not unwatch'd go." Thank you for your attention, and I wish your patients EXCELLENT care!
  23. shirleyTX

    Difference between the ICU's

    Can anyone explain the different cases in the MICU/SICU/TICU. CCU is pretty self explanatory but I don't quite get the difference between these.