New Nurse Podcast
Summary: As a new nurse you might be worried about killing your patient. This podcast will help you avoid doing that by teaching you what to do if you find yourself in a "worst case scenario" in the ICU..
Ever wondered what kind of fluids are hanging in your IV bag and why? Hopefully, this audio podcast will answer all of your questions about: Crystalloids Isotonic Solutions: Normal Saline, Lactated Ringers, D5W Hypotonic Solutions: D51/2 NS, .45% NS, D5W Hypertonic Solutions: D5NS, D5LR, 3% NS, 10%NS Colloids Hetastarch, Albumin, Mannitol, Dextran
Dopamine/Inotropin Dopamine is a dose dependent medication, meaning it activates different receptors depending upon the dose given. Low dose activates dopaminergic receptors which causes vasodilation. At 2-10 mcg/kg/min, beta 1 is stimulated and you...
Definitions Vasoactive is an umbrella term for any drug that makes your heart rate and/or blood pressure go up or down. Vasopressor, on the other hand, is a term for a drug that makes your blood pressure goes up by the process of vasoconstriction (squ...
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Why do our ICU patients get sepsis? They are likely on antibiotic therapy, making our patients susceptible to resistant organsims. Plus, our patients are already sick and possibly immunocompromised. Just being in the hospital is a risk as patients deal with the threat of hospital acquired pneumonia, urosepsis from foley catheters and skin infection from wounds/skin tears and IV sites. The Three Stages of Sepsis 1. Uncomplicated- not requiring hospitalization e.g. viral infection 2. Severe- requires hospitalization and involves one or more organs (heart, lungs, kidneys, liver) 3. Septic shock- drop in blood pressure that does not improve with fluid administration, one or more organ involvement and has a 50% mortality rate Pathophysiology of Sepsis The infectious organism secretes an endotoxin that jump starts the inflammatory response and causes massive vasodilation. The patient's organs and tissues are not able to get the oxygen and nutrients they need so organs start to fail. What are the Signs and Symptoms in a Patient with Sepsis? Fever, increased respiratory rate, warm skin, tachycardia, weakness, elevated white blood cell count, positive cultures, and/or elevated serum lactate. The patient may or may not have all of these signs and symptoms. Treatment for a patient with Sepsis Fluid resuscitation with 0.9% Normal Saline (NS) or Lactated Ringers (LR). If unsuccessful at improving blood pressure, vasopressor therapy will be ordered. The first choice pressors in sepsis management are Levophed and Dopamine. Second line is Epinephrine. Our goal is to titrate to a MAP of 65. The MAP goal may need to be higher or lower depending on the patient- some patients tolerate a lower blood pressure and some patients need a higher pressure. Septic patients will also get antibiotic therapy. If the patient comes through the ER, the ER will draw cultures (before antibiotics are started!) and give a broad spectrum antibiotic within 3 hours. If the patient is admitted to the ICU, the ICU will draw cultures and hang antibiotics within 1 hour. Timing is important, sepsis is a life threatening diagnosis. The antibiotic regime will likely be managed by Infectious Disease. In 48-72 hours, they will review the results of the culture and adjust the antibiotics to best attack the organsim involved. The patient will likely be on antibiotics for 7-10 days. Septic patients may also get low dose steroids to help control the inflammatory response and they will also need tight glucose control. The goal for glucose range is 70-150. Other Thoughts CVP: Central venous pressure is an indicator of fluid status. Septic patients have a goal CVP of greater than or equal to 8. Arterial line: Continuous blood pressure monitoring is extremely helpful when you are titrating vasopressors. It also allows you to draw arterial lactate samples and blood gases. Central line: It is helpful for your patient to have a central line if they are receiving vasopressors and/or antibiotics as both of these are caustic to veins. Central lines are also beneficial because they allow for multiple medications to be administered at the same time through different ports. Reference: Surviving Sepsis Campaign www.survivingsepsis.org
Every ICU has a slightly different requirement as far as what you are assessing as the RN. Even though every patient is unique, there is a general ICU assessment that will work for most. In this audio only version, we will go through a basic ICU assessment and cover Neuro, Cardiac, Respiratory, GI/GU, Skin, and other miscellaneous items that will help you form a plan and help you attempt to form your own assessment "flow". Website Links: Hear audio files of heart sound and lung sounds! The Auscultation Assistant http://www.wilkes.med.ucla.edu/inex.htm Littman http://solutions.3m.com/wps/portal/3M/en_US/3M-Littmann/stethoscope/littmann-learning-institute/heart-lung-sounds/
Chest tubes are not as scary as they sound. If the chest tube is already in place and there are no immediate problems, chances are your 12 hour shift is going to be ok. If not, we'll teach you exactly what to do. Chest tubes can be placed in a pleural space or a mediastinal space. Listen to our audio version (link above) for more detailed description of the differences between pleural and mediastinal and a refresher of lung anatomy and physiology. One patient can have 1-4 chest tubes that are often Y-connected together to decrease the number of drainage systems attached to the patient. How do you assess the patient with a chest tube? Is the patient having respiratory distress? Listen over both lung fields- if one is absent or muffled, notify the MD and provide respiratory support. Check the chest tube dressing for drainage, outline any new drainage and notify the MD if there has been a drastic increase in drainage. Is the dressing intact? Vaseline gauze is helpful in preventing air leak around the chest tube and if this has become displaced, it's often helpful to reapply the dressing. Is there any subcutaneous air around the chest tube site? Notify the MD if there is. This is called crepitus and could signify an air leak. Check the tubing for kinks and obstructions. Check the color of the drainage. Notify the MD if there is a change in output color (especially if the change is to bright red blood!) and also if the output has increased significantly. The output should decrease over time, not increase. Check the drainage system for an air leak in the water collection chamber. If there is an air leak, you will see bubbling in the chamber, the louder and higher the bubbling- the worse the air leak. Ideally, there will not be an air leak and you will see fluctuation in the water collected chamber that match the patient's respirations. If it a new or worsening air leak, notify the MD! Determine whether the chest tube is ordered to -20cm H20 (artificially providing negative pressure to the patient) or to water seal. Make sure the chest tubes are not clamped. Chest tubes should only be clamped when you are changing out a collected chamber and when the doctor has ordered clamping. You can also assess where an air leak is coming from by clamping different locations in the tubing. I would not recommend this as a new nurse. Make sure you have two kelly clamps at the bedside for a patient with a chest tube. Make sure you have portable suction if your chest tubes are ordered to suction and you are traveling with your patient. If tubing becomes dislodged from patient, immediately call a code or get an MD there to replace the chest tube, then apply a 3 sided dressing to the site or place your hand over the site, lifting occasionally to vent, especially if patient is having respiratory distress. If tubing becomes dislodged from chest drainage system, ideally you'd clamp and reattach to a new sterile drainage system. If not possible, a glass of sterile water or the old chest tube drainage system might be your best bet. Listen to the New Nurse Podcast on iTunes or download this episode via the above link. You can also listen live from the website. As always, comments and feedback are greatly appreciated.
Download the related podcast about Death in the ICU! When physicians have decided there is nothing more they can do for a patient, they will often speak with the families and encourage them to withdraw care. Our facility actually says “Comfort Measures Only (CMO)” instead of “Withdrawing Care” because withdrawing care implies that we will no longer take care of the patient and this is not true- we do everything we can to make our patients comfortable, free from pain, and free of anxiety. I have recently taken care of two patients that were made CMO and there are some things that I have learned that I can share. First, the decision is made by a group- physicians, the patient, family members, and possibly clergy. Some experienced nurses may feel comfortable gently broaching the subject with the family. This is obviously going to be dependent upon how comfortable the nurse feels about the situation and the nurse’s relationship with the family. Second, comfort measures only usually means turning off all vasoactive drips and taking patients off the ventilator. At our facility, there is policy that dictates what we document and how often we assess our patients. All alarms get turned off and we only monitor heart rate and O2 saturations. If I recall correctly, only one full assessment is made per shift. It is always important to obtain a copy of your hospital policy so you know exactly how to proceed. It is also important to obtain DNR (Do Not Resuscitate) status for the patient. // // If you are the RN who is actually transitioning from full care to CMO, it is important to set up your pain and/or anxiety medication before you remove your patient from the ventilator or turn off drips. My facility has preprinted orders for CMO and usually patients are placed on continuous drips of morphine and ativan. Physician orders dictate maximum rates of these drugs and often physicians write for boluses of morphine in addition to the continuous rate. There is an ethical issue at hand here for some nurses but many nurses I have talked with understand that these maximum doses are not killing the patient. This is illegal. CMO preprinted orders were designed to provide for maximum patient comfort without crossing the line with lethal doses. // // With your comfort drugs already running, the patient is extubated, life prolonging drips are turned off, and the titration of the pain and anxiety medication for comfort begins. Family members are often packed tight into the rooms, the lights can be turned off and as a courtesy, the doors are shut or curtains drawn for privacy. Our ICU rooms are always single rooms and occasionally, if a patient does not expire within a certain time frame, they can be transferred to another private room on a hospital floor. Families will often have a lot of questions and they want to know exactly what to expect. This is the most difficult part because there are no answers. I’ve been told that patients may either die within minutes or continue to have vital signs for days. My first CMO patient was extubated and he died 20 minutes later. He sounded like he was sleeping with loud snores and then he stopped breathing and his heart went into asystole. My second patient was much the same although she had been made CMO earlier in the day and when I came on the night shift, she died 3 hours later. Her HR had been very tachycardic and suddenly she dropped down to the 50’s. Basically her body was working to compensate by pumping faster and then she ran out of energy. It wasn’t very long after that that she died. In both situations, my patients were free from any type of distress. I have, however, heard stories from nurses that have had more traumatizing situations where dying patients have actually been gasping for air. This is why it is imperative to have your comfort medications in place with a full understanding of your max dose and bolus amounts and schedules.
Everything you need to know about Arterial Lines in this audio only version! What types of patients get arterial lines? What does the nurse need to know about arterial lines? How do you troubleshoot arterial lines? And I need a big favor! Go to iTunes and rate my show! I need your help to get my ratings up.
Download to learn more about respiratory failure, and what the nurse does before, during, and after intubation. Causes of Respiratory Failure Sepsis, Pneumonia (aspiration), COPD Exacerbation, Trauma, Pulmonary Embolism, Pneumothorax, and Pleural Effusion What is a pleural effusion? A pleural effusion is an abnormal collection of fluid in the pleural lining which disrupts oxygen exchange and can cause symptoms in a patient when fluid reaches 1500ml. It is caused by CHF, cirrhosis, nephrotic syndrome or an infectious process. They are diagnosed and monitored by CXR, CT Scan and Ultrasound. Treat with diuresis, thoracentesis or pleurodesis. What does an Intubated patient look like before they are intubated? The patient is already intubated. Respiratory sets up the ventilator- the nurse should have sedation ready if necessary. Let the patient settle in, especially if you transferred the patient from bed to stretcher. Check the ventilator settings and note when the next ABG should be drawn. If the patient has not had one, call provider and get an order. Patients in Respiratory Distress on the BiPap. Do not do a full assessment. Let the patient relax and get settled. You can still listen to lung sounds but don’t ask the patient to speak or to perform motor strength tests. Treat anxiety as needed. Make sure there has been a recent ABG and CXR taken. Sudden Respiratory Failure: This is the patient that was doing fine on small volumes of oxygen and suddenly decompensates. Have Respiratory ventilate patient with ambu bag if necessary or place venti mask at highest percentage. Get ABG, CXR and notify provider. Monitor for arrythmias, confusion and sleepiness. Decreased Glasgow Coma Scale Score: This is the patient with a worsening head issue, hepatic encephalopathy, increasing lethargy, etc. We are taught that ET intubation occurs with a GCS less than 8, but this is not ALWAYS the case. Think about intubating any Neuro or Trauma patient who is at risk for aspiration (poor cough and gag reflex) or respiratory decline (low RR, lethargy). Code Blue: A patient that is in VFib, Pulseless Vtach or PEA will likely be intubated in a code situation. Chest compressions are not performed during the actual intubation but are resumed after tube is in place. Patient is ventilated with 100% oxygen while continuous chest compressions are performed. Notes about Positive Airway Pressure (CPAP and BiPAP) Positive Airway Pressure only used with patients who are breathing spontaneously. PAP is often used with pulmonary edema and COPD exacerbation patients. CPAP isn’t used for patients with CO2 retention. CPAP delivers one level of pressure (5-15cmHg) and there is no rate setting so this won’t be used for a patient who is retaining CO2- it helps keep alveoli open so is good for patients with low O2 sats who just need help oxygenation- not ventillating. BiPAP has two settings, an inhaled pressure and an exhaled pressure (IPAP and EPAP). BiPAP ventilation helps recruit alveoli AND delivers a respiratory rate if necessary so it can be used for patients with high CO2. What does the nurse do during an intubation? If you call the ABG results to the provider and he/she tells you to prepare for intubation- grab the intubation tray (usually located on the code cart). Get consent if patient is able to consent or family is present. If it is an emergency, have the MD sign the consent form after the intubation. Ask provider which medications they would like to use. Know the difference between anesthetics, analgesics and paralytics. Listen to the audio version of this post for more information about specific drugs. Anesthetic: Loss of feeling/awareness, do not treat pain→ Etomidate, Versed, Propofol Analgesic: Treat pain → Fentanyl Paralytic: Muscle Relaxers →Rocuronium* *must be given by qualified personnel! Pre-oxygenate the patient for 2-3 minutes with 100% oxygen.
Download! What to do if your patient has a seizure, vomits blood or self-extubates, etc. In this crazy job called nursing, everything that can go wrong WILL go wrong at some point in your career. I am dedicating this post to some worst case scenarios. WORST CASE SCENARIOS: HEAD AND NECK 1. Your patient begins to have seizure activity. Ativan IV, pad the siderails, patient may need to be intubated, consult Neurology and start prophylactic meds like Dilatin or Keppra. Neuro may want to do an EEG or head CT or both. An OGT or NGT might be a good idea after seizure has resolved to help prevent aspiration. 2. Your patient has a decreased in LOC, AMS, new onset confusion. Assess your patient for any other neurological deficits or vital sign changes. If the patient is at high risk for falls, take appropriate precautions like bed alarm and possible restraints or mittens until you can determine the cause. Notify the physician. Depending on the patient’s history- the physician may order a variety of interventions e.g. Stat Head CT, pan cultures to screen for an infectious process, lab work to check for electrolyte imbalances (sodium levels, ammonia levels, etc.) or a stat ABG to determine oxygenation status. If you have a Neuro patient with a sudden decline in LOC or a change in their Neuro exam (for example, the patient was following commands and now is not)- you will likely do a stat Head CT and those results will determine the plan of care. 3. Your Neuro patient has high ICP values. Depending on the cause of the problem, Neurosurgery may place an EVD or take the patient to IR to do a coiling or clipping or craniotomy in the OR. If the patient has an EVD, the drain may be lowered to allow for more CSF drainage. The patient may need hypertonic solutions (3% NS) or an osmotic diuretic (Mannitol). If ICP’s are related to patient activity, sedation may need to be increased. In severe cases, patient may need to be placed into a barbiturate coma. 4. Feeding tube problems are endless. Patients do not like to have feeding tubes (FT) inserted. You may need a one time dose of Ativan, Fentanyl or Morphine, etc. to calm your patient down long enough to place the tube. *Do not use the FT until it is confirmed that it is in the correct place and not in the lungs. Our hospital requires x-ray verification. Once the tube is in and taped firmly onto the nose- there are some things that can go wrong... If the FT is dislodged or gets pulled out, STOP THE FEEDINGS! If the tube has been slightly dislodged- re-secure and shoot a repeat x-ray. If the tube is hanging all the way out, d/c the FT and insert a new one. *Our hospital just started using "bridles" which secure the feeding tubes to the patient’s nasal septum so if the patient pulls on the tube- it causes pain and they stop. Instead of restraining patients who attempt to manipulate the FT, try mittens! **If the FT becomes clogged, try flushing it. You can try warm water and anything with carbonation (soda pop, ginger ale) to try to break up the clog. If nothing works, you may have to d/c and reinsert. If the FT is kinked or coiled on the x-ray, you will likely not be able to get any feedings down the tube so you will have to d/c the FT and insert a new one. Check residuals by pulling back on the FT with the syringe. If residuals are large, do not reinsert the residual and decrease or stop the rate of TF (notify physician). If residuals are moderate, decrease the rate of TF. If the residuals are small, the rate of TF is probably ok. Check residuals every 4 hours at least or more frequently as needed. Also check residuals if you stop hearing bowel sounds, bowel sounds are hypoactive and/or patient complains of pain or nausea. 5. Your patient is vomiting. IV Zofran, place NGT or OGT to low continuous suction or low intermittent suction to suction out the stomach contents.
Download! This AUDIO only version will cover the following topics: ABG interpretation made easy! ABG in the real world: the ICU What do you NEED to know about Ventillator Settings? great link for practice ABG's: http://www.realnurseed.com/abg.htm
Download! What every new nurse wishes he/she knew. In this AUDIO ONLY version, I will blow your mind and tell you everything you need to know about: ICU Dayshift vs ICU Nightshift Traveling with your patients to CT/MRI Lab results, CBC, BMP & Coags: what is really important?
Download! Our documentation requires us to chart pulses and whether they have been confirmed by palpation, Doppler, or if they are absent. I usually check pulses while I'm assessing neurological status in an awake patient but every RN has their own "flow". Until I rotated through the Vascular ICU, I very rarely had to doppler a pulse. Sometimes when patients are extremely edematous, a doppler is necessary to confirm a pulse through all the pedal edema. But in the VICU, you deal with a lot of patients who have PAD (peripheral arterial disease) and also patients who have undergone endovascular surgery like Femoral Popliteal Bypass (Fem-Pop) and are at risk for a failed graft. // To illustrate my point, I'll use the Fem-Pop as an example. When a patient has a blocked blood vessel at or below the knee that is causing symptoms like claudication (tightening of the arteries in the legs on exertion) and/or has risk of limb loss they may undergo a Femoral Popliteal artery bypass. Basically, a graft is applied above the area of blockage to the Femoral artery and attached below the area of blockage to the Popliteal artery (hence the name Fem-Pop). Think about how traffic is re-routed around an accident scene and you've got the same idea. The graft that bypasses the occlusion can either be man-made (like Dacron) or harvested from a healthy vein in the patient. Post-operatively, pedal pulses on the surgical side are monitored frequently to ensure that the bypass is actually working to get blood down to the toes. If the graft fails and the patient loses blood flow to the leg, you will not be able to feel a pulse. If you cannot palpate a pulse or you are not 100% sure if you are palpating a pulse, it it best to confirm by doppler. Remember- if you chart you feel a pulse and you aren't sure- you are putting the patient at risk of losing a leg- which is kind of a big deal! Be liberal with the ultrasound gel and turn the doppler up to full volume. First search where you normally feel a dorsalis pedis artery or an posterior tibial artery. If you cannot hear anything, start up between the big toe and 2nd toe and work your way down slowly. If you hear the pulse, wipe off the gel and grab a black Sharpie to make a big "X" where you felt it. This will help you find it quickly next time and it will really help the RN who follows you. What happens if you don't hear a pulse? Have another RN attempt to doppler a pulse, preferably a charge RN or someone with a few years experience under their belt. Then, notify the surgical team or the attending physician. They might come by to assess the patient themselves or have you order an Arterial Duplex Ultrasound. The tech will arrive at your bedside and assess the patient's arteries for stenosis (narrowing) or occlusion (complete blockage). Notify the physician of the results. He or she may end up taking the patient immediately back to the OR to revise the graft depending on the severity of the stenosis. And that's why pulses really are important!
Download! There are a lot of abbreviations in the Neuroscience ICU and you will almost never hear the layman's term stroke. That is what confused me when I began. I was listening to report and hearing SAH, IVH, ICP, CPP, SDH, DAI, blah blah blah. B...