He’s pulled stakes and moved to http://www.theintensiveart.com/. The silly twit stopped blogging for a loooong time, which annoyed many of us in the medical blogosphere, but he’s back with a new home and a freshly minted theme. If you are interested in nursing, ICUs, and generalized good blogging, check it out!
Archive for August, 2009
Nuggets of wisdom from NNR
Update 8/29: Read Sean’s comment. These nuggets work well for me where I work, but apparently they’re not appropriate across the board. I think they’re good to have in mind as “what is probably going to happen,” but check with your charge nurse, etc., before getting too proactive!
I think my cardio lecture went great this morning: I didn’t see any texting or Facebooking, and I saw a lot of scribbling. There was a lot of “could you repeat that?” Here are the two lists of things that seemed to be most helpful to students, judging from “hang on…hang on…could you say that again….”
List 1: 5 Deadly Rhythms (Drop Everything and Attend! Rhythms)
- V-fib
- V-tach
- PEA
- Extreme bradycardia
- Asystole
If your patient really is in one of these, you’re going to have to code them most often. Unless you’re like me and have a bizarre penchant for getting patients who tolerate V-tach for an hour at a time. For other rhythm changes, see list 2.
List 2: Chores to Complete Before Calling MD on Other Whacky Rhythms
- Check your patient (do they feel OK? get a set a vitals. see if they’re doing jumping jacks and causing the rhythm to look weird. etc.): are they symptomatic?
- We hope you know this from report, but if not, find out if they have a history of this rhythm (“have you ever been told you have atrial fibrillation?” or “an irregular heartbeat?”).
- Slap a couple of liters of oxygen on them and get a 12-lead.
- Ensure you have good IV access and draw a few tubes of blood to send to lab (you’ll probably have orders soon).
- Scan the med list to see if likely culprits appear (if your patient is on a high-dose dopamine drip and gets tachy, you’ve got a pretty high index of suspicion…).
- Write down these lab values (most recent): Na, K, Mg, and last set of cardiac enzymes, if any. If they’re anticoagulated, write down the PT/INR/PTT.
Following this list (to be completed all at the same time) will help you give good information to the doc, quickly. You’ve got the lab values ready they’re most likely to ask for, you can supply a good guess as to the reason for the rhythm change if you’ve got a med culprit (docs don’t have all that stuff in front of them at 2 AM), you have a 12-lead ready to fax if they want it right then, and you’ve got blood in the lab all ready for any tests they want done right now. And if they give orders for a drip, you’ve got a nice working IV (and if you have co-workers like mine, they’ll anticipate the drip and have a pole in the room with the bag hanging!). It all contributes to treating the patient as quickly and efficiently as possible while giving the physician the fewest headaches. At least this is my list so far.
As usual, I invite readers to add on (especially the docs: what can we have ready for you that streamlines these conversations?)!
Scaring nursing students
Poor Chloe happened upon my post Cost of Nursing School and got creeped:
I just happened to luck upon your post and now I can say that you made me scared. I’m starting nursing school on Monday!
This is the kind of thing that makes me wonder whether to write things “how it is” or not. We need nurses on the floor, and I don’t want to scare any of them off; however, nursing school does suck unbelievably, and I might have been better prepared had I known that. Might. I can’t say. I also might have ignored everyone’s advice and done what I wanted anyway.
This profession in general seems extremely, well, extreme. My bad times are very, very bad. Sob in the car bad. The good times are very, very good. Fist-pump good. I don’t have a lot of shifts that are mediocre. Management changed some stuff at work lately that made it intolerable, but they seem to be working with us to change that, so I’m trying to keep an open mind and remember my favorite slogan (semper gumby, baby). It’s hard. But there are still patients who need a nurse who cares about their welfare, and I’m one, so I’m trying to do what I do for any “situation” at work: focus on the patient and not blaming, fault-finding, and excuses. (Plus I’m a hopeless cardiology devotee.)
I have been terribly depressed and wondering if I made a terrible career decision, but I don’t think so. Nursing has plunged me brute-force into the most raw and real triumphs and defeats of the human condition from which we modern folks are normally protected. I may sob with frustration and grief or cry with strange joy, neither of which I did much before I entered the health care field. I have now seen people come into this world and people leave it (in nursing school, btw, Chloe). I’ve shared the lowest and most painful moments of people’s lives with them, and it’s been a dignified honor and privilege. I’ve learned from patients how to handle adversity and pain (in theory, anyway) with grace and fortitude. You get the point. None of that is particularly a goal I had, and I don’t have a masochistic desire to suffer along with people in order to reach nirvana or anything like that. But as a side effect of my chosen profession, I feel more real. Sometimes it backfires and numbs me up. Sometimes it makes me more raw. But it always changes me.
To the nursing students I’m scaring with my blog: toughen up. I am STILL developing the emotional maturity necessary to remain sane in this field, and much of that is simply toughening up. My dean told me to buck up when I wanted to quit school, and it pissed me off and then made me hysterical, but she pretty much had it right. You want to help people? That doesn’t even SOUND easy, really, and it isn’t. It’s a hard job. A tough job. Nurses have to be kind, compassionate…and tough.
Two good cardiology videos
I don’t know why, but YouTube has ceased to present me with pictures of funny pets and has instead begun to recommend cardiology videos. Perhaps it feels I should be more productive online. Some are quite good. Here are two. The first is a really nice visual demonstration of all the various chambers and pumps in the heart. I wish I could show it to patients!
The second is a quick-and-dirty guide to the most common pathologies on EKGs:
Enjoy.
Foley tricks
Foleys seem to be the bugaboo of many a nursing student and new nurse. They were for me. My instructors made it into an incredibly complicated-sounding skill, and our checkoff had about 50 steps in it. Plus it was one of those things I had few opportunities to practice. I’m not sure why, but I felt as if until I had successfully inserted a Foley, I wouldn’t be a REAL nurse. I finally got my chance during my senior Capstone: two Foleys on two men, one of whom was unconscious. I felt a little better, but both times I still had an RN next to me handing me stuff.
It’s not that difficult, I’ve decided. I now deal with Foleys fairly regularly because I get postop cardiac cath patients who can’t move for a while and have orders for them until they can ambulate. I have put a few into vaginas, but I’m not alone there. I’ve adopted the stance that it’s just not that difficult. It’s not rocket science. This stance helps a lot. As do a few tips gleaned from veterans:
- Someone on this blog shared this one: for women, go easy on the lube and told the tube close to the bulb. This WORKS (thanks for that tip!). Otherwise that slippery thing will slither right down into the vagina.
- Get a partner and a flashlight for women. Not a penlight. An actual flashlight. Add it to your work bag, and put your name on it with a Sharpie. Your partner can (a) help you hold the labia open, (b) train the flashlight on microscopic urethras, or (c) both a and b.
- For men, hold the penis straight up while you advance the Foley. Be confident and get a good grip on that thing.
- For people who get crazy bladder spasms, pain, or burning, these things work like magic: (1) B&O suppositories (doctors have often never heard of them so you have to be proactive and specifically ask for them. I think they’re old. B&O stands for belladonna and opium! I’d feel better too). (2) Advance the tube just a little. Sometimes the bulb seems to get tugged down against the bladder wall. (3) Hook up a saline flush to the port where you draw urine out for labs, kink the tube right behind it (you don’t want urine going back into the bladder), and flush the line. Unkink. Remember to subtract 10 cc’s from your catheter output. This isn’t an irrigation, per se, so an order isn’t required, and it works a surprising amount of the time. Perhaps small bits of sediment block those little holes in the bulb or something. I think 10 cc’s barely goes in to the bladder itself, but it does a bang-up job of flushing the rubber tube. Bonus: since you’re not pushing a bunch of fluid into the patient’s bladder, it doesn’t hurt.
Otherwise:
- I read somewhere that cleaning the perineal area with soap and water before insertion cuts down on infection rates, but now I can’t find any literature to that effect. Anyone know? If it does, we should be doing it, because those infections are nasty.
- Catheter care is crazy important. It’s easy to overlook because we aren’t wiping those patients as much, so I’m making it a point lately to ensure my patients with Foleys are getting a soap (Dial) and water once-over on my shifts. Soap and water, it seems, go a long way toward the prevention of many evils.
- THE DRAINAGE BAG CANNOT BE HIGHER THAN THE BLADDER. In caps because I constantly see drainage bags way up in the air so the urine flows backward. I don’t think nurses are placing them there, so it’s a matter of patient education—particularly patients with walkers. They jump up and hook the bag around the handlebars (you’d think they wouldn’t want to display it!). Yes, I’m suggesting we need to remind our patients about gravity.
Readers, share your wisdom!
