Rank #1: What’s in your IV bag?
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
Rank #2: ICU for Dummies!
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?
Rank #3: Vasoactives and Low Blood Pressure Part I
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...
Rank #4: ABG’s and Vents for Dummies
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
Rank #5: Vasoactives and Low Blood Pressure Part II
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...
Rank #6: Sepsis Demystified
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
Rank #7: Hemodynamics: Arterial Lines
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.
Rank #8: How to Become a CRNA- Nurse Anesthetist
Bad News: CRNA is no longer the Best Kept Secret in Healthcare! Yep..Nurse Anesthesia is no longer the best kept secret- a lot of your co-workers in the ICU are thinking about applying and they are going to be your biggest competition. Do you want to get a million steps ahead of them? Sign up for early access to a product that will tell you everything you need to know about CRNA's, everything you need to know about the application process, and access to interviews with real life CRNA's and student CRNA's who talk candidly about their panel interviews with CRNA Admission Committees. The sign up form is right here- to the right of this blog post. Or, click here to sign up now. If you're a nursing student thinking about CRNA, you need to sign up now. This web product will give you invaluable tips that you can start working on while you're earning your BSN. Be ahead of the competition before you even graduate! When you sign up, you are getting: First notification of the product launch date An early bird DISCOUNT! Access to insider information and interviews You have to hurry! After the product launches- this opportunity will expire. So make a move today! All you need is your name and your e-mail address! Send questions and comments to email@example.com Click here to sign up today!
Rank #9: Worse Case Scenario 2: Intubation
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 patie
Rank #10: Worst Case Scenario: Head and Neck
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 in