Before I start an “us” vs. “them” war, let me start off by saying that I cannot imagine the pressure that physicians are under these days. They go for long stretches with no days off, work very long hours, have tremendous responsibility and, basically, have a job that I would never ever ever want. So, with that said, it is understandable that you will, at times, deal with a difficult or demanding physician. These tips about SBAR and effective communication should help!
Taking care of patients with neurological injury means managing their intracranial pressure, or as it’s commonly called, ICP. And when we say neurological injury, keep in mind that we’re not just talking about people getting bonked on the head with a 2 x 4. We’re talking about space-occupying lesions, hydrocephalus, intracranial hemorrhage, subdural/epidural hematoma, even severe hyponatremia…basically anything that’s a key player in (drum roll please….) the Monro-Kellie doctrine.
I first encountered Heliox when working in ICU and assuming care of a patient with severe asthma. As the team brought her up from the emergency room, I saw the respiratory therapists pushing a huge cart with what looked like gigantic oxygen tanks. The patient was wearing an oxygen mask hooked up to these tanks via long tubing and working hard to breathe. As I would learn later, she was on Heliox and it made the difference between ending up on ventilator or improving enough to downgrade to telemetry the next day. Which she did. Go us!
Knowing when you need to intubate a patient in respiratory distress is a key skill you will use regularly as a nurse. This skill applies across the board…not just ED or ICU. Nurses in all settings come into contact with patients who decompensate, and knowing when you need to intubate can mean the difference between life and death.
Capnography and ETCO2 monitoring is one of those super cool things that seem so simple at first blush, but that can really provide you with a lot of very useful data. But first, what the heck is it?
Capnography is a way to monitor carbon dioxide levels using waveform technology. See? I told you it was super cool! Why is this important? Think back to your gas exchange physiology…what is it that drives your need to breathe? Is it low oxygen? Nope. Is it high carbon dioxide? Yep! So, it stands to reason that monitoring the MAIN thing that spurs the respiratory drive would tell us loads about how our patient is doing in the ol’ gas exchange department. When you use capnography to monitor your patient, you will be looking at the “end-tidal CO2” (ETCO2). Your “end-tidal” (as it is often called) is the amount of carbon dioxide present at the end of each breath. Staying with me? This handy number and its corresponding waveform can tell you a lot about your patient, and usually you’ll see it on the ETCO2 BEFORE you see it on your pulse oximetry. Now we’re beyond super-cool…we’re moving into Mega Cool territory here.
When you do your critical care clinical rotation, you will most likely be monitoring your patient’s CVP (central venous pressure). We’ll get into the what’s and why’s of CVPs in another post…for this post we’re going to talk about the basics of setting up the CVP line. With any luck you’ll get an opportunity to practice, so this should give you a wee bit of a head start. Note that I always say there is more than one way to skin a cat….if your preceptor sets up the lines differently, that is great…you’ll learn multiple ways and ultimately figure out the one that works best for you. Ok, let’s get going!
If you are in a critical care clinical rotation, or new to the ICU, you may hear the term “mixed gas” thrown around here and there. What is a mixed gas, why do you measure it, and what does it tell us about your patient?
“Mixed gas” is shorthand for an SVO2 measurement or “mixed venous gas,” which looks at the oxygen saturation levels of blood obtained from the pulmonary artery. However, not every ICU uses PA catheters regularly, but never fear…you can still get some usable data by using blood from the superior vena cava. Note that when the blood is drawn from a central line placed in the superior vena cava vs the PA catheter, the measurement is referred to as an ScVO2. In the ICU where I work, we don’t use PA catheters much , so our mixed gasses are typically taken from the superior vena cava and are used to obtain information related to severe sepsis and septic shock. Unless you are working in a cardiac-surgery ICU, your mixed gas measurements will most likely be done as ScVO2 and related to sepsis and/or shock, so that’s what we’ll focus on here.
As you embark on the journey of being a nurse, you will learn something each and every time you step foot in the hospital. Even if you’ve been a nurse for years, you still learn something every time you work. A great way to keep track of all these pearls of wisdom is to create a practice notebook.
ARDS (Acute Respiratory Distress Syndrome) is a lung condition we see a lot in the ICU. It is extremely serious with a mortality rate of 30-50%…actually, I’m always a little bit surprised when someone survives ARDS. Usually they are dealing with a host of other problems such as sepsis, and when you put those two together the results are often poor.